Every finding on record at Medilodge at the Shore

This citation pertains to intake #: 2674458Based on interview and record review, the facility failed to 1.) implement the facility policy for pressure injuries/wound management and 2.) ensure treatments were completed as ordered, for 5 of 15 residents (Resident #6, #9, #11, #12, and #13) reviewed for alterations in skin integrity.Findings:Resident #6 (R6)Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, Alzheimer's Disease, dysphagia (difficulty swallowing), peripheral vascular disease, and urinary incontinence.Review of a Minimum Data Set (MDS) assessment for R6, with a reference date of 9/19/25 revealed R6's cognitive skills for decision making was severely impaired. Further review of R6's MDS revealed there were no pressure injuries present at that time, however, R6 was at risk for the development of pressure injuries. Review of R6's Functional Abilities assessment dated [DATE] revealed that R6 was dependent on staff with eating (1:1 feeding assistance), personal hygiene, bed mobility (rolling left and right in bed), and transferring (bed to chair). Review of R6's Braden Scale for Predicting Pressure Sore Risk dated 6/17/25 and 9/17/25 revealed a score of 11 which indicated R6 was high risk for the development of a pressure injury.Review of R6's Skin Assessment dated 10/4/25 no new skin breakdown.A Skin Assessment was not completed on 10/11/25.Review of R6's Skin Assessment dated 10/18/25 revealed, Are there any new abnormal skin areas? Yes .Coccyx-opening in skin about pea sized.Review of R6's Electronic Medical Record (EMR) revealed no documentation that the provider or DPOA was notified of the pressure injury or that a wound treatment was initiated at the time of the discovery of the wound. There was no wound assessment completed.Review of R6's Incident Report dated 10/21/25 revealed, Incident Description: Pressure area observed to resident's right buttock. The physician and DPOA were not notified of the pressure injury until 10/29/25.Review of R6's Order Summary dated 10/22/25 revealed, Cleanse with NS (normal saline) and apply foam dressing to coccyx every day shift for Pressure Ulcer.Review of R6's Treatment Administration Record (TAR) revealed the coccyx pressure injury treatment was not completed on 10/26/25.During an interview on 12/10/2025 at 11:08 AM, the Director of Nursing (DON) confirmed that the licensed nurse did not follow the facility policy and procedure following the identification of skin breakdown and confirmed the missing skin assessment on 10/11/25. Review of R6's Skin & Wound Evaluation dated 10/28/25 revealed a facility acquired unstageable pressure injury on the right gluteus measuring 1.7 cm (length) by 1.0 cm (width) and 0.2 cm (depth). 70% of the wound was filled with slough (yellow/white viscous dead tissue). (The base of R6's wound bed was obscured by slough and therefore an accurate depth measurement was unattainable.) Interventions to implement were cushion, foam mattress, incontinence management, moisture control, and turning/repositioning program.Review of R6's provider Progress Note dated 10/30/25 revealed, .(R6) appears increasingly uncomfortable while wound is assessed especially when touching near the area of the wound. A pressure wound is noted to the right side of her sacrum on a bony prominence approximately 2cm x 2cm with unknown depth due to the presence of slough to wound bed. Tissue surrounding wound has discoloration with both light and dark areas surrounding. New dressing applied during visit and urinary incontinence is noted (facility Registered Nurse) tells me that they have been repositioning (R6) frequently on alternating sides using a pillow.Encouraged (facility) staff to report any acute changes or signs of infection to (provider). continue with frequent repositioning and incontinence care.Review of R6's Care Plan revealed, Resident has impaired skin integrity as evidenced by: Unstageable pressure ulcer to right buttock Date Initiated: 10/28/2025.Assist resident with turning and repositioning as needed Date Initiated: 12/24/2024. The care plan did not include the turning/repositioning program or with frequent repositioning and incontinence care.Review of R6's Skin & Wound Evaluation dated 11/4/25 revealed her unstageable pressure injury on the right gluteus now measured 2.0 cm (length) by 1.6 cm (width) and 0.6 cm (depth). The wound bed was filled with 20% slough and there was moderate serosanguineous (thin, watery, light pink fluid) exudate (drainage) with a saturated dressing. Increased pain was also identified. No new interventions were implemented. There was no documentation that the provider was notified of the deterioration of the wound.Review of R6's Wound Evaluation dated 11/4/25 revealed a handwritten order for APM (alternating pressure mattress)-ensure set to alternating.Review of R6's Care Plan revealed .Pressure redistribution mattress to bed Date Initiated: 10/29/2025. Pressure redistribution mattress to bed Date Initiated: 11/25/2025. The care plan did not include the APM settings (level 1-5) or to ensure it was set on alternating versus float.Review of R6's Skin & Wound Evaluation dated 11/11/25 revealed her unstageable pressure injury on the right gluteus now measured 1.7 cm (length) by 2.0 cm (width) and 2.0 cm (depth). The wound bed was filled with 40% slough and 60% eschar (dry, thick, dark dead tissue) and there was moderate seropurulent (light yellow, tan, indicates infection) exudate with a moderate amount of odor. Evidence of infection was documented due to increased drainage. The wound was noted to be deteriorating. New interventions to implement were a mattress with pump and repositioning device(s). A wound culture was obtained (antibiotics ordered on 11/13/25).Review of R6's Skin & Wound Evaluation dated 11/18/25 revealed her unstageable pressure injury on the right gluteus measured 2.0 cm deep with undermining: 3 o'clock 3.5 cm, 6 o'clock 5 cm, 9 o'clock 2.9 cm, and 12 o'clock 2.6 cm. The wound bed was filled with 30% and there was heavy serosanguinous exudate with a strong odor. The wound was documented as deteriorating.Review of R6's Care Plans revealed no new interventions were implemented despite the documented deterioration of the pressure injury on 11/11/25 and 11/18/25 (examples: head of bed less than 30 degrees to reduce pressure, use of a wedge offloading device, frequency of turn schedule, etc.)Review of R6's November TAR revealed he wound treatment was not completed on 11/19/25.Review of R6's Wound Clinic note dated 11/24/25 revealed a debridement surgical procedure was performed (removal of dead/infected tissue from a wound). The wound was documented a stage IV ulceration of the sacrum with the measurements 2.6 cm x 2.4 cm x 0.6 cm post debridement depth 0.9 cm undermining 12 o'clock 2.2cm, 3 o'clock 2.5cm, 6 o'clock 4.5cm, 9 o'clock 2.5cm bone exposed.Review of R6's Skin & Wound Evaluation dated 11/25/25 revealed her stage 4 pressure injury on the right gluteus measured 2.6 cm (length) by 2.1 cm (width) and 2.1 cm (depth), 2.2 cm undermining, and 3.9 cm tunnelling. There was moderate sanguineus/bloody exudate and the wound was documented as deteriorating.Review of R6's Skin & Wound Evaluation dated 12/2/25 revealed her stage 4 pressure injury on the right gluteus measured 2.7 cm (length) by 1.4 cm (width) and 1.4 cm (depth), and 3.2 cm undermining. The wound bed was filled with 20% slough and 10% eschar with a heavy amount of serosanguineous fluid.Review of R6's Skin Issues evaluation dated 12/9/25 revealed her stage 4 pressure injury on the right gluteus measured 2.53 cm (length) by 1.57 cm (width) and 2 cm (depth), 1.9 cm undermining and 4.1 cm tunneling. The wound bed was filled with 10% slough with a moderate amount of serosanguineous exudate.Review of R6's Care Plan (with documentation of revisions made with dates) revealed, Resident has impaired skin integrity as evidenced by: Unstageable pressure ulcer to right buttock. Administer medications as ordered Administer treatment(s) per orders Apply protective barrier cream after incontinent episodes Complete skin inspection weekly and as needed Complete wound evaluation to observe the progress of the resident's skin condition Dietary supplement(s) as ordered Notify Nurse of any new areas of skin impairment noted during bathing or daily care (e.g., redness, blisters, bruises, discoloration, impairment related to medical device/tubing) Notify Physician/NP/PA of noted worsening skin condition or any new areas of skin impairment Notify Physician/NP/PA of signs/symptoms of infection (new or change in type/amount/color of drainage, bleeding, foul odor) Pressure redistribution mattress to bedAll interventions were added/implemented on 11/25/25. The impaired skin integrity Care Plan did not include a turning/repositioning schedule or other interventions to prevent further deterioration and/or promote the healing of the pressure injury.During an interview on 12/10/2025 at 2:55 PM, the DON reported that the frequency of repositioning was not included in the care plan but was instead located in the EMR under Task which transcribed onto the resident Kardex. DON confirmed that no new interventions were implemented following the documented deterioration of the wound on 11/11/25 and 11/18/25.Review of R6's Task revealed MONITOR-Turn and Reposition per Care Plan and PRN.every 2 hours & PRN.Review of R6's Kardex (reference for key resident information) revealed, .MONITOR-Turn and Reposition per Care Plan and PRN (as needed). but did not include the frequency of the repositioning.During an interview on 12/10/2025 at 8:58 AM, CNA N reported R6 had a significant increase in pain since her pressure injury developed, and she was now completely bedbound and required repositioning and incontinence care at least every 2 hours. CNA N reported resident care needs and interventions were found in the care plans which were accessible from the kiosks hanging in the hallway.During an interview on 12/10/2025 at 12:15 PM, CNA N reported that she would find R6 left wet (saturated with urine) when she arrived on her shift which indicated the 3rd shift had not provided prompt incontinence care. CNA N stated, her breakdown is probably from lack of turning and reported difficulty with repositioning R6 timely if she was occupied and helping in another (resident) room. CNA N reported it would be beneficial to find a way for every 2 hour repositioning to be communicated so that it was not missed and/or late and additional staff could step in if she was with another resident.During an interview on 12/10/2025 at 03:32 PM, CNA A was queried on facility acquired pressure injuries. CNA A reported some CNAs needed additional education on following care plans and their job duties. CNA A expressed the importance of reviewing care plans on unfamiliar residents prior to working the floor in order to meet their needs. CNA A reported it is difficult to meet the needs of the residents at times due to some staff don't work hard and do not assist other staff or residents with care.During an interview on 12/10/2025 at 03:40 PM, CNA L was queried on R6's facility acquired pressure injury. CNA L reported some staff refuse to reposition or provide incontinence care or are lazy and some need additional education on the importance of following care plans. CNA L reported she had witnessed R6 left wet for extended periods of time and felt it could be due to the fact that R6 is unable to call out and ask for help which is why following her care planned interventions and repositioning her every 2 hours was necessary. CNA L reported that increased interventions documented in the care plans would assist the CNAs in meeting the residents needs and ensure they received appropriate care.During an interview on 12/10/2025 at 03:45 PM, CNA D was queried on facility acquired pressure injuries. CNA D it was difficult to get to all of the residents that require every 2 hour turns due the high acuity of the residents on the units and staffing concerns. CNA D reported that some staff hide and don't help with their care which only hurts the residents. CNA D reported that they frequently work short staffed and even if staff get mandated it is only for 4 hours.Resident #3 (R3)A review of R3's admission Record, dated 12/10/25, revealed R3 was an [AGE] year-old resident admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 9/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R3 was cognitively intact. During an interview on 12/10/25 at 8:40 AM, R3 stated she has had some issues where staff take a long time to answer her call light. She stated she did not know how long it took, but she had wet herself waiting. R3 also stated she keeps her door open and can see staff walk by her room and ignore her call light. She stated she would watch staff walk into the shower room and just stand there talking. That's where they go to just talk. Resident #14 (R14)Review of R14's admission Record dated 12/10/25 revealed R14 was a [AGE] year-old resident admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for R14, with a reference date of 10/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R14 was cognitively intact During an interview on 12/10/25 at 8:50 AM, R14 stated that staff will take a while to answer her call light, and she has wet herself waiting. One time I was soaked from my waist up my back. R14 stated she sees staff walk by her room when the call light is on and they do not answer it. She also stated she has seen staff stand in the shower room and just talk about personal things even when call lights are on.Resident #10 (R10)Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for R10, with a reference date of 12/3/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R10 was cognitively intact. During an interview on 12/10/2025 at 12:01 PM, R10 reported staff would often ignore his call light causing him to wait extended periods of time for assistance and would treat him like I'm not even here. R10 reported that the 3rd shift was especially troublesome, and he had witnessed staff sleeping in the chapel. R10 3rd shift staff would hide and disregard call lights and were frequently observed on their personal phones. R10 expressed concern for the residents unable to speak for themselves and felt they were getting substandard care and insufficient care to meet their needs. R10 stated there's not enough help to care for elderly in the facility.During an interview on 12/10/2025 at 11:08 AM, the DON reported that the facility had completed a Past Non-Compliance (PNC) regarding R6's facility acquired pressure injury with a compliance date of 11/20/25. The PNC was not accepted due to the following ongoing non-compliance.Resident #9 (R9)Review of an admission Record revealed R9 was a [AGE] year-old female, admitted to the facility on [DATE].Review of R9's Order Summary dated 10/27/25-12/3/25 and 12/4/25 revealed, Cleanse with wound cleanser. Pat dry. Apply Honey Alginate as directed to left buttock wound, cut to fit. Skin barrier wipe to peri wound. Cover with 3x3 bordered foam dressing. every day shift for wound.Review of R9's Treatment Administration Record revealed the treatment was not completed on 12/1/25, 12/3/25, or 12/4/25.Review of R9's Order Summary dated 12/04/2025 revealed, Cleanse bottom with soap and water. Apply barrier cream. every day shift for wound.Review of R9's Treatment Administration Record revealed the treatment was not completed on 12/8/25.Resident #11 (R11)Review of an admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE].Review of R11's Order Summary dated 12/04/2025 revealed: Bilateral buttocks wound: cleanse with NS or wound cleanser. Collagen sheet to open areas, cut to fit, cover with ABD pad every shift for open areas buttocks. To be completed on dayshift, evening shift, and nightshift. Right inner thigh wound: Cleanse with soap and water and apply barrier cream q shift. To be completed on dayshift, evening shift, and nightshift.Review of R11's Treatment Administration Record revealed both treatments were not completed on 12/8/25 dayshift.Resident #12 (R12)Review of an admission Record revealed R12 was a [AGE] year-old female, admitted to the facility on [DATE].Review of R12's Order Summary dated 12/05/2025 revealed: cleanse bilateral heels with NS, apply betadine, leave OTA every day shift for pressure wound cleanse lateral left foot with NS, apply betadine, leave OTA every day shift for pressure wound cleanse groin area with NS or wound cleanser, pack with moistened gauze (NS), cover with dry ABD. No tape. every day and evening shift for wound cleanse sacrum with NS or wound cleanser, apply moistened gauze (NS), apply zinc barrier cream periwound, cover with ABD every day and evening shift for stage 4 pressure wound Left ischial tuberosity: cleanse with NS or wound cleanser, apply moistened gauze (NS), apply zinc barrier peri-wound, cover with ABD every day and evening shift for stage 4 wound Right ischial tuberosity: cleanse with NS or wound cleanser, apply moistened gauze (NS), apply zinc barrier cream periwound, cover with ABD every day and evening shift for stage 3 woundReview of R12's Treatment Administration Record revealed the treatments were not completed on 12/8/25 dayshift.Resident #13 (R13)Review of an admission Record revealed R13 was an [AGE] year-old male, admitted to the facility on [DATE].Review of R13's Order Summary dated 12/05/2025 revealed, skin prep to right medial calf every day shift for scabReview of R13's Treatment Administration Record revealed the treatment was not completed on 12/8/25.During an interview on 12/10/2025 at 4:28 PM, the DON confirmed the incomplete treatments for R9, R11, R12, and R13.Review of the facility policy Pressure Injury Prevention and Management last reviewed/Revised 3/20/24 revealed, .4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics) .e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care. f. Interventions will be documented in the care plan and communicated to all relevant staff. 5. Monitoring .b. The attending physician will be notified of .ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. iii. Any complications (such as infection, development of a sinus tract, etc.) as needed .6. Modifications of Interventions a. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner. b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include .ii. New onset or recurrent pressure injury development. iii. Lack of progression towards healing.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Early identification of high-risk patients helps prevent pressure injuries (see Chapter 48). Interventions aimed at prevention include turning and positioning and the use of therapeutic support surfaces and devices (e.g., low air loss mattresses, heel boots, flotation mattresses) to relieve pressure. Regular skin care (cleansing of soiled areas and use of moisturizers) aims to maintain the condition of the skin. Change the immobilized patient's position according to his or her activity level, perceptual ability, treatment protocols, and daily routines. For example, an obese patient or a very thin patient, both of whom have bowel incontinence, will require more frequent turning than standard practice. Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Reposition patients frequently because uninterrupted pressure causes skin breakdown.Chair-bound patients may benefit from a pressure-relief cushion such as an air, viscous fluid/ foam, or gel/ foam cushion that reduces pressure. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 845). Elsevier Health Sciences. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Consistent, planned skin-care interventions are critical to ensuring high-quality care.Assessment reveals clusters of data to indicate whether a problem-focused or negative diagnosis of Impaired Skin Integrity or a risk diagnosis of Risk for Impaired Skin Integrity exists. In addition, the assessment data provide information about the related factor.After completing an assessment of a patient's wound, the nurse identifies nursing diagnoses that direct the interventions that will be needed to support wound healing and prevent complications.After identifying nursing diagnoses, develop a plan of care for a patient so that interventions promote wound healing and prevent complications of any existing wounds.Professional standards are especially important to consider when you develop a plan of care. Practice standards will ensure your use of appropriate wound therapies. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 1242, 1251-1252). Elsevier Health Sciences. Kindle Edition.

This citation pertains to intake #: 2674458Based on observation, interview, and record review, the facility failed to ensure resident care plans were reviewed, revised, and implemented for 1 of 15 residents (Resident #6) reviewed for comprehensive person-centered care plans.Findings:Resident #6 (R6)Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, Alzheimer's Disease, dysphagia (difficulty swallowing), peripheral vascular disease, and urinary incontinence. R6 had an activated DPOA (Durable Power of Attorney).Review of R6's Admin Order dated 9/17/25 revealed, .(R6) needs to be in a geri chair with direct supervision.and she should NOT be up in a broda chair as it is not supportive enough.Review of R6's care planned intervention dated 12/24/24 revealed, Resident uses a manual wheelchair for locomotion.Review of R6's Physician Order dated 11/20/25 revealed, Tramadol 5 MG/ML (Tramadol HCl) Take 10 ml by mouth twice a day and additional 10 ml once daily as needed for pain (one hour before wound dressing change).Review of R6's Care Plans did not reflect the administration of the pain medication 1 hour prior to dressing changes.Review of R6's Electronic Medical Record revealed new onset of seizures beginning on 8/23/25.Review of R6's Care Plans did not reflect the diagnosis of seizures or include interventions for preventing injuries and/or monitoring.Review of R6's provider Progress Note dated 10/30/25 revealed, .continue with frequent repositioning and incontinence care.Review of R6's care planned intervention dated 12/24/2024 revealed, Assist resident with turning and repositioning as needed and did not reflect the need for frequent repositioning.Review of R6's Skin & Wound Evaluation dated 11/18/25 and 11/18/25 revealed her unstageable pressure injury on the right gluteus was deteriorating.Review of R6's Care Plans revealed no new interventions were implemented despite the documented deterioration of the pressure injury on 11/11/25 and 11/18/25 (examples: head of bed less than 30 degrees to reduce pressure, use of a wedge offloading device, frequency of turn schedule, etc.)Review of R6's Weight Summary revealed she was 116.2 pounds on 9/1/25 and 105.2 pounds on 12/4/25 (9.47% decrease in approximately 3 months).Review of R6's care planned intervention dated 12/25/24 revealed, Provide meals/fluids based on resident food preferences and as ordered. The Care Plan did not include meals and/or snacks that R6 previously enjoyed or suggestions from R6's DPOA and did not include a list of dislikes and/or foods to avoid.Review of R6's Electronic Medical Record and Pain Summary revealed R6 was experiencing increased pain due to her Stage 4 pressure injury.Review of R6's care planned intervention dated 12/24/24 revealed, Offer non-pharmacological interventions to relieve pain and observe for effectiveness. The Care Plan did not include non-pharmacological interventions that had been previously effective or other interventions to try.Review of R6's Admin Order dated 9/24/25 revealed a dietary order for puree, nectar thick, liquids by teaspoon. 1:1 feed small bites/sips, slow rate. Stop feeding if coughing. Use metal utensils and glass/hard plastic cups.Review of R6's care planned intervention dated 9/18/25revealed, 1:1 feeding assist. (Do not use plastic utensils, straws or Styrofoam cups as she will chew through them. R6's Care Plan did not reflect the therapeutic diet order or the use of a teaspoon for liquids. During an observation and interview on 12/10/2025 at 8:58 AM, CNA N reported R6 required 1:1 feeding assistance and required pureed food and nectar thick liquids. CNA N reported her diet order and type of feeding assistance was listed on the meal ticket found on her meal tray as well as on her care plan. R6's meal tray contained pureed food and hard plastic cups with straws. CNA N assisted R6 with drinking the thickened liquids with the straw. During an observation and interview on 12/10/2025 at 12:15 PM, CNA N reported the importance of reviewing resident care plan prior to working the shift and especially if pulled to an unfamiliar unit. CNA N was observed feeding R6 and assisting her with using the straw for her thickened liquids. Review of R6's Meal Ticket displayed on her meal tray revealed Dys (dysphagia) puree-regular, Nectar Thickened Liquids, no Styrofoam cups. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A nursing care plan includes nursing diagnoses, goals and/ or expected outcomes, individualized nursing interventions, and a section for evaluation findings (see Chapter 20). The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures.The plan gives all nurses a central document that outlines a patient's diagnoses/ problems, the plan of care for each diagnosis/ problem, and the outcomes for monitoring and evaluating patient progress. The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 249). Elsevier Health Sciences. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Care plans identify a plan of care based on a patient's appropriate nursing diagnoses, outcomes, and interventions individualized to the patient's unique needs. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 254). Elsevier Health Sciences. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Care planning is patient centered, taking into consideration the patient's most immediate needs and preferences. be vigilant in monitoring the patient and supervising assistive personnel in carrying out activities to prevent complications and potential injury. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 790). Elsevier Health Sciences. Kindle Edition.

This citation refers to intake 2647067. Based on interview and record review, the facility failed to report timely of an allegation of abuse to the state survey agency for 2 of 5 residents (R3 and R4) reviewed for abuse. Findings include:R3 A review of R3's admission Record, dated 12/10/25, revealed R3 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's admission Record revealed they had multiple diagnoses that included anxiety, chronic pain, and insomnia. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 9/25/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R3 was cognitively intact. A review of R3's Pertinent Charting-Behavior note, dated 10/2/25 at 3:36 PM, revealed, Resident had a physical altercation with another resident during second shift on 10/1/25. R4 A review of R4's admission Record, dated 12/10/25, revealed R4 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R4's admission Record revealed multiple diagnoses that included dementia and anxiety. A review of R4's MDS, dated [DATE], revealed a BIMS score of 15 which revealed R4 was cognitively intact. A review of R4's Nurses' Notes, Late Entry: dated 10/4/25 for 10/1/25, revealed, Incident between roommates, physical altercation. No injuries sustained by either resident, no complaints of pain. A review of the Facility Reported Incident (FRI), dated 10/9/25, revealed that on 10/1/25 at approximately 8:30 PM, R3 and R4 were heard with raised voices in their shared room. R4 stated R3 made contact with her arms and shoulder area with open hand. The residents were immediately separated, assessed, and no physical injuries or harm were noted. In addition, the FRI revealed the facility reported the incident to the state survey agency on 10/2/25 at 1:30 PM (17 hours after the incident occurred). The FRI also revealed that the facility was able to substantiate that contact had occurred, however there was no marks, injury, or pain. A review of Certified Nursing Assistant (CNA) L's typed and unsigned statement, dated 10/1/25, revealed she was standing in the doorway to the shower room talking to CNA A and CNA D when she heard a commotion behind her. She wrote she looked into R3's and R4's room and saw R3 standing over and leaning into R4 who was lying in her bed. CNA L also wrote R3 had her hands wrapped around R4's hands/arms and was punching R4 in the face and chest. CNA L wrote she shouted, ran into R3's and R4's room, grabbed R3's hands, and pulled R3 back away from R4. She wrote the other CNA's (CNA A and CNA D), and the nurse were in the room at this point and everyone physically separated R3 from R4. During an interview on 12/10/25 at 11:30 AM, the Nursing Home Administrator (NHA) stated she was called on 10/1/25 and told by the nurse that R3 and R4 had a verbal argument. She stated she told the nurse to talk with the residents and find out what happened. The NHA stated the nurse spoke to the residents and called her back. She stated that R3 said she was coughing and R4 told her she needed to see a doctor. The nurse told her that R3 and R4 started arguing and they had to be separated. The NHA stated she was told that both residents said they felt safe in their room and neither one wanted to move rooms. The NHA stated they had a staff member stay in the hallway and monitor R3 and R4 for the rest of the shift. The NHA stated she came in the next morning and spoke with both residents. She stated neither one said there was physical contact. The NHA stated that they only said they had a verbal argument. The NHA stated a few hours after she spoke to R3 and R4 (around 11:10 AM), she was told R4 wanted to talk to her. She stated when she spoke with R4, R4 told her she wanted the police notified because she wanted to press charges against R3. The NHA stated she told R4 that she would call the police, but charges may not be pressed if there was not any physical contact. The NHA stated the police came and took a report. During the interview on 12/10/25 at 11:30 AM, the NHA was asked if she was ever told that R3 and R4 had physical contact. She stated she was not told that. When I asked her why the facility concluded that there was physical contact (per the FRI that the facility submitted to the state survey agency) if R3 and R4 only verbally argued, she stated R3 and R4 had only had physical contact with crossed arms. The NHA further stated that neither resident hit the other one and there was not any physical injury or evidence that they had. I informed the NHA that according to CNA L's typed statement she had noted that she had seen R3 punching R4 in the face and chest. I then asked the NHA if she had seen CNA L's statement and knew what it said. She stated she had seen the statement and when she read it she called CNA L to ask her about it. The NHA stated when she spoke with CNA L over the phone, CNA L told her that everything happened so fast that she could not be sure if R3 actually hit R4 or if she just saw them swinging at each other and/or contacting each other's crossed arms. The NHA stated she did not document the phone call with CNA L to reflect that she changed her statement and/or modified it. She also stated she did not have CNA L write another statement to reflect that she was not sure if R3 and R4 actually made physical contact with each other or were just swinging their arms at each other. During a phone interview on 12/10/25 at 12:30 PM, Registered Nurse (RN) M stated on 10/1/25 at around 8:30 PM she heard yelling and went to R3's and R4's room. She said when she got there the aides were separating R3 and R4. RN M stated she saw R3 leaning over R4's table swinging at her. She stated she did not see any physical contact because by the time she arrived at the room, the aides were already separating the residents and there was some distance between them. RN M stated she did see R4 lying in bed with her arms up trying to block R3's swings, but she did not see if R3 hit R4's arms. RN M further stated she spoke with R3 and R4 after they were separated and they stated they felt safe, and they wanted to stay in their room together. RN M also stated she spoke with the aides and was told by CNA L that she saw R3 lay a punch on R4. She stated she called the NHA and told her what had happened. She stated she did report to the NHA that CNA L had said R3 laid a punch on R4. RN M further stated she had everyone write a statement and left them on the NHA's desk for her to see in the morning. During an interview on 12/10/25 at 2:30 PM, CNA A stated she was across the hall in the shower room helping CNA L clean up the shower room before the end of their shift. She stated they were looking into R3's and R4's room when she heard CNA L yell No, No, No. She stated CNA L was standing between her and R3's and R4's room. CNA A stated CNA L ran into R3's and R4's room and she followed her. CNA A stated when she entered R3's and R4's room she could see R3's arms swinging and flailing from above CNA L's head and shoulders. She stated CNA L was between her and R3. CNA A said she could see R3 leaning over R4's table but could not see if R3 was actually hitting R4 because she was behind CNA L. CNA A stated CNA L probably saw if R3 hit R4 since she was the first one in the room and was right there. She stated CNA L separated the two residents and the nurse (she could not remember her name) came into the room quickly after that. During an interview on 12/10/25 at 3:30 PM, CNA L stated she was standing in the doorway to the shower room looking out. She stated she was talking to CNA D and another aide about work things. CNA L stated she heard a commotion and heard R3 and R4 yelling at each other. She stated she went into their room and saw R3 hanging over R4's bedside table hitting her. CNA L said R3 was definitely hitting R4 in her upper chest/collarbone area and R4 was lying in her bed with her arms/hands up in a defensive posture trying to defend herself. CNA L stated she immediately pulled R3 away from R4 and separated them. She stated when she did, she noticed that R3 looked livid. She said that R3 had wide open crazy eyes. CNA L stated R4 did not hit R3 back. She just had her arms/hands up defending herself from R3's blows. CNA L further stated that after R3 and R4 were separated. She took R4 down to the dayroom to talk with her. She said that when she asked R4 what happened R4 told her she asked R3 about her cough and R3 told her to go to hell. She stated R4 told R3 to come over here and tell me that. CNA L said that R4 said that was when R3 went over to her bed and started hitting her. CNA L stated that earlier in the day R3 had been coughing and R4 would comment on R3's cough. She said R4 if she was ok whenever she would cough and would ask her if she needed to see a doctor. During the interview on 12/10/25 at 3:30 PM, CNA L stated everything happened so fast, but I saw what I saw. She stated she saw R3 hitting R4. CNA L stated she told the nurse that R3 hit R4. She said the nurse immediately called the NHA and told her that. She stated she has given the same statement about the incident every time she has been asked about it by management and another nurse. She stated she has never changed her statement and would repeat the exact same statement if asked again. A review of the facility's Abuse, Neglect and Exploitation policy and procedure, reviewed/revised 1/10/24, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish (injury may not be apparent at the time of the incident since some injuries such as bruising can develop over time). The facility's Abuse, Neglect and Exploitation policy and procedure defined willful as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's Abuse, Neglect and Exploitation policy and procedure also revealed physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The facility's Abuse, Neglect and Exploitation policy and procedure further revealed that allegations of abuse must be reported to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) immediately, but no later than 2 hours after the allegation is made.

