Every finding on record at Marwood Manor Nursing Home

Based on observation, interview, and record review, the facility failed to timely assess and implement interventions to prevent a right heel pressure ulcer for one (R54) of two residents reviewed for skin concerns resulting in the development of a stage three (full thickness tissue loss without visible bone, tendon or muscle) pressure ulcer. Findings include:Review of the facility record for R54 revealed admission into the facility on [DATE] with diagnoses including Status-Post Right Hip Fracture with Surgical Repair, Diabetes Mellitus, and Difficulty in Walking. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated R54 required Maximal Assistance (caregiver provides more than half the effort) for bed mobility and the Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. The record also indicated R54 currently had a facility-acquired pressure ulcer.Review of R54's hospital discharge documents revealed a Skin Assessment-Wound Documentation report dated 02/17/25 which indicated right hip surgical incision, left arm rash and no findings otherwise. Review of the facility Clinical admission Nursing assessment dated [DATE] revealed the skin notation Multiple areas of discoloration (rash-like) to right arm and bilateral thighs. Surgical dressing right hip. No notation pertaining to the right heel was identified. On the body part-specific checklist where a check mark indicates a problem area, the right foot and right heel boxes were not checked. Review of R54's Braden Scale of pressure ulcer risk dated 02/17/25 revealed a score of 18 with the resident categorized as At Risk.On 07/29/25 at 12:15 PM, R54 was interviewed in their room and asked about any pressure ulcers they may have developed since coming to the facility. R54 stated When I got here the bed I was in was too short. I'm 6'2 and the bed had a footboard at the end that my feet pushed up against. My feet only stayed off the footboard if I stayed perfectly flat and didn't move. It made it especially hard to move my right leg that the surgery was done on. R54 was asked if they discussed the bed with staff and they stated Yes, I know I talked to a maintenance guy about it, and they told me they couldn't take the footboard off. They eventually ended up getting me a different bed that was bigger and didn't have a footboard. R54 was not able to recall how long they were in the original bed.On 07/30/25 at 10:18 AM, R54 was interviewed in their room regarding the impact of the onset and ongoing treatment for the right heel wound. R54 became tearful and reported when they came to the facility they expected to do therapy for a few weeks after the right hip surgery then return home to their spouse. R54 reported they felt their progress with physical therapy was slowed due to weight bearing restrictions and use of an off-loading boot on the right foot due to the wound. They also indicated they have subsequently received intravenous (IV) antibiotic treatments for potential infection in the wound which they feel prolonged their stay. R54 reported feeling depressed and stated I've had at least four panic attacks now. I've had trouble when they talk about the wound not healing. I would get short of breath, and I thought I was having a heart attack. On 07/30/25 at 10:41 AM, Registered Nurse (RN) C was interviewed and reported they did recall R54 from the initial period of their admission. RN C reported they recalled R54 receiving a larger bed following their admission and stated, I think I may have ordered the bed but I'm not sure. RN C reported they could not recall having assessed or identified R54's right heel pressure ulcer prior to the bed being requested.On 07/30/25 at 12:20 AM, the facility Maintenance Director (MD) was interviewed and reported they could not recall having a conversation with R54 about their bed but agreed to check their work order record. The MD provided documentation of the work order being requested by RN C and completed on 02/24/25.On 07/30/25 at 01:50 PM, Licensed Practical Nurse (LPN) E reported they were the facility wound care nurse. LPN E reported they became aware of R54's right heel wound on 02/24/25 via the resident's floor nurse. They reported the concern about the resident's feet pushing up against the footboard was identified and they reported it to maintenance then wound prevention and care interventions were ordered and care planned. LPN E reported that the right heel wound was assessed to be a stage three pressure ulcer upon their initial assessment. LPN E acknowledged that there was no indication in the admission nursing assessment that any concerning right heel condition was present.Review of R54's care plan revealed preventive pressure ulcer interventions were initiated 02/25/25 and were not initiated upon admission or upon completion of the admission Braden pressure ulcer risk assessment. Review of R54's current wound care record verified the right heel wound has remained at a stage three with varying levels of improvement and decline regarding size measurements.On 07/30/25 at 02:05 PM, the facility Director of Nursing (DON) was interviewed and asked about why R54 was admitted on [DATE] with no skin concerns identified with the right heel and remained in bed in which their feet were up against the footboard for seven days, during which there was no identification of the developing pressure ulcer. The DON acknowledged there appeared to be no record of the resident's feet/heels being checked between the admission assessment and identification of the wound on 02/24/25. The DON reported their expectation is staff would have provided direct care such as bathing, donning/doffing of socks, etc. on multiple occasions during that seven-day period and the developing wound should have been identified and reported. The DON reported the facility completes pre-admission assessment of resident's height and weight to determine an appropriate bed size and therefore, their expectation is the resident would have been provided an appropriately sized bed and also that staff should have identified that the bed was too short prior to the identification of the pressure ulcer on the seventh day of admission.Review of the facility policy Pressure Ulcer Prevention and Management dated 07/2023 revealed the following:The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors .Examples of risk factors include but are not limited to: Impaired/decreased mobility or functional ability, co-morbid conditions such as Diabetes Mellitus.Nursing assistants will inspect skin during bath and daily care and will report any concerns to resident's nurse immediately.Interventions will be implemented according to the Braden risk score: (15-18) Heels: Pillows/Float heels.

Based on observation, interview, and record review, the facility failed to ensure accurate Medication Regimen Review (MRR), accurate medication administration, and adequate medication monitoring was completed for one resident (R6) of three dialysis residents reviewed. Findings include: On 07/30/2025 at 8:11 AM, Licensed Practical Nurse (LPN) “A” was observed to administer Plavix (antiplatelet) 75 milligram (mg), Furosemide 20 mg (water pill), with Lokelma/Sodium Zirconium Cyclosilicate 10 grams (potassium binder). LPN “A” reported no concerns of giving the identified medications on a dialysis day. A review of the web page for the manufacturer's prescribing inserts for Lokelma (sodium zirconium cyclosilicate) documented: .Drug Interactions Section: In general, other oral medications should be administered at least 2 hours before or 2 hours after Lokelma Nine (9) of the 20 drugs that showed an in vitro interaction were subsequently tested in [NAME] with Lokelma 10 g (grams) in healthy volunteers . There was an increase in systemic exposure to weak acids such as furosemide and atorvastatin . Edema: Each 5 g dose of Lokelma contains approximately 400 mg (milligrams) of sodium, but the extent of absorption by the patient is unknown. In clinical trials of Lokelma in patients who were not on dialysis, edema was observed and was generally mild to moderate in severity. On 07/30/2025 at 10:53 AM, Pharmacist “C” was asked to review medications for R6 and reported Plavix should be administered two hours before the Lokelma or two hours after related to reduced effectiveness of Plavix. On 07/30/2025 at 11:37 AM, the identified concerns were reviewed with the Director of Nursing (DON). The DON reported monthly Medication Regimen Reviews (MRR) should be completed by the pharmacist. The Consultant Pharmacist Chart Review for January through July 2025 were reviewed and the “review notes” section did not identify any concerns. The DON reported they would have to review the Consultant Pharmacist Chart Reviews (MRRs). Review of the record for R6 revealed: R6 was admitted into the facility on [DATE]. Diagnoses included End Stage Kidney Disease, Stroke, and Diabetes. Review of the Medication Administration Records (MARs) for January 2025 through July 30, 2025, revealed three to four administrations weekly of Plavix with Lokelma. A review of the orders for Plavix and Lokelma revealed use since 11/22/2024. A review of the policy titled “Medication Administration” dated 06/09/2022, revealed, “Medications are administered by licensed nurses in accordance with professional standards of practice…administer mediation as ordered in accordance with manufacturer specifications…” A review of the facility policy titled, Medication Regimen Review and Reporting revised, 03/20/2013, revealed, .The consultant pharmacist reviews the medication regimen along with the medical record at least monthly . Identification of irregularities may occur by the consultant pharmacist utilizing a variety of resources . the consultant pharmacist incorporates federally mandated standards of care in addition to other applicable professional standards . A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to director of nursing, and the medical director and the care planning team .

This citation pertains to Intake: MI00144914. Based on observation, interview, and record review the facility failed to transport a resident safely in a wheelchair for one sampled resident (R42) of eight reviewed for accidents, resulting in a fibula (right lower leg) fracture. Findings include: A review of the intake noted, It was reported the resident was put in a w/c (wheelchair) without foot pegs which resulted in injury. On 7/10/24 at 11:29 AM, R42 was observed sitting in the dining area at a table with other residents. R42 was in a wheelchair with their legs resting on foot pedals. R42's right leg was observed with a gray orthopedic boot. R42 was asked what happened to their leg and was unable to explain due to their cognitive impairment. A review of R42's medical record revealed, R42 was admitted to the facility on [DATE], and readmitted on [DATE] with a diagnosis of Fracture of upper and lower end of right fibula and subsequent encounter for closed fracture with routine healing. A review of R42's annual , Minimum Data Set (MDS) assessment dated [DATE], documented severely impaired cognition and that R42 used a wheelchair and required assistance with activities of daily living. Further review of R42's medical record progress notes revealed: 5/22/2024 21:29 (9:29 PM) Health Status Note: Resident refused foot pedals this shift. While CNA was pushing resident in [their] chair, resident placed [their] foot down. Resident c/o (complaint of) foot pain. No edema noted, resident able to perform ROM (range of motion) on foot. PRN (as needed) Tramadol (pain medication) administered and effective. 5/22/2024 23:25 (11:25 PM) Health Status Note . During HS (bedtime) care resident was yelling out stating [their] foot hurt and attempting to lower self while in mechanical stand. Foot, ankle, and leg assessed with supervisor. Slight swelling noted, no bruising at this time. Resident able to move foot independently. X-ray ordered per standing order. Communication sent to physician at 2325. Unusual occurrence form filled out. 5/23/2024 11:51 (AM) Health Status Note . NP (Nurse Practitioner) to evaluate resident per nursing request. Apparently last evening resident was being pushed in [their] wheelchair and [R42] placed [their] foot on the ground. Subsequently, [R42] complained of foot pain. Resident was seen this morning in bed. Right ankle and foot noted to be quite swollen. Unable to perform any range of motion to right foot or ankle due to significant pain. Right ankle X-ray report revealed an acute fracture of the distal fibula with minimal displacement. Resident will be transferred to [local emergency room ] for further evaluation/treatment of distal right fibula fracture. [Physician] notified of X-ray findings. Nursing to contact family. 5/23/2024 12:58 (PM) Health Status Note . [local x-ray company] right ankle result received via fax, conclusion: Acute fracture of the right distal fibula. results given to . NP immediately. NP assessed res (resident) and ordered [R42] to go to [local hospital] for evaluation and treatment. Res right ankle swollen and painful with slight discoloration. Pain rated a 9 (out of 10), tramadol as given this morning but was not effective . 5/23/2024 20:52 (8:52 AM) Health Status Note . Res returned from [local hospital] at 1800 via EMS (.) Transferred from ambulance stretcher to bed with the assist of 4. Pain level at a (nine) res yelling out Tramadol and Ativan (anxiety medication) given . Foot and ankle put in a temporary immobilizer . On 7/11/24 at 10:52 AM, the Director of Nursing (DON) was asked about the incident with R42. The DON explained that the resident was agitated and did not want the footrest after being asked by the Certified Nursing Assistant (CNA). The DON was asked if R42 had the understanding to make that decision. The DON stated, [R42] is pleasantly confused. The DON was asked what the facility's expectation is in a situation like this. The DON explained, that the CNA could have re-approached or asked R42 to self-propel to see the ducks instead of pushing the wheelchair without the footrest. On 7/11/24 at 1:04 PM, CNA K was interviewed via phone and was asked about the incident with R42. CNA K explained, that R42 was upset and that they wanted to take R42 away from the agitation to calm down. CNA K stated, I was going to take [R42] to see the ducks [on the other unit] and I offered put the foot pedals on [R42] said no. CNA K explained that R42 was agitated and demonstrated to CNA K that R42 could hold their feet up. After R42 demonstrated they could hold their feet up CNA K explained that she gently pushed R42 down hallway. CNA K continued and stated, they got a couple doors away and the wheelchair stopped, R42 had put their foot down. CNA K explained, that when she looked R42's foot was under the chair and out of the shoe. A review of R42's care plan revealed, Focus: The resident is able to get [their] wants across, although [their] words are not always sensible. [R42] has poor awareness of personal space. [R42] is very social. Date Initiated: 01/17/2022. Goal: The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Date Initiated: 01/17/2022. Interventions: The resident prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as looking through the newspaper and listening to music. Simplify steps to more complex programs [R42] joins in. Date Initiated: 01/17/2022. A review of the facility's policy, Transporting Residents in Wheelchairs dated 7/3/2019 revealed, It's is the policy of this facility to promote safe wheelchair transport of residents. 1. Foot pedals will be used for the transport of residents in wheelchairs when traveling outside of their room unless the resident chooses to self-propel . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: [CNA K] was interviewed about the incident. [CNA K] is identified as one of the resident's primary consistent staff members. [CNA K] states she is very familiar with the resident's routine and behavior tendencies, as well as effective interventions used when the resident is agitated. On the evening of the incident the resident had become visibly agitated after a verbal interaction with another resident. [CNA K] knew that the resident could be distracted and calmed by visiting the courtyard to see the baby ducks and offered to take her there. [CNA K] also offered to put the foot pedals on the wheelchair, but the resident refused/decline them, and preceded to demonstrate her ability to hold her own feet up. To avoid further escalation of the resident's agitation, [CNA K] decided to push the wheelchair at a relaxed pace without the foot pedals to their destination. Resident [R42] was evaluated at the emergency department on 5/23 and had a temporary immobilizer issued for [R42]. She then followed with orthopedic services on 5/28 and a fracture boot was issued for the resident's right foot/lower leg. She is non weight bearing on her right leg for 6 weeks. The resident already had foot pedals issued for her use, but refused/declined to used them at the time of the transport. Education with the resident would not have been appropriate at the time of the event due to the resident's agitation. The care plan for the resident was reviewed and updated to include approaches for staff to use in response to any reluctance to use the foot pedals. A building wide audit was completed to identify all other residents without foot pedals. Foot pedals were issued and will be used for all residents when being transported in a wheelchair outside their room. Care plans for residents were reviewed and revised to reflect use of foot pedals and wheelchair locomotion. The policy Transporting Residents in Wheelchairs was reviewed and which identifies that any resident being transported in a wheelchair outside their room will require the use of foot supports/pedals. Education done with all staff regarding the policy, transportation expectations and response to refusals. This facility acknowledges a resident's right to refuse. If a refusal occurs, staff should make the resident aware of the safety concern if foot pedals are not used and offer the resident the alternative option of propelling themselves. Education was conducted from 5/23 thru 6/3/2024. Ongoing monitoring of compliance will be completed through audits, scheduled to be completed weekly x 3, monthly x3 and then quarterly thereafter if needed to assure compliance. These audits will be the responsibility of the Quality Manager. Compliance date: 6/4/2024 The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plan interventions for five residents (R78, R130, R145, R149, and R153) of six residents reviewed for care plans. Findings include: R78 On 07/09/24 at 2:41 PM, R78 was observed sitting up in wheelchair in the dining room. R78 was observed becoming agitated with another resident at their table. A record review revealed that R78 was admitted on [DATE] with the medical diagnoses of Chronic Kidney Disease, and Alzheimer's Disease Late Onset. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] documenteded with a Brief Interview for Mental Status (BIMS) score of 3 which indicates moderately impaired cognition. A physician's order dated 3/21/24 indicated admit to (name of provider) Hospice due to diagnosis of Alzheimer's disease. Further review of R78's care plans revealed no active care plan for R78's hospice care and management. R130 On 07/09/24 at 12:41 PM, R130 was observed sitting up in wheelchair in the dining room. R130 was encouraged by staff to eat their lunch. On 7/10/24 at 1:00 PM, R130 was observed yelling at another resident to move out of the way. A record review revealed that R130 was admitted on [DATE] with the medical diagnoses of Chronic respiratory Failure, Depression, and Anxiety Disorder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderately impaired cognition Further review of R130's medical record revealed an increase in the R130's behaviors. R130 was on a scheduled psychotropic. A review of care plan revealed no active care plan to manage behaviors and agitation. R145 On 07/09/24 at 9:00 AM, R145 was observed in the dining room with staff assisting with breakfast. A nursing assistant was observed encouraging resident to eat however R145 was shaking their head and stating 'no'. A record review revealed that R145 was admitted on [DATE] with the medical diagnoses of Hypertension, Gastrostomy Malfunction, Major Depressive Disorder, and Anxiety Disorder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 6 which indicated impaired cognition. Further review of R145's medical record revealed an increase in behaviors. R145 was on scheduled psychotropics. A review of the care plans revealed no active care plan to manage behaviors and agitation. On 7/11/24 at 10:00 AM, an interview was held with the Social Worker (SW) (L). SW Lwas asked about the behavior care plans for R130 and R145. SW L stated, There are no care plans for behaviors for those residents. On 7/11/24 at 10:40 AM, the Director of Nursing ((DON) reported the expectation for residents with behaviors was they would have a care plan and interventions for the identified behavior. 34851 R149 On 7/09/24 at 11:46 AM, R149 was observed in a low bed, with a high back wheelchair in the room which had a pommel style seat cushion. R149 was unable to be interviewed due to R149's cognitive impairment. On 7/11/24 at 9:50 AM, R149 was observed lying in bed. The pommel cushion was observed in the wheelchair. A review of R149's medical record revealed, R149 was admitted to the facility on [DATE] and 4/25/23 with diagnosis of Hemiplegia and Hemiparesis (paralysis/weakness on one side) following Cerebral infarction (stroke). Further review of R149's medical record revealed, R149's care plan was without a plan of care that addressed the pommel cushion and it's use and or need. On 7/11/24 at 10:48 AM, the Director of Nursing (DON) was asked if R149's pommel cushion should be care planned. The DON stated, It should be care planned, I will check for the assessment. On 7/11/24 at 1:12 PM, the DON confirmed the pommel cushion was not care planned and her expectation was it would be in the care plan. 50223 R153 On 07/09/24 at 9:43 AM, R153 was observed lying in bed with their continuous positive airway pressure (cpap) machine turned on but lying next to them on the bed. R153 was observed without oxygen on. R153 was interviewed and asked if they wear the cpap and oxygen. R153 explained that they wear the cpap at night and oxygen via nasal cannula during the day. A wheelchair was observed in the room containing a portable oxygen tank. On 07/09/24 at 12:17 PM, R153 was observed lying in bed wearing oxygen at three liters per nasal cannula. On 07/10/24 at 8:35 AM, R153 was observed in bed eating breakfast wearing oxygen via nasal cannula. The oxygen concentrator was observed to be set to three liters with the oxygen tubing connecting the concentrator to the cpap machine which was located on a shelf next to R153's bed. The nasal cannula tubing that R153 was wearing was not connected to the concentrator or any other oxygen source. R153 was interviewed and asked how much oxygen they were supposed to be on. R153 said they were on two liters. R153 was asked if they wear oxygen all the time. R153 replied, Yes most of the time and the cpap at night. On 07/10/24 at 10:33 AM, R153 was observed sitting in their wheelchair in their room wearing oxygen via nasal cannula. The oxygen concentrator was observed to be set to three liters with the oxygen tubing connecting the concentrator to the cpap machine which was located on a shelf next to R153's bed. The nasal cannula tubing that R153 was wearing was still not connected to the concentrator or any other oxygen source. On 07/11/24 at 8:53 AM, R153 was observed in bed wearing the nasal cannula which was connected to the oxygen concentrator and set to three liters. A record review revealed that R153 was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia and Chronic Obstructive Pulmonary Disease. Further record review revealed a Brief Interview for Mental Status (BIMS) score of 9/15 indicating cognitive impairment. A record review of R153's orders revealed the following: Active order dated 11/15/23 Place Residents C-Pap on every night while in BED. If Resident refuses to wear machine, good documentation required. three times a day for Apenia (apnea). Oxygen at 2L (liters) when cpap in use Active order dated 6/2/24 Oxygen at 2L when cpap in use Active order dated 5/24/24 OK for resident to use CPAP from home with current home settings Q HS (every night) and naps prn (as needed). Further record review of R153's care plan revealed that neither oxygen use nor cpap use was included in R153's care plan. On 07/11/24 at 8:57 AM, during an interview, Registered Nurse (RN F) was asked if R153 is supposed to be on oxygen. RN F stated Yeah, (R153) wears a cpap at night and then they wear two liters per nasal cannula during the day as needed. RN F was asked if there was a physician order for the oxygen as needed during the day. RN F stated Yes (R153) has a prn (as needed) order. RN F look through R153's orders in the electronic medical record and stated, Hmm, I'm going to have to clarify because there's no order and I thought there was one. On 07/11/24 at 12:51 PM, during an interview, Unit Manager (UM H) confirmed that R153's current orders are for oxygen at two liters with the cpap at night. A review of the facility's policy titled Resident Care Plan revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs they are identified in the resident comprehensive assessment The comprehensive care plan will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. C. Any specialized services rehabilitation services the nursing faculty will exercise as a result of PASSARR recommendations. D. The residents' goals for admission, desired outcomes, and preferences for future discharge. E. Discharge plans, as appropriate. F. Resident specific interventions that reflect the residents needs and preferences and alight with the resident cultural identity, as indicated.

Based on observation, inteview and record review, the facilty failed to ensure medications were dated and labeled with a resident identifier when opened in four of seven medication carts and three of 14 medications carts were locked when unattended. Findings include: On [DATE] at 11:06 AM, the [NAME] hall medication cart was observed with Licensed Practical Nurse (LPN) C. A latanoprost eye dropper vial was not dated when opened. The nurse reported that eye drop was administered in the evening. At 11:22 AM, LPN C reported the facility pharmacy reported the latanoprost expired 28 days after opening. On [DATE] at 11:28 AM, the Drapers Lane medication cart was observed with LPN E. A dorzolamide eye dropper vial not dated was not dated when opened. The nurse noted it was received [DATE]. On [DATE] at 11:37 AM, the Indepedence Pointe North medication cart was reviewed with Registered Nurse (RN) G. A Trelegy inhaler was not dated on the inhaler and did not have a resident identifier on the inhaler. On [DATE] at 11:56 AM, the Dove Lane medication cart was observed with RN H. A Trelegy inhaler received [DATE] was not dated when opened on the box nor the inhaler. 50223 On [DATE] at 11:48 AM, the medication cart which was outside room [ROOM NUMBER] was observed to be unlocked and unattended. On [DATE] at 08:12 AM, the medication cart outside room [ROOM NUMBER] was observed unlocked and unattended. On [DATE] at 08:29 AM, during an interview, LPN A was asked how they make sure no one accesses the medications in the cart if they walk away. LPN A stated we lock it and LPN A demonstrated pushing the lock in. On [DATE] at 10:40 AM, during an interview the Director of Nursing (DON) was asked what their expectation for securing medication carts. The DON explained her expectation is the medication carts are kept locked when unattanded. A review of the facility policy titled, Medication Storage dated [DATE] revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored properly according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Medication Expiration dates and Requirements: 1. The date of expiration should be documented on the container/vial. 2. If the date of expiration is not documented or cannot be determined, the date dispensed may be considered the date of opening for stability purposes .10. Multi-dose vials should be labeled and used for single patient only . A review of the manufacturer's web page at: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Trelegy_Ellipta/pdf/TRELEGY-ELLIPTA-PI-PIL-IFU.PDF, revealed, .Write the Tray opened and Discard dates on the inhaler label. The Discard date is 6 weeks from the date you open the tray .