Based on observation, interview, and record review the facility failed to implement their infection control programs policies and procedures. Resident #6 (R6) Review of an admission Record reflected R6 admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, legal blindness, dysphagia following cerebral infarction and gastrostomy status (a feeding tube). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R6 was severely cognitively impaired and is dependent on staff for care. Review of a Care Plan initiated 4/5/2024 reflected R6 required Enhanced Barrier Precautions related to feeding tube. The goal of the care plan was that R6 would have a reduced risk of acquiring an infection. During an observation on 08/13/2025 at 9:40 AM, Certified Nurse Aide (CNA) X and CNA Y were observed providing a bed bath for R6. Neither CNA X or CNA Y wore a gown, despite signage on R6's room and closet door indicating R6 required Enhanced Barrier Precautions (EBP). A feeding tube site was observed on R6's abdomen. R6's brief was soiled, and it was noted R6 was menstruating. CNA Y removed the soiled brief and continued bathing R6, never changing gloves between soiled activities and obtaining clean supplies. When CNA Y identified additional clean, dry washcloths were needed, CNA Y removed her soiled gloves, kept the soiled gloves in her hands, left the room, did not clean her hands, and proceeded down the hall to the supply room to retrieve additional supplies. Upon returning to the room, CNA Y then washed her hands with soap and water for less than 15 seconds, applied gloves and continued to provide incontinence care to R6, removing a menstrual discharge soiled cloth from R6's front perineal area when she was rolled onto her back and secured a clean brief and maxi-pad under her. CNA X and CNA Y then log rolled R6 over a feces soiled fitted sheet and draw sheet, pulled up her pants, placed a mechanical lift sling under her and completed a transfer of the resident into a Broda chair. During an interview after the observation on 8/13/2025 at 9:55 AM, CNA X and CNA Y said they both knew R6 was supposed to be in EBP, but they forgot to don appropriate personal protective equipment (PPE). When asked, both CNA's pointed out that the PPE (gown and gloves) were in a drawer next to the resident's bed. CNA Y said, The nurse told us to be sure to use enhanced barrier precautions, and we didn't. R108 Review of a Face Sheet revealed R108 has pertinent diagnoses of spastic quadriplegic cerebral palsy and neuromuscular scoliosis. Review of the Minimum Data Set (MDS) dated [DATE] for R108 revealed she is cognitively intact, nonverbal, bilateral upper and lower extremities are impaired, and is totally dependent on staff for care. R108 was at risk for pressure ulcers (PU) and had none at this time. R108 required nutrition through tube feeding and had a foley catheter. During an observation on 8/13/25 at 10:17 AM, Certified Nursing Assistant (CNA) “F” was observed providing morning ADL (activities of daily living) care for R108 with no PPE (personal protective equipment). The closet door inside the room had a sign that indicated R108 required enhanced barrier precautions while providing care. On the bedside table there was a plastic bag with clean, wet wash cloths. R108 was lying in bed with a tube feeding infusing and the foley urinary catheter was hanging on the side of the bed. CNA “F” started with providing peri/catheter care using a clean washcloth. When he was done with the washcloth, the CNA placed the soiled washcloth in the same clean bag with other clean washcloths and pulled out another “clean” washcloth to clean the stool from R108s buttocks. R108 also had a pressure ulcer dressing that was not adhered well to the skin on the lower right corner. When the CNA finished with cleaning R108s buttocks, he placed the soiled was cloth in the same “clean” bag with the now mixed clean/dirty washcloths. CNA “F” then proceeded to pull another “clean” washcloth from the bag and washed R108’s face. CNA “F” continued providing care using the same gloves moving from dirty to clean. CNA “F” continued to dress R108 and removed a hair clip from her hair with the same gloves and opened the nightstand to pull out toiletries. CNA “F” left the room after removing his gloves to get supplies down the hall with no hand hygiene. CNA “F” came back and emptied the foley urinary catheter, gathered the soiled linen bag, and left the room again after removing his gloves and no hand hygiene. CNA “F” returned to R108s room with Registered Nurse (RN) “G” who donned with a gown and gloves to assist CNA “F” who still did not don up with appropriate PPE and transferred R108 to her wheelchair. RN “G” did not direct CNA “F” to don up with the appropriate PPE. During an interview on 8/14/25 at 11:29 AM, RN “G” was aware that CNA “F” did not have the appropriate PPE on the day before while providing care for R108. When questioned about the nurses supervising the CNAs, RN “G” nodded her head yes, indicating they are to supervise/direct CNAs when needed. RN “G” reported CNA “F” is aware that EBP were needed when providing care for R108 and was re-educated. In an interview on 8/14/25 at 1:32 PM, the Director of Nursing (DON) was informed of the infection control concerns for R108 while care was provided the day before and the DON reported the CNAs do know they are to follow EBP for R108. Staff are not to clean residents starting with their peri care and then clean their faces. Staff are not to combine soiled linens with clean linens in the same bag while providing care. Staff are not to provide care moving from dirty to clean areas without removing gloves and appropriate hand hygiene. Staff are not to leave the room without appropriate hand hygiene. During an interview on 08/14/2025 at 1:07 PM, Infection Control Preventionist (ICP) “A” reported that the process for employee call ins was for the call in slip to be completed and forwarded to the Human Resources staff member and the scheduler. If the call in was illness related it was then forwarded to ICP “A.” ICP “A” confirmed that the “Call-In Log” did not identify the unit the staff member worked because she was familiar with the facility staff and knows where the staff are “typically assigned.” ICP “A” reported that if the reason for calling in was identified as illness related without specific symptoms she would call and follow up the staff member. ICP “A” reported that staff are aware of when they can return to work and an “Employee Illness signs and symptoms/return to work guideline” is available for review for all staff where they clock into work. Review of the July and August “Call-In Log” revealed: *On 7/6/25 Certified Nursing Assistant (CNA) “M” “left sick.” There was no additional follow up documentation for symptoms noted. *On 7/6/25 CNA “N” called in for vomiting. *On 7/7/25 CNA “O” called in for “??” (indicating an unknown reason). There was no additional follow up documentation for symptoms noted. *On 7/18/25 Licensed Practical Nurse (LPN) “P” called in for cough, sore throat, and body aches. *On 7/20/25 CNA “Q” called in for fever, vomiting, and diarrhea. *On 7/28/25 Housekeeping Aide (HA) “R” called in for “N/V” (nausea and vomiting). *On 8/4/25 CNA “S” called in for “not feeling well.” There was no additional follow up documentation for symptoms noted. *On 8/7/25 CNA “T” called in for “C/I” (call in). There was no additional follow up documentation for symptoms noted. *On 8/12/25 HA “U” called in for vomiting. *On 8/13/25 HA “V” called in for “nauseous.” *On 8/14/25 a CNA “W” called in for vomiting. *On 8/14/25 HA “V” called in for “nauseous.” There was no documentation that ICP “A” identified the unit the employees worked, the residents they came into contact with, the date they last worked, confirmed/suspected illness, or a date they could return to work in order to prevent the spread of infection to the vulnerable residents. During an interview on 08/15/2025 at 9:45 AM, ICP “A” confirmed the “Call-In Log” did not include the unit the staff members worked, the onset date of the symptoms, specific symptoms, or a return-to-work date. Review of the “Employee Call In/Absence Procedure” revealed, “…When the employee calls in to report off work the supervisor taking the call in will complete the call in sheet notating the reason for the call off. The call in sheet will be routed to the Infection Preventionist, and or DON (Director of Nursing) to review the line listing of staff and residents for any clusters of respiratory illness and take appropriate action. On weekends the call in information will be reported to the nurse manager on call. The call in sheet provides data collection and active monitoring of staff during suspected respiratory illness cluster or outbreak at a nursing home…” Review of the facility policy “Infection Surveillance” last revised 10/26/2023 revealed, “Policy: A system of infection surveillance serves as a core activity of the facility’s infection prevention and control program. Its purpose is to identify infections, monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infection…6. The facility will collect data to properly identify possible communicable diseases or infections before they spread by identifying: a. Data to be collected, including how often and the type of data to be documented, including: i. The infection site, pathogen (if applicable), signs and symptoms, and resident location, including summary and analysis of the number of residents (and staff, if applicable) who developed infections…9. Employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection outbreaks…” Review of the “Infection Preventionist Checklist Playbook” provided by ICP “A” revealed, “…3.) Enter staff infections into Infection Watch a. Transcribe staff info and symptoms into Infection Watch. 4.) Review line listing for outbreaks and trends…” Review of the “Infection Preventionist Checklist” provided by ICP “A” revealed, “DAILY Infection Watch…Enter staff infections into Infection Watch…”

Based on interview and record review, the facility failed to provide the influenza immunizations and pneumococcal immunization per consent and the recommendation by the Centers for Disease Control and Prevention (CDC) for 4 residents (Resident #124, #11, #96, and #1) out of 5 residents reviewed for immunizations, resulting in residents not receiving the pneumococcal and/or influenza immunization.Findings:Resident #124 (R124)Review of an admission Record revealed R124 was a [AGE] year-old male, admitted to the facility on [DATE]. R124 was his own responsible party. Review of R124's Electronic Medical Record revealed no documentation of R124's last influenza immunization or pneumococcal immunization. There was no consent or other supporting documentation of the last time it was administered, offered, or declined.During an interview on 08/14/2025 at 1:07 PM, Infection Control Preventionist (ICP) A reported that R124 was a new admission within the last 2 weeks and confirmed that she had not met with him to obtain the consent and/or declination for the influenza or the pneumococcal immunizations. ICP A reported she attempted to meet with new admissions within the first 2-3 weeks to obtain consents and administer the vaccinations. Resident #11 (R11)Review of an admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 2 Diabetes Mellitus.Review of R11's Electronic Medical Record revealed no documentation of R11's last pneumococcal immunization. There was no consent or other supporting documentation of the last time it was administered, offered, or declined.During an interview on 08/14/2025 at 1:07 PM, ICP A confirmed there was no pneumonia immunization administered, or consent obtained because R11 was not 60 and per the facility policy the pneumococcal immunization is recommended for all adults 65 years and older.Review of the CDC Adult Immunization Schedule (dated 7/2/25) revealed it was recommended for adults ages 50 years or older who had not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown to receive 1 dose of PCV15 or 1 dose of PCV20, or 1 dose PCV21.Resident #96 (R96)Review of an admission Record revealed R96 was a [AGE] year-old male, admitted to the facility on [DATE].Review of R96's Electronic Medical Record revealed no documentation of R96's pneumococcal immunization. There was no consent or other supporting documentation of the last time it was administered, offered, or declined.During an interview on 08/14/2025 at 1:07 PM, ICP A reported she was waiting to hear back from an outside entity regarding R96's immunization history and therefore did not know if R96 was due for any immunizations. ICP A reported that she did not have access to MCIR (Michigan immunization portal) to look up resident immunization history and reported only the MDS (Minimum Data Set) nurse was able to access that information. ICP A confirmed she had not obtained a MCIR report from the MDS nurse.Review of R96's Electronic Medical Record revealed an immunization history form from his admission documentation dated 7/15/25. The form revealed that R96 had never received a pneumococcal immunization. Further review of the immunization history revealed R96 was DUE NOW for PCV15/PCV20/PCV21.Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE].Review of R1's immunization history revealed she received the PCV13 on 03/28/2018 and the PCV23 on 08/29/2014.Review of the CDC PneumoRecs Vax Advisor revealed a recommendation to give one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose for residents that received the PCV13 and PCV23 prior to the age of 65.Review of R1's Electronic Medical Record revealed no consent or other supporting documentation that PCV20 or PCV21 had been administered, offered, or declined.During an interview on 08/14/2025 at 1:07 PM, ICP A reported she would follow up with R1 on receiving the additional recommended pneumococcal immunization.Review of the facility policy Pneumococcal Vaccine (Series) last reviewed/revised 10/30/23 revealed, .1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders.5. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations.8. A pneumococcal vaccination is recommended for all adults 10-64 years' and older and based on the following recommendations: a. For adults 65 years' or older who have certain chronic medical conditions or other risk factors which may include.k. Diabetes mellitus. Review of the Infection Preventionist Checklist Playbook provided by ICP A revealed, .9.) Review influenza and pneumonia vaccines for residents a. Review new admits for completion of consent for pneumonia and influenza vaccines, offer accordingly. i. Utilize MCIR to monitor past administration and the (sic) document immunizations given.

Based on observation, interview and record review, the facility failed to follow physician orders and the care plan for 1 (R25) of one resident reviewed for range of motion. Findings include:Review of a Face Sheet revealed R25 had pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness), vascular dementia, and pseudobulbar affect (uncontrolled episodes of crying). Review of the Minimum Data Set (MDS) dated [DATE] revealed R25 is moderately cognitively impaired and has an impairment on the upper and lower extremities on one side. Review of the Order Summary for R25 revealed on 2/3/25 an order for a splint to the left upper extremity is to be placed upon rising as the resident allows, removed for lunch, reapplied after lunch and removed at bedtime. During an observation on 8/12/25 at 10:17 AM, R25 was observed in bed with her left hand contracted. When asked if she had splints, R25 said they never did it and didn't know where they were. During an observation on 8/12/25 at approximately 1:00 PM after lunch, R25 did not have any splints on her left hand. During an observation on 8/13/25 at approximately 1:00 PM, R25 was observed not wearing her splint in her left hand. Review of the risk for impaired skin integrity Care Plan for R25 revealed: interventions that may contribute to wound development with use of braces to left hand and left leg/foot for contractures ., initiated 8/23/23. Interventions included: If resident refuses interventions/treatments, encourage compliance to minimize skin impairment, initiated 8/23/23. Review of the Resident has an impaired musculoskeletal status related to contractures of left elbow, left wrist, left hand, left ankle, abnormal posture, osteoporosis. Resident often declines/removes splint, last revised on 7/25/24. Interventions included but not limited to: Apply and remove splints as ordered, initiated on 8/23/23. During an observation and an interview on 8/13/25 at 1:11 PM, the Physical Therapy Director (PT) Z reported that according to R25's care plan, staff are to apply splints to R25's left extremity twice a day. PT Z was informed that R25 has not had them on for 2 days now and did not know where they were. At this time, PT Z went to R25's room and found the splint in her top drawer. R25 allowed PT Z to put them on without resistance or difficulty. Review of a 30-day documentation dated 7/14/25 to 8/12/25 for R25 regarding Splint/Brace assistance: L (left) hand orthotic (WHO) to left upper extremity to be applied in AM during morning care and removed at HS (bedtime) during care or per resident's tolerance (resident removes at times). During this time, there were 21 times it was documented Did not occur. There was no follow up documentation to show the resident was reapproached or the potential root cause of refusals by a licensed professional. In an interview on 8/14/25 at 11:29 AM, Registered Nurse (RN) G was questioned about R25 not wearing her splints. RN G reported that R25 can put up a fight at times when its time to put on her splints. RN G reported that she does expect the Certified Nursing Assistants (CNAs) to follow the care plan, and if the resident refuses, she expects them to tell her so she can reapproach or try another time. If the resident still refuses, the nurse should document it.

Based on interview and record review, the facility failed to follow professional standards for medication administration for 3 residents (R124, R81 and R86) out of 8 residents reviewed for nursing professional standards of practice.Findings:Resident #124 (R124)Review of an admission Record revealed R124 was a [AGE] year-old male, admitted to the facility on [DATE].Review of R124's Order Summary dated 8/1/25-8/6/24 revealed, HYDROcodone-Acetaminophen (Norco) Oral Tablet 7.5-325 MG.Give 1 tablet by mouth every 4 hours as needed for breakthrough pain.Review of R124's Control Substance Record revealed that on 8/6/24 a dose of Norco was administered at 6:00 AM and a dose of Norco was administered at 9:00 AM. (Administered 3 hours apart).Review of R124's August Medication Administration Record revealed that the Norco was documented as administered for the 6:00 AM or the 9:00 AM doses.Review of R124's Electronic Medical Record revealed no documentation for a rationale for administering the Norco outside of the ordered 4 hours.Resident #81(R81)Review of an admission Record revealed R81 was a [AGE] year-old male, admitted to the facility on [DATE].Review of R81's Order Summary dated 7/7/25 revealed, Percocet Oral Tablet 10-325 MG (Oxycodone w/ Acetaminophen) Controlled Drug Give 1 tablet by mouth every 4 hours for pain. To be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM.Review of R81's Control Substance Record revealed:*On 8/8/25 a dose of Percocet was administered at 5:36 PM (approximately 1.5 hours after it was due) and the subsequent dose administered at 7:50 PM. The doses of Percocet were administered approximately 2 hours apart.*On 8/10/25 a dose of Percocet was administered at 5:30 PM (approximately 1.5 hours after it was due) and the subsequent dose was administered at 7:25 PM. The doses of Percocet were administered approximately 2 hours apart.*On 8/11/24 a dose of Percocet was administered at 4:30 PM and the subsequent dose was administered at 7:00 PM. The doses of Percocet were administered approximately 2.5 hours apart.Review of R81's's Electronic Medical Record revealed no documentation for a rationale for administering the Percocet 2-2.5 hours apart instead of the ordered 4 hours.Resident #86 (R86)Review of an admission Record revealed R86 was a [AGE] year-old male, admitted to the facility on [DATE].Review of R86's Order Summary dated 2/3/25 revealed, Metoprolol Tartrate Tablet 50 MG Give 25 mg by mouth every morning and at bedtime for HTN (hypertension) Hold for systolic (top blood pressure number) < (less than) 100 or hold if HR (heart rate) < 60. To be administered in the morning and in the evening.Review of R86's Blood Pressure Summary, Pulse Summary, and August Medication Administration Record (MAR) revealed:*On 8/4/25 R86's blood pressure and pulse were not assessed prior to the evening dose of Metoprolol and morning results of the blood pressure and pulse assessments were documented in the MAR (indicating the assessments were completed prior to the evening dose of Metoprolol).*On 8/6/25 R86's blood pressure and pulse were not assessed prior to the evening dose of Metoprolol and morning results of the blood pressure and pulse assessments were documented in the MAR.*On 8/9/25 R86's blood pressure and pulse were not assessed prior to the evening dose of Metoprolol and morning results of the blood pressure and pulse assessments were documented in the MAR.During an interview via email on 08/15/2025 at 9:25 AM, Nursing Home Administrator (NHA) confirmed the above errors and reported there was no additional information/documentation to disprove the medication errors.Review of the facility policy Medication Administration dated 1/17/23 revealed, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview and record review, the facility failed to follow policies and procedures and physician orders for pressure ulcer care for 1 (R108) of 4 residents reviewed for pressure ulcers.Findings include:Review of a policy titled Pressure Injury Prevention and Management dated 3/20/24 revealed: . 4. Interventions for Prevention and to Promote Healing: a. the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure assessment . Basic or routine care interventions could include, but are not limited: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, ect.); . iii. Provide appropriate, pressure-redistributing, support surfaces; . f. Interventions will be documented in the care plan and communicated to all relevant staff. 5. Monitoring: a. The attending physician will be notified of: i. The presence of a new pressure injury upon identification. ii. The progression towards healing, lack of healing, or worsening of any pressure injuries weekly. Review of a Face Sheet revealed R108 has pertinent diagnoses of spastic quadriplegic cerebral palsy and neuromuscular scoliosis. Review of the Minimum Data Set (MDS) dated [DATE] for R108 revealed she is cognitively intact, nonverbal, bilateral upper and lower extremities are impaired, and is totally dependent on staff for care. R108 was at risk for pressure ulcers (PU) and had none at this time. R108 required nutrition through tube feeding. Review of a risk for impaired skin integrity care plan for R108 initiated on 12/23/23 and revised on 7/18/25 revealed on 7/18/25 a re-occurred stage 4 PU to sacrum. Interventions dated 12/23/23 included but not limited to: Assist resident with turning and repositioning as needed (does not indicate an objective time frame). On 1/5/24 If resident refuses interventions/treatments, encourage compliance to minimize skin impairment.Review of a Skin assessment dated [DATE] for R108 revealed a new stage 4 pressure ulcer reopened on her sacrum on 7/18/25. On 8/12/25 R108's wound measured 4.7 cm (centimeters) x 2.1 cm x 2.8 cm x 0.1 depth and on 7/18/25 the pressure ulcer measured < 0.1cm x 0.4 cm x 0.4 cm x 0.1 cm depth. A significant increase between 7/18/25 and 8/12/25.During an observation on 8/12/25 at 9:19 AM, R108 was observed sitting upright in the common area of the hallway in an electric wheelchair with tube feeding infusing. Shortly after observation, R108 was taken to her room for oral care and came back out to the common area sitting upright in her electric wheelchair.During the following observations on 8/12/25 at 12:00 PM, 1:50 PM, and 4:07 PM, R108 was observed in the same common area in her electric wheelchair sitting upright. During an observation on 8/13/25 at 8:15 and 8:42 AM, R108 was in her room lying on her back at a 45-degree angle with the tube feeding infusing. (this position puts pressure on sacrum)During an observation on 8/13/25 at 10:17 AM, Certified Nursing Assistant (CNA) F provided morning care for R108 and transferred her to her electric wheelchair. R108 observed sitting upright in the common area of the hallway when care was completed. During an observation and an interview on 8/13/25 at 2:24 PM, CNA K and CNA L were questioned about R108 observed in the common area all day without being repositioned. Both CNAs reported R108's wheelchair does recline back but if R108 reclined, she would not be able to people watch or see her iPad that R108 really enjoys. They indicated that R108 will get upset if she cannot do that. Review of the Nursing Progress notes for R108 revealed no documentation indicating resident refused to be repositioned. Review of the July 2025 Medication Administration and Treatment Administration Record (MAR/TAR) for R108 revealed on 7/19/25 an order to Cleanse sacral wound with wound cleanser. Apply small piece of calcium alginate to wound bed. Cover with foam dressing as needed for disruption, was discontinued on 7/23/25 and was not documented as done all 5 days before it was discontinued. On 7/23/25 a new order to cleanse sacral wound with soap and water, apply Triad wound paste, every dayshift was not documented as done on 7/24, and on 7/29 and 7/31 it was coded not done and to see the nursing notes. Review of the August 2025 MAR/TAR for R108 revealed the sacral wound care was not done on 8/2, 8/3, 8/7, and 8/8 with no supporting documentation as to why. Review of the nursing notes do not address the reason wound care was not done on the above indicated dates in July and August and no indication the physician was notified. Review of the Practitioner progress notes since the onset of R108's pressure ulcer on 7/23/25 revealed on 8/1/25 the resident was seen, and no practitioner oversight of the wound was documented. During an observation on 8/13/25 at 10:17 AM, Certified Nursing Assistant (CNA) F provided peri care for R108 when a 4x4 dressing was observed on R108's sacrum and the right lower corner of the dressing was not adhered to the resident. CNA F continued to dress R108 and transfer her to the wheelchair.In an interview on 8/14/25 at 11:29 AM, Registered Nurse (RN) G was questioned about R108's pressure ulcer and was not aware she had one and was not aware of any dressings that needed to be done until she looked in the medical record during this interview. RN G reported the float nurses provide wound care for the residents. RN G reported she was not aware that when she assisted R108 to the wheelchair the day before with CNA F that R108 had a dressing on her coccyx that was not adhered to the resident on one side. RN G reported she would expect the CNAs to report those things to her. RN G was not sure if R108 has a special cushion in her wheelchair for pressure ulcer care. When queried about R108 being up in her wheelchair all day and not being repositioned, RN G reported staff should be turning her every 2 hours. RN G reported R108's wheelchair does tilt back but the staff do not want to upset the resident by doing so.In an interview on 8/14/25 at 1:32 PM, the Director of Nursing (DON) reported R108 does have a recurrent pressure ulcer on her sacrum and is followed by their wound care team once a week. The DON reported R108 should be repositioned every 2 hours but does not like being laid down because she will scream and cry. Staff will reposition the best they can. The DON was informed that R108 was not repositioned after she got out of bed at approximately 10:00 AM the day before and the DON reported that R108 really likes her iPad and cannot use it when she is reclined back. When questioned about R108 only being able to visually engage in the iPad and positioning it so it is in her visual field, the DON did not have an answer. When asked about the CNAs documenting they repositioned R108 per the plan of care with several entries of the same time stamp, the DON reported it can be hard to document in real time. The DON did not know why dressing changes for R108 were missed and reported there is a breakdown in communication sometimes between the floor nurses and the float nurses.

Based on observation, interview and record review, the facility failed to have policies and procedures for tube feed positioning, follow standards of practice for positioning, and follow physician orders for 1 (R108) of 2 residents reviewed for tube feedings.Findings include:Review of a policy titled Feeding Tubes last revised 10/15/24 revealed: . 8. The plan of care will reflect the use of a feeding tube and potential complications. 9. The facility will utilize the Registered Dietician in estimating and calculating a resident's daily nutritional and hydration needs. This policy does not address the positioning of a resident while receiving tube feeding.Review of the Nutrients Journal, ([NAME], J. (2022). Enteral nutrition overview. Nutrients, 14(11th ed.), 11. https://doi.org/10.3390/nu14112180) revealed The head of the bed should be elevated 30-45 degrees, if possible, for any patient in the supine position who is at risk for aspiration [44-49].Review of a Face Sheet revealed R108 has pertinent diagnoses of spastic quadriplegic cerebral palsy and neuromuscular scoliosis. Review of the Minimum Data Set (MDS) dated [DATE] for R108 revealed she is cognitively intact, nonverbal, bilateral upper and lower extremities are impaired, and is totally dependent on staff for care. R108 was at risk for pressure ulcers (PU) and had none at this time. R108 required nutrition through tube feeding. During an observation on 8/13/25 at 10:17 AM, Certified Nursing Assistant (CNA) F was providing morning are for R108. At this time R108 was receiving a tube feeding (TF) at 50 mL (milliliters)/hour (hr). CNA F lowered the head of the bed flat while it was infusing. CNA F continued to clean and dress R108 alone and R108 was not able to assist. The tubing line was taut when R108 was turned to the left side with one hand of CNA F and his other hand was providing care. When CNA F completed care, the TF machine read complete, and the nurse came in to disconnect the TF. In an interview on 8/14/25 at 11:29 AM, Registered Nurse (RN) G was questioned about R108s tube feeding and reported that the TF should not be infusing when the head of the bed is lower than 30 degrees and the CNA should have informed the nurse so she could turn it off or disconnect the resident during care. When asked about R108 needing 2 staff for ADL (activities of daily living) care but observed only one staff providing care, RN G reported there would be less potential for mishaps if R108 had 2 staff providing care. RN G reported they have plenty of staff and it was just a matter of coordinating care with other staff. Review of a Nursing progress note dated 2/1/25 for R108 revealed a new event started on 1/23/25- Location of skin area being documented: peg tube site continues to be red with drainage present .Review of the Nursing progress notes dated 4/19/25 at 9:23 PM for R108 revealed: . While staff continued ADL care feeding tube became displaced. On-call provider notified and ok to send to ER for replacement.Review of a Practitioner progress note dated 6/17/25 for R108 revealed: . cerebral palsy, quadriplegia dysphagia with PEG tube. She is unable to provide any information. Reportedly had problems with her PEG tube and was sent to hospital and had that replaced. No reported issues since.Review of the July 2025 Medication Administration/Treatment Administration Record (MAR/TAR) for R108 revealed an order dated 6/16/25 to infuse Jevity 1.5 at 50 mL/hr (milliliters per hour) x 18 hours until a full dose of 900 mL was administered and was documented R108 received only 750 mLs from 7/1/25 to 7/31/25. No supporting documentation supporting the change in the amount received. Review of the August MAR/TAR for R108 revealed an order dated 7/17/25 to cleanse the gastrostomy tube (G-tube) site with soap and water daily and as needed. This was not done on 8/2, 8/3, 8/7, and 8/8. Another order dated 6/16/25 to infuse Jevity 1.5 at 50 mL/hr (milliliters per hour) x 18 hours until a full dose of 900 mL (milliliters) was administered and 8/1/25-8/7/25 only had 750 mL documented as administered. Review of the Nursing progress notes dated 7/30/25 at 8:19 AM for R108 revealed: Nurse found resident unhooked from tube feed this morning. Resident refusing to allow me to hook her up at this time. Tube flushing ok. No follow up documentation and incident report provided. Review of the Practitioner progress notes dated 8/5/25 revealed: Nurse reported yesterday evening that resident had a large emesis of TF formula. Pump was found to be set at a higher rate at that time, so TF was turned off and holding at this time. She was sitting up at time of emesis so at this time there is no concern for aspiration. Order given to hold x 2 hours, and if there were no further episodes of emesis, may resume TF @ the ordered 50ml/hr. Nurse then called back later to report that she obtained 260ml residual of feeding in stomach 2 hours after incident. Instructed to discard residual, give Zofran 4mg a6h as needed, then if no further emesis 1 hour after Zofran given, may resume TF. Nurse voiced understanding. Review of the Nursing progress notes dated 8/5/25 at 2:32 AM for R108 revealed: pt's (patient's) complaining of stomach pain, residual l volume came to 250 in PEG Tube. Tube feed is currently on hold. Called the on-call provider who gave verbal orders for Zofran 4mg q6 hours to help with stomach pain. Review of the Dietary Progress notes for R108 dated 8/8/25 revealed R108 had a stage 4 sacral pressure ulcer and requires enteral supplemental nutrition via percutaneous endoscopic gastric (PEG) tube and is to receive Jevity (tube feed supplement) 1.5 at 50 milliliters (mL) for 18 hours for a total of 900 mLs and 160 mLs of fluid 5 times a day before/after medications and tube feedings (TF).Review of the ADL Care Plan for R108 revealed she required 2 people to assist with care. Review of the overall Care Plan for R108 revealed it does not address the position of the HOB while the tube feeding is running.In an interview on 8/14/25 at 11:29 AM, Registered Nurse (RN) G reported R108 should be a 2 person assist with ADL care and bed mobility due to her tube feeding and her foley catheter. Having 2 staff assisting with care would reduce the chances of any mishaps while repositioning her. In an interview on 8/14/25 at 1:32 PM, the Director of Nursing (DON) reported the CNAs are to get the nurses to turn off the tube feeding prior to providing care that requires the HOB to be lower than 30 degrees and to wait a little longer after that.

Based on interview and record review, the facility failed to ensure that the physician, or non-physician practitioner conducted a face-to-face visit at least once every 60 days after the initial 90 days post-admission visits for 1 of 23 sampled residents (R7). Findings include:A review of R7's admission Record, dated 8/14/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R7 had multiple diagnoses that included dementia, diabetes, bipolar disorder, depression, and hepatic encephalopathy (a loss of brain function when a damaged liver does not remove toxins from the blood). A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which revealed R7 was severely cognitively impaired. A review of R7's electronic medical record (EMR), dated 10/3/24 to 8/14/25, failed to reveal that a physician (or non-physician practitioner- a nurse practitioner, a physician assistant, or a clinical nurse specialist) had conducted face-to-face visit with R7 since 2/27/25 (over 5 months prior to the survey). During an interview on 08/14/2025 at 3:30 PM, the Director of Nursing (DON) was informed that R7 did not have any physician visits notes in their EMR after 2/27/25. The DON stated R7 also receives physician services from an outside company. She stated she would call them and see if they had any documentation that a physician or non-physician practitioner from that company had conducted a face-to-face visit with R7 since 2/27/25. During a second interview on 08/14/2025 at 4:00 PM, the DON stated the outside company that also provides physician services to R7 sent her documentation that a non-physician practitioner (a nurse practitioner) had conducted a face-to-face visit with R7 on 6/25/25, 7/16/25, and 8/6/25. The DON also stated that R7 had been hospitalized from [DATE] to 6/24/25. The DON verbally confirmed that R7 had not been seen by a physician or non-physician practitioner between 2/27/25 and 6/1/25 (a period of 93 days prior to hospitalization). The DON also confirmed that the facility did not have any documentation that R7 was seen by the facility's physician or non-physician practitioner during that time period. The DON verbally agreed with the surveyor that a physician or non-physician practitioner should have had a face-to-face visit with R7 by 4/27/25, but no later than 5/4/25.

Based on interview and record review, the facility failed to ensure the pharmacist sent a report for a medication recommendation/comment and/or a physician reviewed the pharmacy recommendation for 1 of 5 residents (R7) reviewed for monthly pharmacy medication regimen reviews. Findings include:A review of R7's admission Record, dated 8/14/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R7 had multiple diagnoses that included dementia, bipolar disorder, and depression. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which revealed R7 was severely cognitively impaired. A review of R7's Pharmacy Medication Review Progress Note, dated 3/31/25, revealed that the line for Comment/Recommendation noted-see report was checked. This indicated that the pharmacist had made a recommendation to the physician or had noted an irregularity in R7's medication regimen. A review of R7's electronic medical record (EMR), dated 3/1/25 to 8/14/25, failed to reveal documentation (e.g., a Physician Recommendations for, a Nursing Recommendation form, a progress note, a physician note) that would indicate what the pharmacy comment/recommendation was on 3/31/25. During an interview on 08/14/2025 at 3:18 PM, the Director of Nursing (DON) was informed that the pharmacist had made a comment/recommendation on 3/31/25, however the report and/or any other documentation that would indicate what the comment/recommendation was could not be located in R7's EMR. The DON stated the report should have been scanned into R7's EMR under the Miscellaneous (Misc) tab under the subheading Pharmacy. The DON stated she would look and see if she could locate the 3/31/25 pharmacy recommendation report and she would provide a copy to the surveyor, if she could locate it. During a second interview on 08/14/2025 at 3:30 PM, the DON stated she had called the outside company that also provides physician services to R7 to see if they had a copy of the pharmacy report that would indicate what their comment/recommendation was on 3/31/25. The DON indicated during the interview that the facility has had issues with the outside company providing documentation to them in the past, but she would provide copies of any documentation that they sent to the survey team. During a third interview on 08/14/2025 at 4:00 PM, the DON stated the outside company that also provides physician services to R7 had said they did not have a copy of the report that would reveal what the pharmacist's recommendation/comment was for 3/31/25. The DON stated because the facility did not have a copy of that report and the outside company did not have a copy of that report, then she had no way of knowing if the pharmacy sent a report, what the pharmacy recommendation/comment was, and if the physician was ever made aware of it. A review of the facility's Addressing Medication Regimen Review Irregularities policy, reviewed/revised 12/28/23, revealed, It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident to identify irregularities and respond in a timely manner to prevent the occurrence of an adverse drug event. 4. The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and the reports must be acted upon. Any irregularities noted by the physician during this review must be documented on a separate, written report which may be in paper or electronic form. The attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. The report should be submitted to the DON within 10 working days of the review.

Based on observation and interview, the facility failed to appropriately label medications in 1 of 2 medication carts inspected (Southwest Medication Cart).Findings include:During an inspection of the Southwest Medication Cart with Registered Nurse (RN) B on 08/12/2025 at 4:20 PM, the following observations and interview were made: - A box of Desmopressin Nasal Spray 10 mcg/ 0.1 ml (10 micrograms per 0.1 milliliters) was observed with Resident #7's name on it. However, the nasal spray container inside the box was not labeled with R7's name or any other identifying information that would indicate the spray was his if it became separated from the box. - A box of fluticasone and salmeterol was observed with Resident #32's name on it. However, the diskus inside the box was not labeled with R32's name or any other identifying information that would indicate the spray was hers if it became separated from the box. - RN B stated that the pharmacy usually labels the individual vials, inhalers, and diskus' in the boxes with the resident's name and other identifying information in case the vial/ inhaler/diskus becomes separated from the box. RN B stated if the vial/inhaler/diskus was not labeled by pharmacy, then she would label it with the resident's name. She also stated she does this in case the vial/inhaler/diskus becomes separated from their respective boxes, so she knows who they belong to. RN B further stated this was especially important if more than one resident had the same medications. She stated otherwise, It would be just plain gross if a resident used another resident's inhaler or diskus. During an interview on 08/13/2025 at 8:30 AM, Licensed Practical Nurse (LPN) D stated she labels the individual nasal sprays, diskus', and inhalers with the residents' names. LPN D stated the medication labels on the boxes contain a smaller label with the resident's identifying information that can be peeled off the larger label and placed on the individual nasal spray, diskus, and inhaler in the box. She further stated if a smaller label was not available, then she would write the resident's name on the individual inhaler, diskus, or nasal spray. LPN D stated the reason that the individual nasal sprays, inhaler, or diskus' should be labeled with the residents' name was in case they fall out of the box. That way I know whose they are. During an interview on 08/14/2025 at 2:25 PM, RN C stated medications in boxes in the medication cart should be labeled on the vial/inhaler/diskus with the resident's name and the date opened. She stated this should be done in case the vial/inhaler/diskus fell out of the box and they need to identify who the vial/inhaler/diskus belonged to.

Based on interview and record review, the facility failed to ensure the medical records for 1 of 23 sample residents (R7) was complete and accurate. Findings include:A review of R7's admission Record, dated 8/14/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R7 had multiple diagnoses that included dementia, bipolar disorder, and depression. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which revealed R7 was severely cognitively impaired. A review of R7's Pharmacy Medication Review Progress Note, dated 3/31/25, revealed that the line for Comment/Recommendation noted-see report was checked. This indicated that the pharmacist had made a recommendation to the physician or had noted an irregularity in R7's medication regimen. A review of R7's electronic medical record (EMR), dated 3/1/25 to 8/14/25, failed to reveal documentation (e.g., a Physician Recommendations for, a Nursing Recommendation form, a progress note, a physician note) that would indicate what the pharmacy comment/recommendation was on 3/31/25. During an interview on 08/14/2025 at 3:18 PM, the Director of Nursing (DON) was informed that the pharmacist had made a comment/recommendation on 3/31/25, however the report and/or any other documentation that would indicate what the comment/recommendation was could not be located in R7's EMR. The DON stated the report should have been scanned into R7's EMR under the Miscellaneous (Misc) tab under the subheading Pharmacy. The DON stated she would look and see if she could locate the 3/31/25 pharmacy recommendation report and she would provide a copy to the surveyor, if she could locate it. A second review of R7's EMR, dated 10/3/24 to 8/14/25, failed to reveal that a physician (or non-physician practitioner- a nurse practitioner, a physician assistant, or a clinical nurse specialist) had conducted a face-to-face visit with R7 since 2/27/25 (over 5 months prior to the survey). During a second interview on 08/14/2025 at 3:30 PM, the DON stated she had called the outside company that also provides physician services to R7 to see if they had a copy of the pharmacy report that would indicate what their comment/recommendation was on 3/31/25. She stated she could not locate this documentation in R7's EMR. The DON was also informed that R7 did not have any physician visits notes in their EMR after 2/27/25. The DON stated she would call the outside company again and see if they had any documentation that a physician or non-physician practitioner from that company had conducted a face-to-face visit with R7 since 2/27/25. The DON indicated during the interview that the facility has had issues with the outside company providing documentation to them in the past, but she would provide copies of any documentation that they sent to the survey team. During a third interview on 08/14/2025 at 4:00 PM, the DON stated the outside company that also provides physician services to R7 sent her documentation that a non-physician practitioner (a nurse practitioner) had conducted a face-to-face visit with R7 on 6/25/25, 7/16/25, and 8/6/25. The DON stated the facility did not have this documentation prior to the outside company sending it to her. She also stated that the outside company had said they did not have a report that would reveal what the pharmacist's recommendation/comment was for 3/31/25. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Documentation is sometimes viewed as burdensome and even as a distraction from patient care. High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care. Communications with other health care professionals regarding the patient. Order acknowledgement, implementation, and management. Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on 7/27/25).

This citation is related to intake # MI00151188 Based on interview and record review, the facility failed to follow professional standards for medication administration for one of three residents (Resident #4) reviewed for medication errors. Findings: Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of recent brain bleed requiring an extensive hospital stay and resulting in left sided weakness and paralysis, chronic kidney disease-stage 4, morbid obesity, Insulin dependent diabetes mellitus, and need for a feed tube for nutrition. Review of an Electronic Medication Administration Record (Emar) for R4, dated January 2025 revealed an order for Clonidine transdermal patch 0.1 mg (milligrams)/24 hours to be given weekly. Documentation reflects that R4 had a patch placed on 01/20/25 and on 01/29/25. There was documentation present in the electronic health record (EHR) that indicated the Clonidine patch was not available on 01/27/25 and was not placed until 01/29/25. Further review of R4's EHR revealed that the facility had initiated a new order for the Clonidine transdermal patch on 01/20/25. R4 had not previously been prescribed this medication and no new monitoring was ordered to evaluate whether R4 had any side effects to the new medication. Review of a physician Progress Note for R4, dated 02/10/25, reflected .(R4) lying in bed sleeping upon entering the room, labored breathing, using accessory muscles to breath, unresponsive, unable to awaken with rubbing and calling his name .will send to ER for evaluation. Review of an emergency room Patient Record for R4, dated 02/10/25, revealed .patient came in from (a nursing home), he was found by staff with a decreased level of consciousness. When (R4) arrived to the ER (emergency room ), RN (registered nurse) found 2 unidentified patches on each of (R4's) upper arms, one dated 1/20/25 and one dated 1/29/25. When the RN called (the nursing home), staff at (the nursing home) stated that they were old Clonidine patches that were supposed to be removed and admitted ly were not removed .this is quite concerning. Clonidine does have opiate like effects in higher doses. I did try Narcan with no change in his mental status .(R4) is extremely drowsy .difficult to arouse and is not responding .(R4) is having periods of apnea (not breathing). Review of the Fundamentals of Nursing revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.

This citation pertains to intake # MI00151188 Based on observation, interview, and record review, the facility failed to follow the standards of practice for two of two residents reviewed (Resident #7 and Resident #8) for tube feeding. Findings: Resident #7 (R7) Review of an Admission Record revealed R7 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of paraplegia, difficulty speaking, and protein-calorie malnutrition. During an observation on 03/19/25 at 3:10 PM, an irrigation container and syringe for R7's tube feed flushes sat on the bedside table. The plunger was inside the syringe and the syringe sat in the graduated container that contained a clear liquid. The date on the graduated container read 3/18/25. During an observation on 03/20/25 at 7:30 AM, R7's tube feed pump ran at 65 ml (milliliters) per hour. The bottle of Jevity 1.5 cal tube feed did not have the time the tube feed was initiated on 03/19/25. Review of an Electronic Medication Administration Record (Emar) for R7, dated March 2025, reflected the order .enteral feed order, every night shift change feeding syringe and/or container, daily (label with resident name and date). Resident #8 (R8) Review of an Admission Record revealed R8 was a [AGE] year-old female, last admitted to the facility on [DATE], with a pertinent diagnoses of spastic quadriplegic cerebral palsy. R8 is dependent on a tube feed for all nutrition and hydration. During an observation on 03/20/25 at 7:20 AM, R8 laid in bed resting with her eyes closed and the tube feed pump ran. The bottle of tube feed solution did not have the ordered rate written on it nor did it have the date the tube feed was initiated. On the bedside table sat a cylinder with clear liquid in it and the syringe and plunger were not separated and sat in the cylinder in the clear liquid. During an interview on 03/20/25 at 8:08 AM, the Director of Nursing (DON) indicated that the tube feed solution bottles should contain the date and time the feed was initiated as well as the ordered rate and that the syringe and plunger should be separated, rinsed, and allowed to dry between uses. The DON reported that the facility did not have a policy to address these standards of practice discussed.

This citation pertains to Intake Number MI00149340. Based on observation, interview, and record review, the facility failed to ensure that (1) Resident's needs were met timely and that (2) Call lights were within reach for two residents ( Resident #6, Resident #9) of four residents reviewed for accommodation of needs. Findings include: Resident #6 (R6): Review of an Admission Record reflected R6 was a [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's and rheumatoid arthritis. Review of a BIMS (Brief Interview for Mental Status) revealed R6 had severely impaired cognition. During an observation on 01/08/25 at 7:40 AM, the call light touch pad for R6 sat on the bedside table covered by a hat, out of sight and out of reach of the resident. During an observation on 01/08/25 at 9:35 AM, the call light touch pad for R6 remained on the bedside table, out of sight and out of reach of the resident, and covered by a hat. R6 sat up in bed eating breakfast. During an interview on 01/08/25 at 11:32 AM, CNAO indicated that placement of call lights and other items used frequently were to be checked anytime staff go into a room or walk by and look into a room. During an observation on 01/08/25 at 11:40 AM, R6 sat up in bed with very bright red lipstick on and the call light touch pad sat on the bedside table out of sight and out of reach of the resident. When asked how she would notify staff if she needed something, R6 looked around her bed and replied 'I don't know. During an observation on 01/08/25 at 3:27 PM, R6 remained in bed and the call light touch pad sat on the bedside table out of sight and out of reach of the resident and was no longer covered by the hat. During an observation on 01/09/25 at 7:54 AM, R6 laid in bed resting with her eyes open and the call light touch pad sat on the bedside table out of sight and out of reach of the resident. Review of the facility policy Call Lights: Accessibility and Timely Response, last reviewed 12/28/23, reflected .staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Resident #9 (R9): Review of an Admission Record revealed R9 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of multiple sclerosis and difficulty speaking and was dependent on staff for bathing and hygiene care. During an interview on 01/08/25 at 12:20 PM, R9 sat at a table in the dining area listening to music. R9 indicated that it took a long time for staff to answer his call light, especially on third shift and that many times when staff did answer the light, they would come in and turn off the light and not come back. During an interview on 01/08/25 at 12:50 PM, R9's roommate stated the following regarding third shift staff answering the call light for R9: if staff answer the light it takes along time, and they have told him (R9) things like you can wait and you are a two hour check and it hasn't been that long yet. During an interview with a confidential staff person (CSP-F) on 01/08/25 at 2:30 PM, the following was indicated: CSP-F has received such complaints from residents (1) nobody checked on me all night, (2) third shift staff were rough and rushed with cares, (3) call lights, if answered, takes a really long time, and (4) I have been soaked all night, please help me. During an interview with a confidential staff person (CSP-B) on 01/09/25 at 8:00 AM, CSP-B reported hearing comments from residents that third shift staff do not answer call lights or if they do, it takes a long time for them to be answered. Review of the facility policy Call Lights: Accessibility and Timely Response, last reviewed 12/28/23, reflected .any staff member who sees or hears an activated call light is responsible for responding.

This citation is related to intake Number MI00149340. Based on observation, interview, and record review the facility failed to provide quality care to two residents (Resident#1 and Resident #6) out of 5 residents reviewed. Findings include: Resident #1 (R1): Review of an Admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], following a 30 day inpatient hospital stay for a cerebral aneurysm with a stent placement, right sided stroke, and required intubation due to hypoxia. R1 admitted to the facility with pertinent diagnoses of left sided weakness and paralysis after a stroke in May 2024 with subsequent difficulty speaking, swallowing and impaired vision, high blood pressure, restlessness, claustrophobia, overactive bladder, broken lumbar fusion hardware (rod) in her back, use of a tube feed for nutrition (placed during recent hospitalization on [DATE]), and muscle weakness. Review of Hospital Wound Care orders for the new tube feed site: wash with dermal wound cleanser once daily (feeding tube site). Dry thoroughly especially under external bolster/bumper. During an interview on 01/08/25 at 3:00 PM, R1's daughter and guardian L reported visiting R1 on 01/06/25 and observed what looked like pus draining from the tube feed insertion site and it smelled awful. During an observation on 01/08/25 at 3:40 PM, R1's tube feed insertion site had pus like drainage (thick yellowish/brown). It hurts. R1 held the drain sponge and it was saturated with a thick brown substance. Review of an electronic medication administration record (Emar) for R1, dated January 2025, reflected an order for staff to clean the tube feed site with normal saline ( not a wound cleanser as listed on the hospital discharge wound care orders), dry, and apply a drain sponge daily and as needed. Resident #6 (R6): Review of an Admission Record reflected R6 was a [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's and rheumatoid arthritis. Review of a BIMS (Brief Interview for Mental Status) revealed R6 had severely impaired cognition. On 01/08/25 a review of nursing Progress Notes for R6 revealed the last two nursing notes entered into the EHR (electronic health record) were recorded on 12/03/24 and 11/07/24. The nursing progress note entered on 12/03/24 was a notation regarding a low blood pressure (100/46) that had been taken on 11/17/24. There was no documentation found that, at the time of the low blood pressure reading on 11/17/24, indicated that the physician was notified nor was R6's blood pressure re-checked until 11/21/24.

This citation is related to Intake Number MI00147654 Based on observation, interview, and record review the facility failed to secure 1 of 4 unattended medication carts. Findings include: During an observation on 01/08/25 at 7:20 AM, the unattended medication cart for rooms 1-15 displayed resident information on the computer screen. Upon further observation, the unattended medication cart was unlocked. Found in the second drawer down on the left side of the medication cart were 14 different loose unidentified pills. Found in the second drawer down on the right side of the medication cart was an unsecured metal box that contained controlled substances. During an interview on 01/08/25 at 7:25 AM, License Practical Nurse (LPN) A approached the unlocked medication cart and stated you busted me, I'm sorry. During an interview on 01/08/25 at 7:35 AM, LPN B indicated that medications carts and narcotic boxes were to be locked at all times when the nurse was not at the medication cart. Review of the facility policy Medication Storage last reviewed on 01/30/24 revealed: It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations and sufficient to ensure .security. All drugs will be stored in locked compartments (i.e., medication carts, drawers) .Schedule 2 drugs and back-up stock of schedule 3, 4, and 5 are stored under double lock and key.