Based on observation, interview, and record review the facility failed to ensure that residents' personal information was not visible on two of 13 medication cart computers. Findings include: On 07/09/24 at 11:48 AM, the medication cart which was outside room [ROOM NUMBER] was observed to be unattended. The computer on the top of the medication cart had the screen unlocked with a resident's personal information visible. On 07/09/24 at 11:52 AM, an unidentified staff member was observed walking away from a medication cart and leaving the computer open and unlocked with a resident's personal information visible. On 07/09/24 at 2:06 PM, the medication cart outside room [ROOM NUMBER] was unattended and was observed with the computer screen unlocked and open to a resident's personal information. A piece of paper was also observed on the top of the medication cart containing a resident's personal information. On 07/10/24 at 8:12 AM, the medication cart outside room [ROOM NUMBER] was observed unattended with the computer open with a resident's personal information visible. On 07/11/24 at 8:29 AM, during an interview, Licensed Practical Nurse (LPN A) was asked how they ensure a resident's personal information on the computer screen is kept private. LPN A explained that Everyone has their own log in and we either log off or close the lap top if we walk away. On 07/11/24 at 8:33 AM, the medication cart outside room [ROOM NUMBER] was unattended and was observed with the computer screen open to a resident's personal information. An unidentified housekeeping staff member was observed to be in the hallway within view of the computer screen. On 07/11/24 at 8:39 AM, (LPN B) was observed returning to the medication cart outside room [ROOM NUMBER]. During an interview LPN B was asked if it was typical that a computer would be left unattended and open with a resident's information visible. LPN B responded, No. Not usually. LPN B stated I would normally click the lock button, so the information wasn't visible. On 07/11/24 at 9:05 AM, the medication cart outside room [ROOM NUMBER] was observed unattended with the computer screen open with a resident's personal information visible. On 07/11/24 at 10:40 AM, during an interview the Director of Nursing (DON) was asked about their expectation for securing medication carts and medication cart computer information. The DON explained her expectation is the computers are closed so resident information is not accessible to comply with HIPAA (Health Insurance Portability and Accountability Act). A review of the facility's policy titled Acceptable use of technology resources revealed the following: Users will log off the application(s)/system when leaving a workstation for an extended period of time. Except in areas where a workstation is shared, the user may use the lock down process to lock the workstation (with applications running) if leaving the workstation for a brief time.

Based on observation, interview, and record review the facility failed to obtain a physician order for oxygen administration for one resident (R153) of one resident reviewed for respiratory care. Findings include: On 07/09/24 at 9:43 AM, R153 was observed lying in bed with their continuous positive airway pressure (cpap) machine turned on and the mask lying next to them on the bed. R153 was observed without oxygen on. R153 was interviewed and asked if they wear the cpap and oxygen. R153 explained that they wear the cpap at night and oxygen via nasal cannula during the day. A wheelchair was observed in the room containing a portable oxygen tank. On 07/09/24 at 12:17 PM, R153 was observed lying in bed wearing oxygen at three liters per nasal cannula. On 07/10/24 at 8:35 AM, R153 was observed in bed eating breakfast wearing oxygen via nasal cannula. The oxygen concentrator was observed to be set to three liters with the oxygen tubing connecting the concentrator to the cpap machine which was located on a shelf next to R153's bed. The nasal cannula tubing that R153 was wearing was not connected to the concentrator or any other oxygen source. R153 was interviewed and asked how much oxygen they were supposed to be on. R153 said they were on two liters. R153 was asked if they wear oxygen all the time. R153 replied, Yes most of the time and the cpap at night. On 07/10/24 at 10:33 AM, R153 was observed sitting in their wheelchair in their room with the oxygen observed the same as noted above. On 07/11/24 at 8:53 AM, R153 was observed in bed wearing the nasal cannula which was connected to the oxygen concentrator and set to three liters. A record review revealed that R153 was admitted to the facility on [DATE] with the following diagnoses: Unspecified Dementia and Chronic Obstructive Pulmonary Disease. Further record review reveals a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment. A record review of R153's orders revealed the following: Active order dated 11/15/23 Place Residents C-Pap on every night while in BED. If Resident refuses to wear machine, good documentation required. three times a day for Apenia (apnea). Oxygen at 2L (liters) when cpap in use Active order dated 6/2/24 Oxygen at 2L when cpap in use Active order dated 5/24/24 OK for resident to use CPAP from home with current home settings Q HS (every night) and naps prn (as needed). No orders for oxygen per nasal cannula were found. On 07/11/24 at 08:57 AM, during an interview, Registered Nurse (RN F) was asked if R153 is supposed to be on oxygen. RN F stated yeah, (R153) wears a cpap at night and then they wear two liters per nasal cannula during the day as needed. RN F was asked if there was a physician order for the oxygen as needed during the day. RN F stated yes (R153) has a prn (as needed) order. RN F was observed to look through R153's orders in the electronic medical record and stated, Hmm, I'm going to have to clarify because there's no order and I thought there was one. On 07/11/24 at 10:43 AM, during an interview, the DON (Director of Nursing) confirms that if a resident is wearing oxygen via nasal cannula there should be a physician order for it. During the interview the DON was notified of the observations of R153's oxygen. The DON explained that they will have to look at R153's orders and get clarification. On 07/11/24 at 12:51 PM during an interview, Unit Manager (UM H) confirmed that R153's current orders are for oxygen at two liters with the cpap at night. UM H explained that there was a discontinued order for oxygen per nasal cannula at night if needed. UM H confirmed that there was no physician order for oxygen during the daytime. UM H was asked if there should be a physician order if a resident is wearing oxygen during the daytime. UM H stated, per policy if (R153) is wearing it during the day there should be an order. UM H said they will do some education regarding observations of resident wearing nasal cannula without being connected to an oxygen source. A facility policy titled OXYGEN: SIMPLE FACE MASKS, VENTI MASKS, AND NASAL CANNULA Simple Oxygen therapy is delivered via simple face mask, venti masks, or nasal cannula, based upon individual resident's need and a physician order.

Based on observation, interview, and record review, the facility failed to provide restorative services/functional maintanence to one (R139) resident out of one reviewed for range of motion/mobility. Findings include: On 07/11/24 at 8:37 AM, R139 was observed sitting up in bed. R139 was interviewed and confirmed they have not had restorative services since 05/24. R139 was asked if they feel they have had a decline in their functional status since they stopped receiving therapy services. R139 stated Yes I'm much stiffer. My hip has been stiffening up more and more and I don't want to lose the function of another joint. Use it or lose it. A record review revealed that R139 was admitted to the facility on [DATE] with the following diagnoses: urinary tract infection, weakness, need for assistance with personal care. Further record review revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. A record review of R139's orders revealed the following: Active order dated 6/4/24: Restroative Nursing as Indicated. Further record review of R139's careplan revealed the following: Resident requires restorative services r/t (related to) at risk for further physical decline and/or impaired physical mobility secondary to HTN (high blood pressure), CHF (congestive heart failure), Obesity, UTI (urinary tract infection), osteoarthritis, history of falls Date Initiated: 04/01/2024 Revision on: 04/01/2024 Resident's restorative program will include 1)Resident will perform AROM (active range of motion) BUE (bilateral upper extremities) exercises with 2lb (pound) straight weights above head raises, rowing forward and backwards x 40 reps. 4-7 days a week. Date Initiated: 04/01/2024 Revision on: 04/01/2024 Restorative coordinator or designee will complete a progress note and monthly summary to track resident's progress or lack of progress towards their goal and reevaluate for any changes as needed. Record review of R139's restorative report revealed the last service was on 5/30/24. On 07/11/24 at 9:35 AM, during an interview Restorative Coordinator (RC J) confirms that R139 was getting restorative care after physical therapy services ended. RC J explained that R139 should be getting restorative services but said they do not know what services R139 is getting currently and they would need to check and see. On 07/11/24 at 10:43 AM, during an interview, RC J said R139's maintenance plan was due to start June 18th 2024 and confirms that it has not started and states it is late. RC J was asked if the restorative interventions on R139's care plan were being implemented. RC J stated the care plan is not current so I will go in and update it now. RC J was asked if restorative is supposed to put in progress notes. RC J responded yes and confirms that there are no progress notes entered and stated I will go in and add one. A review of the facility's policy titled Restorative Nursing Services revealed the following: Residents will receive, and the facility will provide, the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and Plan of Care .When a resident is discharged ROM (range of motion) restorative to nursing services, the restorative nurse will develop a discharge plan in PCC under tasks for the resident and present it to the nursing staff. It will include resident's current level of function and a plan of daily care that will be implemented by the nursing staff using restorative techniques that have been developed for the particular resident. Restorative nurse will conduct random Q.A. audits to assure that the nursing staff is following restorative's discharge plan of care. When residents are turned over to the neighborhood for floor maintenance programs for restorative, the restorative nurse will make the necessary care plan and task changes in PCC.

Based on observation, interview, and record review, the facility failed to ensure food items were labeled and dated, in the Grand Central kitchen, [NAME] kitchen, Hummingbird kitchen, Dove Lane kitchen, and Bridgeport North kitchen. This deficient practice had the potential to affect all residents that consume food orally. Findings include: On 5/1/23, during an initial tour of the main kitchen and satellite kitchens with Dietary Manager (DM) D, between 9:20 AM-10:45 AM, the following items were observed: Grand Central kitchen: In the Arctic Air refrigerator, there was a resident's container of pasta and chicken that was undated. In addition, in the True refrigerator, there was an opened, undated container of cottage cheese, an opened, undated container of chicken salad, and an opened, undated container of whipped spread. DM D confirmed the items should have been dated when opened. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. [NAME] kitchen: The thermometer located inside the True refrigerator was broken apart and non-functional. DM D stated he would replace the thermometer. Hummingbird kitchen: In the True refrigerator, there was an undated container of bean dip. DM D confirmed the dip should have been dated. Dove Lane kitchen: In the True refrigerator, there was an undated container of meat and pasta. Bridgeport North kitchen: In the True refrigerator, there was an undated container of chili. Review of the facility's policy Resident/Guest Personal Food revised 1/5/23 noted: When food is brought into the facility the following will take place: .c. The food will be labeled/dated for a maximum of three days and stored in the designated area.

Based on observation, interview, and record review the facility failed to ensure that sufficient staff were available to distribute meals in a timely manner for two residents (R64, R254) and five confidential group residents, resulting in the residents being served cold food and having feelings of dissatisfaction during meals. Findings include: On 5/1/23 at 11:10 AM, during an initial tour of the facility, R254 was interviewed regarding the care and services at the facility. R254 stated, The food is cold and bland. R254 expressed dissatisfaction with the food being served to them at the facility primarily due to it being cold when served to them on Most occasions. On 5/1/23 at 11:45 AM, R64 was interviewed about the care and services at the facility and stated, I wish the food was warmer. On 5/1/23 at 11:46 AM, an observation was made of four uncovered food trays being brought to the rehabilitation unit of the facility on an open cart by a Resident Service Assistant (RSA) and placed in the hall by R64's room. On 5/1/23 at 11:56 AM, the trays remained on the cart by R64's room. On 5/1/23 at 11:56 AM, Dietary Manager (DM) arrived on the unit and temperature check the food. The results were the following: Roast beef: 80 degrees Farenheight; Cooked carrots: 90 degrees Farenheight. The DM taste tested the food and stated, Obviously the food is cold. The DM indicated that he was going to go to the kitchen and prepare four new meal trays for the residents on the unit. The DM was interviewed and asked about the process for passing meal trays to residents and stated, If they eat in their rooms, trays should be passed out right away by the Certified Nursing Assistants (CNAs). On 5/2/23 at 10:30 AM, a confidential group meeting was held with eight confidential group residents. The group was asked about the palatability and temperature of the food at the facility and five group members indicated that the food was frequently Cold when served to them which caused dissatisfaction during meals. One confidential group resident stated, Who wants to eat cold French fries or a cold baked potato, the butter doesn't melt on it. Another confidential group resident stated, It makes you not want to eat the food. All five group members with food concerns indicated that there were not enough staff available to serve meals in a timely manner. On 5/2/23 at 1:00 PM, R254's electronic medical record (EMR) was reviewed and revealed that R254 was admitted to the facility on [DATE] with diagnoses that included, Strain of left quadriceps muscle fascia and tendon (injury to muscles in the front of the leg) and Fibromyalgia (chronic disorder characterized by widespread pain and fatigue). R254's most recent MDS dated [DATE] revealed that R254 had an intact cognition. On 5/2/23 at 1:10 PM, R64's EMR was reviewed and revealed that R64 was admitted to the facility on [DATE] with diagnoses that included Chronic obstructive pulmonary disease (COPD) (constriction of the airways) and Type 2 diabetes (condition which affects the way the body processes blood sugar). R64's most recent MDS revealed that R64 had an intact cognition. On 5/3/23 at 11:08 AM, CNA A was interviewed about staffing during mealtimes and stated, Sometimes we are busy providing care and the RSAs bring the food cart to the unit and don't let us know. CNA A further indicated that food carts sit while CNAs provide care. On 5/3/23 at 11:12 AM, CNA B was interviewed about staffing during mealtimes and stated, They should have small kitchens open on every unit to allow meals to be served quicker. On 5/3/23 at 11:17 AM, CNA C was interviewed about staffing during mealtimes and stated, My personal opinion is that the residents do not deserve to be served cold food. On 5/3/23 at 12:09 PM, the Director of Nursing (DON) was interviewed regarding their expectations for meal service by staff to the residents. The DON stated, Ideally, they should be served right away by the CNAs assuming the resident is set up for their meal. Trays should be given out to residents in less than five to ten minutes. On 5/3/23 at 12:30 PM, a facility policy titled Food Temperatures Issue Date: 02/16/2016 was reviewed and stated the following, Procedure: 6. Foods sent to the unit for distribution will be .delivered to maintain temperatures at or .above 135 [degrees Fahrenheit] for hot foods.

Based up interview and record review, the facility failed to document a 14-day stop date and to either discharge or document rationale for an order extension of an as needed (PRN) psychotropic medication upon conclusion of the initial 14 day period for five (R12, R26, R57, R84, R99) of eight residents reviewed for psychotropic medication use, resulting in the potential for unneccessary medication use and adverse side-effects. Findings include: R57 Review of the facility record for R57 revealed an admitted [DATE] with diagnoses that included Diabetes Mellitus, Osteoarthritis, Peripheral Vascular Disease and Depression. The Minimum Data Set (MDS) assessment dated [DATE] indicated R57 required primarily Maximum/Total Assistance for self care and mobility tasks. The Brief Interview for Mental Status (BIMS) assessment score of 9/15 indicated Moderate cognitive impairment. Review of R57's active status physician orders revealed an order for Lorazepam 0.5 MG dated 03/17/23 with the description Give one tablet by mouth every four hours as needed (PRN) for Anxiety/restlessness. The End Date column of the order was not populated. Review of the pharmacy Controlled Substance Prescription related to this order and also dated 3/17/23 indicated no stop date. Further review of R57's EMR revealed no documentation of rationale for or extension of the Lorazepam order. Review of the facility policy titled Use of Psychotropic Medication dated 10/26/18 revealed under the heading Responsible Party - Actions Required: the entry 7. Orders for PRN psychotropic medications will be time limited to 14 days, but can be extended beyond 14 days with the prescribing practitioner's documented rationale and duration. On 05/03/23 at 12:25 PM, the facility's Director of Nursing (DON) reported that the expectation for a PRN anti-anxiety medication order is that the 14 day stop date be specified in the electronic medical record (EMR) and that an order that has exceeded the 14 days and has not been extended by the physician would be discharged and removed from active status in the EMR. The DON reported that although the expanded version of the EMR order indicates the 14 day limit on the order, this does not auto-populate the end date column for the order and the end date should be manually entered to support compliance. 40384 R12 On 5/1/23 at 10:39 AM, R12 was observed in bed sleeping. R12 was observed in bed for the duration of the survey with one exception where they were observed sitting in their geri-chair eating snacks. A review of R12's medical record revealed that they were admitted into the facility with diagnoses that included Anxiety, Hypertension, and Diabetes. Further review of R12's medical record revealed that they were cognitively intact and required extensive to total assistance for Activities of Daily Living (ADL's). A review of R12's medical record revealed the following order dated for 2/10/23: Xanax Oral Tablet 0.25 MG (Alprazolam). Give 1 tablet by mouth every 24 hours as needed for Anxiety. The order did not reveal a 14-day stop date. A review of R12's February and March 2023 Medication Administration Records revealed that the resident received PRN (as needed) anti-anxiety medication 10 times. A review of R12's April 2023 Medication Administration Record revealed that the resident received the PRN anti-anxiety medication 15 times. In addition, the medical record did not reveal non-pharmacological interventions prior to the administration of the medication. R26 On 5/1/23 at 10:44 AM and 12:08 PM, R26 was observed in bed asleep. A review of R26's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dementia and Anxiety. Further review of the medical record revealed that the resident had a moderate cognitive impairment, and required extensive assistance with Activities of Daily Living. Further review of R26's medical record revealed the following order dated for 2/14/23: Xanax Oral Tablet 0.25 MG (Alprazolam). Give 1 mg by mouth every 6 hours as needed for anxiety. The order did not reveal a 14-day stop date. Further review of R26's physician orders also revealed that the resident had a scheduled anti-anxiety medication order dated for 3/28/23: Alprazolam Tablet 0.25 MG. Give 1 tablet by mouth three times a day for anxiety/restlessness. A review of R26's March 2023 Medication Administration Record revealed that the resident received the PRN medication seven times. A review of R26's April 2023 Medication Administration Record revealed that the resident received the PRN medication three times. In addition, the medical record did not reveal non-pharmacological interventions prior to the administration of the medication. 39918 R84 On 5/1/23 at 11:13 AM, R84 was observed lying in bed. R84 indicated that they were, Fine. R84 was unable to appropriately answer further interview questions. A bed alarm was noted on the resident's bed, and a chair alarm was noted to be on R84's wheelchair. On 5/2/23 at 11:36 AM, Licensed Practical Nurse (LPN) F was interviewed regarding R84. LPN F indicated that R84 has difficult behaviors at times that have no identifiable trigger. LPN F explained that there is usually no indication that R84 is going to act out and if it happens, it happens, Out of nowhere .and like a light switch. LPN F stated that today, during a group exercise activity, R84 was participating normally but then began yelling out of nowhere. LPN F stated that the group leader (another resident) calmly thanked R84 for participating and ended the exercise group. LPN F added that R84 then said that they wanted to go lay down in their bed. LPN F stated, That was probably the best thing for [R84], it gave [the resident] a minute to have some calm and quiet. A review of R84's record revealed that the resident was admitted into the facility on [DATE] and most recently readmitted on [DATE] with medical diagnoses of Esophageal Obstruction, History of Falling, and Kidney Disease. Further review revealed that the resident is severely cognitively impaired and requires limited assistance from staff for activities of daily living (ADLs). A review of R84's physician orders revealed the following: -Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 8 hours as needed (PRN) for anxiety .Active 04/07/2023. The directions in the Ativan (benzodiazepine) medication order indicated the medication was to be discontinued after 14 days, however, the order remained active. No explanation for the continuation of the medication order was found in the record. R84 received the medication 15 times since 4/7/23 to the end of April, per the Medication Administration Record (MAR). Further review of R84's physician orders indicated that a consult to psychiatric services was ordered on 4/6/23. The facility was asked to provide psych services notes for R84 and a signed consent/documented consent for the administration of Ativan to R84. On 5/2/23 at 4:21 PM, the Nursing Home Administrator (NHA) indicated that the resident had not yet been seen by psych due to a lack of signed consent for psych services. The NHA also indicated that a signed consent for the Ativan was not required per the facility's policy, therefore, one was not provided. A review of R84's May MAR on 5/3/23 revealed that the resident was administered Ativan PRN on 5/3/23 at 9:35 AM. Record review did not reveal documentation of the reason for the Ativan administration, nor documentation of non-pharmacological interventions attempted prior to administration. R99 On 5/1/23 at 10:27 AM, R99 was observed lying in bed. The resident indicated they were comfortable and had no current concerns. The resident was unable to appropriately respond to further interview questions. A brief review of the resident's record revealed that the resident recently started receiving hospice services. Continued review of the resident's record revealed that the R99 was admitted into the facility on [DATE] with medical diagnoses of Heart Disease, Chronic Kidney Disease, Respiratory Failure, Anxiety Disorder, and Cognitive Communication Deficit. Further review revealed that the resident is severely cognitively impaired and requires limited to extensive assistance from staff for ADLs. A review of R99's physician orders revealed the following: -Xanax Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 6 hours as needed (PRN) for anxiety .Active 03/22/2023. The directions in the Xanax (benzodiazepine) medication order indicated the medication was to be discontinued after 14 days, however, the order remained active. No explanation for the continuation of the medication order was found in the record. R99 received the medication 16 times in April 2023 per the Medication Administration Record (MAR). On 5/3/23 at 10:55 AM, Social Worker (SW) G was interviewed and queried regarding medications such as Ativan or Xanax requiring consent for administration. SW G indicated she believes consents are to be obtained for all psychotropic medications. SW G was then queried regarding her role in ensuring residents are seen by psych services. SW G indicated that she recalled being told about a consult for R84 but would have to check on what has caused the delay. On 5/3/2023 at 10:40 AM, the Assistant Director of Nursing (ADON) was queried regarding observed PRN anxiolytic orders without stop dates. The ADON responded that it is an ongoing challenge and part of the education with nurses. The ADON added that between herself and the pharmacy, they try to catch them. The ADON stated that the physicians are aware of the 14 day stop-date requirement and have been educated. On 5/3/23 at 12:00 PM, the Director of Nursing (DON) was interviewed and queried regarding the process for obtaining consent for the administration of anxiolytic medications such as Ativan or Xanax. The DON indicated that the facility only requires a signed consent for antipsychotic medications. The DON did confirm that PRN anti-anxiety medications, such as those for R84 and R99, should have a stop date on the order. The DON was then asked to review the record in relation to the PRN Ativan administration to R84 at 9:35 AM. The DON indicated that non-pharmacological interventions should be documented prior to administration and typically they can be found on the MAR. A review of R84's progress notes, MAR, and Treatment Administration Record (TAR) with the DON found no documented non-pharmacological interventions for R84 prior to the PRN Ativan administration. A review of the facility's policy/procedure titled, Behavioral Health Services, Management and Monitoring, revised October 2022, revealed, .Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. The effectiveness of each non-pharmacological intervention, on identified problematic behaviors, will be documented in the EMR. Interventions that are assessed as ineffective will be revised or discontinued and, if feasible, new non-pharmacological approaches/interventions will be attempted .If non-pharmacological approached are ineffective, the resident's primary physician may be contacted to assess and address the problematic behaviors, which may include nursing staff obtaining a doctor's order for 'Psych consult and treat'. The social worker will obtain a signed consent from resident or responsible party in order for the consult to occur with the appropriate psychiatric services .

Based on interview and record review, the facility failed to appropriately complete a Do-Not-Resuscitate (DNR) order for one sampled resident (R147) of nine reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's advance directive being improperly implemented. Findings include: A review of R147's medical record revealed a Do-Not-Resuscitate (DNR) order signed by R147's declarant/son on 3/16/23. Further review of the form revealed that the form was missing the signature of the resident's physician, in addition to the attestation of two witnesses. Further review of the form revealed the following statement, This form was prepared pursuant to, and is in compliance with, the Michigan do-not-resuscitate procedure act. Further review of R147's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Acute Kidney Failure, Diabetes and Parkinson's Disease. A review of R147's Minimum Data Set (MDS) assessment dated for 3/26/23 revealed that the resident had a moderate cognitive impairment. On 5/3/23 at 10:47 AM, Social Worker G was asked about the process for the implementation of an advance directive. Social Worker G explained that the resident or their representative sign the DNR form, and it would then be uploaded into the resident's file. Social Worker G was asked if anyone else was supposed to sign the form, and explained that two witnesses are supposed to sign the form, but was unsure if the physician was supposed to sign, as she was new to the position and was unsure. On 5/3/23 at 12:16 PM, the Director of Nursing (DON) was asked about R147's DNR order not being signed by their physician or two witnesses. The DON explained that she would expect that the advance directive be signed, but would look further into it. On 5/3/23 at 1:09 PM, the DON provided an Order Audit Report indicating that R147's physician provided a verbal order for R147's DNR order on 3/22/23. The DON also admitted that the form was missing the attestation of two witnesses. A review of the facility's Advanced Directives policy was reviewed, and did not address the process for which a DNR order would be considered in effect based on documentation of a physician and two witnesses.