Based on observation, interview, and record review, the facility failed to provide adequate supervision, conduct timely root cause analysis of fall incidents, implement appropriate interventions to prevent future falls and re-evaluate the effectiveness of interventions for 3 residents (R48, R102, and R456) out of 3 residents reviewed for falls, resulting in R48 falling and sustained a wrist fracture and R102 fell and sustained a laceration requiring emergency room treatment. Findings included: R48 Review of R48's face sheet dated 9/18/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Bipolar Disorder, epilepsy (seizure disorder), muscle weakness and diseases of intestine. R48 was listed as her own responsible party. Review of R48's care plan date initiated 2/20/24 and revision on 9/17/24 revealed, Resident has behavior (s) related to (SPECIFY: diagnosis/reason) as evidenced by makes accusatory statement, medication seeking, physically aggressive toward staff, refuses treatments, resistant to care, sexually inappropriate toward staff, throwing objects, Destruction and damaging property, Threatening or intimidating comments, removal of medical necessary devices. Transfers and ambulates independently when she is aware she needs assist. Review of R48's care plan date initiated 2/7/24 and revision on 9/17/24. Resident is at risk for falls/injury related to impaired mobility, weakness, chronic pain, incontinence, morbid obesity, epilepsy, osteoporosis, psychotropic med use, opioid pain medication. Transfers self and ambulates independently without asking for assist. Interventions included: anti-roll back to w/c (wheelchair) 9/12/24, Educate family on resident's safety interventions, 9/17/24, Educate resident and family to call for assistance before transferring, dated 9/19/24, Educate on safety interventions, dated 2/7/24, Encourage resident to keep needed items within reach, dated 2/7/24, Encourage resident to keep walker within reach, dated 9/17/24, Encourage resident to keep wheelchair accessible within reach, 9/17/24, monitor resident's position to reduce the risk of sliding/falling, dated 9/17/24, non-skid footwear to reduce the risk of slipping as the resident allows, dated 9/12/24, Keep bed at a safe transfer height. Disabling bed control so height can not be adjusted so residents bed will remain at the safe height at all times, dated 9/12/24. R48 was observed on 9/18/24 at 12:10 PM partially sitting on the edge of her bed. Resident (R48's) feet were on the floor (no shoes or socks on her feet). Resident (R48's) bed height appeared to be in the highest position. (higher than the surveyor waist and resident was not able to fully sit back on the mattress with her feet on the floor). R48 had her lunch tray in front of her and her curtain was pulled so she could not see her roommate. No staff in the room. R48 was not able to recall the last time she fell or any details of the fall that resulted in her wrist fracture. When the resident could not recall the answers, her roommate said she had fallen twice last week and said R48 does not remember to put on her call light. The roommate said she tries to put on the call light when she is aware R48 is walking independently. R48's roommate was very concerned about the falls last week because she thought she broke her hand. R48 confirmed that her left hand was sore and was not upset with her roommate answering questions for her. R48 did not deny any of the information her roommate provided. R48 denied knowing anything she should be doing differently to stay safe. Review of R48's incident and accident reports revealed she had 4 falls between 5/29/24 and 9/12/24. Review of R48's incident and accident report dated 5/29/24 at 3:25 AM revealed R48 was using the bathroom while the Certified Nurse Aide (CNA) was making her bed. R48 stood up using her walker independently, lost her balance and sat on the floor. Review of R48's Fall Assessment for R48's fall effective date of 5/29/24 at 3:36 AM revealed the only new care plan intervention was, Bed height adjustment. No investigation/witness statements or root cause analysis was located. Review of R48's incident and accident report dated 7/3/24 at 18:26 (6:26 PM) revealed R48 had an un-witnessed fall in her room. When the nurse entered her room, she was found laying on her stomach near her bed. R48 was barefoot, she was not using her walker, call light was on the bed but not in use. R48 said she came out of the bathroom because her phone rang. Bathroom call light was not on. Under Injuries Report Post Incident, Fracture Right Wrist. Review of R48's Fall Assessment for effective date 7/3/24 at 18:38 (6:38 PM) revealed no investigation or witness statements, no root cause analysis. The only new intervention listed was, change in footwear. Review of R48's progress note dated effective 7/3/24 at 18:38 revealed, the same fall information as the incident and accident report with the additional information the nurse received a telephone call from the emergency room reporting R48 had a right wrist fracture. Review of R48's incident and accident report for 9/11/24 at 7:40 AM revealed R48 was witnessed dropping to the floor onto her buttock while walking to her bed with her walker. R48 said she was trying to sit on her bed, but the bed was too high, and she dropped to the floor. A staff witness statement revealed, I was behind the resident, supporting her buttock, when she dropped suddenly to the floor, having tried to sit on her bed which was raised too high by the resident prior to ambulating to the bathroom independently. Review of R48's Fall Assessment for effective date 9/11/24 at 19:00 (7:00 PM) revealed no investigation or root cause analysis. The only new intervention listed was, bed height adjustment. (see observation 9/18/24 at 12:10 PM, R48 sitting on the edge of her bed, bed in high position, no staff in her room). This intervention was not implemented. Review of R48's incident and accident report dated 9/12/24 at 00:50 (12:50 AM) revealed R48 self-transferred from her walker to her wheelchair in her room. The wheelchair was not locked, and the resident tried to lock the wheelchair, but the wheelchair slipped and she fell to the floor. Under injuries observed at the time of the incident revealed, strain, right wrist. Under predisposing physiological factors, the boxes for confused, drowsy recent change in medication/new medications, sedated, gait imbalance, and weakness/fainted were all marked. Under predisposing situation factors the following boxes were marked, during transfer, improper footwear, using walker, using wheeled walker. No witness statements or investigation was found. Review of R48's Fall Assessment for effective date 9/12/24 at 1:23 AM revealed, no investigation or root cause. The only new intervention listed was change in footwear (see previous falls this was also an intervention). Change in footwear describe box listed, Must wear non-skid footwear. Review of an Interdisciplinary Team note for R48 dated 9/18/24 at 13:30 PM, for and effective date of 9/12/24 at 9:53 AM revealed the interdisciplinary team discussed R48's incident form 9/11/24. R48 often transfers and walks independently even though she needs assistance from staff. R48 frequently raises her bed to an unsafe high level. The root cause was identified to be R48 raising her bed to an unsafe level and then transferring independently. The new intervention was to have maintenance disable the up/down controls on the bed at a safe transfer level so when R48 self-transfers it will be safer. (See observation on 9/19/24 this intervention was not implemented). Root cause was completed during the survey process, 7 days post fall. Review of R48's Interdisciplinary Team note dated 9/18/24 at 13:34 (1:34 PM) for effective date 9/12/24 at 10:02 AM (meeting held during the survey) revealed the team discuss an incident that occurred on 9/12/24 where R48 was found on the floor. There was no mention of her confusion, drowsiness, medication changes, gait imbalance, sedation or weakness that were listed as predisposing physiological factors. The IDT team identified the root cause as the wheelchair not being locked. The new interventions identified were anti-lock brakes and non-skid footwear. On 9/17/24 at 11:11 AM the Director of Nursing (DON) provided 2 of R48's fall incident and accident reports and post fall assessment. The DON was asked again if these were all the fall reports and full investigations. The DON said the facility had identified a few weeks ago that they were not compliant with fall regulations and were currently in the process getting into compliance with falls. The DON was asked to briefly describe the issues they identified and the DON said it was the follow up information related to the falls and the root causes. Review of the facility Fall Policy dated 11/2/23 revealed, 8. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. 9. Post fall analysis items to be considered. The A/I (accident incident), the nurses notes, review for med changes in the last 30-90 days, review for previous lab findings, review for acute changes, review staff and witness statements (to include last time resident seen, provided care and what type of care), Review of care plan and CNA (certified nurse aide) assignments/Kardex that were in place at the time of the fall, observe any equipment involved (i.e. wheelchair, bed, commode, shower chair, etc.), observation of the resident's room or area of the fall, reenactment. 10. Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the Standards of Care notes. R102 Review of R102's face sheet dated 9/18/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: congestive heart failure, dysphagia, pharyngeal phase (swallowing problem), cognitive communication deficit, unsteady on feet, muscle weakness, Alzheimer's disease, difficulty in walking and abnormal posture. R102 was not her own responsible party. Review of R102's falls care plan dated 3/17/24 with no revision date revealed R102 was at risk for falls related to bladder incontinence, decreased strength and endurance, functional problems and generalized weakness. The interventions included wheelchair anti-rollback dated 9/10/24 and place reminder to call signs in bathroom and resident area to room dated 9/10/24. Grip strips to floor next to bed dated 7/12/24, keep wheelchair locked at bedside when in bed dated 7/12/24, educate resident and family to call for assistance before transferring dated 3/17/24, educate on transfer and ambulation techniques as resident allows dated 9/16/24, encourage resident to keep needed items within reach dated 9/16/24, encourage resident to keep wheelchair in reach dated 9/16/24, non-skid footwear to reduce the risk of slipping as the resident allows, place call light in reach dated 9/16/24. (most of the interventions were placed during the survey, the inventions did not address the resident's memory deficits, history of falls and unsafe transfers, no interventions were located to determine how the facility was providing supervision due known safety issues and impaired cognition). R102 was observed on 9/18/24 at 12:20 PM eating lunch at a bedside table. The table was facing the room outside wall. R102 had no idea how long she had been here and no recall of any falls. There were no staff and no roommate in the room at that time. Review of R102's incident and accident reports revealed she had 4 falls between 3/26/24 and 9/9/24. Review of R102's incident and accident report dated 3/26/24 at 19:47 (7:47 PM) revealed she had an unwitnessed fall in her room. Her roommate witnessed the fall and reported she was waling towards her closet when she was about to sit in her wheelchair, the wheelchair wasn't locked she slid off. Predisposing psychological factors indicated R102 was confused. Predisposing situation indicated R102 was ambulating without assist. No staff witness statements were found, no investigation, no indication of previous care or condition prior to the fall was located. Review of R102's Fall Assessment for effective date 3/26/24 at 20:02 (9:02 PM) revealed. R102 was toileted at 18:00 (6:00 PM) and was in bed prior to the fall. No investigation of this event was located. Review of R102's incident and accident report dated 4/10/24 at 14:10 (2:10 PM) revealed R102 had a witnessed fall and was attempting to sit on her walker but forgot to lock the brakes. Predisposing Physiological Factors on the fall incident report indicated, gait imbalance, recent change in cognition, weakness/fainted. No statement or names of witnesses were located. Review of R102's Fall Assessment for effective date 4/10/24 at 14:36 (2:36 PM) revealed R102 was toileted at 14:00 (2:00 PM) 10 minutes before (R102) fell . The box for other was marked on new care plan interventions (no note for what this meant was located on this form). No witness names or statements were listed. No root cause was located. No interdisciplinary note was provided. Review of R102's incident and accident report dated 7/12/24 at 5:25 AM revealed she had an unwitnessed fall. She was found lying on the floor in her room on her left side. R102 said she fell walking to the bathroom. R102 had a laceration above her right eye actively bleeding. Under mental status was noted, Resident remained on the floor until EMS (emergency medical services) arrival. Resident transferred to stretcher via EMS and taken to ER (emergency room ) for evaluation and treatment. Injury listed laceration to face. Predisposing Physiological Factors marked impaired memory. Predisposing Situation Factors marked ambulating without assistance and improper footwear. No statements, investigation or documentation of R102 condition prior to the fall were located. R102's Fall assessment dated effective 7/12/24 at 5:38 AM revealed they received physician orders to send R102 to the emergency room . R102 was toileted at 3:00 AM (2 hours and 25 minutes prior to finding her on the floor. New intervention listed as other. No witness or witness statements were located, no other information about R102's condition prior to the fall was located. No root cause analysis or interdisciplinary notes were provided. Review of R102's incident and accident report for 9/9/24 at 12:41 PM revealed the nurse heard R102's roommate call out and when she entered R102 was sitting on the floor on her bottom in the bathroom with the back of her head leaning on the wall. R102 had appropriate footwear with nonskid sole. R102 did not use the call light or indicate a need for help. R102 said she was attempting to use the bathroom. Predisposing Physiological Factors marked gait imbalance and impaired memory. Predisposing situation factors marked ambulating without assist. Under statement listed a resident name, Resident reported that R102 had entered the bathroom and stated she was going to wash her hands, resident then attempted to stand up and fell . Immediate action taken was, placed sign to use call light to help prevent self-transferring place in bathroom (R102 was cognitively impaired and there was no indication she could read posted signs) and resident room. Requested anti roll back for wheelchair. Review of R102's Fall Assessment effective date 9/9/24 at 12:42 PM revealed she was toileted at 11:30 AM (a little over 1 hour prior to the fall). New intervention marked other. Review of R102's Interdisciplinary note effective date 9/10/24 at 9:52 AM revealed the team discussed R102's fall that occurred on 9/9/24. Resident has poor gait and needs assistance with transfers and ambulation. Resident also has poor cognition and forgets to lock her breaks and ask for assistance. Root cause identified as resident attempting to transfer without assistance. New intervention for call light reminder signs in both her bathroom and her bedroom and request for anti-roll back device. There was no indication of how the facility planned to assess or increase her supervision or notes for her previous falls with injuries. Similar/Identical interventions were not successful at preventing unsafe transfers/ambulation. There was no indication of ongoing assessment for effectiveness of interventions. Review of the facility Fall Policy dated reviewed 11/2/23 revealed, 8. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. 9. Post fall analysis items to be considered. The A/I (accident incident), the nurses notes, review for med changes in the last 30-90 days, review for previous lab findings, review for acute changes, review staff and witness statements (to include last time resident seen, provided care and what type of care), Review of care plan and CNA (certified nurse aide) assignments/Kardex that were in place at the time of the fall, observe any equipment involved (i.e. wheelchair, bed, commode, shower chair, etc.), observation of the resident's room or area of the fall, reenactment. 10. Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the Standards of Care notes. R465 Review of R465's face sheet dated 9/17/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and diagnoses included kidney failure, dementia, macular degeneration (visual problem), dysphagia (swallowing problem) and cognitive communication deficit. R465 was not his own responsible party. Review of R465's activities of daily living care plan dated 9/11/24 revealed that he could not walk, he required assistance of one person for bed mobility, dressing, eating, hygiene, toileting, transfers, he needed encouragement to use his call light for assistance. Review of R465's fall care plan dated 9/11/24 revealed he was at risk for falls related to dementia, OA (osteoarthritis) macular degeneration (visual problems), CHF (congestive heart failure), HTN (hypertension), DDD (degenerative disc disease) compression fracture, edema (swelling). Interventions listed: foot pedals to be removed form wheelchair unless being propelled. Educated resident on safety interventions, encourage resident to keep needed items within reach, encourage resident to use call light, ensure resident's room is free from accident hazards (e.g., providing adequate lighting (not in place on 9/16/24 see incident and accident report), ensuring there are no trip hazards, providing assistive devices), PT/OT/SLP (physical therapy, occupational therapy, speech language pathology). No interventions for supervision were located. Review of R465's incident and accident report dated 9/13/24 at 14:38 (2:38 PM) revealed he had an un-witnessed fall. He was found sitting on the floor on his foot pedals of his wheelchair. Predisposing environmental factor marked poor lighting. Predisposing physiological factors marked admitted within last 72 hours. One staff statement was listed, I found the resident sitting on his wheelchair legs when I walked into the room. There was no information located as to who had provided care or what time last care was provided. No interdisciplinary note or root cause analysis was located. No new interventions were located. R465 was observed in bed awake on 9/16/24 at 9:23 AM. R465 wanted water but did not know how to use his call light. Resident was assisted by the Surveyor to put on his light as staff were not in the room. R465 was observed on 9/17/24 at 12:05 PM eating lunch. No staff in room and resident was requesting cold water but did not know how to put on the call light. Staff came in the room at 12:10 PM and left again attempting to get R465 thickened cold water. R465 was observed alone in his room eating breakfast on 9/18/24 at 9:29 AM. R465 was not aware of where he was and asked 5 times in approximately 5 minutes how the weather was outside today. R465 did not recall falling in the facility or recall how long he had been here.

Based on interview and record review, the facility failed to accurately assess/implement advanced directives (upon admission) for 2 Residents (R102 and R110) of 4 Residents reviewed for advanced directives. Findings include: R102 Review of R102's face sheet dated 9/18/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: congestive heart failure, dysphagia, pharyngeal phase (swallowing problem), cognitive communication deficit, unsteady on feet, muscle weakness, Alzheimer's disease, difficulty in walking and abnormal posture. R102 was not her own responsible party. Review of R102's electronic medical record revealed no signed copy of R102's advanced directive. During an interview with the Director of Nursing on 9/17/24 at 11:40 AM, the DON said the nurses complete the advanced directives on admission. The DON said R102's son was her Durable Power of Attorney. The DON could not find any information that validated R102's son was contacted about R102's advanced directives. On 9/17/24 at 11:47 AM, the DON had an advanced directive form for R102 dated today 9/17/24 that was signed by R102. The DON was not able to locate an advanced directive completed by R102's son. The DON confirmed that R102 was not her own responsible party, and she was not able to locate any information that R102's son had been contacted to complete R102's advanced directive. Review of R102's advanced directive dated 9/17/24 revealed that the box for I do not choose to formulate or issue any Advanced Directive at this point was marked. It was signed by R102 (R102 was not her own responsible party, see the face sheet). After the Facility Representative/Title it was signed by the facility social worker. R110 Review of R110 face sheet dated 9/16/24 revealed she was a [AGE] year-old female admitted on [DATE] and had diagnoses that included: acute respiratory failure, sepsis, pneumonia, diabetes mellitus 2, dysphagia (swallowing problems) and cognitive communication deficit. R110 was listed as her own clinical responsible party. Record review reveal no advanced directive on record for R110. During an interview with the DON on 9/17/24 at 10:30 AM the DON said they had identified issues with the nurses not completing new admission advanced directives. During an interview with the facility Social Worker (SW) N on 9/17/24 at 10:35 AM, SW N confirmed that R110 was still her own responsibility party and R110's husband had not provided the facility with a Durable Power of Attorney (DPOA) papers. During an interview with the Director of Nursing on 9/17/24 at 11:40 AM, the DON had located an advanced directive for R110 dated 8/29/24 that was signed by R110's husband. The DON said R110 is her own responsibility party and should have signed her own advanced directive. Review of R110's Advanced Directive revealed the box for I do not choose to formulate or issue any Advanced Directive at this time was marked. After resident signature was the husbands, signature dated 8/29/24.

Part 1 This Citation refers to MI 758 Based on observation, interview, and record review, the facility failed to provide one Resident (Resident (R) 7) necessary services to include: providing water, providing consistent Doctor ordered wound dressing changes, failed to implement the Comprehensive Care Plan for pain, failed to revise the Comprehensive Care Plans for Pain and Actual Impaired Skin Integrity, failed to document in the medical record pertinent care, and failed to provide a sanitary living environment, resulting in a worsening wound, unresolved pain concerns, unmet care needs and the potential for infection and dehydration of a dependent and chronically immune-compromised Resident and the potential for all dependent residents to not receive necessary care and services. Findings: R7 originally admitted to the facility 10/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), Section C dated 4/22/22 reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R7 was cognitively intact. Section G of this MDS reflected R7 required extensive assistance of two staff members for bed mobility, transfers, locomotion on and off the unit, and for personal hygiene. On 6/6/22 at 10:29 AM an observation and interview were conducted with R7 in his room. R7 was observed to be sitting in a large wheelchair with pillows behind his back and his lower legs and feet resting on a low bed. It was observed that both lower extremities were wrapped with Coban (a self-adherent wrap intended as an elastic wrap to provide compression and to secure dressings). The front of the Coban wrap on the right lower leg had two areas greater than one inch in diameter where reddish brown drainage had saturated through the surface of the Coban wrap and one area on the front left Coban wrap on the lower extremity greater than one inch in diameter that had also saturated through. Unraveling from under the left leg wrap and protruding from the top of the Coban wrap was a length of white gauze with several visible areas of reddish-brown drainage. This gauze dangled onto the bed and floor below the Resident's suspended legs. R7 reported the leg dressings were last changed the previous Thursday when he had a shower (this interview was conducted on the following Monday). Areas of reddish-brown drainage were observed on the bed sheets and on one pillowcase. A urinal that contained urine was observed on the over-the-bed table next to R7. No water for drinking was observed in the room. R7 reported he had asked staff for water about an hour prior, but he had not received any yet. R7 also reported that he told staff this his fanny is on fire and that staff responded by telling him he should be laying on his side. R7 stated I've been waiting for someone to come put me on my side for about an hour. R7 reported he receives scheduled pain medication but often has unrelieved pain in between doses. R7 reported he has informed staff of the pain he experiences but that he is told you get your [MEDICATION(S)], that should be enough. R7 reiterated that he was very uncomfortable in the wheelchair and was observed frequently moving his feet off and onto the bed seeking a position of comfort. The soiled gauze that was hanging out of the left leg wrap was dragging on the floor and bedding as the Resident repositioned his legs. R7 was asked to initiate his call light and Certified Nurse Aide (CNA) E responded nine minutes later. At the request of R7 CNA E provided water and emptied the urinal that was on the over-the-bed table. Although in full view of CNA E no attempt was made to address the dangling soiled wrap, soiled bedding, mentioned the wraps that were saturated through with drainage or asked R7 about pain or repositioning. At 11:03 AM, CNA E was asked to have the nurse come to the room of R7. Twenty-five minutes later, at 11:28 AM, Licensed Practical Nurse (LPN) D arrived at the room and reported that a unit manager or a treatment nurse completes the dressing changes for R7. The current presentation of R7 was highlighted for the LPN to include the saturated leg wraps with the loose soiled wrap hanging out of the left leg wrap and the discomfort of R7. LPN D was also informed that the surveyor wanted to observe the legs and buttocks of R7. LPN D reported she would inform the Unit Manager. While waiting for the Unit Manager R7 continued to complain of pain and discomfort and was frequently repositioning his legs from the bed to the floor continuing to drag the length of soiled gauze across the bed and floor. At 11:55 AM, twenty-seven minutes later, Unit Manager (UM) A arrived at the room of R7. UM A reported that R7 is often non-compliant with laying on his side in his bed and began assembling supplies for a dressing change. R7 reported that dressing changes are painful and that he is not offered any pain medication prior to the treatment stating, I wish they would give me something. At 12:05 PM, UM B arrived to assist UM A. A mechanical lift was brought into the room. UM B raised the bed to change the bedding that had areas soiled with reddish-brown draining. When the bed was raised a large puddle of an unknown liquid was observed under the bed. After additional preparations R7 was secured in a sit-to-stand mechanical lift and raised off the wheelchair. On the seat of the chair was observed a saturated brief with areas of reddish-brown drainage and active bleeding of the buttock was noted. A dressing saturated with reddish-brown drainage dated 6/4/ (22) was loose but still held to the right buttock. This dressing was removed and discarded. It was observed that when R7 was raised off the wheelchair a foul odor became prominent in the room. As R7 was moved in the mechanical lift large spots of blood dripped from his buttocks onto the floor landing in four 50 cent sized spots. R7 was transferred to the bed and turned to his left side exposing all the right buttocks and part of the left buttocks. UM A obtained photographs of the buttocks using a device that measured the open areas of concern. Review of the documentation of the above Skin and Wound Evaluation dated 6/6/22 reflected that the wound on the right buttocks was facility acquired and was described as Moisture Associated Skin Damage (MASD). The documentation reflected measurements of 13.14 centimeters (cm) in length and 12.06 cm wide with a total area of 125.42 cm squared (sq) or 19.44 square inches. Review of the EMR Skin and Wound Evaluation dated 5/3/22 reflected measurements of 2.7 cm by 3.6 cm with a total area of 6.7 cm sq. The 6/6/22 measure reflected an increase in total area of 118.72 cm sq from 5/3/22. Section I of the Skin and wound Evaluation form reflected a heading of Progress (of the wound) and included check boxes for notifications. This section was not completed and the box for Practitioner notified was not checked. Review of the Comprehensive Care Plan for R7 reflected a Focus of The resident his (sic) at risk for chronic pain related to . (ten diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . initiated 10/19/21 and revised on 4/25/22. The interventions of this Care Plan included: Administer pain medications as ordered. Give ½ hour before treatments or care initiated 10/19/21. And Anticipate the resident's need for pain and respond immediately to any complaint of pain, initiated 10/21/19. And Monitor/document for probable cause of each pain episode. Remove/limit causes where possible, initiated 10/21/21. And Observe and report changes in usual routine, .or resistance to care initiated 10/21/21. The Comprehensive Care Plan for chronic pain does not reflect any resolved or new interventions documented since the Care Plan was first formulated on 10/21/21. On 6/6/22 review of the Comprehensive Care Plan for The resident is at risk for pressure ulcer development (related to) admitted with severe excoriation, areas open throughout whole buttock (MASD). Chooses to sit in (wheelchair) and not lie down even at night for pressure relief. Incontinent of (bowel and bladder) at times, Initiated 10/19/21 and revised on 5/3/22. The Care Plan reflected interventions that included Administer treatments as ordered . and If resident refuses treatment confer with interdisciplinary team and family to determine why and try alternative methods to gain adherence. Document alternative methods. These Care Plan Interventions were implemented 10/19/21 and 10/21/21 without any noted revisions. Review of the CNA documentation from 5/9/22 to 6/7/22 reflected R7 a range from independent to extensive assistance for bed mobility with no documentation in the refusal section. Review of the EMR Progress Notes for R7 from 4/1/22 to 6/5/22 revealed two entries (4/8/22 and 5/14/22) that indicated R7 declined to reposition off the buttocks. The Progress Note entry of 4/22/22 at 3:45 AM reflected R7 was compliant with most cares. No other documentation was found in the EMR Progress Notes was found that reflected an ongoing pattern of resident refusals. No documentation was found in the Progress Notes that reflected the Interdisciplinary Team or the family had discussed alleged non-compliance or attempted any alternative methods to gain adherence to the Care Plan or treatment plan. The EMR Progress Notes did not reflect that involvement was sought by Social Services to investigate/determine a cause for the alleged non-compliance. Review of the Medication Administration Record (MAR) for May 2022 for R7 reflected administration of [MEDICATION(S)]- Acetaminophen Tablet 10-325 milligram (mg) ([MEDICATION(S)]) at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM with documentation of pain levels rated using the 1 to 10 pain scale with 10 being the highest level of pain. For the month of May 2022, the documentation reflects 32 instances where R7 reported a pain level of 7 or greater. Review of the EMR did not reflect follow up documentation that the medication was effective. No documentation was found that indicated R7 was provided pain medication 30 minutes prior to dressing changes as indicated by the Care Plan. No documentation was found that reflected the probable cause of each pain episode was reviewed or that efforts were made to remove or limit the causes of pain where possible as indicated by the Chronic Pain Care plan. No documentation was found that indicated revision of the Comprehensive Care Plan was considered. On 6/7/22 a review was conducted of the MAR for May 2022. The MAR reflected a current order for Tylenol Tablet 325 mg (Acetaminophen) Give 650 mg by mouth every 12 hours as needed for pain do not exceed 3000mg/day. The MAR reflected R7 received 1300 mg of acetaminophen daily from the scheduled [MEDICATION(S)]. This results in 1700 mg remaining available from 3000mg daily limit or allows for two doses of the as needed Tylenol. The MAR for May 2022 reflected R7 was not offered or had received any doses. During an interview conducted 6/7/22 at 4:21 PM R7 reported that for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 reported he is not offered the as needed Tylenol because of some ingredient that is in [MEDICATION(S)]. R7 reported he was told by staff that he can't get too much of that. Review of the Treatment Administration Record (TAR) for April and May 2022 reflected daily dressing changes were ordered for the buttock's wounds. The documentation of the medical record reflected no documentation that the dressings were changed fourteen times In April and May (4/4, 4/7, 4/15, 4/22, 4/23, 4/29, 5/2, 5/4, 5/6, 5/15, 5/18, 5/19, 5/25, and 5/28/22). The TAR for June 2022 reflected two dressing changes were not documented for the first five days of June (6/3 and 6/5). The observation of the saturated dressing dated 6/4 that was adhered to the buttocks of R7 on 6/6/22 validated the lack of dressing changes and documentation of the TAR. Review of the Physician Assistant (PA) Progress Note dated 4/29/22 reflected R7 was hospitalized [DATE] with Acute Kidney injury (AKI) [CONDITION(S)] (high potassium), and [CONDITION(S)] likely secondary to dehydration. The PA Progress Note further reported that R7 was again sent to the hospital on 4/12/22 and was diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The PA documented that the wound on the sacral region (buttock) is still problematic and described the wound as a Pressure injury and not as MASD. The PA also noted that R7 is noncompliant with pressure relief but to Continue local care to wounds and sacral/buttocks region. The entry did not reflect the source of the of the PA claim of non-compliance by R7 as this data could not be confirmed through review of the medical record. Review of the Nurse Practitioner (NP) Progress Note dated 5/26/22 did not reflect an evaluation or any comment on the pressure injury of the sacral/buttocks region that was documented the previous month as still problematic. The NP Progress Note did not indicate the NP was aware that 13 buttock dressing changes (to date) had not be documented for April and May 2022. During an interview conducted 6/7/22 at 9:20 AM, UM A reported no one certain Medical Provider is following the wounds of R7. UM A reported R7 is followed as a routine resident. During an interview conducted 6/7/22 at 4:35 PM, UM was informed of the concerns of the care of R7 to include wound care, meeting of needs, pain, Care Planning, and the living environment. UM A reported the R7 is already, in a hole to us for quite a bit (financially). UM a reported that the facility has given to R7 the tools so that he can improve. UM A acknowledged that the improvement of the wound on R7 was likely impeded by the dressing changes not always being completed daily as ordered. UM A was informed that the medical record did not reveal documentation by nursing and CNA staff of consistent refusals to reposition or attempts to encourage R7 of the importance of off-loading the wounds. UM A stated, you may have to go back a way (in the medical record) to locate documentation of refusals. Two days following the interview of UM A when the concerns of the care of R7 were conveyed to UM A a review of the medical record revealed an entry dated 6/9/22 by the Nurse Practitioner (NP). The NP note reflected staff had reported to the NP that R7 was non-compliant with repositioning and refuses to lay in his bed. The entry did not reflect an NP review of the medical record to confirm a pattern of non-compliance or documentation that interventions were attempted to encourage compliance. The NP entry quoted R7 that the pain of the wound was not that bad. However, the entry did not provide context if the pain was at that moment and did not reflect the NP had reviewed the elevated pain levels documented on the MAR for April and May 2022. The NP entry reflected the wound on the right coccyx/gluteal region as well as the posterior scrotum is now a Stage II (stage 2) pressure ulcer (not MASD), with a Plan of Reinforce the need to reposition off his buttocks frequently, change brief as soon as soiled to prevent worsening In a telephone interview conducted 6/8/22 at 2:23 PM, the Director of Nursing (DON) reported R7 was going to a wound clinic but did not have the buttocks wound at that time. The DON reported that R7 has refused many pain medications because R7 can't tolerate them. The DON reported R7 Palliative Care had evaluated and attempted to care for R7 but discharged him for cause. The DON reported that the cause was that R7 was non-compliant. No further pertinent information was provided by the facility prior to survey exit. Although interviews reflect R7 was noncompliant with repositioning the medical record does not reflect documentation of a pattern of refusals by R7 or efforts by the facility to gain adherence as reflected in the At Risk for Pressure Sore Care Plan. No documentation was found in the medical record that reflected facility efforts to reapproach R7 to reposition, investigate reasons for alleged refusals, implementation of interventions, or attempts to revise the treatment plan or revising the Care Plan. The Care Plan does not reflect a history of good faith revisions aimed at healing or preventing worsening of the wounds. The documentation of the medical record reflects numerous dressing changes were not documented (23% of the ordered dressing changes not documented). UM A acknowledged in an interview that these likely impeded the improvement, thereby contributing to the degradation, of the buttocks wound. This wound had increased in total area of 118.72 sq cm from 5/3/22 to 6/6/22 preceding the NP entry of 6/9/22 that the wound was assessed as a Stage 2 pressure sore. While interviews reflected attempts were made to address the pain issues experienced by R7 the medical record reflected numerous entries of elevated pain levels with no documented follow up or that the Chronic Pain Care Plan interventions were implemented or revised. Additionally, the observations of 6/6/22 validated the concerns conveyed to UM A on 6/7/22. These observations included: R7 did not have hydration available, lived in an unsanitary environment of drainage on bedding and an unraveling soiled left leg wrap, and R7 was found to be wearing a saturated brief and a two-day old buttock dressing that was saturated with reddish brown drainage and was making repeated claims of discomfort. Additionally, R7 claimed he had asked for water and was told he would be laid on his side about an hour prior. These, collectively with the medical record concerns, demonstrate that R7 was not provided services that were Doctor ordered, directed by a Care Plan, or as an expectation of Standard of Care. Part 2 This citation refers to MI 340. Based on interview and record review, the facility failed to prevent physical, verbal, and/or mental abuse for 2 of 9 residents (R1 and R2) reviewed for abuse, resulting in R1 being physically abused and R2 being verbally and/or mentally abused, the potential for abuse to go undetected, and the potential for residents not being protected from abusive individuals. Findings include: A review of the facility's Abuse, Neglect and Exploitation policy and procedure, reviewed/revised 7/28/20, revealed, abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of the facility's Abuse, Neglect and Exploitation policy and procedure, reviewed/revised 7/28/20, revealed, verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. A review of the Legal Dictionary, dated 10/29/16, revealed, Definition of Verbal Abuse: The repeated improper and excessive use of language to humiliate someone, or to undermine someone's dignity . Any of the following actions can be considered forms of verbal abuse: Accusing/blaming; Name-calling; Ordering the victim around; Judging/criticizing; Abusive anger; Discounting or minimizing the victim's experiences; Threatening (https://legaldictionary.net/verbal-abuse). A review of the Law Insider, undated, revealed, Mental abuse means any willful action or inaction of mental or verbal abuse. Mental abuse includes, but is not limited to, coercion, harassment, inappropriately isolating a vulnerable adult from family, friends, or regular activity, and verbal assault that includes ridiculing, intimidating, yelling, or swearing (https://www.lawinsider.com/dictionary/mental-abuse). A review of R1's Admission Record, dated 6/7/22, revealed R1 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's Admission Record revealed multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/4/22, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 9 which revealed R1 was cognitively intact. A review of R2's Admission Record, dated 6/7/22, revealed R2 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R2's Admission Record revealed multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R2's MDS, dated [DATE], revealed a BIMS score of 0 which revealed R2 was severely cognitively impaired. A review of the facility's undated Investigative Summary revealed on 4/18/22 at approximately 9:45 PM, R2 was observed making contact with [name of R1]'s left cheek lightly with a closed hand and holding her left wrist. Residents were immediately separated and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of waiver care aide (WCA) J's typed statement, dated 4/18/22, revealed, on 4/18/22 As I was walking out of [number of a resident's room], I seen [name of R2] hitting [room number and bed of R1], closed fisted, lightly on the left cheek with his right hand and holding [name of R1] left arm towards the wrist with his left hand. [Name of R1] was screeching as [name of R2] was hitting her. I hollered for help while I tried to split them apart. As I was wheeling [name of R2] to his room he told me she (R1) was in the way. A review of WCA K's written statement, undated, on 4/18/22 revealed WCA K saw R1 and R2 hugging. WCA K wrote she yelled over at [name of R2] to leave [name of R1] alone before going into a room. During an interview on 6/8/22 at 3:05 PM, WCA J stated she was going into another resident's room to provide care with WCA K. She stated she heard hollering and told WCA K to look into the hall and see what was going on. WCA J stated WCA K looked into the hallway and told her that R1 and R2 were hollering at each other. WCA J stated she stepped out of the room and as she was walking toward R1 and R2, she saw R2 hit R1 with a closed fist on the right cheek. WCA J stated she saw R2 holding R1's left arm with his (R2's) left arm. WCA J stated R2 bopped R1 five times on her left cheek with his closed fist. She stated as R2 was hitting R1 in the face, R1 was screeching and yelling. WCA J stated R2 did not hit R1 hard. But he really doesn't when he hits you. WCA J stated she has been hit by R2 before and he does not put too much effort behind his punches. WCA J stated she immediately separated R1 and R2 and wheeled R2 back to his room. WCA J stated on the way back to R2's room, she asked him why he was hitting R1. WCA J stated R2 said, She was in my way. WCA J stated prior to seeing R2 hit R1, she was not aware that there was an issue between them. During an interview on 6/8/22 at 3:15 PM, WCA K stated she went into a resident's room with WCA J to provide care. Prior to entering that room, WCA K stated she saw that R1 and R2 were arguing. She stated she could not hear what was being said because she was too far away, but could hear R2 talking very loudly to R1. WCA K stated R1 was trying to move away from R2 while he was arguing with her. She stated she saw R2 grab R1's wheelchair. WCA K stated when she saw R2 grab R1's wheelchair, I yelled at [name of R2] to let her go. WCA K stated after she yelled at R2, she went into a resident's room to help WCA J provide care. WCA K stated, I probably should have stayed out there and watched them. But I didn't. During an interview on 6/8/22 at 3:15 PM, WCA K stated she does not remember if she told anyone about R1 and R2 arguing before the incident occurred. WCA K stated she did not recall hearing any arguing or yelling in the hallway before WCA J left the resident's room. She stated she just remembered WCA J leaving the resident's room for some reason and hearing WCA J yell can someone help me from the hallway. WCA K stated the nurses and WCA J separated R1 and R2 while she stayed with the resident in their room. A review of R2's behavior care plan, dated 8/12/19, revealed staff were to observe for environmental stressors and intervene as indicated. However per WCA K's interview on 6/8/22 at 3:15 PM, WCA K observed R1 and R2 arguing; R2 grabbed R1's wheelchair as R1 tried to leave the area; and WCA K entered a resident's room to provide care after yelling at R2 to leave R1 alone and did not appropriately intervene to prevent an escalation of the situation. As a result, R2 hit R1 five times on R1's left cheek with his closed fist. A review of R2's impaired cognitive function or impaired thought processes care plan, dated 8/5/19, revealed staff were to cue, reorient, and supervise as needed. However per WCA K's interview on 6/8/22 at 3:15 PM, WCA K observed R1 and R2 arguing; R2 grabbed R1's wheelchair as R1 tried to leave the area; and WCA K entered a resident's room to provide care after yelling at R2 to leave R1 alone and did not supervise R2 to prevent an escalation of the situation. As a result, R2 hit R1 five times on R1's left cheek with his closed fist.