Based on observation, interview, and record review, the facility failed to provide restorative (range of motion) services per order for one resident (R181) of three reviewed for limited mobility, resulting in the potential for functional decline. Findings include: On 5/1/23 at 11:38 AM, R181 was observed sitting upright in their wheelchair in a small dining room. R181 was dressed and appeared thin, but was smiling and able to feed themselves. R181 was observed with a mechanical soft diet and thickened liquids. R181 was noted to also be receiving enteral nutrition (liquid nutrition through a feeding tube in the abdomen). R181 was unable to appropriately answer interview questions. On 5/1/23 at 12:47 PM, Confidential Witness H was interviewed regarding R181's care at the facility. Witness H indicated that after R181 had finished therapy, the resident was supposed to be receiving restorative services. Witness H questioned how often restorative care was being offered/provided to the resident. A review of R181's record revealed that the resident was admitted into the facility on [DATE] and is moderately cognitively impaired with medical diagoses of Abscess of Lung with Pneumonia, Chronic Kidney Disease, Dysphagia, Cognitive Communication Deficit, Pressure Ulcers, Urine Retention, Glaucoma, and History of Falling. A review of Section GG of the resident's Minimum Data Set (MDS) assessment assessment review date (target) date 4/5/23 indicated that R181's discharge performance was mostly supervision to moderate assistance for Self-Care and Mobility. A review of R181's physician orders indicated that the resident had been re-enrolled into therapy services as of 4/23/23 (Occupational Therapy (OT)) and 4/25/23 (Physical Therapy (PT)). Restorative orders/documentation for R181 were requested from the facility. Upon review, the documents indicated that on 4/5/23, therapy ordered the initiation of a daily restorative range of motion and ambulation program for R181. Upon further review, the documentation in R181's record did not reflect that the resident received restorative services consistently per order from 4/6/23 to 4/20/23 (dates missing documentation: 4/7, 4/9, 4/10, 4/13, 4/15, 4/16, 4/18, and 4/19). R181 was recommended to be evaluated and treated by PT and OT again on 4/20/23. On 5/2/23 at 3:11 PM, Certified Nursing Assistant (CNA) J was asked about restorative services, and who is responsible for providing it to residents. CNA J stated that while the facility has a few restorative aides, CNAs working on the floor are typically responsible for providing restorative. Licensed Practical Nurse (LPN) F and CNA J were interviewed regarding R181 at this time. Both staff indicated that R181 was having an, Off day, today and seemed, Stiff. Both staff also indicated that R181 had been doing well while on the rehab unit in the facility, but that the resident seemed to experience a decline after moving to their current unit (where CNA J and LPN F typically work). The staff also explained that the resident had recently been placed back onto therapy's caseload, however, the resident's transfer status had just been downgraded. On 5/2/23 at 3:18 PM, Registered Nurse (RN) I, who oversees the restorative program, was interviewed. RN I was queried regarding the restorative documentation provided for R181. RN I acknowledged the lack of daily documentation to support that R181 received restorative per order. RN I added that she had just given an inservice to staff regarding restorative services and expected charting. RN I also explained that she had observed R181 as unable to complete the ambulatory portion of the ordered restorative program, which prompted her to refer the resident again to therapy. On 5/3/23 at 12:15 PM, the Director of Nursing (DON) was interviewed. The DON was queried regarding the expectation for documentation of the provision of restorative services. The DON indicated that if restorative is ordered daily, that she would expect daily documentation. The DON also indicated that assigned unit CNAs are ultimately responsible for the ordered restorative intervention on the task list. A review of the facility's policy/procedure titled, Restorative Nursing Services, revised 6/14/17, revealed, .All residents on the restorative program are assigned treatment components. The restorative treatment program is documented be the assigned CNA in PCC under tasks .Floor CNA - Responsible for ACTIVE programs only. Daily documentation in PCC .

Based on observation, interview, and record review, the facility failed to provide adequate supervision for an active exit seeking resident (R400), resulting in the potential for elopement and decrease in safety. Findings include: On 5/1/2023 at 11:39 AM, R400 was observed on the locked unit of the facility in the common dining area. No staff were observed in the dining room. R400 was noted to be carrying a chair from one room to another. On 5/1/2023 at 12:15 PM, R400 was observed walking around asking other residents to help find their spouse. R400 was noted to be going to the exit door and placing their hand on the bar. A sign was noted stating that if the bar is held for 15 seconds, then the door would be released. A family member of another resident was observed attempting to distract R400 away from the exit door. A review of the medical record revealed that R400 admitted into the facility on [DATE] with the following diagnoses, Alzheimer's Disease and Anxiety. A review of the Nursing Admission Assessment revealed that R400 admitted with wandering behaviors and was independent with supervision with walking and transferring. Further review of an Elopement Risk and assessment dated [DATE] that noted R400 was a high risk for elopement. Further review of the progress notes revealed the following; 4/29/2023 at 6:35 PM .Resident observed wandering throughout the unit. Going in other rooms searching for [their] [spouse]. Resident able to redirect for short periods 4/30/2023 at 6:37 PM .Resident observed wandering unit looking for [spouse], kids, and mother. Able to redirect for short periods. Resident reapproaches staff with concerns of missing family members. Resident redirected from pushing other wheelchairs. Resident noted very tearful and anxious A review of the physician orders did not reveal that R400 had a wander guard (braclet that monitors wandering residents that alarms specific doors if resident attempts to leave) placed. On 5/3/2023 at 10:47 AM, an interview was conducted with Social Work (SW) G regarding R400 and their behaviors. R400 stated that if a resident has dementia and wanders then they would usually attach a wander guard to ensure they are safe and do not elope. SW G stated that R400 is a newer resident, and they were not sure if they had a wander guard placed or not. A review of the facility policy titled, Elopement noted the following, 1. Interventions-Once a resident has been assessed as being at risk of elopement, appropriate interventions will be implemented.

Based on observation, interview, and record review, the facility failed to coordinate and ensure dental services were received for one resident (R196) of one resident reviewed for the provision of dental service, resulting in untreated and unmet dental needs, and resident complaints of pain. Findings include: On 5/1/2023 at 12:15PM, R196 was observed in the dining room drinking coffee. R196 was asked what they would like to eat for lunch. R196 stated that they did not want to eat because their dentures did not work. R196 proceeded to take out their lower dentures and show them to staff. On 5/1/2023 at 12:21 PM, R196 was brought a lunch tray. R196 refused it and stated that they could only eat soft foods because their dentures did not work. The certified nursing assistant (CNA) proceeded to take the tray away and stated that they would try again later. On 5/2/2023 at 12:00 PM, R196 was asked what they wanted for lunch. R196 stated that they were not eating lunch because their dentures did not work and that they would only be drinking coffee. A review of the medical record revealed that R196 admitted into the facility on [DATE] with the following diagnoses, Dysphagia and Adjustment Disorder with Anxiety. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0/15 indicating severely impaired cognition. R196 also required extensive two person assist with bed mobility and transfers. A review of a progress note dated 4/1/2023 at 7:36 PM, revealed the following, Several times on shift resident c/o (complained of) ill fitting denture, and denture causing discomfort. Resident told we could speak to family about setting up appointment. On 5/3/2023 at 10:49 AM, an interview was conducted with Social Work (SW) G. SW G stated that for someone to be seen by dental they have to sign up for health drive, then they are seen once a month. SW G stated that if someone needs to be seen by the dentist then either the nurse, physician, or a family member will inform them. On 5/3/2023 at 12:00 PM, an interview was conducted with the Director of Nursing. The DON stated that if a concern is brought up to one of the floor nurses, then they can bring it up to the family. The DON stated that R196's family would have to sign a consent form stating if they want the facilities dental services, or an outside dentist. On 5/3/2023 at 12:33 PM, an interview was conducted with Family Member (FM) K. FM K was asked if they were ever asked about getting a dental appointment for R196. FM K stated that they never were told about dental services in the facility. FM K stated that R196 did bring up their dentures causing discomfort and was going to bring it up to the facility. FM K stated that they were unaware that R196 was refusing meals because of this. A review of a facility policy titled, Dental Services revealed the following, A resident shall be assisted in obtaining routine and 24-hour emergency dental care. Dental services will be made available for all residents as prescribed by the attending physician in Mobile Care Group.

This citation pertains to Intake: MI00129843. Based on observation, interview and record review, the facility failed to prevent a fall with injury for one sampled resident (R901) of three residents reviewed for falls resulting in the resident experiencing pain and hospitalization . Findings include: A review of Intake MI00129843 revealed the following, Incident Summary: The resident was being assisted by staff to get weighed in [their] bathroom. [R901] was stepping down from the floor scale when [they] lost [their] balance and fell backwards. [R901] landed on bottom. The aide was present with the resident but was unable to intercept the fall. The resident voiced complaints of pain and was transferred to the emergency room to be evaluated. [R901] was found to have a mild acute fracture of the L1 vertebral body of 15% On 3/27/23 at 10:15 AM, R901 was observed lying in bed and asked about the fall they sustained in July 2022. R901 explained that while in the bathroom with facility staff, they slipped causing them to fall backwards onto the floor causing pain. R901 explained that the facility staff were present, attempted to catch them but was unable to do so. A review of R901's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dementia, Acute Kidney Disease, and Depression. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required limited assistance for transfers, walking, and locomotion in their room. Further review of R901's medical record revealed the following progress notes: 7/16/2022 12:21 (12:21pm) Incident Note Note Text: Patient had a fall at 1140a this shift. Patient was getting [their] daily weight and ended up on [their] bottom. [R901] bumped [their] head, no loss of Loc (loss of consciousness), alert, denies headache only sore lower back. Neuro checks started, super (supervisor) notified, pt (patient) did not want family notified and left msg (message) for dr (doctor) abt (about) fall @ (at) 1220p. patient does take a blood thinner, no open areas. Neuro checks have all been WNL (within normal limits) yet. Will await any further orders & continue neuro checks. 7/16/2022 14:20 (2:20pm) Incident Note Note Text: Patient had increasing pain, cld (called) & left msg (message) for [physician] who is on call for [resident's physician]. advised super and patient sent out via stretcher w/EMS to [local hospital] at 1420 (2:20pm). Cld and spk (spoke) w/ [hospital staff] in ER(emergency room ) & provided report of lower back pain w/radiating pain to bil (bilateral) hips and new complaints of frontal face pain. 7/16/2022 18:49 (6:49pm) Health Status Note Note Text: Resident admitted to [local hospital] with L1 vertebral fracture. Further review of R901's medical record revealed an orthopedic consultation dated for 7/18/22 revealing the following, .The patient sustained a fall at [nursing facility] injuring [their] lumbar spine. Reviewing of imaging shows evidence of an acute L1 compression fracture deformity. After reviewing of imaging, physical examination the patient, and further discussion with the patient, will currently plan to continue with conservative treatment at this time. At this time we'll plan for bracing . On 3/27/23 at 1:49 PM, the Assistant Director of Nursing (ADON) who is responsible to reviewing falls along with the Director of Nursing (DON) were asked about R901's fall and explained that R901 had been assisted to the bathroom to get their weight on the floor scale, and when R901 stepped back, they fell on to their bottom. The ADON explained that she investigated the root cause of the fall, and discovered that the facility staff did not have a gait belt at the time of transfer although it was available. The ADON explained that the staff member was educated on the use of a gait belt. On 3/27/23 at 3:09 PM, LPN A (licensed practical nurse) was interviewed via phone regarding R901's fall. LPN A explained that at the time of the fall, she was employed as a certified nurse assistant (CNA), and had assisted R901 to the bathroom. LPN A explained that she was aware that she needed to obtain R901's weight for the day and had R901 step onto the scale. LPN A explained that as R901 was stepping off of the scale, they lost their footing and fell backwards landing on their bottom bumping their head. LPN A was asked if they had received any education following R901's fall, and she explained that she had received education regarding the use of gait belts, as she had failed to put the gait belt on the resident. A review of the facility's Lifting, Transferring & Repositioning Residents policy revealed the following, Resident Lift/Transfer. Every precaution is used to safeguard the resident when making a mechanical or manual lift, transfer, or move. Plan any lift, transfer, or move ahead of time. Have proper equipment or personnel on hand .Arrange environment as necessary. Make sure there is appropriate space to maneuver and work in to ensure a safe lift, transfer, or move . A review of the facility's Gait belts policy revealed the following, .1. All employees that are trained to assist with resident transfers will have access to a gait belt to use for patient care.3. The belt will be fastened around the resident's waist allowing qualified, trained staff to assist the resident from the side and/or back as indicated, this will afford a firm grip and will reduce risk of accidents. 4. Trained personnel will use a gait belt on all residents who have been assessed to required it per the Resident Transfer Assessment, in the EMR (electronic medical record). This transfer status will also be identified on the resident identification armband . Facility Corrective Actions: 1. [R901] was returned from the hospital and was re-evaluated for ]their] transfer status. [Their] care plan was updated to reflect the current transfer method, which is a transfer with assist of one person with the use of a gait belt. 2. An audit was conducted to identify all residents that require the use of a gait bet for transfers, The rooms were audited to assure that a gait belt was available to sue for transfers, 3. Facility policies titled Gait Belts, Falls Assessment, Intervention and Prevention and Lifting, Transferring and Repositioning Residents were reviewed. Policies remain appropriate. 4. Education was conducted with all nurse aides regarding policies, how to identify residents that require the use of gait belt for transfers, and the proper use of a gait belt. Education conducted from 7/26-8/3/22. 5. Observations and audits of transfers for residents requiring the use of a gait belt will be completed weekly x 3, then monthly x1 to assure complaint. These audits will be the responsibility of the Director of Nursing or designee. Compliance date: 8/3/22.

Based on observation, interview, and record review, the facility failed to ensure food items were dated when opened and discarded when expired, resulting in the increased potential for foodborne illnesses. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On [DATE] at 9:15 AM during an initial tour of the kitchen with Dietary Staff G and Environmental Services Supervisor B, the following items were observed: In the [NAME] reach-in cooler, there was an opened undated bottle of [NAME] sauce, and 2 opened, undated bottles of barbecue sauce. In addition, the light bulb inside the refrigerator was not functioning. Dietary Staff G confirmed that the food items should have been dated when opened. In the Hummingbird kitchenette, there was an unlabeled, undated container of meat and rice in the True reach in cooler. Environmental Services Supervisor B confirmed the food container should have been dated. In the Dockside kitchenette, there was a container of Spam dated ,d+[DATE]-,d+[DATE] in the True reach-in. Environmental Services Supervisor B confirmed the Spam should have been discarded. According to the 2013 FDA Food Code section ,d+[DATE].17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. In the Serenity Circle kitchenette, in the True reach-in cooler, there was an undated bowl of oatmeal and sausages, and an opened, undated 3 pound container of whipped spread. In the cupboard, there was an unlabeled, undated plastic container of brown sugar, that had been removed from the original packaging. According to the 2013 FDA Food Code section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. In the [MEDICATION(S)] Cottage kitchenette, there was an undated container of dessert, and an opened, undated container of whipped spread. In addition, the interior of the microwave was soiled with dried on food debris. According to the 2013 FDA Food Code section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview and record review the facility failed to ensure showers were provided as care planned and per resident preference for one sampled Resident (R147) of five residents whose showers were reviewed, resulting in resident dissatisfaction and unmet care needs. Findings include: On 03/27/22 at 9:53 AM, R147 was observed to be seated in a wheelchair bedside their bed. R147 was dressed in a hospital style gown. The skin at the base of their neck and across the upper chest appeared dry and scaly. R147 was asked how well their needs were met by the facility. R147 commented they only received one shower a week. R147 reported that this makes them feel grubby. R147 noted staff had a good attitude but indicated the shower felt hurried and that they were likely short staffed. R147 reported they would like to shower more often. The roommate of R147 indicated they also received one shower a week. R147 also commented that at times staff were not fast enough to get them into the restroom before they were incontinent. R147 reported they also had at times been left to dangle on the commode too long. R147 commented they would just like staff to take care of things and not have to wait for them to come back. On 03/28/22 at 12:35 PM, R147 was observed seated in their wheelchair bedside, dressed in a hospital style gown. On 03/29/22 at 3:04 PM, the Director of Nursing (DON) was interviewed and asked about the frequency at which showers are provided and reported showers were provided at least once a week and may be done more often if desired. Documentation for R147's showers was requested and reviewed with the DON and Assistant Director of Nursing (ADON). A schedule/staff assignment of showers, calendar, task reports and progress notes were reviewed. Progress notes indicated R147 had help at home for showering once a week. The progress notes did not document R147's request for more than one shower a week. The calendar indicated a shower was not documented as provided the second week of March 2022 and one shower was documented the first and fourth week of March. The Task Report for bathing recorded bathing assistance was provided in February and March 2022 on Saturday 02/19, Monday 02/21, Thursday 02/24, Thursday 03/03, Sunday 03/13, Thursday 03/17 and Thursday 03/24. Activity did not occur was documented for the balance of the days since admission on 02/17/22. A further review of the facility record for R147 revealed R147's bathing task was to be completed on Tuesdays and Fridays on the day shift. A review of the Task: (Activities of Daily Living) ADL bathing includes washing up in am (morning) and hs (evening) documented the same days as those provided in the Task Report. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing care plan initiated 02/18/22 documented, Resident has an ADL self care deficit .Bathing/showering .provide sponge bath when full bath or shower can not be tolerated .resident require (extensive assist) EA (of) 1 staff with bathing and showering . The (nurse aide care guide) Kardex revealed, ADL - Bathing includes washing up am and hs as well as shower or bath. Tues(day) / Fri(day) days. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with 15/15 Brief Interview for Mental Status score and the need for extensive assist of one or two persons for bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. A review of the facility policy titled, Bathing Schedule with revised date of 11/25/15 documented, All residents of (facility) will be given regular baths or showers to ensure cleanliness and an over all feeling of well being .Frequency of bathing schedule may be increased by request and or physician order. A review of the facility policy titled, Resident Care Plan 1 with revised date of 03/14/18 documented, Procedure: Each discipline is responsible for implementation and maintenance of the care plan as they pertain to their department .3. An individualized resident care plan will be developed for each resident after admission. This plan will indicate how the IDT team (interdisciplinary team) will attain/maintain a resident's highest well being .4. Input from the resident, family and staff on all shifts should be integrated into the plan of care .

Based on observation, interview, and record review, the facility failed to assist two Residents (R73 & R83) during mealtime out of two reviewed for activities of daily living (ADL), resulting in the potential for weight loss and frustration. Findings include: Resident #73 (R73) On 03/28/2022 at 9:14 AM, R73 was observed in the dining room with a bowl of oatmeal in front of them. The oatmeal and toast were observed on R73 pants and table in front of them. R73 was observed attempting to eat oatmeal with a fork and appeared visibly frustrated. R73 was approached by an activity's employee who asked R73 if they needed help eating their food and R73 replied, Yes. The activity's employee then proceeded to find someone to assist R73 with their breakfast. On 03/28/2022 at approximately 9:24 AM Certified Nursing Assistant (CNA) C came and helped R73 eat their breakfast. CNA C was queried as to whether R73 usually needed help eating to which they replied, This is the first time [R73] has needed help eating, usually they can eat on their own. On 03/28/2022 at 9:40 AM, R73 was queried if they always have a hard time feeding themselves. R73 stated, Sometimes I have a hard time seeing the food, its better when there is a red plate then I can feed myself. No red plate was observed in front of R73 during breakfast. A review of the medical record revealed that R73 was admitted into the facility on [DATE] with the following diagnoses, Dysphagia, [CONDITION(S)], and Hypertension. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15, indicating a moderately impaired cognition. R73 also required extensive to limited one person assistance with bed mobility and transfers. The MDS also noted R73 as independent with set up help only for eating. A review of the progress notes revealed the following, Date: 03/07/2022-Nutrition/Dietary: New Adaptive Wear order per SLP for Red Plate at meals as resident has vision deficits and finds it easier to locate plate/food items when on red plate. Meal tickets updated. No changes to diet order-remains on a Regular diet at meals. [R73] eats meals in dining room and staff continue to encourage intake and honor preferences as able .Weight (2/27) 105.8#-same as prior weight on 2/23. Weight up 2.4# in past month, down 6.4# (5.7%) in 3 months, and down 4.2% since 8/15. Hx (History) significant weight changes, but none noted at this time. On 03/29/2022 at 01:46 PM, an interview was conducted with Registered Dietitian (RD) F. RD F stated, [R73] can usually feed themselves. They recently changed to a red plate which [R73] verbalized that it has helped them. [R73] has had periods of times where they have needed help, but for the most part they are able to feed themselves. RD F was queried about the observation of R73 needing help with their breakfast. RD F stated, We obviously can't put oatmeal on a red plate. Somebody should have been there if [R73] is having a hard time eating their food. If anyone is having trouble eating, then they should help them eat. [R73] has not lost a significant amount of weight. My current goal is for [R73] to maintain their weight. Resident #83 (R83) On 03/28/2022 at 12:58 PM, R83 was observed in bed with their lunch tray in front of them. R83 stated, I'm having a hard time keeping food on the fork. Someone just told me that they were going to help me get out of bed and eat. I'm still hungry. On 03/28/2022 at 1:04 PM, R83 was overheard in the hallway saying hello and attempting to get someone's attention. On 03/28/2022 at 1:06 PM, R83's tray was picked up from their room without R83 having received help to complete their breakfast. On 03/29/2022 at 8:57 AM, R83 was observed in bed during mealtime. A review of the medical record revealed that R83 was admitted into the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7/15, indicating impaired cognition. R83 also required two persons extensive to total dependence with bed mobility and transfers. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Up in chair 90 degrees for all meal, in dining room. Plate guard, red grips for utensils, blue spill proof cup. A review of R83 care plan revealed the following, .Provide and serve diet ordered; mechanical soft ground meat and gravy, up in chair in dining room at meals . On 03/29/2022 at 1:28 PM, an interview was conducted with Registered Dietitian (RD) D regarding R83 being up in the chair for meals. RD D stated, That's a speech decision to put those orders in. It is more of a safety intervention. It really varies with [R83] if they need help of not, and sometimes they need cueing and encouragement. It really changes meal by meal. On 03/29/2022 at 3:07 PM, an interview was conducted with Speech Language Pathologist (SLP) E. SLP E stated, [R83] has that intervention to be up in chair for all meals because of their swallowing. It is also just better for [R83] to be up in the chair for their meals and in the dining room. A review of a facility policy titled, Feeding, Assisting Resident to Eat revealed the following, 9. All attempts will be made to assist the resident with eating as soon as the tray is delivered.

This citation pertains to Intake numbers MI 044 and 4. Based on interview and record review the facility failed to use a gait belt during a physical therapy exercise as per facility policy and procedure affecting one resident, (R502) of two residents reviewed for falls, resulting in a fall with injury. Findings include. On 10/13/20 at 8:27 AM, R502's confidential complainant's allegation was reviewed and revealed, On the morning of 9/29/2020 (R502) was doing physical therapy for a hairline fractures in the lower back. (R502) was directed to walk up the steps as a a part of the therapy session, (R502) then fell face first into the ground and suffered from a broken femur . Record review of R502's Electronic Health Record (EHR) revealed R502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed R502 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating an intact cognition and needed supervision to extensive assistance with Activities of Daily Living (ADLs) including transferring and ambulating. Review of the progress notes regarding the incident revealed, 9/29/2020 08:49 Health Status Note Note Text: Per Therapy, resident was lowered to the floor during PT (Physical Therapy) this shift. While stepping off the last step residents right knee gave out and was lowered to the floor. Resident was screaming that both knees were hurting. Unable to assess ROM (Range of Motion) r/t (related to) resident did not want to be touched. (R502) did not hit their head. (R502) is currently taking Eliquis r/t history of PE (Pulmonary Embolism). No bruising or redness observed on resident. TLSO ([MEDICATION NAME] Lumbar Sacral Orthotic) brace on appropriately. Pillow place immediately under head and waited until EMS (Rmergency Medical Services) came to assist resident off floor and take to (nearby) Hospital at time of fall. Review 9/30/2020 12:19 Health Status Note Note Text: Clarification received from the therapist that the event was not a controlled descent. Review of R502's Fall Risk Assessment revealed a score of 16 on 09/18/2020 which is below the point the initiation of falls intervention program. Review of R502's Care Plan regarding fall prevention initiated on 09/22/2020 revealed the use of a gait belt was not an intervention. Review of the Investigation Guide revealed, The therapist was present but was unable to prevent the fall or control the descent to the floor. The resident was descending the stairs, stepping down to the floor level with right lower extremity when the right knee buckled and (R502) fell .There was no gait belt in place during the therapy exercise. Review of the conclusion of the investigation revealed, Conclusion: Per gait belt policy from (Company name) rehab, there was a deficient practice involved with this event, as a gait belt was not in place during the mobility activity. On 10/13/20 at 1:41 PM, Certified Nurses Aide (CNA A) was interviewed regarding the transfer status of R502 and stated, We always have to use a gait belt during transferring any resident. (R502) was very cooperative with care, in fact (R502) was one of the better residents. On 10/13/20 at 1:53 PM, Physical Therapist (PT B) was asked about the use of a gait belt during R502's therapy and stated, The only thing I can think of is that (R502) had a back brace on that (R502) didn't like wearing and the brace was black and my gait belt is black. I was written up and educated and I always use the gait belt and if I see others not using the gait belt I educate them. Review of the facility's policy and procedure regarding fall prevention titled, FALL ASSESSMENT, INTERVENTION AND PREVENTION dated as Revised Date 06/30/2017 revealed that the use of gait belts were not addressed.

Based on observation, interview, and record review, the facility failed to safely transport a resident (R42) by not placing the foot-rests on the wheelchair, resulting in R42's right foot being caught underneath the wheelchair and suffering a right leg fracture and pain. Findings include: On 6/10/19 at 11:08 AM, R42 was observed in their bed, positioned on their back. The Resident (R42) was dressed and was wearing a brace on their lower right extremity. The Resident said, I am going to the doctor's office today because of my broken leg. R42 was asked how and when did they break their leg and R42 said, In December, the music therapist was pushing me in my wheelchair and my foot got caught underneath the chair. R42 was asked if the foot-rests were on the wheelchair and R42 said, The foot-rests were not on the wheelchair. They was pushing me so fast. I could not keep my feet up that long. My right foot got stuck under the chair and I yelled out real loud because it hurt so bad. The Music Therapist H stopped. The nurse looked at it (right leg) and said it looked ok. I then went to music therapy. R42 was asked how it made her feel and R42 said, It hurt so bad. I was not able to walk or move around good prior to the incident. Now it's even harder to move around. On 6/11/19 at 12:10 PM, the medical record review revealed that R42 was admitted to the facility on [DATE] with a medical history of [REDACTED]. On 6/11/19 at 12:10 PM, the medical record review revealed the following: 12/14/2018 at 3:46 PM Health Status Note Text: At 1430 (2:30 PM) music therapist reported to writer that they were transporting resident in their wheel chair to an activity when resident right foot 'rolled under her chair', resident wheel chair foot pedals were not on the chair, at that time resident showed full ROM to right foot with no signs and symptoms pain/discomfort, res (resident) stated at the time that 'it aches a little but not much', writer was unable to determine if there were and swelling as resident normally has 2-3+ [MEDICAL CONDITION] to lower extremities, resident chose to go back to their room, writer took resident to their room and educated resident to inform a nurse if they begin to feel any pain, at 1500 resident called to writer and stated, 'it aches me so bad right now', resident noted with tears on their face, when writer applied mild touch to area approximately two inches above resident right ankle resident flinched, resident also had facial grimacing with touch, resident foot was elevated and placed on a pillow with an ice pack applied, call was made and consent for STAT x-ray was given, order was placed with mobile as STAT for right foot, ankle and lower leg, [MEDICATION NAME] was given at 1500 (3:00 PM) . Local Hospital determined it (fracture) was a non-operative break because of (R42) age. On 6/12/19 at 11:15 AM, The review of the progress note dated 12/14/2018 on 3:57 PM, that was initiated by nurse I revealed, Music therapist and resident were educated that if a resident is being transported in a wheel chair the foot pedals for that chair need to be in place before. On 6/12/19 at 11:15 AM, The review of the physician order [REDACTED]. On 6/12/19 at 11:15 AM, The Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADL's), Transfers, and Locomotion (via wheelchair) off the unit (one-person physical assistance when moving off the unit). On 6/12/19 at 11:15 AM, The review of the care plan with a revision date of 9/4/18 noted: Self-care deficit, resident requires extensive assistance with activities of daily living and at risk for fall, impaired mobility, and not able to ambulate related to stroke. Transfers: Resident needs extensive assistance with transfers with mechanical stand yellow sling. Resident does not ambulate. There was no documentation within the care plan regarding wheelchair locomotion or foot-rest implementation. On 6/12/19 at 11:15 AM, The Safety and Security Report entered on 12/20/19, noted the following: Resident was being transported in their wheelchair to an activity event off of the unit. While being Wheeled, (the Resident)'s feet dropped to the floor and their right lower leg was pulled underneath the wheelchair .No foot-pedals were in use .On 12/14/19 at 10:06 PM, the physician was notified of the x-ray results showing acute fracture. Order was given for resident to be evaluated in the ER (emergency room ). Resident was transferred to the ER and returned at 1:30 AM with recommendations to follow up with orthopedic services. Injury noted: Impacted fractures of distal tibia and fibula seen with moderate displacement. Follow-Up Actions noted the following: The injury is not of unknown origin. The event was recalled by both the resident and the staff member. The event was not willful. Per the most recent MDS, the resident was able to self-propel and perform her own locomotion on the unit with supervision only, for which Resident engaged her feet. She may require extensive assistance off the unit. The foot pedals were not in use for the reason of allowing the resident to self-propel, as she uses her feet with this activity. The Safety and Security Report statement by Music Therapist H noted the following: Writer was pushing Resident (R42) from their room to an activity in the Grand Central Dining Room. Writer and Resident were near the end of the Hummingbird Dining Room when Resident's right foot dropped to the floor. Writer immediately stopped the chair and moved backward but the Resident's foot did go slightly underneath their chair. Writer alerted (Nurse I) who performed an assessment. On 06/12/19 at 8:43 AM, an interview was conducted with the Physical/Occupational Therapy Manager G. Therapy Manager G was asked what the professional standard was when transferring a resident in a wheelchair and stated, Although we like to increase their (residents) independence, it is a professional standard that when residents are being transported (pushed) in their wheelchair, they (residents) should have foot-rest in-place. On 6/12/19 at 9:12 AM, an interview was conducted with Music Therapist H. When queried regarding R42 wheelchair incident on 12/14/19, Music Therapist H stated, It was time for music therapy and I was pushing the resident (R42) in her wheelchair from their room to the dining room then located on Grand Central. We were outside of the Hummingbird dining room area when the Resident's (R42) foot went underneath the wheelchair. The Resident (R42) yelled and I immediately stopped pushing the wheelchair and notified Nurse I. (Nurse I ) came to the resident and looked at her leg. Music Therapist H was asked if the foot-rests were on the wheelchair and they said, No they were not. On 6/12/19 at 10:09 AM, an interview was conducted with Nurse I regarding the resident's (R42) incident and they stated, I did not see the actual incident, but I heard the Resident yell. I looked at their leg and did not notice anything immediately. Shortly afterwards the Resident was having leg pain and an x-ray was ordered and it showed a fracture. On 6/12/19 at 10:10 AM Music Therapy Assistant J was observed transporting an unknown resident in the hallway in a wheelchair to look at birds without foot-rests on the wheelchair. The resident's feet were in slippers with the soles dragging on the ground. On 6/12/19 at 10:54 AM, an interview was conducted with the Director of Nursing (DON). When queried about clinical and non-clinical staff training on wheelchair safety, the DON stated, I guess I would say that they (staff) are trained when they are hired. So, to determine if they (staff) need training on wheelchairs and the need for foot-rests, we do not have a wheelchair transport training course. But I know where you are going with that but transporting a resident with foot-rests depends with the resident's condition. Some (residents)are able to be pushed in a wheelchair without foot-rests and hold their legs up from one end of the facility to another. On 6/12/19 at 11:40 AM, an interview was conducted with the Maintenance Director K. The Maintenance Director K was queried about the distance from Hummingbird dining room to the Grand Central dining room and reported at 11:49 AM. Maintenance Director K reported, The distance from Hummingbird dining room to the Grand Central dining room is 303 feet. Requested from the DON policies for the following: Wheelchair Policy, General Transport Policy, and Foot-Rest Policy. The DON stated they did not have the requested policies.

Based on observation, interview and record review, the facility failed to ensure assessment, care and documentation of indwelling urinary catheters per professional standards of practice for two (#'s 192 and 581) of two Residents reviewed for catheters, resulting in unsanitary placement of urinary drainage bags, inappropriately placed catheter tubing securement device, lack of assessment and timely intervention, increased risk of infection, and a Resident experiencing a skin ulceration at the catheter insertion site and unnecessary pain. Findings include: Resident #192 On 6/10/19 at 10:42 AM, observation occurred of Resident #192 and Witness V in the Resident's room. The Resident was sitting in a high back wheelchair. A urinary catheter drainage bag was observed under the wheelchair. The drainage bag was not hooked to the wheelchair was directly touching the floor. The Resident's urine in the tubing and drainage bag was observed to be dark yellow in color with a large amount of sediment. An interview was conducted with Resident #192 and Witness V at this time. When queried regarding the catheter, Witness V stated, They (staff) don't move the (drainage) bag before they move (Resident #192) and it pulls on the catheter. (Resident #192) had bleeding from it. With further inquiry pertaining to the catheter, Witness V stated, (Resident #192) has had a UTI (Urinary Tract Infection) too. During the interview, Resident #192 was pleasant and shook their head indicating agreement with Witness V's statements. On 6/11/19 at 7:38 AM, Resident #192 was observed sitting in a wheelchair in their room. The Resident's urinary catheter drainage bag was under the wheelchair and was touching the floor. Record review on 6/11/19 revealed Resident #192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to perform Activities of Daily Living (ADL's). The MDS further revealed the Resident had an indwelling urinary catheter and bladder training/removal had not been attempted. An interview was conducted with Infection Control Nurse M on 6/11/19 at 2:26 PM. When queried regarding catheter drainage bags on the floor, Infection Control Nurse M replied, They should not be touching the floor. At 1:16 PM on 6/12/19, observation occurred of Resident #192 sitting in a wheelchair in their room. The Resident's urinary catheter drainage bag was under the wheelchair and was touching the floor. Resident #581 On 6/10/19 at 10:19 AM, Resident #581 was observed laying in bed in their room. The Resident was observed to have a urinary catheter. The urinary catheter drainage bag was positioned on the right side of the Resident's bed and was touching the floor. The urine was dark in color with a large amount of sediment noted in the tubing. Record review on 6/10/19 revealed Resident #581 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission/Readmit Assessment, dated 5/31/19, revealed the Resident was cognitively intact, unable to ambulate, and required assistance to complete Activities of Daily Living (ADL's). Additional record review revealed the Resident had a stage three (full thickness tissue loss) pressure ulcer (wound caused by pressure on their coccyx) and had an indwelling urinary catheter. Review of Resident #581's care plans on 6/11/19 revealed the Resident did not have a care plan in place related to having an indwelling urinary catheter. Resident #581 was observed in their bed, positioned on their back on 6/11/19 at 7:54 AM. An interview was conducted with the Resident at this time. When queried regarding their urinary catheter, Resident #581 stated, It was hurting my penis so bad yesterday. If anything touched it, it was just terrible. My spouse ended up cleaning it yesterday. There was a bunch of dried blood on it. When queried regarding frequency of care and cleaning of the catheter by facility staff, Resident #581 stated, No, my spouse just did it. When asked how long the catheter had been causing discomfort, Resident #581 stated, It started a week ago. They (staff) they would pull the diaper up and the rubbing was about unbearable. When queried if they reported the discomfort from the catheter to facility staff, Resident #581 indicated they had. The Resident's catheter drainage bag was positioned on the right side of the bed. The urine was dark in color with a large amount of orange and red colored sediment. An interview was conducted with Nursing Assistant R on 6/12/19 at 8:39 AM. When queried regarding facility policy/procedure of urinary catheter care, Nursing Assistant R stated, Nursing Assistants do cath care with daily care. When queried how catheter care is charted, Nursing Assistant R replied, It is charted in PCC (electronic medical record) with the other daily care. On 6/12/19 at 8:49 AM, observation of daily care for Resident #581 occurred with Nursing Assistant R and Nursing Assistant S. Dark colored urine with a large amount of sediment was observed in the Resident's urinary catheter drainage bag and tubing. Upon removal of the Resident's blanket and brief, the end of the Resident's penis and the urinary meatus (hole where the catheter was inserted) was observed to have bright red blood and dried blood on it. Thick, yellow/gray colored drainage was observed on the end of the penis, the urinary meatus, and on the catheter. The skin surrounding the area on the Resident's penis was bright red in color. When queried regarding the blood and drainage, Nursing Assistant R indicated they would need to clean it up. Nursing Assistant R proceeded to use a damp washcloth to remove the blood and drainage from the end of the Resident's penis and catheter. Whenever staff touched the area to clean their penis, Resident #581 would yell out in pain. At this time, Nursing Assistant R asked Resident #581, Did your catheter get pulled? I know someone's did. After the drainage and blood was removed, an open, ulcerated area was noted on the distal (under) aspect of the Resident's urinary meatus and penis. A Stat-Lock (adhesive catheter tubing securement device) was observed on the Resident's right thigh. The catheter tubing was noted to be taut from the securement device to the insertion site in the Resident's urinary meatus and was pulling the Resident's penis to the right side and downward. When staff turned the Resident on their side, the catheter tubing became increasing taut and was pulling on the Resident's penis. When queried, Nursing Assistant R indicated Resident #581 had been complained of pain in their penis and genital area for a few days and that is why the Resident did not want their brief secured on the sides. Wound care observation for Resident #581 was completed with Nurse W and Nurse X on 6/12/19 at 10:05 AM. Following coccyx wound care treatment completion, Nurse W and Nurse X were asked if they were aware of the area on the Resident's penis. Nurse W and Nurse X indicated they were unaware, and the Resident proceeded to tell them about the area. Nurse W and Nurse X assessed the Resident's penis, urinary meatus, and catheter at this time. The distal end of Resident #581's urinary meatus was bright red with an opened, ulcerated area on the distal side of the opening. When queried, Nurse W stated, It's an ulcer starting. The securement device is too tight and created an ulcer. The securement device did not include a date of when it was placed on the device. The Resident's scrotum and groin were also observed to be excoriated, swollen, and bright red in color. When asked, Resident #581 indicated the area was very painful. An interview was completed with Nurse Y on 6/12/19 at 10:40 AM. When queried regarding Resident #581's catheter, urinary meatus, and penis, Nurse Y indicated the Resident's groin and scrotum were swollen and excoriated when the Resident was admitted to the facility. Record review on 6/12/19 of Resident #581's medical record revealed the following documentation: -6/11/19 at 4:04 PM: COMS: Skilled Evaluation . Cardiovascular: Skin warm and pink with brisk capillary refill (< 3 seconds). No [MEDICAL CONDITION] present . [MEDICAL CONDITION]: Urinary catheter intact. Catheter patent. Leg band in place. Perineal care provided: YES. Catheter care provided: YES Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Skin Issue: Surgical Wound Skin Issue Location: midline abdomen . -6/10/19 at 8:45 PM: COMS: Skilled Evaluation . Cardiovascular: Resident positive for [MEDICAL CONDITION] . [MEDICAL CONDITION] . Urinary catheter intact. Catheter patent. Draining urine. Leg band in place. Perineal care provided: YES. Catheter care provided: YES . Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Skin Issue: Surgical Wound Skin Issue Location: midline abdomen . -6/8/19 at 3:38 PM: COMS: Skilled Evaluation . Cardiovascular: Resident positive for [MEDICAL CONDITION] . [MEDICAL CONDITION] . Urinary catheter intact. Catheter patent. Draining urine. Perineal care provided: YES. Catheter care provided: YES . Skin: Skin color is WNL (Within Normal Limits) Skin Note: Lateral surgical incision to abdomen . Review of Resident #581's skin and wound documentation on 6/12/19 revealed no documentation of an ulceration on the Resident's penis/urinary meatus and/or excoriation or swelling in the Resident's groin area. On 6/12/19 at 11:08 AM, observation occurred of Nursing Assistant S and Nursing Assistant U transferring Resident #581 from the bed to the wheelchair utilizing a Hoyer (mechanical lift). When the Resident was suspended in the Hoyer sling, the Resident's urinary catheter drainage bag was observed, not hooked, hanging freely and swinging under the Resident. An interview was conducted with Nursing Assistant S on 6/12/19 at 11:20 AM. When queried regarding observation of the Resident's catheter drainage bag hanging freely and swinging when in the Hoyer sling and facility policy/procedure pertaining to catheter drainage bag placement when a Hoyer is used, Nursing Assistant S stated, No, (catheter drainage bag) should be hung on the Hoyer. An interview was conducted with the Director of Nursing (DON) on 6/12/19 at 2:01 PM. When queried regarding observations of Resident #192 and Resident #581's catheter drainage bags on the floor, the DON indicated the drainage bags should not be on the floor. When queried regarding Resident #581's catheter including verbalization of discomfort for a week, placement of catheter during transfer, securement device placement, ulceration on the Resident's penis, and documentation, the DON did not provide further explanation. Record review of facility policy entitled, Catherization of the Urinary Bladder (Revised: 4/12/18) revealed, Indwelling Catheterization (IDC) . 6. Residents that are catheterized are to have urinary output documented in the medical record. 7. Routine catheter changes are not recommended. However, changes are needed if the catheter has calcified deposits, or when the drainage bag appears contaminated with old blood, mucus, or microorganisms . Peri-Care Of the resident with Indwelling Catheter (Foley) . The Foley should be held in place by a leg band to prevent tension on meatus. Keep tubing free to insure flow of urine. Drainage bag must always be kept below the level of the bladder to prevent back flow and risk of infection. Keep the catheter clean. Wash with cleansing agent. Cleanse catheter at meatal junction during am and PM care and at bath time with cleansing agent checking for irritation or redness . Record review on 6/12/19 of facility policy entitled, Basic Resident Care (Revised: 1/23/17) revealed, To ensure a high quality of care . maintain a consistent standard of care according to current recognized guidelines .

Based on observation, interview and record review, the facility failed to ensure assessment, monitoring, and care per professional standards of practice for a change in condition for one (#116) of four Residents reviewed for a change in condition, from a total sample of 38, resulting in a Resident with identified respiratory compromise experiencing respiratory distress, not receiving continued assessment, monitoring, and supportive oxygen therapy, and the potential contribution to [MEDICAL CONDITION] and death. Findings include: On [DATE] at 10:18 PM, Resident #116 was observed lying in bed with their eyes closed and receiving oxygen via nasal cannula at two liters. Record review on [DATE] at 11:05 PM revealed that resident #116 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADL's). Review of the resident's care plans on [DATE] at 11:10 PM revealed that the Resident did not have a care plan in place pertaining to oxygen therapy and/or impaired respiratory status. On [DATE] at approximately 3:02 PM, an overhead facility page indicated code blue in Resident #116's room. At 3:05 PM on [DATE], observation revealed that the resident was lying in bed, with the head of the bed flat and positioned on their back. The Resident was wearing pants but did not have a shirt on. The Resident's lips were blue in color and was observed gasping to breathe and their respirations were agonal (irregular, labored breathing). The Resident was receiving oxygen by means of a nasal cannula at six liters per minute. A whooshing sound was noted from the oxygen. Unit Manager Nurse I and Nurse M removed the Resident's pants. A rolling emergency supply cart was observed in the room. At this time, a facility staff member stated, (Resident #116) is a no code but is a send to hospital. The Resident's lips and ears were observed to be dusky blue in color and their skin was pale and dusky. The head of the Resident's bed remained flat and Resident #116 continued to display agonal breathing. On [DATE] at 3:18 PM, Nurse I stated, We got a pulse. Nurse I then stated, We should get a blood sugar. At 3:20 PM, a bedside blood glucose test revealed Resident #116's blood glucose level was 258 (elevated). Facility staff attempted to obtain a blood oxygen saturation level (SpO2 -measurement of oxygen in blood) and indicated they were not able to obtain an SPO2 measurement. At 3:21 PM, Resident #116's respirations continued to be agonal and gasping and their lips and ears were darker, dusky blue in color. The respiratory rate at this time was noted to be eight breaths per minute. The head of their bed remained flat and oxygen remained in place via nasal cannula at six liters per minute. Nurse Z and the Director of Nursing (DON) were observed entering and exiting the Resident's room. On [DATE] at 3:22 PM, Emergency Medical Service (EMS) personnel entered Resident #116's room and began assessing the Resident. The Resident was no longer observed to be breathing. At 3:25 PM, EMS personnel connected a cardiac monitor to Resident #116 and stated, Rhythm on monitor, rate 31. EMS personnel proceeded to conduct additional assessment including auscultation of the Resident's heart and stated, It's PEA (Pulseless Electrical Activity- no actual heart beat). EMS personnel then indicated they would need to contact the emergency room Physician per EMS policies/procedures. At 3:34 PM, EMS personnel stated, Time of Death 1534. On [DATE] at 3:58 PM, an interview was completed with Unit Manager Nurse I. When queried regarding Resident #116, Nurse I stated, (Resident #116) was recently in hospital. Nurse I further indicated the Resident had been very ill recently. When queried regarding events prior to Resident #116's death, Nurse I indicated facility staff had just given the Resident a shower. Facility policy/procedure related to Resident change in condition was requested at this time. An interview was completed with Nursing Assistant J and Nursing Assistant K on [DATE] at 4:07 PM. When queried regarding Resident #116, Nursing Assistant J stated, The shower was done and (Resident #116) was back in their room. We were drying the Resident. With further inquiry, Nursing Assistant J indicated Resident #116 was transferred with a Hoyer lift and was laid in their bed after their shower was completed to be dried off. Nursing Assistant J then stated, (Resident #116) was in the lift, in the air. They were partially dressed when it happened. When asked what happened, Nursing Assistant J stated, (Resident #116) was saying I got to get up, I got to get up then they stopped talking. I tried to get (the Resident) to respond. When asked, Nursing Assistant J specified, (Resident #116) was up in the sling. We going to put (the Resident) back in their wheelchair but they went unresponsive and started turning blue. When queried if Resident #116 had their oxygen on while when they received their shower and when being transfered in the Hoyer lift, Nursing Assistant J replied, No, not from their room to the shower room and back. When asked if Resident #116 was wearing their oxygen before they went to the shower, Nursing Assistant J replied, Yes. With additional inquiry regarding the length of time Resident #116 did not have the oxygen in place, Nursing Assistant J stated, Probably around a half hour. We took it (oxygen) off in the room, took (the Resident) to the shower room, came back to their room, put them in their bed to dry them, and then put them back up in the Hoyer. We didn't put it (oxygen) back on. When asked what occurred after the Resident turned blue and went unresponsive, Nursing Assistant K and Nursing Assistant J indicated Nursing Assistant J ran to the nurses' station and got (Nurse M) and Resident #116 was transferred back in their bed. When queried if oxygen was placed on the Resident after being transferred to their bed and how many liters the oxygen was set at, Nursing Assistant K and Nursing Assistant J both indicated Nurse M put oxygen on the Resident, but they were unaware of the rate. Nursing Assistant K detailed, It is normally at 2.5 liters. When queried regarding the order for oxygen and if the Resident was supposed to use it continuously, Nursing Assistant J indicated that prior to their last hospitalization , the Resident only wore their oxygen at night, but they thought the Resident was supposed to wear it continuously now. Nursing Assistant J proceeded to state, (Resident #116) was panicking in bed (when we laid them down to dry them). (The Resident) has been (anxious) all week. Before I even started the shower, (the Resident) apologized because they had been freaking out. Ever since they got back from hospital they have been saying things that haven't been making sense. I just figured something was going on since (Resident #116) spiked that temp on Monday during day shift and their sugar dropped. They were not with it on Monday. Nursing Assistant J then stated, (Resident #116) has had a cough since they got back from the hospital. It sounded really deep and wet. Nursing Assistant K voiced confirmation of the Resident's cough and stated, (Resident #116) has also been really hot. They wanted their fan right next to them last night and today. With further inquiry, Nursing Assistant J stated, Yesterday (Resident #116's) blood pressure was ,[DATE]'s. It wasn't on my screen to chart it but I told (Nurse L). When queried how they know Resident's code statuses and what to do in situations when a Resident's condition changes, Nursing Assistant K stated, I don't know because we don't do it here. We don't do CPR (Cardio-Pulmonary Resuscitation). When queried regarding how they receive report or information regarding the Resident's they are assisted, Nursing Assistant K indicated facility Nursing Assistants receive a printed information sheet. When asked if Resident's code status and/or advance directive wishes is provided on the information sheet, Nursing Assistant K obtained the document from their pocket. Record review of the Nursing Assistant care information sheet with Nursing Assistant J and Nursing Assistant K revealed no documentation of Resident code status or advance directive wishes. Review of Resident #116's medical record occurred on [DATE] at 4:45 PM. Review revealed a care plan entitled, MAD (Medical Advance Directives)/End of Life Choice: CPR - no, hospitalization - yes, IV antibiotics - yes, Tube Feeding - TBD (To Be Determined) .Resident is very social and musically inclined . loves to be around people and activities and is generally optimistic . (Initiated: [DATE]; Revised: [DATE]). Additional review revealed documentation entitled, Medical Advance Directive for Emergency Response. The form was signed by the Resident, dated [DATE], and indicated, Yes, I want to be hospitalized . This means that the Resident will be sent to the hospital for any and all acute conditions (such as [MEDICAL CONDITION], acute respiratory distress . pneumonia) . The form further revealed, No, I do not want CPR. I do not want any life -sustaining measures to be used to prolong my life. I would like to be made comfortable at the end of my life through all available means other than CPR . On [DATE] at 8:20 AM, an interview was conducted with Unit Manager Nurse I. When queried regarding Resident #116's oxygen therapy order, Nurse I stated, I think it was supposed to be continuous since the Resident returned from the hospital. When queried regarding staff statements and medical record documentation indicating the Resident was not wearing oxygen, Nurse I indicated they would have to check. Record review of facility provided policy on [DATE] at 8:30 AM entitled, Nursing Services: Nursing (Revised [DATE]) revealed, 2. Treatment procedures and modalities will be instituted and modified according to the Resident's response to treatment/interventions 3. The nursing staff . will document each treatment of [REDACTED]. 4. Nursing will inform the physician/responsible party when there is a . significant change in the Resident's physical . status . Review of Progress Note documentation within Resident #116's medical record on [DATE] at 8:35 AM revealed the following: -[DATE] at 1:21 PM: Health Status Note: Restless anxious sob (Short of Breath) SpO2 room air 80% with o2 ,[DATE]%, calling out c/o unable to breath updraft given bring up thick yellow phlegm x 1. call to NP (Nurse Practitioner) new order. give [MEDICATION NAME] 40 mg now then at 1800 if effective, if no effect call back consider sending to ER. -[DATE] at 3:05 PM: Health Status Note: Upon entering room at 15:05, (Resident #116) was noted to be cyanotic and non-responsive. MAD was verified as DNR and yes to hospitalization . EMS and (Resident family) were called at 15:10. Supplemental oxygen was on and increased to 6 L. Periodic agonal breaths were noted, no apical, radial or femoral pulse was present. Vital signs were obtained: CBG (Blood Glucose) 258, breaths 8, pulse ox no reading, BP (Blood Pressure) no reading. 15:22 EMS arrived, breaths ceased and resident was placed on LifePak which showed PEA. EMS called ER for confirmation of death and time of death was 15:34. Medical examiner was informed per policy of unexpected death. -[DATE] at 4:09 PM: Health Status Note: 1530 (Resident family) notified, and 1546 NP notified and received order to release the body. -[DATE] at 4:37 PM: Health Status Note: At 1500 called to resident room by CNAs (Nursing Assistants). Resident was observed in bed, unresponsive, agonal breathing noted. Attempted sternal rub with no response. Skin noted to be cyanotic. Supervisor notified and immediately at bedside. Directed to verify code status. Resident is no CPR, yes to hospitalization . EMS called at 1510. Supplemental oxygen started via nasal cannula. Call placed to (Resident family). EMS arrived at 1522 and assumed resident care An interview was completed with Unit Manager Nurse I on [DATE] at 10:42 AM. When queried regarding Resident #116's oxygen therapy, Nurse I stated, By the time I got in there (Resident #116's room), the oxygen was being put on by (Nurse M). I checked the pulse. When queried regarding the provided facility policy related to significant change and request for a change in condition policy, Nurse I stated, I don't think we have anything like that. We are so focused on the MDS. When asked how staff know what to do in response to a change in Resident condition, Nurse I indicated, I will look. On [DATE] at 11:55 AM, an interview was completed with Nurse M. When queried regarding Resident #116, Nurse M stated, I was in the charting room and the (Nursing Assistant) knocked on the door and said they needed us. (Nurse L) and I went in there right away. (Resident #116) was in the sling (Hoyer lift) and was in distress. (Resident #116) was turning blue so we immediately laid (the Resident) back down (in their bed). We put oxygen on (Resident #116). With further inquiry related to oxygen administration, Nurse M stated, I put the nasal cannula on and cranked it. Nurse M then stated, I tried a sternal but it didn't bring (Resident #116) back. When asked about Resident #116's code status and how facility staff are aware of code status, Nurse M stated, It's on their charts. A blue dot means they are a full code. With further inquiry regarding Resident #116's documentation indicating they wanted to go to the hospital but did not want to be resuscitated and if that information was conveyed in nurse to nurse report, Nurse M replied, No. At this time, documentation within Resident #116's medical record was reviewed with Nurse M. When queried regarding nursing note documentation indicating the Resident was experiencing shortness of breath and required interventions on [DATE] at 1:21 PM, Nurse M stated, I gave (the Resident) [MEDICATION NAME] (diuretic medication) around 2:00 PM. The girls (Nursing Assistant K and Nursing Assistant J) took (Resident #116) in the shower so (the Resident) must have been feeling a little bit better. When queried if the medication was administered orally, Nurse M indicated it was. When asked if the Resident had output following the administration of the [MEDICATION NAME] and if the medication had been in the Resident's system long enough to begin to work (peak onset for oral [MEDICATION NAME] is one to two hours), Nurse M stated, I guess it didn't. When queried further regarding medical record documentation, Nurse M indicated Resident #116's SPO2 was 80% on room air and increased to ,[DATE]% when oxygen was placed. When queried why Resident #116 was taken to the shower without oxygen when they had just experienced respiratory distress and difficulty breathing, Nurse M stated, I don't know, the girls (Nursing Assistant K and Nursing Assistant J) took them. When queried if the Resident was reassessed and if their SPO2 was checked prior to removal of oxygen therapy and going to the shower, Nurse M replied, No, I did not check it. When queried regarding the last time the Resident was assessed and their SPO2 checked, Nurse M stated, Right after I put the oxygen on them (when oxygen was initiated). An interview and record review was completed with Unit Manager Nurse I on [DATE] at 4:00 PM. When queried regarding documentation of Resident #116 experiencing difficulty breathing, requiring oxygen therapy and medications approximately two hours before they died and not being reassessed prior to having the oxygen removed and being taken for a shower. Nurse I stated, (Resident #116) should have been re-assessed. I see what you are saying. On [DATE] at 10:14 AM an interview was completed with the Director of Nursing (DON). When queried regarding the Resident's code status indicating they did not want to be resuscitated but that they wanted to be sent to the hospital for treatment and why the Resident was not sent for treatment earlier, the DON indicated the physician was notified. When queried regarding documentation of the Resident experiencing difficulty breathing, requiring oxygen therapy and medications approximately two hours prior to being pronounced dead and not being assessed prior to having the oxygen removed and receiving a shower, the DON stated, They should have been reassessed. When asked if Resident's are able to take showers while wearing oxygen, the DON indicated they were. When queried why the Resident was taken off their oxygen for approximately 30 minutes to receive a shower, the DON stated, The shower could have waited. With further inquiry related to the Resident's oxygen rate at six liters with a regular nasal cannula and if alternative oxygen deliver devices are available within the facility, the DON indicated oxygen masks are available. When asked why the head of the Resident's bed was not elevated when the Resident was displaying agonal breathing to assist and aid in the ease of respirations, the DON stated, We could have done that for comfort. Record review of facility policy entitled, Oxygen- Tanks and Concentrators (Revised [DATE]) on [DATE] at 5:10 PM revealed, Oxygen is considered a prescribed medication by the FDA and must be administered as such . Nursing may administer oxygen to Resident at 2 L/m (liters/minute) or via venti-mask set at 35% (if clinically indicated for respiratory distress) . Only licensed nursing staff can administer oxygen. Review on [DATE] at 5:15 PM of facility provided document entitled, Standing Orders (Revised ,[DATE]) revealed, 10. Oxygen: (MONTH) use oxygen at 2 L/m per nasal cannula at 6 L/min per face mask for respiratory distress (for O2 sat of 88% or less) . A policy/procedure pertaining to change in condition requested by not received by the conclusion of the survey.