This citation pertains to intake # MI 491 Based on interview and record review, the facility failed to prevent the worsening of a pressure ulcer for 1 Resident (R5) resulting in R5's pressure ulcer worsening to stage IV. Findings include : Review of R5's face sheet dated 6/8/22 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 was not his own responsible party. Review of R5's Nursing Admission Evaluation dated, 4/22/22 at 10:14 PM revealed, Resident has stage 2 on coccyx, Wound bed has sloughing Present. No measurements were located. Review of R5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily and prn (as needed). Review of R5's, Skin & Wound Evaluation dated 4/25/22 revealed R5 had a stage II pressure ulcer that was present on admission. The pressure ulcer measured, 3.9 cm in length, 2.0 cm in width and had no depth. This wound was noted to be Healable. Review of R5's, Physician Assistant (PA) progress note dated, 4/29/22 revealed, Staff requesting that patient be evaluated today for anxiety and not sleeping. Unfortunately, no further documentation available. Patent reports that is (sic) not feeling well today, has pain all over. Specifically, he has pain in his tailbone from falling twice. He has not had any falls since admission to this SNF (skilled nursing facility). He does have a stage 2 pressure ulcer to the coccyx. Review of R5's Skin assessment dated [DATE] revealed R5 had a stage 2 pressure ulcer on admission. No measurements were located on this form. Review of R5's Skin & Wound Evaluation dated 5/10/22 revealed, R5 had a stage II ulcer that measured, 7 cm in length, 6.1 cm in width and was 1.5 cm deep and had 20% eschar (black tissue), wound status was deteriorating. Review of R5's, Physician Assistant (PA) progress note dated, 5/11/22 revealed, (Wound present on admission to this SNF (skilled nursing facility) from LTAC (long term acute care facility). It is felt to be worsening per nursing. Patient is on tube feeding with an oral diet for nutrition. Wound bed appears to be all slough, nursing plans to change dressing to honey alginate. Likely stage 3-4 but unable to stage due to slough. Will ask dietician to review and optimize tube feeding for improved nutrition and wound healing. Review of R5's care plan revealed he had a care plan for at risk for skin breakdown/pressure ulcer development associated with neurofibromatiosis (tumor from brain to spinal cord), gastrostomy status (tube feeding), left [CONDITION(S)], current stage II to sacrum, B & B (bowel and bladder incontinence), healing [CONDITION(S)] site, decreased mobility, dated 4/22/22. Interventions included: APM (alternating pressure mattress) started 4/22/22, pressure relieving cushion to wheelchair started 4/28/22 (5 days after known pressure ulcer to sacrum). Review of R5's care plan revealed he had a care plan for Actual impairment to skin integrity of the following location - sacrum - stage II pressure ulcer, present on admission, dated 4/22/22. Interventions included: The resident needs pressure relieving/reducing cushion to protect skin while up IN CHAIR. Dated 5/11/22 (19 days after admission with a known pressure ulcer on sacrum). Review of R5's Treatment Administration Record (TAR) for April 2022 revealed, Sacral pressure ulcer cleanse with NS (Normal Saline), apply calcium alginate, hydrolock dressing, skin prep to surrounding skin secure with tape, change daily. Start date 4/23/22 and discontinue date 5/16/22. Treatments for 4/26/22, 4/29/22 and 4/30/22 were all blank. Indicating no treatment provided. Review of R5's progress note dated 5/1/22 at 1:48 AM, event 4/30/22, revealed resident refused AM medications this morning, refused treatment to sacrum and old [CONDITION(S)] site, refuse hoyer for weight or transfer to chair, refused thickened liquids, putting on call light every couple minutes since shift started at 6 am requesting ice chips, despite education about taking medications, completing wound care, obtaining weight and getting out of bed into chair as tolerated and drinking thickened liquids resident continues to refuse and will often call out for help as well as using call light. There was no indication R5's responsible party or physician was notified of refusing treatment that could result in serious harm. Review of R5's Treatment Administration Record (TAR) for May 2022 revealed, Sacral pressure ulcer cleanse with NS (Normal Saline), apply calcium alginate, hydrolock dressing, skin prep to surrounding skin secure with tape, change daily start date 4/23/22 and discontinued 5/16/22. 5/1/22 the treatment boxes all had an x and at the bottom was noted 9 for see progress notes. 5/2/22 and 5/6/22 were blank indicating no treatment done. The only progress note indicating the reason for note treatment was dated 5/1/22. According to the April and May 2022 TARS, R5 did not receive wound care 6 times. There was only one note 5/1/22 indicating R5 refused treatment. There were no notes that documented different approaches attempted, responsible party notification of physician notification of R5 missing 6 wound treatments. Review of R5's, Sacral debridement OPERATIVE NOTE dated 5/14/22 revealed R5's sacral wound was debrided at the hospital and findings included: infected stage IV sacral ulceration. During an interview with the Director of Nursing (DON) on 6/9/22 at 8:20 AM the DON said she reviewed R5's wound documentation. The DON was aware documentation was missing for several wound treatments that indicated R5 did not receive wound care. The DON was not able to explain why R5 did not have weekly wound measurements but did say the facility had started a new wound care process the first of May.

This citation has 2 separate deficient practice statements A and B. (A)Based on observation, interview, and record review, the facility failed to prevent falls for 2 of 6 residents (Resident #29 and #74) reviewed for falls. This deficient practice resulted in Resident #29 sustaining multiple avoidable falls and a fractured right ankle and Resident #74 sustaining multiple avoidable falls and facial bruising. Findings include: Resident #29 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #29 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 13 out of 15 which represents Resident #29 was cognitively intact. On 6/9/21 at approximately 10:30 AM Resident #29 was observed lying in bed and was not able to answer specific questions related to falls and safety due to her fluctuating cognitive status. Record review of an X-Ray report for the right ankle dated 4/6/21 reflected, Results: Distal fibula fracture with malalignment, Mild soft tissue swelling. Joint space narrowing. Conclusion Acute distal fibula fracture as noted. According to the Activities of Daily Living (ADL) care plan dated 9/9/20 reflected Resident #29 required the assistance of 2 to use the bathroom, and the assistance of 2 for transfers with the use of a sit to stand mechanical lift. According to the Falls care plan dated 9/11/20 reflected the following interventions, Anticipate and meet the resident's needs based on nursing assessments. Date initiated: 9/11/2020 .Determine Causative factors of fall and resolve or minimize. Date initiated: 9/11/20 .The resident should wear gripper socks when in bed for safety should the resident get out of bed without assistance. Date initiated: 9/11/20 .Keep floor clear of clutter and cords, to avoid things being in the way of resident while ambulating. Date initiated: 10/25/20 .The resident uses the following alarming device. Silent alarm. Ensure the device is in place as needed. Dated initiated: 2/22/21 .Do not leave unattended in the bathroom. Date initiated: 2/22/21. During an interview and record review on 6/10/21 at approximately 10:00 AM, the Unit Manager (UM) V and this Surveyor reviewed the fall incident reports from 3/31/21 - 6/6/21 in which Resident #29 sustained 7 falls, in 67 days. The UM V stated that Resident #29 has avoidance disorder and at times will not communicate with staff, she has a fractured ankle, and now wears a walking boot and requires the assistance of 2. When asked how often residents are checked for supervision, the UM V stated that the facility's expectation is that all residents be checked every two hours and further added the staff should assess and monitor resident comfort, hunger, thirst, safety concerns and offer the bathroom during the rounding. The falls timeline is as follows: -3/31/21 at 5:10 AM an unwitnessed fall in her room by the door, resident reports trying to use the bathroom, was wearing regular socks (not gripper socks), and bed alarm was not plugged in correctly and subsequently did not activate. According to the care plan intervention dated 2/22/21 the staff were to ensure the alarm was in place and to ensure gripper socks were on while in bed. -4/6/21 at 5:30 AM an unwitnessed fall in the bathroom, resident reported attempting to go to the bathroom, root cause was attempted self-transfer, the facility added the interventions of educate to use the call light for bathroom, (which the UM V states is not very effective), and to offer assistance to the bathroom before and after evening meals and last rounds on the midnight shift for a targeted area of 4-6 AM. According to the care plan the staff were to already anticipate the resident needs. When asked if this was already a staff expectation with every 2-hour rounding, the UM V stated, Yes. The UM V stated that Resident #29 complained of ankle pain and an X-Ray was order that reflected a fracture to the right ankle. Resident #29 required a walking boot to the ankle. -4/30/21 at 1:00 AM an unwitnessed fall on the bathroom floor, resident reported going to the bathroom, and the root cause was attempted self-transfer. The UM V stated the intervention to offer assistance with the bathroom on 1st rounds of the midnight shift. When asked if this was already a staff expectation with every 2-hour rounding, the UM V stated, Yes. -5/21/21 at 6:30 PM an unwitnessed fall next to the bed, the resident reported trying to leave, the root cause was attempted self-transfer and wearing personal gripper socks. The UM V stated the new interventions included wearing the facility gripper socks, a physician assessment, lab orders, and IV fluids. -5/27/21 at 10:15 PM an unwitnessed fall beside of the bed, resident reported the need to go to the bathroom, the root cause was attempted self-transfer and a recent change in condition with increased restlessness. The UM V reported the new intervention of a concave mattress was implemented. -5/31/21 at 5:00 PM an unwitnessed fall on the bathroom floor, resident reported going to the bathroom, the root cause was attempted self-transfer. The UM V stated the new intervention was to target offering the assistance to the bathroom before and after meals. When asked if that was already a staff expectation with the 2-hour rounding, the UM V stated, Yes. -6/6/21 at 12:00 PM (noon) an unwitnessed fall next to the bed, sustained a bruise (the incident report did not indicate to where), the resident was unable to explain what she was attempting to do, the root cause was attempted self-transfer, potentially attempting to transfer from the wheelchair back to bed. The UM V stated the new intervention of offering transfer back to bed after meals was implemented. Resident #74 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #74 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 3 out of 15 which represents Resident #74 had severe cognitive impairment. According to the ADL care plan dated 2/21/19 reflected Resident #74 required assist of 1 staff member for toileting and transferring. According to the Falls care plan dated 2/22/19 reflected the following interventions, Anticipate and meet the resident's needs based on nursing assessments. Date initiated: 11/25/19 .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date initiated: 2/22/19, Grip socks or slippers at all times. Date initiated 2/22/19. During an observation and interview on 6/9/21 at 11:14 AM, Resident #74 was observed wheeling herself down the hall in her wheelchair. This Surveyor observed a large blue/purple bruise to the right forehead that extended to the eye. When asked how she sustained the bruise, Resident #74 stated, I fell in the bathroom the other day. Resident #74 was unable to answer any other specific questions related to the fall and injury. During an interview and record review on 6/10/21 at approximately 10:00 AM, the UM V and this Surveyor reviewed the fall reports from 3/12/21 - 6/8/21 in which Resident #74 sustained 6 falls in 88 days. The UM V stated that Resident #74 has poor short-term memory, hallucinations, delusions and does not walk but can pivot transfer. The falls timeline is as follows: -3/12/21 at 11:15 PM an unwitnessed fall in the bathroom, resident reported attempting to transfer to the toilet. Resident slipped off the toilet and sustained a bruise to the back of her head. The UM V stated the new intervention of toileting to be offered with rounds and continue the bedside commode was added to the care plan. When asked if staff should have already been offering assistance with the bathroom with every 2-hour with rounding the UM V stated, Yes. -3/31/21 at 4:10 AM an unwitnessed fall next to the bed, resident reported trying to use the toilet. The new intervention was to add nonskid strips to the floor. -4/15/21 11:10 PM an unwitnessed fall next to the bed by the commode. The resident reported she was using the bathroom. The new intervention to keep the night light plugged in next to the commode was added to the care plan. -5/9/21 at 4:30 AM am unwitnessed fall next to the bed. The resident reported trying to use the bathroom. The new interventions of a therapy evaluation, educate to use call light, clean floor with rounds as needed, and observe for clutter and debris were added to the care plan. When asked if the staff should already be assessing clutter, and debris on the floor with every 2-hour safety rounds, the UM V stated, Yes. When asked if Resident #74 has the ability to retain the teaching of the call light use, the UM V stated, No. -5/19/21 at 12:50 AM an unwitnessed fall between the wheelchair and the commode. The resident reported trying to use the bathroom. The UM V stated that Resident #74 was wearing regular socks at the time of the fall and nonskid socks were added to the care plan. According to the care plan gripper socks were already added on 2/22/19 and this was not a new intervention but rather an intervention that should have already been in place to prevent the fall. -6/8/21 4:30 AM and unwitnessed fall in the bathroom and a large bruise was noted to the right side of the forehead. The resident reported trying to go to the bathroom. The UM V stated the root cause was attempted to self-transfer and unattended in the bathroom. The new intervention was to supervise in the bathroom if found there and stay with her until she is finished. According to the Falls care plan the staff were to anticipate and meet the resident's needs based on nursing assessments dated 11/25/19. When asked if the resident could remember to put the call light on to request help with a transfer to or from the bathroom, the UM V stated, No. When asked if the staff should have already anticipated that the resident would attempt to self-transfer from the bathroom back to bed, the UM V stated, Yes. B) Based on observation, interview, and record review the facility failed to ensure the use of a gait belt during a transfer for two Residents (Resident #14 and Resident #86) who are at risk for falls, resulting in an unsafe transfer and the potential for injury to the Residents and the potential for unsafe transfers and injury for all facility residents who require assistance for transfers. Findings include: Resident #14 Resident #14 was originally admitted to the facility 8/27/20 and had diagnoses that included: History of Right Femur Fracture, Difficulty in Walking, and Repeated Falls. The Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 4 which indicated the Resident was severely cognitively impaired. Section G of the MDS reflected Resident #14 required the assistance of one staff member for transfers. Section J 1900 A and B of the MDS reflected that since the previous MDS the Resident had two falls without injury and two falls with injury. Review of the Care Plan for Resident #14 reflected on page 6 that, therapy recommends that staff walk to and from bathroom with (one) assist with 4 Wheeled Walker (4ww) and gait belt initiated 2/26/21. On 6/08/21 at 2:31 PM, while passing by the room of Resident #14, the Resident was observed standing at the open bathroom door with one hand on the bathroom door handle and one hand on the room door handle leaning backward and swaying. Resident #14 was secured, and staff were summoned. The Resident indicated he had to use the bathroom. Staff arrived and Certified Nurse Aide (CNA) T remained with the Resident in the bathroom. While meeting the need of Resident #14 CNA T did not attempt to summon additional assistance to ensure devices were available for a proper return transfer of Resident #14. Continuing the observation, CNA T was observed assisting Resident #14 back to his bed without a gait belt in place and without the use of a 4ww. When ask if a gait belt should have been used with this Resident CNA T reported that the Resident was hanging onto her arm and using fixed objects for support along the way back to the bed. On 6/9/21 at 3:16 PM, an interview was conducted with Unit Manager (UM) U. UM U reported Resident #14 has a history of falls and that the Resident thinks he can make it to the bathroom on his own, but that he cannot. UM U reported that staff are expected to know resident care needs (including type of transfer) which are on a Kardex (a summary of Care Planned needs) on the kiosks (in the hall). UM U reported if a staff member is unfamiliar with a hall the nurse is expected to review the Kardex with the staff member. UM U reported that staff carry gait belts with them and are expected to use a gait belt with transfers depending on Therapy (recommendations). UM U further clarified by reporting that the use of a gait belt for transfers is implied. In an interview conducted 6/09/21 a 3:45 PM, the DON reported that CNA staff carry gait belts on their person and are expected to use these for transfers. On 6/10/21 at 10:38 AM, an interview was conducted with the Therapy Manager (TM) F. TM F reported that the Therapy Department makes resident transfer recommendations to care staff. TM F reported that gait belts are supposed to be used with resident transfers stating, you don't move people without it. Resident #86 According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #86 had multiple diagnosis including multiple fractures and dementia. Resident #86 admitted to the facility on [DATE] and required assistance of one staff member for moving in bed, transferring, dressing, bathing, and other hygiene needs including using the bathroom. Staff assessed Resident #86 as moderately cognitively impaired. During an observation and interview on 6/8/21 at 10:33 AM, Certified Nursing Assistant (CNA) C stated that Resident #86 recently had fallen at home and fractured both arms. At this time CNA C assisted Resident #86 into the bathroom and had Resident #86 grab the bar and stand up from the wheelchair. CNA C then had Resident #86 sit back down and instructed Resident #86 to grab my arm, Resident #86 reached for CNA C's elbow while CNA C lifted Resident #86 under the armpit. Resident #86 became unsteady, hollered out, and then sat down hard on the toilet. CNA C explained that Resident #86 gets scared that she may fall again. CNA C did not use a gait belt while transferring Resident #86 from the wheelchair and onto the toilet. During an observation on 6/9/21 at 8:07 AM, CNA C transferred Resident #86 from the bed to the wheelchair. CNA C guided Resident #86 to grab CNA C's right arm while CNA C assisted Resident #86 to stand by lifting under her right arm. CNA C did not use a gait belt while transferring Resident #86 from the bed to the wheelchair. During an interview on 6/9/21 at 3:51 PM, the Director of Nursing (DON) stated that everyone (resident) should have a gait belt. According to Resident #86's Activity of Daily Living care plan, Resident #86 is able to transfer self without assistance (intervention revised on 5/15/21) but requires assist of one staff member for using the toilet (intervention revised on 5/18/21). According to facility policy Safe Transfers and Movement of Residents, revised 1/24/11, gait belts can be used to assist with safe transfer.

This citation pertains to intake MI 8336. Based on observation, interview and record review, the facility failed to prevent one resident (Resident 1) from becoming wedged on top of a heat vent for an unknown amount time when he was found on 2/15/21 by the CNA a little after 6 AM morning report, that resulted in a partial thickness (2nd degree) burn of his upper right arm. R1, who was assessed to be a risk for falls, an extensive assist of one for bed mobility, and known to roll to his right side, had his bed pushed up against the outer wall and heater vent that protruded several inches out from the wall that encased 170-degree hot water boiler lines that were used to heat the rooms (as an intervention to prevent falls). R1 rolled off his bed and landed on his right side where he was wedged on top of the heat register vent (covering the boiler lines running the 170-degree water), the wall, and his bed. R1 was unable to get himself off the heat register and out from between the bed and the wall. This deficient practice resulted in R1 becoming entrapped between the bed and wall, on top of a hot heat vent, and sustaining a 2nd degree burn, and for the high likelihood of other residents requiring assistance, supervision, and/or protection from accident hazards to sustain harm, injury and/or death. The Immediate Jeopardy started on 2/15/21 and was identified on 3/19/21. The Administrator was notified of the Immediate Jeopardy on 3/23/21 at 10:00 AM and was asked for a plan to remove the immediacy. The IJ was removed on 2/15/21, based on the facilities implementation of the removal plan as verified onsite on 3/23/21. According to admission record dated 3/16/2021, Resident #1 was an [AGE] year-old admitted to the facility on [DATE] with the diagnoses: Alzheimer's Disease, type 2 diabetes mellitus with Diabetic [CONDITION(S)], peripheral vascular disease, and weakness. Resident #1 according to a Minimum Data Set quarterly assessment dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating Resident #1 was cognitively impaired. Section G of 2/16/21/ reflected R#1 required extensive assistance from one person for bed mobility and section J revealed 2 falls since the last Quarterly MDS on 12/23/20. Review of Resident #1's Incident form dated 2/15/21 at 7:30 AM written by Registered Nurse (RN) D, revealed the following, walked to the room to assess resident because CNA found shoulder (rt) skin burn. Resident appeared to have rolled far to the right side of his bed and rolled onto the wall heater vent for an unknown amount of time. Wound is (4cm X 5cm). Area dressed with a thin layer of [MEDICATION(S)] ointment- [MEDICATION(S)]-Bordered foam. Review of Physician Assistant (PA) C progress notes signed on 2/15/21 at 2:42 PM, reflected the following, Patient is an [AGE] year-old male being seen today for the above chief complaint (Burnt right arm). Nursing staff noted an open area to the right deltoid region this a.m. It appeared as though a blister had been there and unroofed. Patient is a limited historian. His bed was pushed up against the wall next to the heat register. Further review of the progress note revealed that under the physical exam the skin: warm and dry. Open area to the right deltoid region, oval shaped, approximately 4 x 5 cm. No surrounding [CONDITION(S)] or warmth. PA C's assessment was a partial thickness burn of upper right arm. Review of Resident #1's Non-Pressure Skin Condition Record document reflected a right shoulder burn first observed date of 2/15/21. 1. On 2/15/21 Measurement states: Length (cm) 3.5 x Width (cm}: 2 Depth (cm}: 0.1 Exudate: Serous, Amount: Scant, Wound Bed: Pink, pale tissue, Surrounding Skin: Reddened, Pain-No, Treatment - Continue. 2. On 2/22/21 Measurement states: Length (cm) 3.5 x Width (cm}: 5 Depth (cm}: Exudate: Serous, Amount: Scant, Wound Bed: Pink, pale tissue, Surrounding Skin: Normal for Skin, Pain-No, Progress- Improved Treatment - Continue, Progress Note: Improving. 3. On 3/01/21 Measurement states: Length (cm) 2.5 x Width (cm}: 2 Depth (cm}: 0.1 Exudate: Serous, Amount: Small, Wound Bed: Normal for Skin, Surrounding Skin: Normal for Skin, Pain-No, Progress- Improved Treatment - Continue, Progress Note: Improved. 4. On 3/08/21 Measurement states: Length (cm) 1.5 x Width (cm}: 1.2 Depth (cm}: 0.1 Exudate: None, Amount: None, Wound Bed: Pink, pale tissue, Surrounding Skin: Normal for Skin, Pain-No, Progress- Improved Treatment - Continue, Progress Note: Improved. 5. On 3/12/21 Measurement states: Length (cm) __ x Width (cm}: __, Depth (cm}: Exudate: None, Amount: None, Wound Bed: Normal for Skin, Surrounding Skin: Normal for Skin, Progress Note: Healed. On 3/18/21 Regional Director of Clinical Services (RDOCS) A, measured Resident #1's right shoulder wound as Length (cm) 1.7 x Width (cm): 1.1 and was scabbed, but the scab would come off with some saline and a gauze pad. RDOCS A further described the burn area as 3.3 cm x 3 cm of fresh pink skin. Review of a facility progress note for Resident #1 reflected, 2/15/21 16:18 IDT Interdisciplinary Progress Note: Late Entry: Note Text: Resident discussed with IDT regarding recent noted skin alteration. Resident has no other skin alteration, provider notified, bed re-arranged. Resident seen by provider; new orders written. Will monitor skin alteration. Review of a facility progress note for Resident #1 reflected, 2/16/21 03:21 Nurses' Notes: Note Text: N.O. per (Name of PA C) 1.) Apply [MEDICATION(S)] cream to right arm burn, cover with nonocclusive dressing, change daily. Review of Resident #1's Treatment Administration Record reflected, [MEDICATION(S)] Cream 1 % (Silver sulfadiazine) Apply to Right arm burn topically every day shift for Burn Apply to right arm burn, cover with non-occlusive dressing, change daily until healed. -Start Date- 02/16/2021 0600 -D/C Date-02/22/2021 1502. Review of Resident #1's Treatment Administration Record reflected, Cleanse wound to right shoulder with normal saline, cover with non-adherent gauze in the morning-Start Date-02/23/2021 0700 -D/C Date- 03/16/2021 1420. Review of a facility progress note for Resident #1 reflected, 2/16/21 05:40 Nursing Evaluation Summary: Note Text: Resident is an 85- year- old male admitted to facility for long term care. Resident has shown a steady decline. Resident has recently been noted to have had a decline in protective sensory mechanism. Resident sustained skin alteration due to inability to sense disturbance. Resident is otherwise stable, oral intake is stable, bowel and bladder excretion are at baseline. Resident denies any pain. Review of a facility progress note for Resident #1 reflected, 2/22/21 16:45 Nurses' Notes: Note Text: Resident wound assessed, wound appears to be worsening, provider notified, order changed. Resident would has increased moisture, no odor, increased sough noted. Order changed and updated as listed. During an interview on 3/17/21 at 10:24 AM, RN D revealed he was made aware (Name of Resident #1's burn when), The CNA's were doing morning rounds. Stated it looked like a blister that had popped, loose skin, red with some serous drainage. RN D reflected that it was a 2nd degree burn, that he cleaned, put a bandage on and contacted the (name) of PA C. RN D revealed after the resident was taken care of, we did a sweep of the rooms and pulled beds away from the walls on my unit. Review of the North East Roaster revealed on 2/15/21 that seven resident beds were moved away from the heat vent. During an interview on 3/17/21 at 10:01 AM, Certified Nurse's Aide (CNA) E, revealed that she had come in at 6:00 AM an describes that she usually comes in and checks all the residents real quick 1st to make sure nobody is on the floor or hurt So I go up and down the hall and check every room, then I grab the vitals cart and go around again. CNA E revealed that Resident #1's room was the 1st room she went into after morning report, When I found him he was stuck between the bed and the heater, he was directly on the heater and I pulled him off the heater. The bed was not low, the resident had rolled and was wedged. The next time I went in, (about 20 minutes later) he was slumped over to the right leaning that way toward the vent, he cursed and fussed at me when I did the vitals and said ouch, which was not like him. Then when I cleaned him up to do care he said ouch again. Noticed blood on his shirt and burn and went and got RN D right away. CNA E described Resident #1's burn as follows, The top layer of skin was burnt off his arm it, was probably the size of a tennis ball, it was a nice size burn. The skin was completely off at the time, it had rolled off and down, it was shriveled up and was red and bad. CNA E further revealed the resident's whole right side of his body was really hot, his pants were hot, and she feels they saved him from [CONDITION(S)]. During an interview on 3/16/21 at 3:00 PM, Director of Nursing, (DON) revealed that on 2/15/21 maintenance staff and nursing went together and did a 100% audit of resident rooms. DON stated that they moved the beds of those residents whose BIM's were low away from the vents, and care planned those residents that wanted to stay there. DON when asked to describe Resident #1's burn stated, I believe it was a second-degree burn, just the first layer of skin came off. You could see the rolled skin from the blister and then that came off pretty quickly. The DON informed this surveyor nobody else, had any [CONDITION(S)]. On 3/17/21 at 3:50 PM, Maintenance Director (MD) H was interviewed. MD H indicated that on the day Resident #1 was burned, I went around that day and moved everyone's bed if they were close to the register away from the register. Moved quite a few rooms MD H further explained that the 170-degree water pipe (from the boilers) runs through the (metal) register vents is what heat the resident's rooms. MDH revealed to this surveyor that it was difficult to get room temps because if he hit the pipe with the thermometer the readings read very high. However, after this incident they did shut down boiler #3, and did turn the temps down on the other boilers. During an interview on 3/18/21 at 10:37 AM, Housekeeper F revealed, I move things around when I clean and put them back, Resident #1's bed had been against the wall when she started in August. I think his bed was against the wall because he was a fall risk. Housekeeper F revealed that beds must now be away from the heat vent. During an interview on 3/18/21 at 10:45 AM, Certified Nurse's Aide (CNA) G revealed that, basically told beds were not to be near the heater vents and don't move them. If we do see them (the beds against the heater vents) we have to let our nurse know or our supervisor. During the interview CNA G stated that maybe the reason Resident #1's bed was up against the wall because he had fallen before, and that he had a fall mat for the left side of his bed. CNA G explained when the resident sleeps he rolls to the right, just what he does. On 3/18/21 at 10:57 AM, Resident #1 was observed sitting up and eating in his wheelchair. The gray fall matt was located between the wall/heater vent and the resident's bed. On 3/18/21 at 2:23 PM, the Responsible Party (RP) I revealed she was notified that Resident #1 had a burn on his arm and that they put medication and a bandage on it. RP I stated she did not know how exactly he got the burn or the kind of burn (degree). RP I explained that R#1's bed is up against the wall because he used to fall out of bed a lot, and that it had been up against the register since before COVID started. I think he snuggles up to heater because he is cold. Review of Resident #1's Care Plan dated 3/18/21 including all resolved interventions, indicated falls was a focus for the resident and did not include having the bed pushed against the wall as a current or resolved intervention. However, under his Care Plan interventions for his Diabetes Mellitus Date Initiated: 08/27/2019 reflected the need to Avoid exposure to extreme heat or cold. Date initiated: 8/27/19. Review of a policy titled Accidents and Supervision reviewed/revised 10/30/2020 and implemented 1/1/2021 revealed: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard (s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. On 3/23/21, the surveyor verified the facility implemented the following steps as indicatede in the removal plan for the 2/15/21 event: 1. Rounds were completed on 100% of resident rooms, and any resident beds that had access to the radiator/heater were moved away from the radiator and in most cases a chair or nightstand was place between the bed and the wall to keep beds from getting too close to the radiator on 2/15/21. 2. Skin assessments were reviewed on all residents for the 7 days prior to 2/15/2021. No other Residents had a burn from a radiator. 3. The Maintenance Director completed random audit to check surface temps of the radiator on 2/15/21. 4. Boiler#1 & Boiler #2 were both reduced in temperature on 2/15/21. 5. Boiler#3 was turned off on 2/15/21. 6. The facility administration has reviewed the abuse policy and found it to be appropriate on 2/15/21. 7. Staff were verbally educated on keeping beds away from the wall on 2/15/21. All shifts were included on 2/15/21. Any staff not educated on 2/15/21 were re-educated prior to working their next shift. All staff were educated by 2/25/21. 8. Night shift supervisor was educated and verbally educated third shift employees on keeping beds away from radiators on 2/15/21. 9.Rounds are competed by Caring Partners (management) 5 times per week and residents are observed for safety concerns and room environment is assessed for concerns and reported in stand-up meeting. 10. Dignity rounds are completed 3 times per week by management and rooms are observed at that time. Any hazards are addressed immediately. 11. Accident and Hazard rounds are completed Mon-Fri and environment is reviewed for hazards. 12. A POC was written after received (2567 report) on 2/11/21. Education was initiated on 2/18/21 related to the POC which included Accidents and Hazards where education was provided for all staff observe for potential environmental hazards report immediately to your supervisor. Education was completed by all staff by 2/25/21. Although the Immediate Jeopardy was removed on 2/15/21, the facility remained out of compliance at the scope of isolated and a severity of actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

This citation pertains to intake M 6194, M 6435, and MI 589 Based on observation, interview, and record review, the facility failed to provide oxygen or respiratory support for (Resident #2, Resident #3, Resident #16 and Resident #18) per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure of the facility to follow physician orders, implement their established oxygen policy and procedures and lack of securing an oxygen canister, assessing, documenting, and administering oxygen to meet the needs of the resident put all residents requiring oxygen or respiratory support at a high risk for serious harm, injury, or death. Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . COVID diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility, transfers, and toileting. Resident #3 had limited range of motion (ROM) impairment on one side of her upper and lower extremities, at risk for pressure ulcers, none upon admission. Resident #18 Review of a Face Sheet revealed Resident #18 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had a BIMS indicating she is cognitively intact and requires extensive assistance of 2 staff for transfers and requires oxygen therapy. Resident #3 Review of Standing Orders signed by the Physician on [DATE] for Resident #3 revealed: Skin issue-skin tear, abrasion, minor laceration - see wound protocol - Barrier cream for excoriation, Stage I wounds. Oxygen- ,d+[DATE] liters per nasal cannula for oxygen saturation below 88% until physician can be contacted for further orders. These orders are not on the electronic MAR (medication administration record.) Review of a Facility Reported Incident reported to the State Agency on [DATE] revealed an allegation of neglect of Resident #3 reported to the facility on [DATE]. Certified Nursing Assistant (CNA) F alleged Registered Nurse (RN) E removed Resident #3's oxygen on [DATE] causing her to expire sooner than she may have done naturally. CNA F reported the incident to Detective (DT) U at the police department prior to informing the facility on [DATE]. On [DATE] the facility interviewed RN E who reported Resident #3 was on 8 liters of oxygen and admitted she unplugged the oxygen tubing from the oxygen concentrator to complete a nursing assessment when she passed medications at 9:30 p.m. ([DATE]) and replaced the oxygen before she left the room. During that time, CNA F walked into the room and saw the oxygen tubing disconnected from the concentrator. RN E felt the need to explain to CNA F the reason for disconnecting the oxygen tubing from the concentrator and that it was necessary for a nursing assessment. RN E reported she did remove the oxygen for approximately 10 minutes and the resident maintained oxygen saturations of ,d+[DATE]%. At 12:00 a.m., RN E reported Resident #3 starting abdominal breathing. RN E checked on Resident #3 several times from 12:00 a.m. to 4:00 a.m. ([DATE]). At 4:20 a.m. Resident #3 passed away and hospice was contacted at 4:30 a.m. On [DATE] at 2:30 p.m., the facility interviewed CNA F again who reported she was taking Resident #3's vital signs on [DATE] at 10:00 p.m. and noted her respirations were in the 30's and reported it to RN E who indicated she expected the resident to pass during the night. CNA F reported she saw the pulse oximeter monitor several times and the lowest oxygen saturation was 76%. CNA F reported RN E left Resident #3's room at 4:00 a.m. and took a break. At 4:20 a.m., CNA F entered Resident #3's room and reported the resident appeared she had passed. CNA F then went to get RN E who called the time of death at 4:20 a.m. On [DATE], RN O reported when her shift ended at 9:30 p.m. ([DATE]), Resident #3 was stable, however expected her to pass within the next couple of days. RN E was suspended [DATE] pending investigation. The facility reported they were unable to substantiate the allegation based on the fact that CNA F and RN E were on the COVID Unit and there were no other employees on the unit. The facility was unable to substantiate that actions by the nurse contributed to the resident's death. Review of several handwritten statements/timelines obtained from the facility from staff who cared for Resident #3 revealed: On [DATE] at 2:30 p.m. CNA F started working on the COVID unit at 10:00 on ([DATE]-[DATE]) and around 10:30 p.m. she noticed Resident #3 had respirations between ,d+[DATE] per minute (normal is ,d+[DATE] breaths per minute) and RN E told her she expected the resident to pass this night and she stayed with Resident #3 through the night even though she had too much to do. CNA F popped in and out of the room throughout the night and RN E stayed in the room until the resident passed away. RN E was noted to be in Resident #3's room from 10:30 p.m. until 4:30 a.m. CNA F reported Resident #3's door was closed but not shut and the curtain was pulled with the bed light on. RN E told CNA F she took Resident #3's oxygen off several times and was maintaining. The lowest oxygen saturation CNA F noticed was 76%. After the first rounds, RN E came out of the room to medicate with Roxinol ([MEDICATION(S)]) and gave Roxinol, (pics were sent via text at 12:30 a.m.) and the oxygen saturations were 65% and 76%. RN E told CNA F she gave the resident more [MEDICATION(S)] than she needed but no one would notice because more is in the bottle than should be. RN E told CNA F that she did not want Resident #3 to pass away on the next shift because that nurse was a [OBSCENITY] and wanted her pass with people who cared for her. CNA F reported she went to Resident #3's room and with her phone propped on (Resident #3) R E was watching YouTube videos with one hand holding the residents' hand and her face in the residents face. At 4:00 a.m., RN E left the residents room and went to the Green Room (a community room down the hall). CNA F reported she went to Resident #3's room and the resident had no oxygen on and (the tubing) was laying on top of the concentrator and the concentrator was on, and the oxygen saturation monitor was not on her finger, and Resident #3 had passed. CNA F reported she went to tell RN E. CNA F reported RN E and another CNA removed oxygen from Resident #12 so he would pass. On [DATE], RN E reported she passed medications to Resident #3 at 9:30 p.m. and mixed a medication for secretions with [MEDICATION(S)]. At 10:00 p.m. and assessed the resident. Resident #3 was awake, right eye open, right hand good grip, no verbalization, VS (vital signs assessed), HR (heart rate) within normal limits, oxygen saturations ,d+[DATE]% on 8 liters, respirations within normal limits. RN E assumed 8 liters was ordered and unplugged the oxygen tubing by disconnecting it from the concentrator for 10 minutes and sat there the entire time and said there was no gasping or change of condition. Then plugged the oxygen back in before leaving the room. The facility asked why, and the documented response was she did not know why and wanted to question the doctor if Resident #3 needed to be on it. RN E reported CNA F walked into the room to relay a message to the nurse and noticed the oxygen was unplugged and RN E reported she plugged the oxygen back in and left the room. The facility asked if she documented the events and RN E said no and did not know why. RN E reported she sat with Resident #3 at 12:20 a.m. and passed midnight medications. RN E checked on Resident #3 (,d+[DATE]= )10 times (peek, assess) and 5 minutes at a time tops. At 3:45 a.m. RN E reported breathing and oxygen saturations were up and down constantly and at 12:07 a.m., the resident had oxygen saturations of 65% and a pulse of 47 and she called her daughter. At 12:29 a.m. the resident was at 76% oxygen saturations and pulse of 99. At 3:45 a.m. oxygen saturations were ,d+[DATE]%. The facility asked her if she called hospice and she said no. At 4:20 a.m., she opened the door, cracked open, curtain pulled back and she had passed away. On [DATE] 12:00 p.m., Licensed Practical Nurse (LPN) RR reported that CNA F told her on [DATE] she had concerns with Resident #3's oxygen prior to her death. LPN RR told CNA F she needed to report it and if she didn't, then LPN RR would. On [DATE] LPN RR asked CNA F if she reported the situation yet and CNA FF said she did not but I will. LPN RR reported she did not know who RN E was. On [DATE] at 12:00 p.m., RN KK reported she received a text message on [DATE] from RN E at 12:10 a.m. that said Resident #3 was going to pass, currently waiting at bedside for it, 65% pulse ox (oxygen saturations) - We're close (12:07 76%), she is fighting, she won't stop. At 12:40 a.m., RN KK texted she sure is, pulse doubled also. RN E texted yes, she won't stop. On [DATE], CNA QQ reported to the facility that CNA F told her that RN E was in Resident #3's room for 3 hours the night she passed and was messing with the resident's oxygen and told her the resident had oxygen saturations of 76%, which is low. CNA QQ said CNA F told her that RN E said she was removing oxygen so she would pass while RN E was there because she didn't want her (Resident #3) to pass with RN O because she didn't think RN O cares (about) residents. On [DATE] at 11:30 the facility revealed RN O took report from RN E that morning ([DATE]) and RN E was frazzled and stated she sat in the room with Resident #3 when she had time, so she was not alone and left the room to pass medications and that was when Resident #3 passed. RN O took care of that resident the day before and reported Resident #3 was alert and oriented throughout her shift and her vital signs were pretty stable, nothing alarm, no need to call doc (doctor). RN O reported she worked as an aide on the same unit ([DATE]) after her shift until 8:30 -9:00 p.m. and Resident #3 did not have any difficulty breathing. Review of the Police Report with a documented interview on [DATE] revealed the detective was contacted via email from a person who claimed to have received a text message from a friend that said, I saw someone end a life and that is was the second time. CNA F told the Detective that an RN told her that a resident (Resident #3) was going to pass away soon and did not want the resident to pass away on a shift other than hers and she did not care for the nurse working the following day shift. CNA F said this RN removed the resident's oxygen, she passed away and this situation was [OBSCENITY] ed up. CNA F said she learned the same thing happened with a resident 2 weeks ago named (Resident #12). CNA F .CNA F said RN E sent her pictures of Resident #3's O2 stats from her Pulse Ox while she was doing the med passes and vital assessments of other residents and this seemed strange RN E was sharing pictures and then Resident #3 passed away. CNA F also mentioned RN E admitted to giving Resident #3 more [MEDICATION(S)] than she was supposed to. Review of a Police Report with a documented interview on [DATE] around 12:30 p.m., Dt U interviewed the daughters of Resident #3 who reported RN E told them she would take their mother off her oxygen. RN E told them 10 minutes before Resident #3 died , she grabbed her hand and squeezed it Both (daughters) explained their mother was able to communicate until the day she passed away. Both said their mother died quicker than they expected. (Daughter) reported RN E told her (Resident #3) maintained after she removed her oxygen then mentioned her taking a 10 minute break. when she returned from break, (Resident #3) had passed away. she (RN E) would tell them how she would lay with their mother and stroke her hair. They (daughters) said the last call they received from (RN E) was from her personal phone before midnight the night she passed away and was told their mother was fading and they should tell her it was time to go. At 4:20 a.m. on [DATE] they were informed Resident #3 passed away. The daughters had concerns that during the last phone call with their mother (Resident #3), they could not hear the oxygen concentrator in operation. They explained the loud swoosh of this machine could always be heard, but not the night she passed away. Review of a Police Report with a documented interview on [DATE] at 3:00 p.m., RN E reported she crushed a medication for secretions and liquid [MEDICATION(S)] together and dripped it into Resident #3's mouth. (Resident #3) obviously was passing. RN E reported the resident was on 8 liters of oxygen and was alert, opening one eye like she always did and reported the resident would squeeze her hand really tight during this shift, like she knew what was happening. RN E reported she kept (Resident #3's) door closed during her shift because she didn't want other people to be looking in at the resident. RN E revealed text messages and screen shots she exchanged with another nurse and other residents about Resident #3's stats. RN E showed on her phone she called the family of Resident #3 at 11:44 p.m. on [DATE] because she felt Resident #3 was declining even though her stats were not changing yet and wanted them to talk to the resident and tell her it was time to let go. RN E could not recall events between midnight [DATE] and 4:20 a.m. RN E reported she found out later that Resident #3 was on 8 liters oxygen as needed and Administration told her she needed to be sure and read her orders before caring for residents. RN E reported I assume when someone is on oxygen, we are going to keep it on. RN E said when she went in Resident #3's room earlier in the night the resident seemed fine, failed to look at the order, and wondered if the resident really needed to be on oxygen. RN E said she removed the nasal canula from the residents' face and watched her stats which did not change. RN E wanted to know if the resident could maintain without oxygen and kept it off for a few then she left the residents room and told CNA F how the stats maintained without oxygen. RN E reported she went back into the resident's room and put the canula back on after talking with CNA F. DT U asked RN E if she ever unplugged (Resident #3s) oxygen from the concentrator as well and she said yes. RN E reported CNA F saw Resident #3's oxygen unplugged from the concentrator and that is when she went back into the room to plug it back in. RN E reported she shouldn't have done this, and it is something she could lose her license over. RN E reported she entered Resident #3's room a 4:19 a.m. and knew she was dead, touched the resident and turned the concentrator off and removed her canula. She felt for signs of life. RN E reported Resident #12 went so fast and his O2 (oxygen) stats were down to 47 when they were trying to adjust his canula. his death was quick, but she cranked his oxygen on the night he died . The Detective (DT) U met with the facility on [DATE] around 10:00 a.m., the Director of Nursing (DON) contacted RN E via text and asked her what happened. RN E reported Resident #3 was actively dying when she arrived on her shift and struggled on night long. The DON asked RN E about removing her oxygen and she said this did occur and she wanted to assess the resident to see how her body would maintain without the 8 liters of oxygen she was being administered and confirmed Resident #3 was on 8 liters of oxygen via nasal cannula. Review of a Police Report with a documented second interview at the facility, CNA F reported RN E expected Resident #3 to pass away sometime during the night. Throughout the night RN E decided she was going to stain the Resident #3's room and not complete her charting. CNA F reported RN E was in Resident #3's room up until around 15 minutes before she passed away. CNA F reported she went into Resident #3's room and found her passed away around 4:20 a.m. on [DATE]. CNA F said RN E was in the room with her all the entire shift except the last 15 minutes of her life and never left the room to care for other residents and refused to come out to assist with another resident that fell . CNA F said again that RN F was in Resident #3's room all night with the door closed but not completely shut. CNA F reported RN E removed Resident #3's oxygen numerous times . CNA F reported she saw Resident #3 at least a dozen times throughout the shift and saw on the pulse ox was 76%. RN E took picture of the pulse ox monitor and showed CNA F Resident #3 had a pulse ox below 70% and then above it. CNA F reported RN E said she was giving Resident #3 [MEDICATION(S)] every hour, and no one would know how much she gave because of how it is registered. CNA F reported they (RN E) talked about assisted suicide and RN E reported she could be prosecuted and did not want the resident to pass away on any other shift than her because the oncoming nurse was a [OBSCENITY] and didn't think she cared for the residents. RN E told CNA F what the risks could be and that she was removing oxygen. CNA F reported she was the first to see Resident #3 deceased and she was not on oxygen and the canula was laying on top of the concentrator and the pulse oximeter was not on her finger. CNA F called RN E to the room and RN E who told CNA F that Resident #3 had passed away. Review of a Police Report with a documented interview at the facility revealed LPN KK reported RN E taking off (Resident #3's) oxygen was a big deal and not the best care we are to give, saying that's causing harm to one of our residents. LPN KK became aware of the incident from coworker and was going to tell the administration of CNA F did not. LPN KK reported that Resident #12 would get frustrated wearing his nasal canula but for the most part left it on. LPN KK reported she received text messages from RN E showing Resident #3's pulse ox readings of 65% and that RN E was at Resident #3's bedside waiting for her to pass. LPN KK reported RN E did not follow proper procedures. Review of a Police Report with a documented interview at the facility revealed LPN RR was notified by CNA F on [DATE] around 6:30 a.m. of RN E removing the oxygen from Resident #3 and the resident passed away. CNA F was very upset and LPN RR told CNA F she needed to report it and if she did not, she was going to. Review of a Police Report with a documented second interview at the facility revealed RN E reported her shift started at 6:00 p.m. on [DATE] and received report from LPN KK that Resident #3 was now COVID positive and on hospice now and aware the resident was on 8 liters of oxygen via nasal canula and oxygen concentrator. RN E said the resident would probably pass during the night or the next shift or soon according to LPN KK. RN R passed medications around 9:30 p.m. and mixed a crushed pill in with [MEDICATION(S)] and gave it to the resident via dropper in the back of her cheek and said Resident #3's oxygen saturations were ,d+[DATE]% on 8 liters of oxygen and her respirations were good. RN E said she had a pulse ox on the resident from 9:45 to 10:00 p.m. and thought the 8 liters of oxygen was quite high as she sat in a chair next to her bed. (RN E) said she unplugged the oxygen tubing from the concentrator and held it in her hand, and said the resident maintained her stats as I sat there for no longer than 10 minutes. RN E said the residents breathing did not change and she wasn't gasping and didn't' hear a death rattle or anything like that and plugged the oxygen back in when she walked out of the room. Staff asked RN E why she would plug (Resident #3's) oxygen back in when she left her room if her body was maintaining. (RN E) replied she did not want to question the doctor or the orders. She was asked why, if she thought there was an order, would she remove oxygen. RN E replied, I just don't have an answer. RN E said CNA F walked into the room when the oxygen tubing was unplugged from the concentrator. When asked about documenting the things she did, RN E said she did not know she was supposed to. Staff asked (RN E) what she learned in nursing school and she replied, basically if you didn't chart it, it didn't happen. RN E reported she told CNA F she removed Resident #3's oxygen and she was maintaining her stats pretty well. RN E reported around midnight Resident #3 started abdominal breathing when she checked on her and her oxygen was being administered at this time. RN E reported she called the residents daughter to encourage the resident to go and then sat with the resident for a little bit but not too long and checked on her quite a few more times until she was found deceased . RN E reported she checked on Resident #3 around 3:45 to 3:50 a.m. and she was on her oxygen but was fighting and that the oxygen sats were changing. In an interview on [DATE] at 9:56 a.m., the Regional Nurse Consultant (RC) M and the Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported CNA F came to the administrators 7 days after the incident with Resident#3 but had told other staff about it beforehand and felt it was just a she said, she said incident and had to look at the facts. RC M reported she spent a lot of time on this reported incident and felt CNA F does not usually come forth to Administration with concerns and instead talks about problems with staff and thinks she tells everyone else in the facility about things instead. RN E told them she did take off the oxygen off Resident #3 only once and put it back on. RC M reported E was a new nurse and who provided compassionate care for her residents and during the care of Resident #3, she contacted LPN KK for support. RN E changed her story about the resident's oxygen being on or off and found there is even discrepancies on who found Resident #3 dead. Resident #3 had been in and out of the hospital 4 times since admission. Both RN E and CNA F kept changing their story. They reported they re-educated RN E and gave redirection and verbal counseling to CNA F. The facility reported they re-educated staff on several things including abuse and oxygen. The facility reported RN E has a lawyer now and may not talk to this surveyor without the attorney present and would not allow the attorney at the facility. RN E is still employed and actively working at the facility. In an interview on [DATE] at 3:00 p.m., CNA F reported the night of [DATE] was her second time to working with RN E. CNA F reported she did not tell the management about her concerns with Resident #3 and RN E because people get in trouble and they don't' do anything. CNA F said the night started out normal and she started taking vital signs around 10:30 p.m. Resident #3 was laying on her side facing the doorway with oxygen on but not sure how many liters and her saturations were low around 80% (normal is ,d+[DATE]%) and respiratory rate was round 30 breaths per minute (normal is ,d+[DATE]). CNA F went to tell RN E who said the resident was actively passing, so CNA F reported that is what she was expecting. RN E told CNA F that she was going to sit with Resident #3 until she passed because that is what she told the family she would be there. CNA F reported she checked on the resident and RN E about every half hour and once saw RN E laying her head down next to Resident #3 with face towards the resident who was COVID positive. Another time she looked into the room she saw RN E prop a phone up on the body of Resident #3 reviewing social media and videos. Around 4:00 a.m., RN E came out of Resident #3's room and went down the hall to the Green Room (a community room on the unit) where CNA F was. Before the resident passed, RN E told CNA F that she didn't want the oncoming nurse to help Resident #3 because she was such a [OBSCENITY] and didn't care. RN E said she knew Resident #3 was ready to die and told CNA F that she could get into trouble and lose her license and that what she is doing is negligent homicide. CNA F reported that when she looked in on Resident #3 during the night, she sometimes had her oxygen on and sometimes did not but was not alarmed because the nurse told her she wanted to see how Resident #3 was maintaining. The pulse ox was on the resident the whole time and didn't think anything was wrong until after RN E went to the Green Room and had a conversation with CNA F about the negligent homicide conversation. When RN E came into the green room around 4:00 a.m., CNA F said 15 minutes later she went to do her rounds on her residents. At 4:20 a.m., she entered Resident #3's room and noticed the nasal canula was draped over the concentrator, the resident was still on her side and was unable to get a pulse ox reading. Then RN F came in and said, oh look she died with one eye open looking for me. RN F never went back into the room. CNA F reported the facility told her prior to this interview if this incident is substantiated, they could lose thousands of dollars. CNA F said she had been employed at the facility 4 months and they just started calling her references at the time of this investigation. In an interview on [DATE] at approximately 10:30 a.m., LPN S reported she would not take oxygen off a resident that is ordered by a physician, and especially not if they are dying. In an interview on [DATE] at 11:15 a.m., RN E is working this day at the facility and was in the DON's office. She reported she has an attorney and is not sure if she can talk to this surveyor at this time and is to let this surveyor know. In an interview on [DATE] at 12:02 p.m., the DON reported RN E's attorney will not let her talk to this surveyor without their presence but is willing to talk via zoom or in person at their site. In an interview on [DATE] at 3:43 p.m., RN E reported her nursing documentation on residents has been poor but is getting better at it and that this surveyor will not find that she put oxygen on Resident #3 in the charting. There are standing house orders though and the physician signs the standing orders after looking at the patient. RN E felt she did not have enough training or good training with the nurses she was paired up with. She remembered being the only nurse on the COVID unit and had 2 deaths and one fall in one night. A male resident was having a death rattle and sounded like he was ready to die and died at 9:04 p.m., then (Resident #3) was hanging upside down on her bed and was hanging off her bed like she was looking under her. RN E believes Resident #3 called out when RN E reported she asked the resident what she was doing when she lowered her and got her back into bed and started working on paper when the CNA came to tell her that another male resident (Resident #12) had low oxygen saturations and she told the CNA to put his oxygen back on. RN E reported how she kept finding Resident #12's oxygen off him and would remind him to keep it on. Then the CNA told her his oxygen levels were still very low, but she was in the middle of doing a tube feeding. Once RN E finished with the tube feeding, she went to Resident #12 and noticed he was at 2 liters and the CNA did not do it. So she turned the oxygen up to 5 liters and his oxygen saturations kept dropping. RN E reported she did not call the doctor when Resident #12's oxygen saturations were low. RN E reported she only had one CNA that night to a potential 19 residents and thinks there were ,d+[DATE] of those residents that were COVID positive. Staffing was hard because nobody wanted to work the COVID unit. RN E reported she worked 6 p.m. to 6 a.m. that next morning and did not do respiratory assessments, just looked at the vital signs and documents them. RN E reported she only listens to the resident's lungs if needed. RN E reported she gave Resident #12 his evening medications and had a great conversation, constantly reminded him to put on his oxygen, but did not expect him to go downhill. RN E reported she did not remember Resident #3 wearing oxygen that night she went in to see her and cannot remember is she put oxygen on her that night but remembered her hacking a lot. RN E reported she put a non-rebreather oxygen mask on her because her oxygen dropped when she hacked. RN E reported she put a non-rebreather on at 1 liter and her oxygen saturations came up to around 94% or so. RN E reported the non-rebreather was in a closet in someone's room and grabbed it and connected it to the oxygen concentrator. RN E reported the CNA that was working with her that night before 10:00 p.m. when the CNA observed Resident #3 trying to lean over to reach something in the window and maybe that is what she did. She just rolled like she was looking for monsters under the bed. The bed was low and RN E reported Resident #3's feet were tangled in the blankets that held the top half of her body on the bed. When queried what RN E did once she saw Resident #3 hanging over the bed dangling, she reported she slowly untangled her feet from the blankets while she was hanging over the side and fell to the floor. Once the resident was on the floor, the CNA came to help her get the resident back up. RN E reported she thinks the incident with Resident #3 happened around 9:30 p.m. RN E then reported she called Resident #3's daughter and told her their mom had a spider man fall but no injuries were noted. RN E reported Resident #3 did not have oxygen on when she put her back in bed at that time. RN E reported she put the non-rebreather oxygen mask on Resident #3 after her fall but could not say the specific time. RN E reported she could call her managers anytime if she needed or had concerns. When queried about the date Resident #3 died , RN E said she heard that Resident #3 was COVID positive and on hospice. Resident ## was not that responsive and kept her left eye closed, and could squeeze her hand if she held it, but did not talk at all. Resident #3 was on 8 liters of oxygen via nasal canula. RN E reported she was not in the room when Resident #3 died and was the first one to find her lying in bed on her side. She had like a yellow hue, which seems to happen with residents with COVID. RN E reported when she saw Resident #3, she was stiff and her chest was not moving and she just knew and called the time of death, then took off her oxygen tubing and turned off the concentrator. The CNA then walked in and asked if she was dead and RN E told her yes. RN E reported she was only in Resident #3's room the night she died for ,d+[DATE] minutes at a time. One time RN D held her hand and laid her head next to Resident #3 on the bed even though she knew she had COVID with her N95 mask and a personal protective equipment (PPE). RN E reported earlier that night she was passing medications and gave Resident #3 her [MEDICATION(S)] and [MEDICATION(S)] for secretions by crushing the [MEDICATION(S)] and mixing it with the [MEDICATION(S)] and water, then drew it up in a syringe and put it in her mouth slowly in the back of her cheek. RN E reported she signed the [MEDICATION(S)] out in the narcotic book but not the MAR and remembered she gave Resident #3 more than one dose that night. When queried about Hospice, RN E reported she did not know she needed to contact Hospice if there are significant changes because she is a new nurse bu[TRUNCATED]