This citation has 2 Deficient Practice Statements ( DPS) Based on observation, interview and record review, the facility failed to implement, thoroughly assess and care plan interventions to prevent further suicide attempts for one (#726) that attempted to commit suicide by wrapping a headphone cord around his neck, out of 30 residents sampled, resulting in the potential for further suicide attempts, untreated depression and the resident not receiving care necessary to promote mental health well being. Findings include: On 6/21/17 at 8:00 a.m., a review of Resident #726's face sheet and Minimum Data Set (MDS) assessment revealed that Resident #726 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].#726 was severely cognitively impaired and needed assistance with activities of daily living. On 6/21/17 at 8:10 a.m., Resident #726 was observed sitting up in his wheelchair eating breakfast. Resident #726 was alone at the table watching television (TV) and nonverbal. On 6/21/17 at 9:35 a.m., a review of the progress notes in the electronic medical record for Resident #726 revealed the following: On 4/26/17 at 14:19, Nurse Y had documented that a nurses aide had informed him that Resident #726 had tried to hang himself with his headphone cord. According to the documentation, Nurse Y initiated a 24 hour watch, educated the staff to monitor the resident and notified a nurse manager of the situation. On 4/26/17 at 21:59 stated that the headphones were removed from the residents room. On 4/27/17 at 04:05 stated that there were no further attempts to harm self from Resident #726 and every 15 minute checks continued. On 4/27/17 at 10:52 stated that Resident #726 denied wanting to hurt himself, had no further attempts to harm himself and was continuing to be monitored. There was no further documentation regarding the incident in the electronic medical record. There was no documentation as to whether or not the physician or responsible party was notified. On 6/21/17 at 10:10 a.m., Resident #726 was observed laying in bed with corded headphones on his head, watching TV. On 6/21/17 at noon, Resident #726 was observed resting with his eyes closed with his corded headphones wrapped around the right mobility bar of his bed within his reach. On 6/21/17 at 12:15 p.m., a review of the Psychosocial Notes written by Social Worker (SW) I for Resident #726 revealed the following: On 8/17/16, 12/7/16, 3/21/17 and 6/20/17-stated, Resident #726 was, depressed at times and had a history of [REDACTED]. The 8/17/16 note also stated that Resident #726 had recently returned from the hospital and had been placed on hospice and had been receiving support services from the hospice chaplain. On 6/21/17 at 12:25 p.m., a review of the mood care plan (no initiation date on printed copy) revealed that Resident #726 has a [DIAGNOSES REDACTED]. Interventions included: Behavior health consults as needed. Monitor/record/report to doctor as needed, mood patterns, signs and symptoms of depression, anxiety, and sad mood. Resident needs extra time to talk or express self as needed, encourage to express feelings. On 6/21/17 at 1:20 p.m., an interview was completed with the Director of Nursing (DON) in regards to Resident #726 having attempted to hang himself with the cord of his headphones and still having the headphones in his possession. At first the DON did not recall the incident but then stated that Resident #726 had recanted his statement of hanging himself and that he was an unreliable historian. When explained that according to the documentation, Resident #726 had been observed with the cord wrapped around his neck, the DON did not provide any explanation as to why he still had the headphones and why there was no care plan with updated interventions to inform the staff as to how to care for Resident #726. The DON confirmed that Resident #726 was not or had not been followed by a psychiatrist or psychologist following the incident. On 6/21/17 at 1:30 p.m., an interview was completed with SW I. SW I stated that she did not remember Resident #726 having a history of suicidal ideations. When SW I was reminded of the incident on 4/26/17 and the note written (by her) on 6/20/17 that stated he had a history of [REDACTED].#726 did have suicidal ideations at times but currently there was no changes or concerns with him. When asked to why Resident #726 was not referred to behavioral health services, SW I had explained that Resident #726 had Hepatitis and could not metabolize medications. On 6/21/17 at 2:00 p.m., an interview was completed with Family Member J, who is the responsible party listed on the face sheet in regards to the history of Resident #726's mood and behavior. Family Member J was unable to provide an adequate history but did state she was unaware of Resident #726 wrapping a cord around his neck on April 26. Family Member J stated, Nobody told me about that! No one called me or anything! They are going to hear it from me! I am old and disabled myself, so I am unable to come in there a lot. On 6/21/17 at 2:15 p.m., an interview was completed with the DON as to why Resident #726 was not referred to behavior health services and what the protocol is for caring for residents who have suicidal ideations or attempted suicide. The DON stated, I think we were concentrating so much on his falls. Normally the social worker would complete assessments. When queried why the responsible party for Resident #726 was not notified, the DON stated, She should have been notified. On 6/21/17 at 2:45 p.m., an interview was completed with the Administrator in regards to Resident #726's suicide attempt on 4/26/17 and the lack of follow up. The Administrator stated, I remember the incident, I normally don't get involved in the follow up. I rely on my team. He (Resident #726) seemed okay after that, he was eating and in therapy. On 6/21/17 at 3:45 p.m., an interview with the Director of Social Services Z was completed. According to the Director of Social Services Z, the social workers assess the residents for an actual threat. The Director of Social Services Z also stated that Resident #726 was on behavior health services but when he was placed on hospice he was discontinued from the behavior heath services. The Director of Social Services Z was further queried about why the doctor did not order a psychiatric evaluation. The Director of Social Services Z was unable to verify if the doctor was notified but did state, It is very traumatic for a patient to go to a psych hospital. The Director of Social Services Z was able to verify that Resident #726 was off hospice. On 6/21/17 at 4:00 p.m., Nurse Y was interviewed in regards to the suicide attempt of Resident #726 on 4/26/17. Nurse Y stated, I was in the middle of a situation with another resident when the aide came and got me and told me that he (Resident #726) had the cord of his headphones around his neck and said he was trying to hang himself. I went in there and he (Resident #726) was laying with his legs and feet out of his bed on the floor and the headphones were lying on the floor. I asked him what he was doing and he told me he was trying to get out of bed. I told my manager and started the every 15 minute check sheet. Nurse Y could not recall who the nurses aide was that initially had seen the cord wrapped around Resident #726's neck. On 6/21/17 at 4:30 p.m., a record review of the policy titled Suicide Precautions, Monitoring revised 11/12/2016 was completed and revealed the following: Procedure-All residents who express suicidal ideations in conjunction with symptoms of depression, substance abuse or other mental illness should be evaluated promptly by a mental health professional. All threats should be taken seriously. #2.-Staff will be designated to remove all items from the resident's room which could be used in a suicide attempt . #6.-Orders for mental health consult will be sought. A.-Request that psychology or psychiatry visit or phone consultation for recommendations. B.-Request that the resident is seen by a psychologist or social worker. C.-Request a rapid evaluation with recommendations for appropriateness or inappropriateness of further action, including psychiatric hospitalization s. #9.-There is a legal responsibility to report threat of harm to self or others to family, involved members . #11.-The social worker or designated staff will do an evaluation of suicide risk at least daily until such time as the attending physician, psychiatrist, and other team members feel the risk has passed. DPS#2 Based on observation, interview and record review, the facility failed to adequately monitor 3 (#'s 707, 709, and 716) of 14 residents reviewed for falls from a total of 30 sampled residents, resulting in a hip fracture, stables to the head and the the potential for further injuries. Findings Include: On 6/20/17 at 9:00 am, a record review of Resident #709's face sheet revealed an admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #709's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated an intact cognition and that the resident required one person assistance for transfers and bed mobility. On 6/20/17 at 9:20 am, a review of Resident #709's Care Plan indicated that resident was at risk for falls and requires assistance with transfers and walking. On 6/20/17 at 12:20 PM, Resident #709's falls/accidents were reviewed. The following falls were reviewed: Fall #1: Occurred on 5/29/17 at 11:15 PM. Per the incident and accident (I/A) report; Resident #709 was standing at the sink washing their hands when the resident lost strength and the resident knees began to buckle. Resident was hanging onto the sink with resident's right arm and resident's left arm was on resident's walker. Staff lowered resident to the floor then assisted her into her wheelchair. This report further revealed that aide had stepped away while resident was at the sink washing her hands. Aide was educated that residents that need assistance with transfers and ambulation are at risk for falls and need to have hands on support for all activities that involve standing. Fall #2: Occurred on 6/11/17 at 3:05 PM. Per I/A report; Resident was found on the floor in her room. Resident was reaching for a tissue that was on the floor and fell . No changes to plan of care were indicated following this fall. On 6/20/17 at 12:50 PM, Resident #709 was queried on the fall which occurred on 5/29/17. Resident #709 indicated being at the sink in the bathroom, losing strength in the legs, and falling to their knees. Resident #709 was queried about if Certified Nursing Assistant (CNA) was in the room with the resident when the fall took place. Resident #709 stated, No, the CNA left the room. Resident #709 indicated that staff typically stay in the room with resident when standing. On 6/21/17 at 11:00 am, CNA A was queried on standard practice used when Resident #709 uses the bathroom. CNA A stated, The resident is not to be left alone in the bathroom. I stay in the bathroom with the resident. On 6/21/17 at 1:20 PM, CNA B was queried on the fall which occurred involving Resident #709 on 5/29/17 at 11:15pm. CNA B indicated that she assisted Resident #709 to the bathroom and monitored Resident while using the toilet. When Resident #709 was washing their hands CNA B admitted to leaving the room and shortly thereafter, resident was observed with her knees buckling by the sink. CNA B was queried on if CNA B would normally leave Resident #709 unsupervised while standing. CNA B stated, No. On 6/21/17, at 1:45 PM, Nurse Supervisor C was queried on what should be done when Resident #709 is standing. Nurse Supervisor C stated, The resident should be monitored. The resident is a one person assist when standing and walking. On 6/21/17, at 2:00 PM, the Director of Nursing (DON) was queried on standard practice used for Resident #709 when standing. DON stated, Typically someone should be standing next to the resident when standing. On 6/21/17 at 2:30 PM, a review of the Facility's Policy, Falls Assessment, Intervention and Prevention with the revision date of 5/3/2017 revealed .The purpose of this program is to identify residents at risk for falls, in order to prevent and/or decrease the number of falls through early identification and implementation of preventative interventions . Resident # 707 On 6/19/17 at 3:37 p.m., a review of the Care Plan revealed, Resident #707 is at risk for falls and requires extensive assistance with activities of daily living. On 6/19/17 at 4:15 p.m., a review of the Minimum Data Set (MDS) revealed Resident #707 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS dated [DATE] revealed that Resident #707 was severely impaired for cognition with a Brief Interview Assessment for Mental Status (BIMs) of 4. MDS notes extensive assistance for all transfers with one person physical assist. On 6/20/17 at 9:40 a.m., a review of the Facility Fall Incident Reports for resident #707 revealed that the Resident had two falls, one on 4/18/17 and one on 4/20/17. Incident report was requested, but only the report from 4/18/17 was given. The incident report from 4/20/17 was discovered during a search into the paper charting. The Incident Report revealed the following: On 4/18/17 at 8:45 a.m., the CNA was helping Resident to the restroom to assist with morning care and directed resident to turn around back up and sit on toilet, resident did a 360 degree turn was positioned to take step back to reach toilet but instead began to sit down on floor. When asked by nurse what happened, the Resident indicated that she felt dizzy, was weak and her knees and legs hurt. No injury noted. The follow up investigation noted that nurses implemented use of standard wheelchair with frequent checks and ambulating with use of assistance with one person assist. On 4/19/17, nursing observed swelling with some redness pulse present/weak and Resident was placed in bed with legs elevation. On 4/20/17 at 11:10 am., CNA was in the hallway when she heard someone call, Help me, and when entering the room, Resident was seen lying on her back on the floor with her walker over her facing backwards. Nurses were called. Resident was lying on her back beside bed 2. Resident was sent out to the hospital with a [DIAGNOSES REDACTED]. On 6/21/17 at 8:10 a.m., a review of the Critical Incident Report revealed staff who had been assigned to the Resident seen the Resident lying in bed approximately 5 minutes before. Resident had ambulated to dining room and back to her bed. On 6/21/17 at 8:44 a.m., during a review of the paper charts for Resident #707, it was discovered that Resident #707 had a fall on 4/20/17. Hospital Discharge Summary dated 4/20/27 indicates, Patient was found on the floor at Marwood. Patient unable to bear weight on the right leg and had extreme pain in right hip region. Upon arrival to hospital, imaging test demonstrated right femoral neck fracture. Patient had surgery for [REDACTED]. On 6/21/17 at 8:55 a.m., during an interview with Nurse D when queried about the incident on 4/20/17, stated, yes she had a fall with fracture on 4/20/17 and she had one two days before. We sent her to the hospital. She have not had anymore falls. I will get you a copy of the incident report for her. On 6/21/17 at 9:30 a.m., a review of the Clinical Care Plan revealed, Resident will not have any falls thru review date. Resident will be free of injury if they do fall thru review date. On 6/21/17 at 11:33 a.m., during interview with Director of Nursing (DON), who stated, I thought I gave you the incident report for 4/20/17. Yes, she had a fall and we had to send her out. The wound care nurse had just left from the resident's room when she was discovered lying on the floor. We have put interventions in place for her. When queried about falls two days apart, she stated, yes, we know. When asked if the intervention was put in place before she fell the first time and DON stated, We noticed we were having quite a few falls with fractures, we went back to review them to see why. A review of the Facility's Policy, Falls Assessment, Intervention and Prevention with the revision date of 4/1/2014 documented the following: Falls risk assessment will be completed for every resident, upon admission, quarterly, with any significant change and after a fall. On Admit: complete a Falls Risk Assessment and falls intervention program decision tree. No fall assessment was noted in the Assessments. Resident #716 On 6/19/17 at 3:37 p.m., a review of the Care Plan revealed, Resident #716 is at risk for falls. It was also revealed that Resident #716 has impaired mobility, need for assist with all ambulation, history of falls, unsteady gait. Fall assessment reveal a score of 27 which indicates fall risk. On 6/19/17 at 4:15 p.m., a review of the Minimum Data Set (MDS) revealed Resident #716 has [DIAGNOSES REDACTED]. Further review of the MDS dated [DATE] revealed that Resident #716 has limited assistance for all transfers with one person physical assist. On 6/20/17 at 9:40 a.m., a review of the Facility Fall Incident Reports for resident #716 revealed that the Resident had three falls: 11/21/16, 3/1/17 and 3/9/17. The Incident Report revealed the following: On 11/21/16 at 6:35 p.m., Resident was getting up from electric recliner in her room and stated that she reached over to her manual wheelchair (that was locked) for support and missed it. Resident stated that she slid down to the floor and hit her back and buttock on the wall air/heating unit. Lower right side of the back slightly pink. No other injuries noted. No change in care plan indicated. On 3/1/17 at 5:50 p.m., Resident stated she was standing up and was going to pick up something that she dropped on the floor. She stated that she held on the over bed table and it rolled and she lowered her self to the floor. No injury noted. Reviewed with the resident that she has a grabber to retrieve items she has dropped or she can use the call light to get staff to assist. No change in plan of care indicated. On 3/9/17 at 6:10 p.m., another resident walked out of her room (#241) looked down the hall and noticed Resident #716 laying on her back on the floor in the dining room by the nurse's med cart with her walker at the bottom of her feet. She was laying with her feet pointed toward the windows facing Beard Street. Resident was admitted to the hospital following the fall. The resident had a [DIAGNOSES REDACTED]. The resident also sustained visible bruising to the left side of her shoulder/neck area. There were still a slight bump noted to the left side of the back of the head where the staples were. On 6/20/17 at 10:50 a.m., an interview with Resident #716 when asked about her falls, stated, I was in the dining room and wanted to go back to the room and I got up, I was walking with my walker and my knee gave out. I don't think I had my knee brace on. When asked if someone walked with her to the dining room, she stated, I don't remember if someone was with me or not. On 6/20/17 at 12:15 p.m., during an interview with Director of Nursing (DON), who stated when queried about Resident #716 fall in the dining room, Registered Aides are in there, but we don't station people in there all the time. A review of the Facility's Policy, Falls Assessment, Intervention and Prevention with the revision date of 4/1/2014 documented the following: A fall risk score of 20 or above indicates the resident is at a higher risk for falls and/or potential injury