This citation pertains to MI 589 and M 6435. Based on interview and record review, the facility failed to implement its established Abuse Prevention Program when it was alleged two Residents (Resident #3 and Resident #12) passed away after alleged nursing misconduct, abuse and neglect (intentionally removing physician ordered oxygen for extended periods of time and over-medicating with narcotics) while under the care of a Registered Nurse (RN E) resulting in an Immediate Jeopardy (IJ) that began on [DATE] when a Certified Nurse Aide (CNA) and other licensed nursing staff aware of the situation failed to immediately report alleged abuse to facility administration and when local police detectives made the facility Administration aware of an open investigation into a report of suspicious circumstances surrounding the death of Resident #3 who passed away on [DATE] on [DATE]; and when it was discovered during the police investigation Resident #12 also passed away under similar suspicious circumstances while under the care of the same RN (RN E) on [DATE]. This deficient practice has the high likelihood to cause serious harm, serious injury and/or death for all 106 residents living at the facility. Findings include: Review of the facility Abuse Prevention Program last revised [DATE] revealed policies and procedures consistent 42 CFR Part 483, Requirements for Long Term Care Facilities for the screening, training, prevention, identification, investigation, protection, reporting and response following any alleged abuse, neglect, exploitation or misappropriation for residents living in a long-term care facility. Review of a Facility Reported Incident (FRI) dated [DATE] reflected the facility learned of an allegation of neglect of Resident #3 reported to the facility on [DATE]. Certified Nursing Assistant (CNA) F alleged Registered Nurse (RN) E removed Resident #3's oxygen on [DATE] causing her to expire sooner than she may have done naturally. CNA F reported the incident to Detective (DT) U at the police department prior to informing the facility on [DATE]. Details in the FRI indicated RN E admitted to unplugging the oxygen tubing from the oxygen concentrator to complete a nursing assessment for approximately 10 minutes. The FRI indicated the facility was unable to substantiate the allegation (of abuse) based on the fact that CNA F and RN E were on the COVID Unit and there were no other employees on the unit. The facility was unable to substantiate that actions by the nurse contributed to the resident's death. Review of a [Local Police Department] Field Case Report, Case# ,d+[DATE] dated [DATE], reflected that on [DATE] an associate of Certified Nurse Aide (CNA) F emailed the public safety department to report that CNA F sent a text message the night before, saying I saw a person end a life and this is the second time. The report indicated CNA F alleged RN E had removed physician ordered oxygen from two residents (Resident #3 and Resident #12) and had given more narcotics than was ordered for one resident (Resident #3) possibly hastening their deaths. The interviews documented in the report included an admission from RN E that she had removed oxygen from Resident #3 and reflected multiple licensed nurses and CNA staff corroborated CNA F's claims and were aware of RN E's alleged abuse and misconduct perpetuated against Resident #3 and Resident #12 days before the local public safety detective made contact with the facility on [DATE]. Review of RN E's employee file reflected a Performance Improvement Form dated [DATE]. RN E had been issued a Counseling/Corrective Action that revealed During (an) investigation of (an) allegation, there were a few areas of opportunity identified for improvement, including documentation of assessment, changes of condition, and medication administration, and oxygen administration. Review of RN E's timecard revealed she was suspended on [DATE] and returned to work on [DATE]. RN E worked 13 shifts between [DATE] and [DATE]. During an interview on [DATE] at 10:10 AM, the Nursing Home Administrator (NHA) said a Facility Reported Incident (FRI) was not submitted to the State Agency regarding Resident #12's death because they did not feel an allegation had been made to warrant a FRI. Resident #12 Review of the Electronic Medical Record (EMR) revealed Resident #12 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 died in the facility on [DATE]. Review of a Progress Note documented by Registered Nurse (RN) E dated [DATE] at 2:02 AM reflected approx. 12:30am a CNA (Certified Nurse Aide) came to me and told me [Resident #12's] O2 (oxygen) saturation was 47% with oxygen on and at 5L (liters per minute). [Resident #12] was unresponsive in his bed with declining vitals. I called family to update them, no answer. The family called after the resident passed away. Time of death was 12:52am. Dr ordered body to be released. [Funeral home] was called at approx. 1:30am Review of transcripts from interviews conducted at the facility after it became aware of the open police investigation into alleged abuse/neglect and misconduct obtained from the facility reported incident investigation file revealed the following: CNA F: reported: -On [DATE] at 2:30 p.m. CNA F started working on the COVID unit at 10:00 p.m. on ([DATE]-[DATE]) and around 10:30 p.m. she noticed Resident #3 had respirations between ,d+[DATE] per minute (normal is ,d+[DATE] breaths per minute) and RN E told her she expected the resident to pass this night and she stayed with Resident #3 through the night even though she had too much to do. CNA F popped in and out of the room throughout the night and RN E stayed in the room until the resident passed away. RN E was noted to be in Resident #3's room from 10:30 p.m. until 4:30 a.m. CNA F reported Resident #3's door was closed but not shut and the curtain was pulled with the bed light on. -RN E told CNA F she took Resident #3's oxygen off several times and (Resident #3) was maintaining. The lowest oxygen saturation CNA F noticed (on Resident #3) was 76%. After the first rounds, RN E came out of the room to medicate with Roxinol ([MEDICATION(S)]) and gave Roxinol, (pics were sent via text at 12:30 a.m.) and the oxygen saturations were 65% and 76%. -RN E told CNA F she gave the resident more [MEDICATION(S)] than she needed but no one would notice because more is in the bottle than should be. -RN E told CNA F that she didn't want Resident #3 to pass away on the next shift because that nurse was a [OBSCENITY] and wanted her to pass with people who cared for her. -CNA F reported she went to Resident #3's room and with her phone propped on (Resident #3) watching YouTube videos with one hand holding the resident's hand and her face in the resident's face. At 4:00 a.m., RN E left the resident's room and went to the Green Room (a community room down the hall). -CNA F reported she went to Resident #3's room and the resident had no oxygen on and (the tubing) was laying on top of the concentrator and the concentrator was on, and the oxygen saturation monitor was not on her finger, and Resident #3 had passed. -CNA F reported she went to tell RN E about Resident #3's passing. -The investigation statements also indicated that CNA F reported to facility administration that RN E and another CNA removed oxygen from Resident #12 so he would pass. According to another statement included in the facility investigation related to the allegation made by CNA F about RN E's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -On [DATE], RN E reported she passed medications to Resident #3 at 9:30 p.m. and mixed a medication for secretions with [MEDICATION(S)] at 10:00 p.m. and assessed the resident. Resident #3 was awake, right eye open, right hand good grip, no verbalization, VS (vital signs assessed), HR (heart rate) within normal limits, oxygen saturations ,d+[DATE]% on 8 liters, respirations within normal limits. -RN E assumed 8 liters was ordered and unplugged the oxygen tubing by disconnecting it from the concentrator for 10 minutes and sat there the entire time and said there was no gasping or change of condition, then plugged the oxygen back in before leaving the room. The facility asked why RN E didn't document the insufficient oxygen and Resident #3's response and the documented response was she didn't know why and wanted to question the doctor if Resident #3 needed to be on it. -RN E reported CNA F walked into the room to relay a message to the nurse and noticed the oxygen was unplugged and RN E reported she plugged the oxygen back in and left the room. The facility asked if she documented the events and RN E said no and didn't know why. -RN E reported she sat with Resident #3 at 12:20 a.m. and passed midnight medications. RN E checked on Resident #3 (,d+[DATE]= )10 times (peek, assess) and 5 minutes at a time tops. -At 3:45 a.m. RN E reported breathing and oxygen saturations were up and down constantly and at 12:07 a.m., the resident had oxygen saturations of 65% and a pulse of 47 and she called her daughter. -At 12:29 a.m. the resident was at 76% oxygen saturations and pulse of 99. At 3:45 a.m. oxygen saturations were ,d+[DATE]%. The facility asked her if she called hospice and she said no. At 4:20 a.m., she opened the door, cracked open, curtain pulled back and she (Resident #3) had passed away. The facility investigation revealed that on [DATE] 12:00 p.m., Licensed Practical Nurse (LPN) RR reported the following: -CNA F told her on [DATE] she had concerns with Resident #3's oxygen prior to her death. -LPN RR told CNA F she needed to report it (her concerns with RN E's conduct regarding Resident #3) and if she didn't, then LPN RR would. -On [DATE] LPN RR asked CNA F if she reported the situation yet and CNA FF said she did not but I will. -LPN RR reported she did not know who RN E was. Review of an interview documented by the facility on [DATE] at 12:00 p.m. revealed RN KK reported the following: -RN KK reported she received a text message on [DATE] from RN E at 12:10 a.m. that said Resident #3 was going to pass, currently waiting at bedside for it, 65% pulse ox (oxygen saturations) - We're close (text message sent at 12:07 indicating Resident #3's pulse ox was at 76%), she is fighting, she won't stop. At 12:40 a.m., RN KK texted she sure is, pulse doubled also. RN E texted yes, she won't stop. The facility investigation reflected that On [DATE], CNA QQ reported the following: -CNA F told her that RN E was in Resident #3's room for 3 hours the night she passed and was messing with the resident's oxygen and told her the resident had oxygen saturations of 76%, which is low. -CNA QQ said CNA F told her that RN E said she was removing oxygen so she would pass while RN E was there because she didn't want her (Resident #3) to pass with RN O because she didn't think RN O cares (about) residents. On [DATE] at 11:30 the facility investigation revealed RN O reported the following: -RN O took report from RN E that morning ([DATE]) and RN E was frazzled and stated she sat in the room with Resident #3 when she had time, so she was not alone and left the room to pass medications and that was when Resident #3 passed. -RN O took care of that resident the day before and reported Resident #3 was alert and oriented throughout her shift and her vital signs were pretty stable, nothing alarming, no need to call doc (doctor). RN O reported she worked as an aide on the same unit ([DATE]) after her shift until 8:30 -9:00 p.m. and Resident #3 did not have any difficulty breathing. During an interview on [DATE] at 9:56 a.m., the Regional Nurse Consultant (RC) M, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported CNA F came to administration 7 days after the incident (on [DATE]) with Resident#3 but had told other staff about it before hand and felt it was just a she said, she said incident. RC M reported she spent a lot of time on this reported incident and felt CNA F does not usually come forth to Administration with concerns and instead talks about problems with staff and thinks she tells everyone else in the facility about things instead of reporting alleged abuse/neglect. RC M said that during their investigation RN E told them she did take off the oxygen off Resident #3 only once and put it back on. RC M reported RN E was a new nurse and who provided compassionate care for her residents and during the care of Resident #3 (on [DATE]), she contacted LPN KK for support. RN E changed her story about the resident's oxygen being on or off and found there is even discrepancies on who found Resident #3 dead. Resident #3 had been in and out of the hospital 4 times since admission. RC M indicated both RN E and CNA F kept changing their story. The facility reported they re-educated RN E and gave redirection and verbal counseling to CNA F. The facility reported they re-educated staff on several things including abuse and oxygen. The facility reported RN E has a lawyer now and may not talk to this surveyor without the attorney present and would not allow the attorney at the facility. RN E is still employed and actively working at the facility. During an interview on [DATE] at 3:00 p.m., CNA F reported the night of [DATE] was her second time working with RN E. CNA F reported she did not tell the management about her concerns with Resident #3 and RN E because people get in trouble and they (facility administration) don't' do anything. CNA F said the night started out normal and she started taking vital signs around 10:30 p.m. Resident #3 was laying on her side facing the doorway with oxygen on but not sure how many liters and her saturations were low around 80% (normal is ,d+[DATE]%) and respiratory rate was around 30 breaths per minute (normal is ,d+[DATE]). CNA F went to tell RN E who said the resident was actively passing, so CNA F reported that is what she was expecting. RN E told CNA F that she was going to sit with Resident #3 until she passed because that is what she told the family. CNA F reported she checked on the resident and RN E about every half hour and once saw RN E laying her head down next to Resident #3 with face towards the resident who was COVID positive. Another time she (CNA F) looked into the room she saw RN E had propped a phone up on the body of Resident #3 reviewing social media and watching videos. CNA F reported that at around 4:00 a.m., RN E came out of Resident #3's room and went down the hall to the Green Room (a community room on the unit) where CNA F was. Before the resident passed, RN E told CNA F that she didn't want the oncoming nurse to help Resident #3 because she was such a [OBSCENITY] and didn't care. CNA F reported RN E said she knew Resident #3 was ready to die and told CNA F that she could get into trouble and lose her license and that what she is doing is negligent homicide. CNA F reported that when she looked in on Resident #3 during the night, she sometimes had her oxygen on and sometimes did not but was not alarmed because the nurse told her she wanted to see how Resident #3 was maintaining. The pulse ox was on the resident the whole time and didn't think anything was wrong until after RN E went to the Green Room and had a conversation with CNA F about the negligent homicide. When RN E came into the green room around 4:00 a.m., CNA F said 15 minutes later (at 4:15 a.m.) she went to do her rounds on her residents. At 4:20 a.m., she entered Resident #3's room and noticed the nasal canula was draped over the concentrator, the resident was still on her side and was unable to get a pulse ox reading. According to CNA F, when RN E came into the room she said, Oh look she died with one eye open looking for me. CNA F reported RN E never went back into the room after Resident #3 died . CNA F reported the facility told her prior to this interview if this is substantiated, they could lose thousands of dollars. CNA F said she had been employed at the facility 4 months and they just started calling her references at the time of this investigation. During an interview on [DATE] at approximately 10:30 a.m., LPN S reported she would not take oxygen off a resident that is ordered by a physician, and especially not if they are dying. During an an interview on [DATE] at 12:02 p.m., the DON reported RN E's attorney will not let her talk to this surveyor without their presence but is willing to talk via zoom or in person at their site. During an interview on [DATE] at 3:43 p.m., RN E reported her nursing documentation on residents has been poor, but she is getting better at it and that this surveyor will not find that she put oxygen on Resident #3 in the charting. There are standing house orders though, and the physician signs the standing orders after looking at the patient. RN E felt she did not have enough training or good training with the nurses she oriented with. She remembered being the only nurse on the COVID unit (on [DATE]) and had 2 deaths and one fall in one night. A male resident was having a death rattle and sounded like he was ready to die and died at 9:04 p.m., then (Resident #3) was hanging upside down on her bed and was hanging off her bed like she was looking under her. RN E believes Resident #3 called out (on [DATE]) when RN E reported she asked the resident what she was doing when she lowered her and got her back into bed and started working on paperwork when the CNA came to tell her that another male resident (Resident #12) had low oxygen saturations and she told the CNA to put his oxygen back on. When asked about Resident #12, RN E reported how she kept finding Resident #12's oxygen off him and would remind him to keep it on. Then the CNA told her his oxygen levels were still very low, but she was in the middle of doing a tube feeding. Once RN E finished with the tube feeding, she went to Resident #12 and noticed he was at 2 liters of oxygen and the CNA did not do it, so she turned the oxygen up to 5 liters and his oxygen saturations kept dropping. RN E reported she did not call the doctor when Resident #12's oxygen saturations were low. RN E reported she only had one CNA that night to a potential 19 residents and thinks there were ,d+[DATE] of those residents that were COVID positive. Staffing was hard because nobody wanted to work the COVID unit. RN E reported she worked 6 p.m. to 6 a.m. that next morning and did not do respiratory assessments, just looked at the vital signs and documents them. RN E reported she only listens to the resident's lungs if needed. RN E reported she gave Resident #12 his evening medications and had a great conversation, constantly reminded him to put on his oxygen, but did not expect him to go downhill. RN E reported she did not remember Resident #3 wearing oxygen that night she went in to see her and cannot remember if she put oxygen on her that night ([DATE]) but remembered her hacking a lot. RN E reported she put a non-rebreather oxygen mask on her because her oxygen dropped when she hacked. RN E reported she put a non-rebreather on with 1 liter of oxygen running into the mask and the resident's oxygen saturations came up to around 94% or so. RN E reported the non-rebreather was in a closet in someone's room and grabbed it and connected it to the oxygen concentrator. RN E reported the CNA that was working with her that night before 10:00 p.m. when the CNA observed Resident #3 trying to lean over to reach something in the window thought maybe that is what she did. She just rolled like she was looking for monsters under the bed. The bed was low and RN E reported Resident #3's feet were tangled in the blankets that held the top half of her body on the bed. When queried what RN E did once she saw Resident #3 hanging over the bed dangling, she reported she slowly untangled her feet from the blankets while she was hanging over the side and fell to the floor. Once the resident was on the floor, the CNA came to help her get the resident back up. RN E reported she thinks the incident with Resident #3 happened around 9:30 p.m. RN E then reported she called Resident #3's daughter and told her their mom had a spider man fall but no injuries were noted. RN E reported Resident #3 did not have oxygen on when she put her back in bed at that time. RN E reported she put the non-rebreather oxygen mask on Resident #3 after her fall but could not say the specific time. RN E reported she could call her managers anytime if she needed or had concerns. When queried about the date Resident #3 died , RN E said she heard that Resident #3 was COVID positive and on hospice. Resident #3 was not that responsive and kept her left eye closed, and could squeeze her hand if she held it, but did not talk at all. Resident #3 was on 8 liters of oxygen via nasal canula. RN E reported she was not in the room when Resident #3 died and was the first one to find her lying in bed on her side. She had like a yellow hue, which seems to happen with residents with COVID. RN E reported when she saw Resident #3, she was stiff and her chest was not moving and she just knew and called the time of death, then took off her oxygen tubing and turned off the concentrator. The CNA then walked in and asked if she was dead and RN E told her yes. RN E reported she was only in Resident #3's room the night she died for ,d+[DATE] minutes at a time. One time RN E held her hand and laid her head next to Resident #3 on the bed even though she knew she had COVID with her N95 mask and a personal protective equipment (PPE) on. RN E reported earlier that night she was passing medications and gave Resident #3 her [MEDICATION(S)] and [MEDICATION(S)] for secretions by crushing the [MEDICATION(S)] and mixing it with the [MEDICATION(S)] and water, then drew it up in a syringe and put it in her mouth slowly in the back of her cheek. RN E reported she signed the [MEDICATION(S)] out in the narcotic book but did not document the administration in the MAR (Medication Administration Record) and remembered she gave Resident #3 more than one dose that night. When queried about Hospice, RN E reported she did not know she needed to contact Hospice if there are significant changes because she is a new nurse, but now knows that if there is a huge change she needs to call (physician or the hospice nurse). RN E reported 3 other nurses started working at the facility after her, but they are not float nurses like her and had different training. RN E reported at one point there were not enough aides to help and it was stressful and a lot of mandated hours that nurses complained about. In a second interview on [DATE] at 11:42 a.m., RN E denied being in the room with Resident #3 for more than ,d+[DATE] minutes at a time. RN E said she broke HIPAA (Health Insurance Portability and Accountability Act) by having her phone in the room and texting her pulse oximeter pictures to RN KK. RN E reported Resident #3 was on 8L nasal canula and had orders for ,d+[DATE] liters nasal canula but is not sure who gave the orders. RN E reported she did take off the oxygen from Resident #3 to get a baseline oxygen saturation and tried to get her on room air for about ,d+[DATE] minutes and felt it was a mistake but was at her bedside the whole time. The ,d+[DATE] liters of oxygen gave Resident #3 an oxygen saturation of 86%, but when she removed the oxygen the resident oxygen saturations stayed at 86% and felt she could have turned her down to 6L but kept her at 8 L. RN E reported that during report at shift change, she heard Resident #3 was on 8L of oxygen and felt she could probably come down but now knows she needs orders to titrate the oxygen on a resident and has since received education. RN E reported she also was written up for poor documentation and felt she learned a lot from this situation. When queried about using the non-rebreather oxygen mask on Resident #3 the week prior, RN E reported that was all the facility had at the time, and there were no extra nasal cannulas available, and Resident #3 remained on the non-rebreather until the next day when the day shift arrived. RN E reported the bag did not inflate at first but then pulled it apart and heard the air blowing and the bag blew up (inflated with air). RN E had the CNA get oxygen supplies but brought back several supplies like the non-rebreather and nebulizers. When queried about combining [MEDICATION(S)] and [MEDICATION(S)] together for Resident #3, RN E reported she had asked a Hospice nurse before who told her she can crush the pill and add [MEDICATION(S)] and a dash of water for residents who cannot swallow, every nurse does that. RN E reported that around midnight, Resident #3 was different in her breathing and was heavier with her oxygen and was starting to decline a little more. RN E reported she called her daughters and encouraged them to talk to their mom. The resident was on her right side and RN E said she laid the phone next to her ear so she could hear them and opened her eyes a little bit. In an interview on [DATE] at 1:13 p.m., the Hospice Nurse (HN) DD reported she expects the facility to reach out to them if a hospice resident is in pain, has shortness of breath, or is unresponsive. HN DD reported she saw Resident #3 on [DATE] and could not tell she was declining but did talk to her and she made sense. There was no indication the resident was going to die this day and did remember she was on oxygen via nasal canula but did not remember how much oxygen. HN DD reported she does not tell staff to mix [MEDICATION(S)] with [MEDICATION(S)] tablets together to administer to the residents. HN DD reported she was not notified of any concerns or changes in condition until [DATE] at 4:20 a.m. when the resident had died . In an interview on [DATE] at 3:24 p.m., the facility Nursing Educator (RN) H reported RN E had a new staff training on [DATE] and again for their skills fair on [DATE]. RN H reported there are wound care books at the nurse's station. RN H reported she tells nurses they need a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She does review what hospice protocols with new staff and what they are to do for residents on hospice. In an interview on [DATE] at 2:09 p.m., the Nurse Practitioner (NP) JJ reported that if a resident who needs oxygen via nasal cannula typically does not have oxygen above 5 liters, but certain circumstances they may need ,d+[DATE] liters such as end of life care. NP JJ reported that a non-rebreather is not used often but utilized it occasionally. It is not appropriate to remove the oxygen from a resident who is on ,d+[DATE] liters to nothing but room air. It is a drastic change and the appropriate thing to do is to wean the resident down off the oxygen slowly. If oxygen order changes are needed, NP JJ would expect the nurse to call the physician or if the resident is on hospice, then they are to contact hospice. If a resident needed to use a non-rebreather, then an oxygen tank could be used short term, but a concentrator should not be used at all. In an interview on [DATE] at 2:40 p.m., RN O reported when she charts oxygen saturations in the computer, there is no place to document how many liters of oxygen a resident is on. RN O reported the facility has standing orders for all residents and the standing orders include oxygen administration and provided this surveyor with a copy. In an interview on [DATE] at approximately 2:45 p.m., the DON denies the facility utilizing standing orders and said they do not exist. In an interview on [DATE] at 2:55 p.m., RN KK reported she is a newer nurse and remembered Resident #3 was declining and called hospice to let them know her oxygen saturations were declining, and hospice had her increase the oxygen to ,d+[DATE] liters. RN KK reported when Resident #3 was admitted to the facility, she was on 2 liters nasal canula and had always had at least 2 liters on. RN KK reported if this resident were rapidly declining, she would have reached out to hospice and learned she needed to do that in nursing school and during the new hire orientation. RN KK is not sure about how much oxygen is to be used with a non-rebreather oxygen mask but if she needed to use one, she would reach out to someone for more guidance. She would not completely remove oxygen from a resident to get a baseline reading. When queried about RN E sending her texts of Resident #3's oxygen levels, RN KK reported she remembered the oxygen levels were in the 70's and that RN E may have been a little nervous because she had 2 deaths on a previous shift. RN KK reported that RN E sent another message later to her that said the resident was still fighting and her oxygen saturations were slightly up. RN KK reported she did not work with that resident the day she died . In an interview and record review on [DATE] at 3:20 p.m., the DON reported Resident #3 did have a 30 milliliter (ml) multidose bottle of [MEDICATION(S)] prescribed to her, but when she died , the left-over [MEDICATION(S)] in the bottle was destroyed and verified with another nurse. There were 29 milliliters left in the bottle when it was destroyed. The DON provided this surveyor with the narcotic log. The narcotic log for Resident #3 revealed [MEDICATION(S)] 20 MG (milligrams)/1ML concentrate, take 0.25 ML by mouth every 2 hours if needed for severe pain. Resident #3 received 4 total doses administered and the last two doses documented by RN E revealed Resident #3 received a dose at 11:00 p.m. on [DATE] and the last dose on [DATE] at 2 a.m. Resident #3 Review of a Face Sheet revealed Resident #3 is a [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was diagnosed with COVID-19 on [DATE]. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility, transfers, and toileting. Resident #3 had limited range of motion (ROM) impairment on one side of her upper and lower extremities, at risk for pressure ulcers, none upon admission. Review of Hospital Discharge Summary to the facility dated [DATE] for Resident #3 revealed she had oxygen saturations of ,d+[DATE]% on room air. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #3 revealed no assessment of the resident's respiratory status and one plan for the resident revealed: Standing order sheet signed. Review of Standing Orders signed by the Physician on [DATE] for Resident #3 revealed: Skin issue-skin tear, abrasion, minor laceration - see wound protocol - Barrier cream for excoriation, Stage I wounds. Oxygen- ,d+[DATE] liters per nasal cannula for oxygen saturation below 88% until physician can be contacted for further orders. Review of handwritten orders dated [DATE] for Resident #3 revealed admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3 revealed no orders for oxygen administration until [DATE] for ,d+[DATE] liters via nasal canula and oxygen monitoring every shift ordered [DATE] and no documentation noted. Standing orders not noted on the MAR. [MEDICATION(S)] Sulfate Solution 10 mg/ml (milligrams/milliliter) ordered, give 0.25 ml by mouth every 2 hours as needed for pain/dyspnea, start [DATE] and discontinued on [DATE]. Resident #3 has 3 doses documented on [TRUNCATED]