This citation refers to intake number MI 059. Based on interview and record review, the facility failed to safely turn and reposition one sampled Resident (#501) of three sampled Residents reviewed for falls from a total sample of three, resulting in a preventable fall when the Resident was rolled away from staff and out of bed, which resulted in acute fractures of both the left and right thigh bones. Findings include: On 1/6/15 at 9:30 a.m., a review of the facility's Unusual Occurrence Report and investigation dated 12/19/14 at 4:55 a.m., revealed the following: Certified Nursing Assistant (CNA) Staff "A" was assisting (Resident #501) with care when Resident (#501) rolled out of bed onto her knees. Nurse Staff "B" was notified and assessed Resident (#501) and documented the following; Blood pressure 164/86 (normal 140/80), pulse 59 (normal 60- 100), respirations 22 (normal 16-20), bruising to both knees and top of right foot. Ice applied and pain medication given. STAT (immediate) X-ray ordered. X-ray results, fracture of right and left femur. Resident #501 transferred to an acute care hospital. Per the Unusual Occurrence Report, Resident (#501)'s transfer status at the time of the incident, "mechanical lift, non-ambulatory with [DIAGNOSES REDACTED]. Further review of the facility investigation documentation revealed the following: An x-ray report dated 12/19/14 at 9:24 a.m., which documented "Acute appearing right distal femur fracture" and "Acute appearing left distal femur fracture." A Nurse's note dated 12/19/14 at 12:24 p.m., documented "Tylenol administered at 7:10 a.m. for complaint of pain to bilateral knees and legs, with minimal effect. Blue bruise noted to both knees with hematoma (a localized collection of blood outside the blood vessels, usually in liquid form within the tissue) to left knee. . .Resident (#501) continues to complain of pain to bilateral knees and legs. . . Scheduled Norco (narcotic pain medication) administered at approximately 11:00 a.m. with positive effect. . .radiology report received at 11:45 a.m., conclusion: Acute appearing right distal femur fracture, acute appearing left distal femur fracture. . . at 12:36 p.m., received call to send to ER (emergency room ) for evaluation and treatment." A statement from Resident #501 taken on 12/19/14 at 12:45 p.m., by Unit Manager, Staff "D" documented "Resident (#501) did not recall the fall or being on the floor. (Resident #501) stated that she went to take a step and fell down. " A statement from CNA "A" per phone on 12/19/14 at 1:00 p.m., taken by Staff "D", and a written statement by CNA Staff "A" (undated) documented, Staff "A" was providing incontinence care to Resident (#501). When Resident "Grabbed her side rail and started to pull herself on her left side as CNA (A) gently assisted her. . . (CNA "A") was behind resident cleansing her buttock area (on right side of Resident's bed). (Resident #501) "Started to slide off of the bed. . ." Resident (#501) "Moved her right leg over the left side of the bed, and as a result, both of her legs started to go over the side of her bed. At that point CNA (A) tried to hold on to her to prevent her from going over the edge, and was yelling out for someone to come help. . (Resident #501) continued to roll off the (left) side of the bed. (Resident #501) was still holding on to the side rail when her legs went over the bed and she ended up on the floor with her legs bent at the knee and behind her right side." A statement (undated) written by CNA Staff "E", documented she was in another resident room and "Heard (CNA "A") yelling for help. . . and found her (CNA "A") with Resident (#501) (who was) on the floor. (CNA "A") told (CNA "E") that she was changing (Resident #501) when she rolled over too far and slid out of the bed." On 1/6/15 at 10:30 a.m., Resident #501's Electronic Medical Record (EMR) was reviewed and revealed the following documentation: Resident #501 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessments dated 8/10/14 and 11/9/14, Resident (#501) was severely cognitively impaired, required extensive assistance of one person for transfer, bed mobility, dressing, hygiene, bathing and toileting, and was always incontinent of bowel and bladder. A review of the Occupational Therapy service sheets dated 5/14/14 to 7/7/14, documented, Resident (#501) was a "long term care resident with increased pain. . .severe active range of motion/strength deficiency secondary to Osteoarthritis and poor self positioning." Resident's reason for referral "Recent decline in functional mobility. . .LE (lower extremity function). . .decline in ADL's, weakness, decreased safety awareness. . ." Occupational therapy sessions dated 5/22/14, 5/31/14, 6/6/14, 6/9/14, 6/13/14, 6/16/14, and 6/27/14 documented services provided included "bed mobility. . . and rolling side to side. . ." An Occupational Therapy outcome note dated 6/16/14 documented "Attempt at bed mobility continued (to require) max pa (maximum person assistance) of at least one person. PT (Resident) is very resistive to any increase in self independence and will verbalize she wants others to take care of her personal needs." An Occupational Therapy outcome note dated 6/27/14, documented, "Functional outcome, Pt unable to perform any activity for self mobility in bed. Pt refuses to self groom. . .Pt. has decreased recall for activities and does not recall any therapy sessions." An Occupational Therapy discharge summary dated 7/7/14, documented Resident #501 "Requested to be discharged " and was discharged as "maximum assist to dependent for toileting, bathing dressing, grooming and transfers." Fall assessments dated 4/2014, 5/2014, 8/2014 and 11/2014 documented Resident (#501)'s score as "20". Per the fall assessment "fall interventions should be initiated if score over 20 and if score is above 20 and no devices are being initiated, write justification statement on back with date and signature." Resident #501's fall assessment did not have any notations on the back. The Plan of Care dated 8/19/14, titled "ADL (activities of daily living) deficit" documented the following: "Problems/strengths. . .Resident requires extensive assistance with ADL's, and is at risk for falls, potential for decline in physical and cognitive status related to diagnoses. . .secondary to anemia, cognitive loss, communication deficit, impaired mobility, incontinence of bowel and bladder, non-compliance, unable to ambulate without assistance. . .Resident with moderate/severe cognitive loss, staff to 'anticipate resident needs' and assist with ADL's." Interventions included: "Resident needs extensive assistance with toileting, wears brief, check and change every two hours and prn (whenever necessary). . .extensive assistance with personal hygiene and bed mobility. . .staff will ensure resident is turned every two hours in bed. . .resident needs total assistance with transfers (mechanical) lift. . ." On 1/6/15 at 1:20 p.m., CNA Staff "F"stated he had cared for Resident #501, several times in the past. Staff "F" stated, Resident #501 was a one person assist but "I would always use two people for my comfort. . .I would always pull her to me before I turned her over. . .I can't imagine how she fell out of bed." On 1/6/15 at 1:55 p.m., Supervisor Staff "C" stated "I was the supervisor that night (12/19/14) and I got a call that she (Resident #501) had a fall. When I entered the room Resident #501 was on the floor. CNA"A" said (Resident #501) rolled too far when she was changing her. (Resident #501) had both hands on the grab bar and her legs went off the bed onto her knees.. . The bed was waist high. . .CNA "A" said she tried to hold onto her but couldn't. . ." Staff "C" said "(Resident #501)'s bed had always been against the wall. I asked (CNA "A") why her bed was not against the wall. She didn't know. Resident (#501) was larger and needed a bigger bed. . . If she was in the center of the bed and rolled to the side she would be on the edge of the bed. I assessed her. She said her legs were hurting below the knees. She landed on her knees. She had bruising starting and redness of both knees. . .x-rays ordered. In my opinion is it wasn't safe because of her size and her bed being away from the wall. . . (Resident #501) would try to assist, by lifting her leg over and lift her butt. But needed assistance." On 1/6/15 at 3:50 p.m., CNA Staff "G" stated "(Resident #501) required a lot of care. She was alert and could help. She would swing her top leg over, but needed help with the top leg and could hold onto the (grab) bar to roll over. She was a large woman and took up the majority of the bed. . .I was very surprised that she fell . I would pull her towards me then roll her." CNA G" stated "How do you roll a resident off a bed? When you are the CNA you look at the resident and the size of the resident and decide if you need another person on that side (rolling the resident away from you). You can feel when a resident who rolled is stable and they aren't going to move." On 1/6/15 at 4:00 p.m., Nurse "B" stated, (Resident #501) was very anxious, and had been physically declining. She didn't move much but did try to help you. She would pull herself towards the edge of the bed. She could move her legs. I ordered a bigger bed for her that night (after the fall). . . When I got there the Resident (#501) was screaming ouch and said her legs hurt. Her knees were bruised. . .The CNA (A) said when the Resident (#501) turned, the top leg went off the bed and the weight pulled her off the bed. . ." On 1/6/15 at 4:05 p.m., CNA "A" was interviewed per phone. CNA "A" stated she was assigned to (Resident #501) on the midnight shift on 12/19/14. She stated, "At 4:55 a.m. (Resident #501) had a bowel movement. I rolled her away from me to clean her, and she put her top leg over the other leg. . . I was changing her and her leg went over the bed edge. I was trying to hold her on her hips and her legs were dangling. She was holding onto the side rail. I was yelling for help for maybe a minute or so. She (Resident #501) was sliding off and went off the bed with her knees under her towards her butt out to the side and was still holding onto the side rail with her bottom on the floor. The bed was raised to my hip level. . .She was trying to help me and went off the other side (of the bed). She was a bigger woman and the bed wasn't big enough. Because of her size even if she was in the center of the bed when she rolled she would have been near the edge of the bed. . . After the fall I talked to other CNA's and they said it wasn't uncommon for her to do that, move her legs like that, one leg over the other. I have always been taught to roll the resident away and make sure they are centered in the bed. . . .Her bed was not against the wall, and in the past it had always been against the wall." When asked if she had received any in-service training after the fall, CNA "A" replied "No." On 1/6/15 at 4:40 p.m., The facility Director of Nursing (DON) was queried regard Resident #501's fall. The DON stated "To my knowledge the Resident did not move on her own and at this time (12/19/14) she tried to help and her leg moved forward and she followed it. I didn't read the report. (The DON then picked up report and investigation for review). The DON then stated "No one passed on to me the Resident (#501) needed a larger bed. I was told she normally did not move and this one time she moved her leg and fell ." The DON was informed staff CNA interviews revealed Resident #501 often tried to assist and moved her legs. The DON replied "I was not informed of that." A review on 1/6/15 at 4:50 p.m., of the facility policy titled "Lifting, Transferring and Repositioning Residents" dated 4/1/14 documented the following: "It is the policy of (facility name) that all resident transfers, lifting, or repositioning is done safely and appropriately to protect the employee and resident from injury. . .Staff: Be accountable for utilizing proper body mechanics, lifting techniques and resident safety. . .Utilize the proper transfer, lift, or repositioning procedure for each resident, applying proper body mechanics. . ."

This citation has two deficient practices. Deficient practice #1: Based on observation, interview, and record review, the facility failed to consistently implement appropriate safety devices and/or provide adequate supervision for four (#'s 502, 508, 510, and 527) of 23 sampled residents reviewed for incidents and accident hazards from a total sample of 32, resulting in falls, skin tears, lacerations, hematomas, and fractures. Findings include: Resident #502 On 3/19/14 at 10 AM, resident #502 was observed sitting in a wheelchair with a fall safety alarm. The resident was alert, but confused and unable to answer open-ended questions. On 3/21/14 at 11:15 AM, resident #502's clinical record and "Unusual Occurrence" (UO) Reports were reviewed with unit nurse manager 'F'. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Nurses notes dated 10/4/13 documented: "Resident newly admitted with right hip surgery (performed on 10/1/13), incision closed with surgical glue." The 10/23/13 MDS also noted that the resident had severe cognitive impairment, was non-ambulatory, and required extensive assistance for transfers and bed mobility. Review of a "Falls Intervention Program Decision Tree" written by nurse 'G' dated 10/4/13 for resident #502 noted: "Is resident attempting to transfer unassisted?" The answer was "Yes." The decision tree also noted: "Needs supervision in bathroom." A "Falls Risk Assessment," dated 10/4/13 by nurse 'G' noted: "Poor safety judgement attempts to transfer/ambulate unassisted." The resident admission falls risk score was 33 (a score of 20 or more=high risk). On 10/4/13, a low bed and a sensor alarm for the bed, to alert staff of self transfer attempts, were implemented. There was no alarm added to the wheelchair. Two UO reports for resident #502, both dated 10/6/13, revealed that the resident had to be transported to the hospital emergency twice that day with the following details: 1. At 10:25 AM, a visitor reported to staff that the resident was on the floor in her bathroom. When staff went to the room, "observed resident on floor next to toilet and beside the wheelchair" and "the resident self transferred and used the toilet." The resident was "laying on back, right leg externally rotated" and "rubbing right thigh." The resident was "transferred from bathroom floor by EMS (emergency medical services)" to the hospital. A hospital right hip x-ray, dated 10/6/13, was negative for fracture. Nurses notes dated 10/7/13 documented that the resident also sustained "a large skin tear on her right upper arm" from this fall. The resident was transported back to the facility the same day. The immediate action to prevent reoccurrence: "Sensor alarm to wheelchair." 2. At 10:10 PM, a nurse aide "found resident (#502) lying beside her bed....on her right side....Had blood on the floor and blood in her hair on the right side of her head....bed alarm did not sound....Transferred to (the) hospital emergency room ...." The resident's fall risk score had increased to 40 by the time this fall occurred, per the UO report. Review of hospital emergency department notes, dated 10/6/13, revealed: "....Scalp laceration....closed with staples x 2" and "....left cerebral subdural hematoma (a collection of blood outside of the brain from severe head trauma)...." A witness statement by nurse 'M' dated 10/7/13 noted that during this fall, steri-strips had to be applied to the right arm skin tear that was sustained during the first fall that morning. A witness statement (undated) by nurse aide 'N' noted: "We didn't hear the bed alarm." The immediate action to prevent reoccurrence: "(Maintenance staff) to get bed alarm fixed...." A follow-up statement on the UO report written by unit manager 'F' noted that the bed alarm had to be replaced. Regarding the second fall, when queried regarding why staff was unaware that the bed alarm was not working, manager 'F' said, "It was working when we first applied it" (on 10/4/13) and did not respond when asked if the alarm was re-checked since then or how often staff was suppose to check the function of the alarm. On 3/21/14 at 1 PM, the following two UO reports for resident #502 were reviewed with nurse unit manager 'H': 1. On 2/13/14, the resident sustained [REDACTED]. The resident "stood up unassisted" in the bathroom and fell . The fall risk score was 42 when the fall occurred. Immediate action to prevent reoccurrence: "Educate staff....to keep resident in view at all times while in bathroom and giving care." When asked about details of the incident, nurse manager 'H' said, "The aide turned her back during care and she (the resident) fell ." 2. On 2/27/14 at midnight, resident #502 was observed lying on her right side "on the floor" by the bed. The resident sustained [REDACTED]." Per nurses notes dated 2/27/14, the resident pointed to the right hip when asked if she was in pain. The fall risk score was 47 when the fall occurred. A stat (immediate) hip x-ray taken at the facility was negative for fracture. Per a follow-up note on the UO report by manager 'H': "Soft (cushioned) mat placed next to bed to protect from injury." At 1:30 PM, a review of resident #502's "Self Care Deficit' care plan dated 11/5/13 revealed an intervention: "Resident is to have supervision in bathroom at all times." There was no mention in the care plan of checking the functioning of safety equipment (alarms). ( ) Resident #510 On 3/18/14 at 9:40 a.m., during the initial tour accompanied by the Unit Manager (Nurse "F"), Resident #510 was observed lying in a low leveled bed wearing a sling to her right arm. Nurse "F" reported Resident #510 had a recent fall in the facility and sustained a fracture. On 3/18/14 at 3:40 p.m., review of an incident report regarding Resident #510, dated 2/22/14 at 12:40 a.m., revealed documentation that read: Per Certified Nursing Assistant (CNA "Z"), "Was walking with resident and walker when I turned head back I saw res (resident) butt hit the floor then res layed on the floor on her back." The incident report indicated that Resident #510 sustained a left shoulder fracture. Under the subtitle "Immediate Action: What Will You Do To Prevent it From Happening Again? read the following intervention: "Have staff walk behind resident. Use gait belt for transfers till fx (fracture) healed and wearing sling." The fall score indicated on the incident report prior to the fall was 22 (at risk for falls). The fall score after the fall with the fractured left shoulder was 25. Review of the radiology report, dated 2/22/14, indicated there was a "fracture of the neck of the left humerus (left shoulder)...mildly foreshortened mildly rotated." The final impression was: "Mildly displaced, foreshortened rotated fracture of the neck of left humerus." Review of the facility's form titled, "Transfer Summary," dated 2/22/14, indicated that Resident #510 was walking to the bathroom with her walker, fell on buttocks and complained of left shoulder/arm pain. The transfer summary did not indicate that Resident #510 was being assisted to the bathroom with the assistance of CNA "Z" at the time of the fall. The Transfer Summary also indicated that Resident #510 was alert with confusion and required limited to extensive assistance for activities of daily living (ADL's). On 3/20/14 at 9:50 a.m., Resident #510 and her daughter (Daughter "Y") were observed at the bedside talking. Resident #510 was queried regarding her left arm. Resident #510 stated, "I fell while going to the bathroom. Daughter "Y" stated, "The emergency cord in the bathroom is too short. My mom had to lay on the bathroom floor for a while before someone finally came to help her up off the floor. They (the facility) said they found her on the floor." Resident #510 was asked if she was being assisted to the bathroom. Resident #510 answered "No." Resident #510 reported that she used the walker for assistance and there was no one present during the time of the incident. Daughter "Y" stated, "They called me at home and said they found her on the floor." On 3/20/14 at 1:35 p.m., review of the nurse's note with the Director of Nurses (DON), dated 2/22/14 at 1:12 a.m., revealed documentation that read: "0040 (12:40 a.m.) called to resident room related resident having a fall. Entered resident room to find resident lying on floor on back. Per resident "I was going to the bathroom." Resident complained of left shoulder and arm pain. Resident unable to grip this writer's hand..." On 3/20/14 at 1:45 p.m., the DON and the Unit Manager (Nurse "F") were queried regarding the incident. The DON reviewed the incident report regarding the fall and stated, "She (CNA "Z") wouldn't say she was walking with the resident if she didn't." Nurse "F" stated, "Her ambulation status was modified independence. She could walk alone with the walker." Review of Resident #510's "Falls Risk Assessment, dated 1/24/14, identified Resident #510 at a risk for falls with an assessment score of "22." The assessment indicated to "initiate falls intervention program if score over 20 and update RCP (resident care plan)." On 3/20/14 at 2:50 p.m., record review of the following revealed: Resident #510's face sheet revealed an admission into the facility on [DATE] and a re-admission on 2/27/14. Review of the history and physical revealed the following Diagnoses: [REDACTED]. Review of the most current quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #510 was cognitively intact, required limited to extensive assistance for ADL's, required limited assistance for transfers with the assistance of one, and required supervision (oversight, encouragement, or cueing) while walking in her room. On 3/21/14 at 12:55 p.m., Nurse "F" was queried as to why CNA "Z" did not use a gait belt (per the facility's policy) while ambulating Resident #510 to the bathroom during the time of the fall. Nurse "F" stated, Not everyone is a candidate for the use of a gait belt. She (Resident #510) transferred independently. Several attempts were made to contact "CNA "Z" by way of telephone, but was unable to make contact. ( ) Resident #508 On 3/19/14 at 9:20 a.m., while making resident observations on the Dockside Unit, the Registered Nurse (RN) Clinical Manager (Staff "B"), approached and said Resident #508 had a fall in her bathroom while being assisted by a Certified Nursing Assistant (CNA) at about 9:00 a.m. this morning. Staff "B" said the Nurse Practitioner was coming to assess Resident #508 and a STAT (immediate) x-ray of the left leg had been ordered. On 3/19/14 at 9:30 a.m. Resident #508 was observed in her room in bed. When queried about her fall she stated, "I walked with my walker to the bathroom with (CNA name) (identified as Staff "A"), and my left leg gave out and I went down on it. She (Staff "A") straightened the leg and got help right away. She (Staff "A") was trying to help me, but my leg just gave out." Resident #508 said she had a fall a few weeks ago in her room when her left leg "gave out" also. Resident #508 verbalized pain to her lower left leg. Staff "B" was applying ice and providing pain medication. On 3/19/14 at 9:45 a.m. CNA (Staff "A") who had assisted Resident #508 earlier at the 9:00 a.m. fall, was queried regarding the fall. Staff "A" stated "she (Resident #508) walks with a rolling walker and a gait belt. She has her own big gait belt but I couldn't find it and my gait belt didn't fit her. At first I had the back of her pants to guide her, she had the walker and got all the way into the bathroom and to the toilet. When she started to turn towards the left, she lost her footing and her left leg and foot went forward and she landed on her butt with her left leg under her. It looked like she bumped her head on the toilet paper rollers and she said she hit her back. . . I asked if she was ok. She was saying my leg, my leg, my leg. She wanted me to move it. I moved it and she said it was better. She was sitting slouched against the wall with her legs out. I got the nurse. . . Later I wrote up an unusual occurrence about what happened." On 3/19/14 at 10:15 a.m. a review of Resident #508's clinical record revealed she was originally admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #508's cognition was intact, and functional status noted she required extensive assistance of two persons for bed mobility and transfer, and extensive assistance of one person for ambulation and toilet use. The MDS section "Balance During Transitions and Walking" documented Resident #508 was "not steady", and only able to stabilize with staff assistance when moving from seated to standing position, while walking, during turning around, when moving on and off toilet and for surface to surface transfer. Per the "Resident Profile" (undated) Resident #508's transfer status was assist with gait belt and rolling walker. The Resident's 2/14/14 Care Plan titled "Resident Needs" documented, needs extensive assistance with one person for toilet use, and assistive devices as needed. A Nurse's note dated 3/19/14 at 9:21 a.m. documented resident #508 had fallen in the restroom while transferring to the toilet. Resident states "I think I broke my knee." STAT x-ray of the left knee and ankle ordered. Staff "B" provided a copy of Resident #508's STAT x-ray report dated 3/19/14 at 12:30 p.m., which revealed, " New acute displaced, periprosthetic proximal tibial (lower leg shin bone) fracture is partially seen. Conclusion: Periprosthetic tibial fracture. Findings are new from 2/16/2014." Staff "B" provided a copy of the Unusual Occurrence" (OU) report dated 3/19/14 at 9:00 a.m. According to a written statement signed by CNA, Staff "A" she was "walking resident (#508) to the bathroom, resident lost her footing, left leg went under her butt. Resident bumped her head on the toilet paper rollers." Resident #508 was documented on the report as alert and oriented times three (person, place and time) and her transfer status was "TWA, R/W, GB (transfer with assist, rolling walker, gait belt)." Resident was transferred to hospital for evaluation and treatment. Fall score prior to event 16, fall score after event 19 (a score of >20 indicates initiation of falls intervention program). On 3/20/14 at 1:40 p.m. the Physical Therapy Assistant (PTA) Staff "C" was interviewed. She said she treated Resident #508 approximately five days a week since 2/2/14. She reviewed her notes on the electronic clinical record and stated, that on 2/2/14 Resident #508 was able to walk short distances with a rolling walker and gait belt in therapy but was labored and required rest periods. When queried about the use of gait belts, Staff "C" said residents who are ambulatory wear the gait belt at all times unless they are in bed. . ." Staff "C" said Resident #508 had her own gait belt she brought from home. She said Resident #508 had been upgraded at one point to self transfer from the bed to the bedside commode, but it was discontinued after a fall on 2/16/14, when she was changed to "transfer with two persons to stand then, one person with gait belt for ambulation. . ." Staff "C" said on 3/19/14 (at the time of the fall), Resident #508's transfer and ambulation status on the unit was contact guard (holding onto the resident) with a gait belt and rolling walker." On 3/21/14 at 1:00 p.m. the facility Director of Nursing (DON) was queried regarding Resident #508's fall. The DON said "My understanding was the resident had been walking well in therapy at the time. The CNA got her into the bathroom and when the resident went to pivot and sit, she got her feet tangled and she fell ." The DON said she was not aware if Resident #508 required a gait belt or that the CNA had transferred the Resident without the use of the gait belt. The DON reviewed Resident #508's Care Plan and Resident profile and said "according to this a gait belt should have been used." ( ) Resident #527 On 3-20-2014 at 12:00 P.M., resident #527 was observed sitting up in wheelchair at a dining room table. It was noted that the resident had a healed laceration to the forehead and was holding her right hand. The resident stated, "I had a bad fall a couple weeks ago when I fell on my face. Someone helped me after. I hurt my face, shoulder and right hand." On 3-20-2014 at 12:30 P.M., the facility's Unusual Occurrence Report and Progress Notes dated 2-22-2014 at 2:15 P.M. were reviewed. It identified that resident #527 was found on the floor in the bath room at around 12:25 P.M.,"Employee "K" (Certified Nurse Aide) stated that the resident #527 was on the toilet when employee "K" went to turn off the bed alarm. Resident #527 stood without warning and fell . Resident #527 was assessed with [REDACTED]. The resident complained of pain in right thumb and left knee. Pressure was applied to the forehead laceration until EMS (Emergency Medical Services) arrived. The physician and family were notified. The resident was transferred to hospital at 1:05 P.M. with physician orders [REDACTED]. The resident returned from the ER (emergency room ) at 6:15 P.M., status [REDACTED]. [DIAGNOSES REDACTED]." On 3-20-2014 at 2:00 P.M., resident # 527's clinical record was reviewed. The resident's current admission was 2-6-2014. [DIAGNOSES REDACTED]. The "Nursing Home Resident Assessment and Care Screening" dated 2-13-2014 noted cognitive skills that were severely impaired. The resident required limited to extensive assistance with transfers and ambulation in room. The resident required extensive assistance with use of toilet and a one person physical assist. A fall risk assessment dated [DATE] noted score of 42 (initiate fall intervention program if score over 20). The fall intervention program dated 2-6-2014 noted that the resident is not safe to transfer unassisted and needs supervision in bathroom. A plan of care was in place, dated 2-18-2014, and noted fall risk due to past history of syncope and generalized weakness. Interventions included providing assistance with toilet use. On 3-20-2014 at 2:55 P.M., employee "I" a Registered Nurse was interviewed. She stated, "I was sitting at the nurse station when the room light went off. I hear a loud noise from the nursing station. Employee "K" came out and said that the resident was on the floor. I went into the room and resident #527 was bleeding profusely, we applied pressure but needed to stop the bleeding. The physician was called and ordered to send the resident to hospital for treatment. Resident #527 had attempted unassisted ambulation and fell face forward. According to our protocol for residents at high risk for falls, employee "K" should have never turned his back on the resident. It is protocol for high risk residents to not be left alone in bathroom, to remain inside the bathroom or close to the door." On 3-21-2014 at 9:45 A.M., employee "L" a Nurse Supervisor was interviewed. She stated, "I was notified of the incident upon arrival, 2:30 P.M., of Resident #527's fall. This prompted me to complete an assessment and obtain statements. I spoke with the certified nurse aide, employee "K" and he completed a written statement. He had placed the resident on the toilet and should have stayed until he had completed assisting the resident. He went to turn off the call light. When he turned the resident attempted to stand and fell . The fall risk protocol identify not to leave a fall risk resident unattended in the bathroom." On 3-21-14 at 11:30 A.M., employee "K" a Certified Nurse Aide was interviewed, by phone. He stated, "I am not comfortable talking with you." But, he verified making a written statement for the facility dated 2-22-2014. The written statement is as follows, "I responded to the bed alarm. When I walked into her bedroom I found her halfway into the bathroom walking with no assisted device. Then I guided her to the toilet. Once sitting I headed back to the bed leaving the bathroom door open to disable the sounding alarm. When I turned around the resident was attempting to stand up. The resident fell , face first still holding onto the commode chair." ( ) On 3/21/14 at 2:30 P.M., per review of the facility's policies on "Gait Belts" dated 10/2008, "Lifting, Transferring and Repositioning Residents" dated 6/1/2011, and "Falls Assessment, Intervention, and Prevention" dated 3/27/2013: -"Gait Belts" policy, will provide gait belts to aid in walking and assisting residents who do not need lifting...." -"Nurses and aides will use a gait belt on all residents who need minimal assistance with balance...." -"Lifting, Transferring and Repositioning Residents" policy will ensure that all resident transfers, lifting, or repositioning is done safely and appropriately to protect the....resident from injury." -"Falls Assessment, Intervention, and Prevention" policy identified residents at risk for falls, in order to prevent and/or decrease the number of falls through early identification and implementation of preventative interventions. All residents are considered at risk for falls." -"A falls risk score of 20 or above indicates the resident is at risk for falls and/or potential injury." ( ) Deficient Practice #2 Based on observation, interview, and record review, the facility failed to maintain a hazard free Resident environment by allowing an unsafe hot water temperature, at the bathroom hand sink for one of one Supplemental Sampled Resident (#110)'s hand sink of 22 randomly sampled Resident bathroom hand sinks located throughout the facility, resulting in the potential for skin burns and/or discomfort to the Resident. Findings include: On 3/19/14 at 10:30 A.M., during general observations of the facility with the Facilities Manager, Supplemental Sampled Resident #110 was observed entering the bathroom unassisted in room #186. On 3/19/14 at 10:35 A.M., the water temperature at the hand sink of Supplemental Sampled Resident #110, in Room #186, was measured using a calibrated digital probe thermometer and observed at 125 degrees Fahrenheit (?F), exceeding the maximum allowed temperature of 120?F. The Facilities Manager, using his probe thermometer confirmed the temperature reading of 125 ?F. At 10:40 A.M., the Facilities Manager was queried as to why the hand sink water temperature was above the maximum allowed water temperature. The Facilities Manager stated, "There are individual controls for each location (water faucets and showers throughout building). The boiler is set to 125 to 126 (?F)." When queried as to how often water temperatures are monitored throughout the facility, the Facilities Manager responded, "We check water temperatures every month, 4 to 5 (different locations) on each unit. It takes 4 to 5 months to hit every room." On 3/19/14 at 12:00 P.M., Supplemental Sampled Resident #110's active clinical record was reviewed. The Resident's face sheet indicated the Resident was admitted into the facility on [DATE]. The Resident's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident's [DIAGNOSES REDACTED]. The MDS Assessment also documented the Resident's was continent of bowel and bladder, and ambulated independently throughout facility. The facility's policy on domestic hot water temperatures was requested. A policy with an issue date prior to 3/21/14 was not provided during the survey. ( )

THIS CITATION HAS THREE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1: BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ONE (#528) OF 22 RESIDENTS REVIEWED FOR FALLS, OUT OF A TOTAL SAMPLE OF 30, RECEIVED SUPERVISION AND SAFETY DEVICES TO PREVENT FALLS, RESULTING IN A FALL WITH INJURIES INCLUDING AN ACUTE EXTRA-CEREBRAL HEMORRHAGE (UNCONTROLLED BLEEDING AROUND THE BRAIN) REQUIRING EMERGENCY hospitalization . FINDINGS INCLUDE: ON [DATE] AT 2:00 P.M., RESIDENT #528'S CLOSED RECORDS WERE REVIEWED WITH THE UNIT MANAGER, NURSE "I" AND THE FACILITY ABUSE/ QUALITY ASSURANCE (QA) COORDINATOR "R", RESIDENT #528 WAS admitted INto the facility on [DATE] WITH A [DIAGNOSES REDACTED]. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] REVEALED RESIDENT #528 HAD MODERATELY IMPAIRED COGNITION (DEMENTIA) AND NEEDED LIMITED PHYSICAL ASSISTANCE FROM ONE STAFF FOR AMBULATION (WALKING), AND NEEDED HUMAN ASSISTANCE TO MAINTAIN BALANCE. A FACILITY FALL RISK ASSESSMENT, DATED [DATE], REVEALED RESIDENT #528 WAS AT RISK FOR FALLS, WITH A SCORE OF 28 (FACILITY FALLS INTERVENTION PROGRAM INITIATED FOR SCORES GREATER THAN 20.) THE FALLS RISK ASSESSMENT NOTED RESIDENT #528 NEEDED TO BE ON THE "STAR SUPERVISION PROGRAM", DUE TO CONFUSION AND UNSTEADINESS. THE ASSESSMENT NOTED THAT RESIDENT #528 USED A RESTRAINT FREE ALARM IN BED AND/OR WHEELCHAIR. REVIEW OF NURSING CARE PLANS FOR RESIDENT #528 REVEALED A CARE PLAN FOR ACTIVITIES OF DAILY LIVING (ADLS) DATED [DATE] WHICH CONTAINED THE FOLLOWING INSTRUCTIONS FOR CARE: 1. "RESIDENT NEEDS SUPERVISION WITH POSITIONING IN RECLINER CHAIR, DOES NOT SLEEP IN A BED. " 2. "RESIDENT NEEDS SUPERVISION WITH TRANSFERS" 3. "RESIDENT NEEDS SUPERVISION WITH AMBULATION. AMBULATE RESIDENT HAND IN HAND." UPDATED INTERVENTIONS (DATED [DATE]) "CHANGED TO WALK WITH ASSISTANCE (WWA), AND RESTRAINT FREE ALARM (RFA) IN RECLINING, WHEELCHAIR, AND DINING ROOM CHAIR", AND (UNDATED) "SENSOR PAD IN RECLINER", "RESTRAINT FREE ALARM IN WHEELCHAIR, OR IF IN REGULAR CHAIR IN DINING ROOM, RESTRAINT FREE ALARM ON IT." REVIEW OF A FACILITY "UNUSUAL OCCURRENCE REPORT" FOR RESIDENT #528, DATED [DATE] AT 5:50 P.M., REVEALED THAT THE RESIDENT HAD FALLEN IN THE DINING ROOM AFTER ATTEMPTING TO WALK WITHOUT ASSISTANCE. THE REPORT NOTED THE RESIDENT'S RESTRAINT FREE ALARM WAS CHANGED TO A SENSOR PAD ALARM IN THE RECLINING CHAIR ON [DATE] , AND RESTRAINT FREE ALARM ON THE DINING ROOM CHAIR AS POST FALL INTERVENTIONS. THE REPORT NOTED THE RESIDENT WALKED WITH ASSISTANCE AND HAD DEMENTIA. REVIEW OF NURSING A NOTE, DATED [DATE] AT 2:30 A.M., REVEALED RESIDENT #528 HAD GOTTEN UP WITHOUT STAFF ASSISTANCE, "RESIDENT SELF TRANSFERRED ONCE DURING THIS SHIFT. CAME TO DINING ROOM TO BE WITH OTHERS." THERE WAS NO DOCUMENTATION INDICATING THE SAFETY ALARM SOUNDED TO WARN STAFF. UNIT MANAGER "I" REPORTED THAT RESIDENT #528'S ROOM WAS ONE OF THE FARTHEST ROOMS AT THE END OF THE HALLWAY. NEITHER UNIT MANAGER "I", OR QA COORDINATOR "R" WAS ABLE TO EXPLAIN HOW RESIDENT #528 SELF TRANSFERED AND WALKED FROM THE ROOM TO THE DINING ROOM WITHOUT STAFF NOTICING, OR THE ALARM SOUNDING. WHEN ASKED WHETHER RESIDENT #528 HAD SELF TRANSFERRED AND WALKED WITHOUT STAFF ASSISTANCE ON OTHER OCCASIONS, THE UNIT MANAGER STATED, "I DON'T KNOW", AND REPORTED THAT UNUSUAL OCCURRENCE REPORTS WERE ONLY COMPLETED IF THE RESIDENT fell . REVIEW OF A FACILITY "UNUSUAL OCCURRENCE REPORT" DATED [DATE] AT 7:30 P.M., REVEALED RESIDENT #528 WAS FOUND ON THE FLOOR OF HIS ROOM, NEAR THE BATHROOM DOOR. THE REPORT NOTED THE RESIDENT WAS DISCOVERED BY STAFF MAKING ROUNDS. THERE WAS NO DOCUMENTATION REGARDING THE STATUS OR FUNCTIONING OF THE RESIDENT'S SAFETY ALARM. THE REPORT NOTED, " WAS MAKING ROUNDS AND FOUND RESIDENT LAYING ON HIS STOMACH WITH SMALL AMOUNT OF BLOOD UNDER HIS HEAD. BRUISE ON TEMPORAL (SKULL) REGION AND RIGHT EYEBROW. RIGHT PUPIL (OF EYE) SLUGGISH. RESIDENT TRANSFERRED TO THE emergency room FOR EVALUATION." WHEN QUERIED ABOUT THE INVESTIGATION OF THE CIRCUMSTANCES OF RESIDENT #528'S FALL ON [DATE], UNIT MANAGER "I" AND QA COORDINATOR "R" REPORTED THAT ALL NURSING STAFF ON THAT SHIFT WERE INTERVIEWED, AND NO ONE REPORTED HEARING THE RESIDENT'S SAFETY ALARM. UNIT MANAGER "I" STATED, " NO ONE SAW RESIDENT #528 LEAVE THE DINING ROOM AFTER DINNER. NONE OF THE STAFF KNEW HOW HE GOT BACK TO HIS ROOM." UNIT MANAGER "I" WAS UNABLE TO STATE IF RESIDENT #528 HAD WALKED TO THE DINING ROOM USING A WALKER WITH STAFF ASSISTANCE AND THEN SAT IN A DINING ROOM CHAIR (AS INDICATED ON THE RESIDENT'S CARE PLAN) AT DINNER ON [DATE]. THE [DATE] UNUSUAL OCCURRENCE REPORT NOTED THE RESIDENT TRANSFERED AND WALKED WITH "PERSONAL ASSISTANCE OF ONE STAFF (PA X 1). WHEN QUERIED, UNIT MANAGER "I" REPORTED THAT DINNER WAS SERVED AT 6:30 P.M., AND WAS UNABLE TO STATE HOW LONG THE RESIDENT HAD BEEN LYING ON THE FLOOR OF HIS ROOM BEFORE HE WAS FOUND AT 7:30 P.M. THE UNIT MANAGER STATED THAT RESIDENT #528 WAS AT HIGH RISK FOR FALLS, AND WAS ON THE STAR SUPERVISION PROGRAM, AND THUS REQUIRED SUPERVISION FROM STAFF. WHEN ASKED WHY NO STAFF KNEW HOW AND WHEN RESIDENT #528 RETURNED TO HIS ROOM AFTER DINNER IF HE WAS BEING SUPERVISED, UNIT MANAGER "I" STATED, STAFF WERE PROBABLY BUSY." REVIEW OF HOSPITAL RECORDS FOR RESIDENT #528 REVEALED AN emergency room (ER)PHYSICIAN NOTE DATED [DATE] AT 8:54 P.M., DOCUMENTING THE RESIDENT WAS admitted INTO THE HOSPITAL FOR BLEEDING AND TRAUMA. A CT SCAN (COMPUTERIZED AXIAL TOMOGRAPHY) OF THE HEAD DATED (FINAL REPORT) [DATE] NOTED RESIDENT #528 HAD BLEEDING AROUND THE BRAIN, "ACUTE EXTRA CEREBRAL HEMORRHAGE. SUBDURAL HEMORRHAGE MOST LIKELY." THERE IS A SMALL SCALP HEMATOMA (BRUISE WITH SWELLING) NEAR THE SITE OF THE HEMORRHAGE." THE [DATE] AT 8:45 P.M. ER PHYSICIAN NOTE DOCUMENTED THE CT REVEALED RIGHT PARIETAL (SIDE OF THE SKULL) BLEED, SUBDURAL VERSUS EPIDURAL (MEMBRANES COVERING THE BRAIN) HEMATOMA, AND NOTED DISCUSSION OF NEUROSURGERY (BRAIN SURGERY) WITH THE FAMILY. ON [DATE] AT 3:00 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING RESIDENT #528'S FALL ON [DATE] AND SUBSEQUENT TRANSFER TO THE emergency room . THE DON WAS UNABLE TO PROVIDE ANY ADDITIONAL INFORMATION REGARDING SUPERVISION AND PERSONAL ALARMS FOR RESIDENT #528 AT THE TIME OF THE FALL, BUT REPORTED THE FAMILY HAD CALLED TO ADVISE THE FACILITY THAT THE RESIDENT HAD EXPIRED. REVIEW OF THE FACILITY POLICY ENTITLED, "FALLS ASSESSMENT, INTERVENTION AND PREVENTION, REVISED [DATE], REVEALED, "THE PURPOSE OF THIS PROGRAM IS TO IDENTIFY RESIENTS AT RISK FOR FALLS, IN ORDER TO PREVENT AND OR DECREASE THE NUMBER OF FALLS THROUGH IDENTIFICATION AND IMPLEMENTATION OF PREVENTATIVE INTERVENTIONS. THE RESIDENT'S CARE TRACKER WILL INCLUDE INSTRUCTIONS FOR STAFF TO ASSURE ALL FALLS PREVENTION DEVICES ARE IN PLACE AND THAT ALARMED DEVICES ARE IN WORKING ORDER." ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO MAINTAIN A CLEAR PATHWAY FOR ONE AMBULATORY SAMPLED RESIDENT (#525) OF TWENTY-ONE RESIDENTS REVIEWED FOR FALLS OUT A TOTAL OF THIRTY, RESULTING IN THE RESIDENT TRIPPING OVER A FALL MAT AND CAUSING LACERATION TO THE FOREHEAD. FINDINGS INCLUDE: ON [DATE] AT 09:35 A.M., RESIDENT #525 WAS OBSERVED UP IN A WHEELCHAIR IN THE MAIN DINING AREA WITH BRUISES ON BOTH CHEEKS AND FOREHEAD. THE RESIDENT APPEARED CONFUSED AND WAS UNABLE TO ANSWER QUESTIONS. AT 10:40 A..M., RESIDENT #525 ACTIVE CLINICAL RECORD WAS REVIEWED AND INDICATED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA ((MDS) dated [DATE] INDICATED THE RESIDENT HAD MEMORY PROBLEMS AND WAS SEVERELY COGNITIVELY IMPAIRED FOR DAILY DECISION MAKING. ALSO INDICATED THE RESIDENT HAD A FALL WITH INJURY SINCE ADMISSION. THE RESIDENT SCORED A 14 ON A FALL assessment dated [DATE]. THE ASSESSMENT INDICATED A SCORE OVER 20," INITIATE FALLS PREVENTION PROGRAM." AT 1: 00 P.M., AN UNUSUAL OCCURRENCE REPORT DATED [DATE] WAS REVIEWED FOR RESDIENT #525. THE REPORT INDICATED THE FOLLOWING "WALKED IN ROOM, OBSERVED RESIDENT ON FLOOR BLEEDING FROM FOREHEAD. CALLED FOR ASSISTANCE, APPLIED PRESSURE TO WOUND. NOTIFIED NURSE... APPROXIMATELY 2 INCH LACERATION TO FOREHEAD WITH BRUISING UNDERNEATH, BILATERAL (B/L) ELBOWS BRUISED ON LATERAL SIDE. RESIDENT SENT OUT FOR EVALUATION TO emergency room ... SOFT MAT ON FLOOR NEXT TO RESIDENT WHEN SHE fell . INTERVENTION: KEEP WALKWAYS CLEAR. RESIDENT IS INDEPENDENT WITH AMBULATION." THE emergency room REPORT DATED [DATE] REVEALED THE FOLLOWING "THE PATIENT PRESENTS FOLLOWING A FALL AT THE NURSING HOME. PATIENT TRIPPED ON A RUG AND fell AND HIT HER HEAD ON THE EDGE OF TABLE. 1.5 CENTIMETER LINEAR SUBCUTANEOUS LACERATION MID FOREHEAD WITH MINIMAL BLEEDING. COMPUTED TOMOGRAPHY OF HEAD REVEALED "SUPERFICIAL SOFT TISSUE SWELLING OVER FRONTAL REGION." ON [DATE] AT 9:55 A.M., RESIDENT #525 WAS OBSERVED WALKING FROM HER BED NEAR THE WINDOW TO THE DINING AREA, UNASSISTED. IN THE RESIDENT'S ROOM , A FALL MAT WAS OBSERVED TO BE STORED BEHIND THE BED OF THE RESIDENT IN THE FIRST BED. AT 11:55 A.M., BOTH THE DIRECTOR OF NURSING (DON) AND UNIT MANAGER "Q" WAS QUERIED CONCERNING RESIDENT #525'S FALL. UNIT MANAGER "Q" STATED WE THINK THE FOLDED MAT MIGHT HAVE TAKEN UP SOME OF THE WALKWAY ROOM FOR HER MAYBE. NOT SURE IF THE MAT fell OR IF THE RESIDENT KNOCKED THE MAT DOWN. BUT SHE DID TRIP OVER IT. THE CNA SAID SHE PLACED THE FOLDED FALL MAT FOR BED ONE AGAINST THE WALL IN THE RESIDENT'S ROOM. PEOPLE WITH DEMENTIA TEND TO LOOK STRAIGHT AHEAD AND BECAUSE OF THIS I WOULD HOPE THAT THE WALKWAY IS LEFT CLEAR. THE DON STATED " WE DON'T HAVE A PARTICULAR PLACE THAT WE STORE THE MATS BUT WE WOULD WANT TO PUT THEM OUT THE WALKWAY OF THE RESIDENTS. ( ) DEFICIENT PRACTICE # 3: BASED ON OBSERVATION AND INTERVIEW, THE FACILITY FAILED TO ENSURE THAT POWER STRIP CORDS WERE NOT UTILIZED FOR RESIDENT CARE EQUIPMENT FOR 12 OF 96 ROOMS (#S 55, 63, 79, 80, 82, 86, 88, 89, 90, 91, 93, AND,101). THE FACILITY ALSO FAILED TO ENSURE THAT AN EXTENSION CORD WAS NOT UTILIZED IN ONE (ROOM #101) RESIDENT'S ROOM. THIS HAD THE POTENTIAL TO AFFECT THREE (#'S 509, 512, 524) OF 27 SAMPLED RESIDENTS AND 17 SUPPLEMENTAL SAMPLED RESIDENTS (#S 59, 60, 71, 72, 77, 78, 79, 80, 81, 85, 86, 88, 89, 91, 95, 97, 98), RESULTING IN THE POTENTIAL FOR ELECTRICAL FIRES. FINDINGS INCLUDE: ON [DATE] AT 9:35 A.M., DURING A GENERAL OBSERVATION OF THE FACILITY WITH THE MAINTENANCE DIRECTOR (EMPLOYEE "E"), MAINTENANCE STAFF (EMPLOYEE "C") AND MAINTENANCE STAFF (EMPLOYEE "D"), THE FOLLOWING WERE OBSERVED: ROOM 55: (SUPPLEMENTAL RESIDENTS #'S 59 AND 60): A POWER STRIP WAS IN USE FOR AN ELECTRIC BED AND AN AIR MATTRESS. ROOM 63: (SUPPLEMENTAL RESIDENTS #'S 71 AND 72): A POWER STRIP WAS USED FOR AN ELECTRIC BED. ROOM 79: (SUPPLEMENTAL RESIDENTS #'S 77 AND 78): A POWER STRIP WAS IN USE FOR A SENSOR PAD ALARM, AND AN AIR MATTRESS. ROOM 80: (SUPPLEMENTAL RESIDENTS #'S 79 AND 80): A POWER STRIP WAS IN USE FOR AN ELECTRIC BED AND A TUBE FEEDING PUMP. ROOM 82: (SAMPLED RESIDENT #524 AND SUPPLEMENTAL RESIDENT #81): A POWER STRIP WAS IN USE FOR A SENSOR PAD ALARM, AN ELECTRIC BED, AND AN AIR MATTRESS. ROOM 86: (SUPPLEMENTAL RESIDENTS #'S 85 AND 86): A POWER STRIP WAS IN USE FOR A NEBULIZER AND AN OXYGEN CONCENTRATOR. ROOM 88: (SUPPLEMENTAL RESIDENTS #'S 88 AND 89) A POWER STRIP WAS IN USE FOR AN ELECTRIC BED AND AN OXYGEN CONCENTRATOR. ROOM 89: (SAMPLED RESIDENT #509): A POWER STRIP WAS IN USE FOR A INTRAVENOUS (IV) MACHINE, AN ELECTRIC BED, AND AN ELECTRIC WHEELCHAIR. AN ADDITIONAL POWER STRIP WAS PIGGYBACKED INTO THE ONE WITH THE MULTIPLE MEDICAL EQUIPMENT. A PHONE CHARGER WAS PLUGGED INTO THE SECOND ONE. ROOM 90: (SUPPLEMENTAL SAMPLED RESIDENT #91): A POWER STRIP WAS IN USE FOR A SENSOR BED ALARM. ROOM 91: (SAMPLED RESIDENT #512): A POWER STRIP WAS IN USE FOR AN ELECTRIC BED. ROOM 93: (SUPPLEMENTAL RESIDENT #95): A POWER STRIP WAS IN USE FOR AN ELECTRIC WHEELCHAIR. ROOM 101: (SUPPLEMENTAL RESIDENTS #'S 97 AND 98): A POWER STRIP WAS IN USE FOR A NEBULIZER AND AN AIR MATTRESS. AN EXTENSION CORD WAS IN USE FOR A TV. ON [DATE] AT 9:45 A.M., EMPLOYEES "C, D, AND E" WERE QUERIED REGARDING THE POWER STRIPS AND THE USE OF AN ELECTRIC CORD IN RESIDENTS' ROOMS. A POLICY FOR THE USE OF THE POWER STRIPS AND THE USE OF EXTENSION CORDS IN RESIDENTS' ROOMS WERE ALSO REQUESTED. WHEN ASKED ABOUT THE POWER STRIPS USED FOR MEDICAL EQUIPMENT, EMPLOYEE "E" STATED, "THOSE ARE UL (UNDERWRITERS LABORATORIES) LISTED. WE DON'T HAVE A POLICY FOR POWER STRIPS AND THE USE OF EXTENSION CORDS. THE USE OF THE POWER STRIPS HAD NEVER BEEN A PROBLEM." EMPLOYEE "D" STATED, "I AM NOT SURE IF THEY ARE MEDICAL GRADE POWER STRIPS. THERE WAS NO FURTHER EXPLANATION FOR THE USE OF THE POWER STRIPS AND THE EXTENSION CORD BY THE EXIT OF THE SURVEY. ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES: DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT SAFETY DEVICES AND PROVIDE ADEQUATE SUPERVISION FOR THREE (#'S 710, 719, AND 720) OF 18 RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 30, RESULTING IN FRACTURES, FALLS AND INJURIES. FINDINGS INCLUDE: ON 2/28/12 AT 2:40 P.M., RESIDENT #710 WAS OBSERVED IN HER ROOM, ASLEEP IN A WHEELCHAIR WITH A RESTRAINT FREE ALARM (RFA) ATTACHED. THE RESIDENT'S FEET WERE BARE, AND HER LEFT ARM WAS IN A SLING. THERE WERE NO FACILITY STAFF IN THE ROOM AND THE RESIDENT WAS OUT OF STAFF VIEW FROM THE HALLWAY. ON 3/1/12 AT 9:20 A.M., RESIDENT #710 WAS IN HER ROOM IN A WHEELCHAIR WITH AN RFA ATTACHED. THE RESIDENT WAS ALERT BUT CONFUSED. THE RESIDENT STATED SHE WANTED TO GO TO BED AND ATTEMPTED UNSUCCESSFULLY TO PROPEL THE WHEELCHAIR CLOSER TO THE BED. THE RESIDENT WAS UNABLE TO RECOGNIZE AND LOCATE THE NURSE CALL SYSTEM (CALL LIGHT) ON THE BED WHEN REQUESTED TO DO SO. ON 3/2/12 AT 9:30 A.M., RESIDENT #710'S CLINICAL RECORDS AND UNUSUAL OCCURRENCE (I&A) REPORTS WERE REVIEWED WITH THE UNIT MANAGER , NURSE "D". THE REVIEW REVEALED A FACE SHEET THAT DOCUMENTED RESIDENT #710 WAS admitted INto the facility on [DATE] AND REadmitted on [DATE] AFTER hospitalization FOR A FALL WITH FRACTURE. THE MONTHLY physician's orders [REDACTED]. THE MINIMUM DATA SET ASSESSMENTS ((MDS) dated [DATE], 11/2/11 AND 1/19/12, DOCUMENTED THAT RESIDENT #710 HAD SEVERE COGNITIVE IMPAIRMENT (DEMENTIA) AND NEEDED EXTENSIVE STAFF ASSISTANCE FOR TRANSFERS TO AND FROM THE WHEELCHAIR AND PERSONAL HYGIENE. ALL THREE MDS ' S DOCUMENTED THAT RESIDENT #710 HAD UNSTEADY BALANCE AND NEEDED STAFF ASSISTANCE FOR STABILIZATION. REVIEW OF THE I&A REPORT DATED 5/31/11 AT 5:10 A.M., DOCUMENTED RESIDENT #710 REPORTED TO THE NURSE THAT SHE HAD FALLEN IN THE BATHROOM AND HURT HER LEFT ARM. UNIT MANAGER "D" WAS QUERIED ABOUT RESIDENT #710'S FALL ON 5/31/11, SHE WAS UNABLE TO PROVIDE A SAFETY NURSING CARE PLAN OR AN ACTIVITY OF DAILY LIVING (ADL) CARE PLAN FOR RESIDENT #710 EFFECTIVE AT THE TIME OF THE FALL. SAFETY INTERVENTIONS FOR RESIDENT # 710 WERE DOCUMENTED, "RFA IN BED, CALL LIGHT IN REACH FOR RESIDENT TO ASK FOR ASSISTANCE." WHEN QUERIED, UNIT MANAGER "D" WAS UNABLE TO EXPLAIN HOW A CONFUSED RESIDENT WITH DEMENTIA WOULD CONSISTENTLY REMEMBER TO USE THE CALL LIGHT. REVIEW OF AN I&A REPORT DATED 10/12/11, REVEALED RESIDENT #710 REPORTED BUMPING HER LEFT ARM AGAINST THE WALL DURING AN UNASSISTED TRANSFER. "THE REPORT DOCUMENTED A REDDENED AREA ON THE RESIDENT'S LEFT ARM. POST FALL CORRECTIVE MEASURES WERE NOTED AS, "INSTRUCTED RESIDENT TO PLEASE USE CALL LIGHT WHEN SHE NEEDS HELP", "OBTAIN FLOOR ALARM MAT" AND "PLACE ALARM WHERE RESIDENT CANNOT REACH IT." A NOTE ON THE REPORT DOCUMENTED, "DISCUSSED WITH NURSE THAT THE RESIDENT IS CONFUSED, UNABLE TO COMPREHEND TO USE CALL LIGHT (C/L). NURSE INSTRUCTED TO PLACE ALARM WHERE RESIDENT CANNOT REACH." REVIEW OF AN I&A DATED 1/5/12 AT 10:15 P.M., DOCUMENTED THAT RESIDENT #710 " fell IN HER ROOM, RESULTING IN A BROKEN LEFT ARM, LACERATIONS (DEEP CUTS THROUGH ALL LAYERS OF SKIN) TO THE NOSE AND CHIN. THE REPORT NOTED, "HEARD FLOOR MAT (ALARM) SOUND. RAN INTO ROOM TO FIND RESIDENT LAYING ON THE FLOOR FACE DOWN WITH LEFT ELBOW OVER BOTTOM RAIL OF ROLLING WALKER. RFA ALARM BOX FROM BED IN RESIDENT'S LEFT HAND, RESIDENT STATING " MY NOSE IS BLEEDING." THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL. REVIEW OF THE HOSPITAL X-RAY REPORT, DATED 1/6/12 NOTED, "THERE IS A COMMINUTED (CRUSHED BONE) FRACTURE INVOLVING THE NECK OF THE LEFT HUMERUS WITH SOME DEGREE OF IMPACTION OF THE FRACTURED FRAGMENTS." REVIEW OF THE ADL CARE PLAN, DATED 1/6/12 (ONE DAY AFTER RESIDENT #710 fell AND BROKE HER ARM) NOTED, "LOW BED, RFA IN PLACE FOR BED AND CHAIR." WHEN QUERIED, UNIT MANAGER "D" WAS UNABLE TO EXPLAIN WHY SAFETY INTERVENTIONS TO MINIMIZE INJURY FROM FALLS FROM BED FOR RESIDENT #710 WERE NOT IMPLEMENTED UNTIL AFTER SHE fell AND BROKE HER ARM. UNIT MANAGER "D" STATED THAT PRIOR TO THE FALL, RESIDENT #710 AMBULATED WITH RESTORATIVE THERAPY STAFF USING THE WALKER, AND "PROBABLY SAW HER WALKER BY THE BED AND FORGOT THAT SHE NEEDED HELP TO WALK." UNIT MANAGER "D" WAS QUERIED WHY RESIDENT #710'S RFA WAS NOT PLACED OUT OF REACH AT THE TIME SHE fell AND BROKE HER ARM (PER PREVIOUS POST INCIDENT CORRECTIVE MEASURES), UNIT MANAGER "D" WAS UNABLE TO PROVIDE DOCUMENTATION ON THE NURSING CARE PLANS, OR THE CERTIFIED NURSING ASSISTANT (CNA),CARE TRACKER TO ALERT STAFF THAT RESIDENT #710'S ALARM SHOULD BE PLACED OUT OF REACH. WHEN QUERIED WHY RESIDENT #710'S RFA BOX ON BOTH W/C AND BED HAD BEEN OBSERVED WITHIN THE RESIDENT'S REACH ON NUMEROUS OCCASIONS DURING THE SURVEY, UNIT MANAGER "D" STATED, "I'M SURE IT'S PLACED WHERE IT'S HARD TO REACH." ON 3/1/12 AT 12:00 P.M., RESIDENT #720 WAS OBSERVED IN BED IN THE ROOM. THE BED WAS IN THE LOWEST POSITION, WITH AN ALARMING FALL MAT AND A RESTRAINT FREE ALARM (RFA) WITH BLUE CLIP (DEVICE TO PREVENT THE RESIDENT FROM DISCONNECTING THE ALARM CLIP). ON 3/2/11 AT 11:30 A.M., RESIDENT #720'S CLINICAL RECORDS AND UNUSUAL OCCURRENCE REPORTS (I&A) WERE REVIEWED WITH THE UNIT MANAGER, NURSE "D". THE REVIEW REVEALED A READMISSION INto the facility on [DATE]. THE ADMISSION MDS,DOCUMENTED RESIDENT #720 HAD MODERATELY IMPAIRED COGNITION, NEEDED EXTENSIVE STAFF ASSISTANCE FOR MOBILITY IN BED, TRANSFERS TO THE WHEELCHAIR AND TOILETING, DID NOT AMBULATE AND WAS INCONTINENT OF BOWEL AND BLADDER. THE MDS ASSESSMENTS ALSO DOCUMENTED THAT RESIDENT #720 HAD POOR BALANCE, AND NEEDED STAFF ASSISTANCE TO STABILIZE REVIEW OF AN ACTIVITIES OF DAILY LIVING (ADL) CARE PLAN FOR RESIDENT #720 DATED 4/22/11, REVEALED THE FOLLOWING INTERVENTIONS, "RESTRAINT FREE ALARM (RFA) IN BED, TOILET EVERY TWO HOURS (Q 2) AND AS NECESSARY (PRN). OTHER INTERVENTIONS INCLUDED, "PEDALS ON WHEELCHAIR (W/C), CALF BOARD (BOARD PLACED BETWEEN W/C LEG RESTS TO PREVENT RESIDENT PUTTING FEET DOWN BETWEEN LEG RESTS), AND RECLINING BACK W/C." THE I&A REPORT DATED 4/25/11 AT 2:30 A.M., DOCUMENTED, "HEARD ALARM. WENT TO INVESTIGATE, FOUND RESIDENT SITTING ON FLOOR WITH HER BACK AGAINST THE BED." THE POST FALL CORRECTIVE ACTIONS WERE NOTED AS, "SHORTEN RFA CORD", "OFFER TO TAKE TO THE TOILET WITH EACH BED CHECK", LOW BED (POSITION)", AND "BLUE BOLSTERS (CUSHION RESTRAINT TIED TO SIDES OF BED." THE REPORT NOTED THE RESIDENT #720 WAS HIGH RISK FOR FALLS PRIOR TO THE INCIDENT, WITH A FALLS SCORE OF 34 (20 OR GREATER = RISK FOR FALLS) AND "POOR SAFETY JUDGEMENT." THE I&A REPORT DATED 7/13/11 AT 5:45 P.M., REVEALED RESIDENT #720 " fell IN HER ROOM ...A BRUISE ON THE LEFT FOREHEAD AND PAIN IN THE RIGHT HIP. " A NURSING NOTE DOCUMENTING RESIDENT #720'S FALL ON 7/13/11 NOTED, "PROVIDED RESIDENT WITH POMMEL CUSHION TO GO IN WHEELCHAIR, AND NOT LEAVE RESIDENT IN ROOM WHILE IN WHEELCHAIR." THE I&A REPORT DATED 9/1/11 AT 2:40 P.M., REVEALED THAT RESIDENT #720 fell IN THE ROOM, SUFFERING A BRUISE AND A SKIN TEAR TO THE RIGHT ELBOW. THE REPORT NOTED, "RIGHT ELBOW BRUISE NOTED. 1 3/4 INCH BY 3/4 INCH SKIN TEAR, 5 STERI STRIPS APPLIED." POST FALL CORRECTIVE MEASURES NOTED ON RESIDENT #720'S I&A WERE DOCUMENTED AS, "SENSOR ALARM FLOOR MAT", AND "NEW VELCRO ON BED FOR ALARM BOX" WHEN QUERIED ABOUT RESIDENT #720'S FALL ON 9/1/11, UNIT MANAGER "D" WAS UNABLE TO EXPLAIN WHY THE ALARM HAD NOT SOUNDED TO ALERT STAFF THE RESIDENT WAS ATTEMPTING TO GET UP WITHOUT ASSISTANCE. WHEN QUERIED WHY THE ALARM BOX WAS ON THE FLOOR INSTEAD OF ON THE BED FOOTBOARD (PER CARE PLAN) UNIT MANAGER "D" STATED, "THE VELCRO CAME LOOSE FROM THE BED", BUT COULD PROVIDE DOCUMENTATION THAT CORRECTIVE MEASURES WERE IMPLEMENTED TO PREVENT THIS FROM REOCCURRING. UNIT MANAGER "D" WAS ALSO UNABLE TO PROVIDE DOCUMENTATION THAT THE ALARM BOX WAS EVALUATED TO ASSESS FOR MALFUNCTION OR THAT CORRECTIVE MEASURES WERE IMPLEMENTED TO PREVENT REOCCURRENCE. REVIEW OF RESIDENT #720 ' S "FALLS REVIEW", DATED 9/11/11 DOCUMENTED THAT RESIDENT #720 fell IN THE DINING ROOM ON 9/11/11 (NO TIME NOTED). NO FACILITY UNUSUAL OCCURRENCE REPORT WAS PROVIDED FOR THIS FALL WHEN REQUESTED. THE FALLS REVIEW REPORT NOTED, "LOCATION OF FALL: DINING ROOM. ANY INJURY: REDDENED AREA LEFT KNEE." "WHAT DEVICES ARE CURRENTLY BEING USED: RFA IN BED AND W/C. POMMEL CUSHION IN W/C, LOW BED." REVIEW OF RESIDENT #720'S ADL CARE PLAN REVEALED THE FOLLOWING NOTATION, DATED 9/11/11 "FOUND ON FLOOR IN FRONT OF WHEELCHAIR IN DINING ROOM." AN INTERVENTION DATED 9/11/11 DOCUMENTED, "NON SKID PAD IN WHEELCHAIR TOP AND BOTTOM OF CUSHION." REVIEW OF A RADIOLOGY REPORT (X-RAY) DATED 9/13/11, TWO DAYS AFTER RESIDENT #720'S FALL REVEALED THE RESIDENT HAD A POSSIBLE BROKEN BONE AND SWELLING OF THE LEFT WRIST. REVIEW OF THE physician progress notes [REDACTED]. SHE HAS SEEN ORTHOPEDICS, PLACED IN HER FOREARM CAST." WHEN QUERIED WHETHER RESIDENT #720 HAD BROKEN HER WRIST AS A RESULT OF THE FALL ON 9/11/11, UNIT MANAGER "D" STATED, "I DON'T REMEMBER. " THERE WAS NO DOCUMENTATION OR EXPLANATION WAS PROVIDED TO EXPLAIN WHETHER THERE WAS STAFF SUPERVISION IN THE DINING ROOM AT THE TIME OF RESIDENT #720'S FALL ON 9/11/11 AND WHETHER RESIDENT &720'S RFA HAD ALARMED (WAS FUNCTIONING AND APPLIED), AND IF THE POMMEL CUSHION WAS PROPERLY APPLIED. UNIT MANAGER "D" WAS UNABLE TO EXPLAIN WHY, IF STAFF WERE PRESENT, THEY WERE UNABLE TO PREVENT RESIDENT #720 FROM FALLING, AND WHY THE RFA DID NOT ALERT STAFF IN TIME TO PREVENT A FALL, OR WHY THE POMMEL CUSHION DID NOT DELAY THE RESIDENT FROM GETTING OUT OF THE WHEELCHAIR IN TIME FOR STAFF TO INTERVENE TO PREVENT A FALL. ( ) ON 3/1/12 AT 1:40 PM, RESIDENT #719 WAS OBSERVED SITTING IN A WHEELCHAIR ALONE IN HER ROOM. THE RESIDENT WAS ALERT, BUT VERY CONFUSED AND GAVE INAPPROPRIATE RESPONSES TO QUESTIONS. SHE WAS RESTLESS AND AIMLESSLY MOVING SHORT DISTANCES IN THE ROOM. ON 3/2/12 AT 10:45 AM, THE CLINICAL RECORD AND I/A REPORTS FOR RESIDENT #719 WERE REVIEWED WITH COMPLIANCE/QUALITY ASSURANCE NURSE 'F', THE ASSISTANT ADMINISTRATOR AND CLINICAL SUPPORT NURSE 'E'. THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS NOTED THAT THE RESIDENT HAD MODERATE TO SEVERE COGNITIVE IMPAIRMENT, WAS NON-AMBULATORY, REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS, MOBILITY AND HAD FALLEN AT THE FACILITY. ON 3/1/12 AT 1:40 P.M., NURSE " E " WHEN ASKED, NURSE 'E' WAS UNABLE TO EXPLAIN WHY RESIDENT #719 WAS NOT ADEQUATELY SUPERVISED WHEN OUT OF BED DURING THE INCIDENTS, OR WHEN OBSERVED ALONE AND RESTLESS IN HER ROOM ON 3/1/12 AT 1:40 PM. THE NURSE WAS UNABLE TO EXPLAIN WHY THE FALL SAFETY ALARMS WERE NOT MONITORED FOR PROPER FUNCTIONING, WHEN ASKED. I/A REPORTS NOTED THE FOLLOWING: 1. ON 6/8/11, RESIDENT #719 WAS ON THE FLOOR IN THE BATHROOM WITH "ALARM STILL ATTACHED TO CHAIR AND RESIDENT....ALARM STRING SHORTENED." NURSE 'F' COULD NOT VERIFY THAT THE ALARM SOUNDED. SHE STATED, "I DON'T KNOW." IN ADDITION, PER NURSES NOTES, THE BATHROOM FLOOR HAD JUST BEEN MOPPED AT THE TIME OF THE INCIDENT. THERE WAS NO NOTED INJURY. 2. ON 6/11/11, RESIDENT #719 WAS ON THE FLOOR BY HER BED. THE FALL SAFETY "ALARM WAS NOT TURNED ON." THERE WAS NO NOTED INJURY. THE CORRECTIVE ACTION: "NURSE AIDE) EDUCATED ALARM ON AND WORKING PROPERLY." 3. ON 7/24/11 AT 10:15 AM, RESIDENT #719 WAS ON THE FLOOR IN HER BATHROOM WITH "ALARM ON/BATTERY WORKING, DID NOT GO OFF." THE RESIDENT'S "ROOMMATE CALLING FOR HELP." THERE WAS NO NOTED INJURY, BUT "RESIDENT STATES SHE HIT HER HEAD ON THE FLOOR BY TOILET." HER FALL RISK SCORE WAS 33 PRE-FALL AND 36 POST-FALL. THE CORRECTIVE ACTIONS: TOILET RESIDENT AFTER EACH MEAL, "DO NOT LEAVE RESIDENT IN WHEELCHAIR IN ROOM ALONE," AND "NEW ALARM PLACED ON RESIDENT." PER THE NURSES NOTES DATED 7/24/11 AT 2:16 PM, "CHAIR ALARM WAS REPORTED "ON" BUT NO ALARM WAS RECORDED TO HAVE BEEN HEARD. (NURSE AIDE) CHANGED BATTERIES AND ALARM WAS REPORTED TO WORK. OLD BATTERY REPORTED TO HAVE WORKED UPON PLACING IN (ALARM) AFTER OCCURRENCE." 4. ON 7/31/11 AT 8:25 PM: "FOUND RESIDENT (#719) ON FLOOR IN ROOM, SHE SAID SHE TOOK HER ALARM OFF TO ANSWER THE DOOR. ALARM WAS NOT SOUNDING." THE resident sustained [REDACTED]. HER FALL RISK SCORE PRE-FALL WAS 38 AND 39 POST-FALL. THE CORRECTIVE ACTIONS INCLUDED: "INITIATED BLUE CLIP (ALARM)." 5. ON 12/16/11 AT 9:20 PM, RESIDENT #719 WAS ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. THERE WAS NO MENTION THAT THE ALARM SOUNDED. HER FALL RISK SCORE PRE-FALL WAS 42 AND WAS 37 POST-FALL. THE CORRECTIVE ACTION: "BLUE WEDGE TO BE USED WHEN RESIDENT IN BED (TO HELP PREVENT ROLLING OUT OF BED." NURSE 'E' WAS UNABLE TO VERIFY THAT THE ALARM SOUNDED, WHEN ASKED. 6. ON 12/17/11 AT 6:45 PM: "RESIDENT (#719) ON FLOOR NEXT TO BED. ALARM SOUNDING. RESIDENT STATED THAT SHE WAS TRYING TO GET INTO BED AND SLIPPED." THERE WAS NO NOTED INJURY. THE FALL SCORE PRE-FALL WAS 37 AND WAS 40 POST-FALL. THE CORRECTIVE ACTIONS INCLUDED: "RESIDENT TO BE PLACED AT THE NURSES STATION AFTER MEALS FOR CLOSER OBSERVATION" AND "STAFF KEEPING RESIDENT OUT OF ROOM UNTIL READY TO PUT IN BED." 7. ON 12/28/11 AT 9:17 PM, RESIDENT #719 WAS ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. THE FALL RISK SCORE PRE-FALL WAS 40 AND WAS 43 POST-FALL. THE "ALARM WAS ON BUT NOT SOUNDING." THE CORRECTIVE ACTION: "EMPLOYEE RECEIVED DISCIPLINARY ACTION RELATED TO NOT CHECKING ALARM AT BEGINNING OF HER SHIFT" AND "ALARM ON RESIDENT BUT NOT IN WORKING ORDER. REPLACED (ALARM)." ( ) ON 3/2/12 AT 1:30 P.M., THE QUALITY ASSURANCE (QA) NURSE WAS INTERVIEWED CONCERNING THE SURVEY TEAMS FINDINGS AT THE FACILITY. THE QA NURSE STATED " WE WERE AWARE IN JANUARY THAT WE HAD PROBLEMS WITH FALLS. THE ALARMS THAT WE ARE USING ARE EASILY BROKEN, SOME OF THE WIRING ARE FRAYED AND WORN. WE MADE CHANGES TO OUR FALLING STAR PROGRAM . STARS WERE PLACED ON THE BATHROOM DOORS OF RESIDENT'S WHO NEEDED ASSISTANCE TO THE BATHROOM AND WHO WERE NOT TO BE LEFT UNATTENDED DURING TOILETING. ( ) PER THE FACILITY'S "FALL ASSESSMENT, INTERVENTION, AND PREVENTION" POLICY REVISED 7/14/11: "THE PURPOSE OF THIS PROGRAM IS TO IDENTIFY RESIDENTS AT RISK FOR FALLS, IN ORDER TO PREVENT AND/OR DECREASE THE NUMBER OF FALLS THROUGH EARLY IDENTIFICATION AND IMPLEMENTATION OF PREVENTATIVE INTERVENTIONS. ALL RESIDENTS ARE CONSIDERED AT RISK FOR FALLS....A FALLS SCORE OF 20 OR ABOVE INDICATES THE RESIDENT IS AT RISK FOR FALLS AND/OR POTENTIAL INJURY. "ANY RESIDENT THAT TRIGGERS ITEMS ON THE FALL RISK ASSESSMENT THAT HAVE AN ASTERISK REQUIRES FURTHER EVALUATION TO DETERMINE THE NEED FOR STAFF SUPERVISION DURING THE TOILETING PROCESS." ITEMS WITH AN ASTERISK INCLUDED: A NEW FALL, LEGAL BLINDNESS, SLIDING DOWN IN THE WHEELCHAIR, POOR SAFETY JUDGEMENT, ATTEMPTS TO SELF TRANSFER, AND CONFUSION. AN I/A REPORT MUST BE INITIATED AT THE TIME OF AN INCIDENT AND ENSURE THAT THE ACTION TO PREVENT REOCCURRENCE IS COMPLETE. STAFF MAY INITIATE INTERVENTIONS, SUCH AS ALARMS AND FLOOR MATS AND THEN WRITE A physician's orders [REDACTED]. ( ) DEFICIENT PRACTICE #2. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SECURE AND DOUBLE LOCK CONTROLLED SUBSTANCES FOR ONE OF THREE MEDICATION CARTS ON THE INDEPENDENCE POINTE NURSING UNIT, RESULTING IN THE POTENTIAL FOR ACCIDENTAL INGESTION, ABUSE OR DIVERSION OF MEDICATION. FINDINGS INCLUDE: ON 2/28/12 AT 11:15 A.M., DURING GENERAL OBSERVATIONS OF THE FACILITY, IT WAS NOTED THAT THE MIDDLE CART ON THE INDEPENDENCE POINTE UNIT, WAS UNLOCKED AND UNATTENDED. THE MEDICATION CART WAS LOCATED IN THE HALLWAY ADJACENT TO RESIDENT ROOMS. THE HALL WAS ACCESSIBLE TO NON-CLINICAL STAFF, RESIDENTS AND VISITORS. THE MEDICATION CART WAS OUT OF VIEW OF THE UNIT NURSE. AT 11:30 A.M., ASSISTANT MANAGER, NURSE "C" APPROACHED THE MEDICATION CART. NURSE "C" WAS ASKED IF THE NURSES LOCKED THE MEDICATION CARTS WHEN UNATTENDED, AND SHE SAID "ABSOLUTELY, IT SHOULD BE LOCKED, IT IS OUR POLICY." PER THE FACILITY'S "PHARMACEUTICAL SERVICES" POLICY, REVISED 4/11; "1....THE CARTS ARE TO BE LOCKED AT ALL TIMES WHEN UNATTENDED." ( )