This citation pertains to MI 589 Based on observation, interview, and record review, the facility failed to ensure covered staff immediately report to administration, the State Agency, and local authorities, an allegation regarding the suspicious resident death of Resident #3 when there were allegations of a nurse, RN (Registered Nurse) E, intentionally removing oxygen from Resident #3 to hasten their death and resulting in an Immediate Jeopardy that began on [DATE] when the facility administration was then made aware of allegations surrounding another death of a different Resident (Resident #12) related to the same nurse, RN E, removing oxygen from Resident #12, hastening his death. The failure of the facility to implement established abuse and neglect procedures and lack of thorough investigation into an allegation of a resident death and reporting to the State Agency the allegation and their findings puts all 106 vulnerable residents at a high risk for abuse, neglect, serious harm and/or death. Findings include: Review of the facility Abuse Prevention Program last revised [DATE] revealed policies and procedures consistent 42 CFR Part 483, Requirements for Long Term Care Facilities for the screening, training, prevention, identification, investigation, protection, reporting, and response following any alleged abuse, neglect, exploitation, or misappropriation for residents living in a long-term care facility. Review of a Facility Reported Incident (FRI) dated [DATE] reflected the facility learned of an allegation of neglect of Resident #3 reported to the facility on [DATE]. Certified Nursing Assistant (CNA) F alleged Registered Nurse (RN) E removed Resident #3's oxygen on [DATE] causing her to expire sooner than she may have done naturally. CNA F reported the incident to Detective (DT) U at the police department prior to informing the facility on [DATE]. Details in the FRI indicated RN E admitted to unplugging the oxygen tubing from the oxygen concentrator to complete a nursing assessment for approximately 10 minutes. The FRI indicated the facility was unable to substantiate the allegation (of abuse) based on the fact that CNA F and RN E were on the COVID Unit and there were no other employees on the unit. The facility was unable to substantiate that actions by the nurse contributed to the resident's death. Review of a [Local Police Department] Field Case Report, Case# ,d+[DATE] dated [DATE], reflected that on [DATE] an associate of Certified Nurse Aide (CNA) F emailed the public safety department to report that CNA F sent a text message the night before, saying I saw a person end a life and this is the second time. The report indicated CNA F alleged RN E had removed physician ordered oxygen from two residents (Resident #3 and Resident #12) and had given more narcotics than was ordered for one resident (Resident #3) possibly hastening their deaths. The interviews documented in the report included an admission from RN E that she had removed oxygen from Resident #3 and reflected multiple licensed nurses and CNA staff corroborated CNA F's claims and were aware of RN E's alleged abuse and misconduct perpetuated against Resident #3 and Resident #12 days before the local public safety detective made contact with the facility on [DATE]. Review of RN E's employee file reflected a Performance Improvement Form dated [DATE]. RN E had been issued a Counseling/Corrective Action that revealed During (an) investigation of (an) allegation, there were a few areas of opportunity identified for improvement, including documentation of assessment, changes of condition, and medication administration, and oxygen administration. Review of RN E's timecard revealed she was suspended on [DATE] and returned to work on [DATE]. RN E worked 13 shifts between [DATE] and [DATE]. During an interview on [DATE] at 10:10 AM, the Nursing Home Administrator (NHA) said a Facility Reported Incident (FRI) was not submitted to the State Agency regarding Resident #12's death because they did not feel an allegation had been made to warrant a FRI. Resident #12 Review of the Electronic Medical Record (EMR) revealed Resident #12 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 died in the facility on [DATE]. Review of a Progress Note documented by Registered Nurse (RN) E dated [DATE] at 2:02 AM reflected approx. 12:30am a CNA (Certified Nurse Aide) came to me and told me [Resident #12's] O2 (oxygen) saturation was 47% with oxygen on and at 5L (liters per minute). [Resident #12] was unresponsive in his bed with declining vitals. I called family to update them, no answer. The family called after the resident passed away. Time of death was 12:52am. Dr ordered body to be released. [Funeral home] was called at approx. 1:30am Review of transcripts from interviews conducted at the facility after it became aware of the open police investigation into alleged abuse/neglect and misconduct obtained from the facility reported incident investigation file revealed the following: CNA F: reported: -On [DATE] at 2:30 p.m. CNA F started working on the COVID unit at 10:00 p.m. on ([DATE]-[DATE]) and around 10:30 p.m. she noticed Resident #3 had respirations between ,d+[DATE] per minute (normal is ,d+[DATE] breaths per minute) and RN E told her she expected the resident to pass this night and she stayed with Resident #3 through the night even though she had too much to do. CNA F popped in and out of the room throughout the night and RN E stayed in the room until the resident passed away. RN E was noted to be in Resident #3's room from 10:30 p.m. until 4:30 a.m. CNA F reported Resident #3's door was closed but not shut and the curtain was pulled with the bed light on. -RN E told CNA F she took Resident #3's oxygen off several times and (Resident #3) was maintaining. The lowest oxygen saturation CNA F noticed (on Resident #3) was 76%. After the first rounds, RN E came out of the room to medicate with Roxinol ([MEDICATION(S)]) and gave Roxinol, (pics were sent via text at 12:30 a.m.) and the oxygen saturations were 65% and 76%. -RN E told CNA F she gave the resident more [MEDICATION(S)] than she needed but no one would notice because more is in the bottle than should be. -RN E told CNA F that she didn't want Resident #3 to pass away on the next shift because that nurse was a b***h and wanted her to pass with people who cared for her. -CNA F reported she went to Resident #3's room and with her phone propped on (Resident #3) watching YouTube videos with one hand holding the resident's hand and her face in the resident's face. At 4:00 a.m., RN E left the resident's room and went to the Green Room (a community room down the hall). -CNA F reported she went to Resident #3's room and the resident had no oxygen on and (the tubing) was laying on top of the concentrator and the concentrator was on, and the oxygen saturation monitor was not on her finger, and Resident #3 had passed. -CNA F reported she went to tell RN E about Resident #3's passing. -The investigation statements also indicated that CNA F reported to facility administration that RN E and another CNA removed oxygen from Resident #12 so he would pass. According to another statement included in the facility investigation related to the allegation made by CNA F about RN E's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -On [DATE], RN E reported she passed medications to Resident #3 at 9:30 p.m. and mixed a medication for secretions with [MEDICATION(S)] at 10:00 p.m. and assessed the resident. Resident #3 was awake, right eye open, right hand good grip, no verbalization, VS (vital signs assessed), HR (heart rate) within normal limits, oxygen saturations ,d+[DATE]% on 8 liters, respirations within normal limits. -RN E assumed 8 liters was ordered and unplugged the oxygen tubing by disconnecting it from the concentrator for 10 minutes and sat there the entire time and said there was no gasping or change of condition, then plugged the oxygen back in before leaving the room. The facility asked why RN E didn't document the insufficient oxygen and Resident #3's response and the documented response was she didn't know why and wanted to question the doctor if Resident #3 needed to be on it. -RN E reported CNA F walked into the room to relay a message to the nurse and noticed the oxygen was unplugged and RN E reported she plugged the oxygen back in and left the room. The facility asked if she documented the events and RN E said no and didn't know why. -RN E reported she sat with Resident #3 at 12:20 a.m. and passed midnight medications. RN E checked on Resident #3 (,d+[DATE]= )10 times (peek, assess) and 5 minutes at a time tops. -At 3:45 a.m. RN E reported breathing and oxygen saturations were up and down constantly and at 12:07 a.m., the resident had oxygen saturations of 65% and a pulse of 47 and she called her daughter. -At 12:29 a.m. the resident was at 76% oxygen saturations and pulse of 99. At 3:45 a.m. oxygen saturations were ,d+[DATE]%. The facility asked her if she called hospice and she said no. At 4:20 a.m., she opened the door, cracked open, curtain pulled back and she (Resident #3) had passed away. The facility investigation revealed that on [DATE] 12:00 p.m., Licensed Practical Nurse (LPN) RR reported the following: -CNA F told her on [DATE] she had concerns with Resident #3's oxygen prior to her death. -LPN RR told CNA F she needed to report it (her concerns with RN E's conduct regarding Resident #3) and if she didn't, then LPN RR would. -On [DATE] LPN RR asked CNA F if she reported the situation yet and CNA FF said she did not but I will. -LPN RR reported she did not know who RN E was. Review of an interview documented by the facility on [DATE] at 12:00 p.m. revealed RN KK reported the following: -RN KK reported she received a text message on [DATE] from RN E at 12:10 a.m. that said Resident #3 was going to pass, currently waiting at bedside for it, 65% pulse ox (oxygen saturations) - We're close (text message sent at 12:07 indicating Resident #3's pulse ox was at 76%), she is fighting, she won't stop. At 12:40 a.m., RN KK texted she sure is, pulse doubled also. RN E texted yes, she won't stop. The facility investigation reflected that on [DATE], CNA QQ reported the following: -CNA F told her that RN E was in Resident #3's room for 3 hours the night she passed and was messing with the resident's oxygen and told her the resident had oxygen saturations of 76%, which is low. -CNA QQ said CNA F told her that RN E said she was removing oxygen so she would pass while RN E was there because she didn't want her (Resident #3) to pass with RN O because she didn't think RN O cares (about) residents. On [DATE] at 11:30 the facility investigation revealed RN O reported the following: -RN O took report from RN E that morning ([DATE]) and RN E was frazzled and stated she sat in the room with Resident #3 when she had time, so she was not alone and left the room to pass medications and that was when Resident #3 passed. -RN O took care of that resident the day before and reported Resident #3 was alert and oriented throughout her shift and her vital signs were pretty stable, nothing alarming, no need to call doc (doctor). RN O reported she worked as an aide on the same unit ([DATE]) after her shift until 8:30 -9:00 p.m. and Resident #3 did not have any difficulty breathing. During an interview on [DATE] at 9:56 a.m., the Regional Nurse Consultant (RC) M, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported CNA F came to administration 7 days after the incident (on [DATE]) with Resident#3 but had told other staff about it before hand and felt it was just a she said, she said incident. RC M reported she spent a lot of time on this reported incident and felt CNA F does not usually come forth to Administration with concerns and instead talks about problems with staff and thinks she tells everyone else in the facility about things instead of reporting alleged abuse/neglect. RC M said that during their investigation RN E told them she did take off the oxygen off Resident #3 only once and put it back on. RC M reported RN E was a new nurse and who provided compassionate care for her residents and during the care of Resident #3 (on [DATE]), she contacted LPN KK for support. RN E changed her story about the resident's oxygen being on or off and found there is even discrepancies on who found Resident #3 dead. Resident #3 had been in and out of the hospital 4 times since admission. RC M indicated both RN E and CNA F kept changing their story. The facility reported they re-educated RN E and gave redirection and verbal counseling to CNA F. The facility reported they re-educated staff on several things including abuse and oxygen. The facility reported RN E has a lawyer now and may not talk to this surveyor without the attorney present and would not allow the attorney at the facility. RN E is still employed and actively working at the facility. During an interview on [DATE] at 3:00 p.m., CNA F reported the night of [DATE] was her second time working with RN E. CNA F reported she did not tell the management about her concerns with Resident #3 and RN E because people get in trouble and they (facility administration) don't' do anything. CNA F said the night started out normal and she started taking vital signs around 10:30 p.m. Resident #3 was laying on her side facing the doorway with oxygen on but not sure how many liters and her saturations were low around 80% (normal is ,d+[DATE]%) and respiratory rate was around 30 breaths per minute (normal is ,d+[DATE]). CNA F went to tell RN E who said the resident was actively passing, so CNA F reported that is what she was expecting. RN E told CNA F that she was going to sit with Resident #3 until she passed because that is what she told the family. CNA F reported she checked on the resident and RN E about every half hour and once saw RN E laying her head down next to Resident #3 with face towards the resident who was COVID positive. Another time she (CNA F) looked into the room she saw RN E had propped a phone up on the body of Resident #3 reviewing social media and watching videos. CNA F reported that at around 4:00 a.m., RN E came out of Resident #3's room and went down the hall to the Green Room (a community room on the unit) where CNA F was. Before the resident passed, RN E told CNA F that she didn't want the oncoming nurse to help Resident #3 because she was such a [OBSCENITY] and didn't care. CNA F reported RN E said she knew Resident #3 was ready to die and told CNA F that she could get into trouble and lose her license and that what she is doing is negligent homicide. CNA F reported that when she looked in on Resident #3 during the night, she sometimes had her oxygen on and sometimes did not but was not alarmed because the nurse told her she wanted to see how Resident #3 was maintaining. The pulse ox was on the resident the whole time and didn't think anything was wrong until after RN E went to the Green Room and had a conversation with CNA F about the negligent homicide. When RN E came into the green room around 4:00 a.m., CNA F said 15 minutes later (at 4:15 a.m.) she went to do her rounds on her residents. At 4:20 a.m., she entered Resident #3's room and noticed the nasal canula was draped over the concentrator, the resident was still on her side and was unable to get a pulse ox reading. According to CNA F, when RN E came into the room she said, Oh look she died with one eye open looking for me. CNA F reported RN E never went back into the room after Resident #3 died . CNA F reported the facility told her prior to this interview if this is substantiated, they could lose thousands of dollars. CNA F said she had been employed at the facility 4 months and they just started calling her references at the time of this investigation. During an interview on [DATE] at approximately 10:30 a.m., LPN S reported she would not take oxygen off a resident that is ordered by a physician, and especially not if they are dying. During an interview on [DATE] at 12:02 p.m., the DON reported RN E's attorney will not let her talk to this surveyor without their presence but is willing to talk via zoom or in person at their site. During an interview on [DATE] at 3:43 p.m., RN E reported her nursing documentation on residents has been poor, but she is getting better at it and that this surveyor will not find that she put oxygen on Resident #3 in the charting. There are standing house orders though, and the physician signs the standing orders after looking at the patient. RN E felt she did not have enough training or good training with the nurses she oriented with. She remembered being the only nurse on the COVID unit (on [DATE]) and had 2 deaths and one fall in one night. A male resident was having a death rattle and sounded like he was ready to die and died at 9:04 p.m., then (Resident #3) was hanging upside down on her bed and was hanging off her bed like she was looking under her. RN E believes Resident #3 called out (on [DATE]) when RN E reported she asked the resident what she was doing when she lowered her and got her back into bed and started working on paperwork when the CNA came to tell her that another male resident (Resident #12) had low oxygen saturations and she told the CNA to put his oxygen back on. When asked about Resident #12, RN E reported how she kept finding Resident #12's oxygen off him and would remind him to keep it on. Then the CNA told her his oxygen levels were still very low, but she was in the middle of doing a tube feeding. Once RN E finished with the tube feeding, she went to Resident #12 and noticed he was at 2 liters of oxygen and the CNA did not do it, so she turned the oxygen up to 5 liters and his oxygen saturations kept dropping. RN E reported she did not call the doctor when Resident #12's oxygen saturations were low. RN E reported she only had one CNA that night to a potential 19 residents and thinks there were ,d+[DATE] of those residents that were COVID positive. Staffing was hard because nobody wanted to work the COVID unit. RN E reported she worked 6 p.m. to 6 a.m. that next morning and did not do respiratory assessments, just looked at the vital signs and documents them. RN E reported she only listens to the resident's lungs if needed. RN E reported she gave Resident #12 his evening medications and had a great conversation, constantly reminded him to put on his oxygen, but did not expect him to go downhill. RN E reported she did not remember Resident #3 wearing oxygen that night she went in to see her and cannot remember if she put oxygen on her that night ([DATE]) but remembered her hacking a lot. RN E reported she put a non-rebreather oxygen mask on her because her oxygen dropped when she hacked. RN E reported she put a non-rebreather on with 1 liter of oxygen running into the mask and the resident's oxygen saturations came up to around 94% or so. RN E reported the non-rebreather was in a closet in someone's room and grabbed it and connected it to the oxygen concentrator. RN E reported the CNA that was working with her that night before 10:00 p.m. when the CNA observed Resident #3 trying to lean over to reach something in the window thought maybe that is what she did. She just rolled like she was looking for monsters under the bed. The bed was low and RN E reported Resident #3's feet were tangled in the blankets that held the top half of her body on the bed. When queried what RN E did once she saw Resident #3 hanging over the bed dangling, she reported she slowly untangled her feet from the blankets while she was hanging over the side and fell to the floor. Once the resident was on the floor, the CNA came to help her get the resident back up. RN E reported she thinks the incident with Resident #3 happened around 9:30 p.m. RN E then reported she called Resident #3's daughter and told her their mom had a spider man fall but no injuries were noted. RN E reported Resident #3 did not have oxygen on when she put her back in bed at that time. RN E reported she put the non-rebreather oxygen mask on Resident #3 after her fall but could not say the specific time. RN E reported she could call her managers anytime if she needed or had concerns. When queried about the date Resident #3 died , RN E said she heard that Resident #3 was COVID positive and on hospice. Resident #3 was not that responsive and kept her left eye closed, and could squeeze her hand if she held it, but did not talk at all. Resident #3 was on 8 liters of oxygen via nasal canula. RN E reported she was not in the room when Resident #3 died and was the first one to find her lying in bed on her side. She had like a yellow hue, which seems to happen with residents with COVID. RN E reported when she saw Resident #3, she was stiff and her chest was not moving and she just knew and called the time of death, then took off her oxygen tubing and turned off the concentrator. The CNA then walked in and asked if she was dead and RN E told her yes. RN E reported she was only in Resident #3's room the night she died for ,d+[DATE] minutes at a time. One time RN E held her hand and laid her head next to Resident #3 on the bed even though she knew she had COVID with her N95 mask and a personal protective equipment (PPE) on. RN E reported earlier that night she was passing medications and gave Resident #3 her [MEDICATION(S)] and [MEDICATION(S)] for secretions by crushing the [MEDICATION(S)] and mixing it with the [MEDICATION(S)] and water, then drew it up in a syringe and put it in her mouth slowly in the back of her cheek. RN E reported she signed the [MEDICATION(S)] out in the narcotic book but did not document the administration in the MAR (Medication Administration Record) and remembered she gave Resident #3 more than one dose that night. When queried about Hospice, RN E reported she did not know she needed to contact Hospice if there are significant changes because she is a new nurse, but now knows that if there is a huge change she needs to call (physician or the hospice nurse). RN E reported 3 other nurses started working at the facility after her, but they are not float nurses like her and had different training. RN E reported at one point there were not enough aides to help and it was stressful and a lot of mandated hours that nurses complained about. In a second interview on [DATE] at 11:42 a.m., RN E denied being in the room with Resident #3 for more than ,d+[DATE] minutes at a time. RN E said she broke HIPAA (Health Insurance Portability and Accountability Act) by having her phone in the room and texting her pulse oximeter pictures to RN KK. RN E reported Resident #3 was on 8L nasal canula and had orders for ,d+[DATE] liters nasal canula but is not sure who gave the orders. RN E reported she did take off the oxygen from Resident #3 to get a baseline oxygen saturation and tried to get her on room air for about ,d+[DATE] minutes and felt it was a mistake but was at her bedside the whole time. The ,d+[DATE] liters of oxygen gave Resident #3 an oxygen saturation of 86%, but when she removed the oxygen the resident oxygen saturations stayed at 86% and felt she could have turned her down to 6L but kept her at 8 L. RN E reported that during report at shift change, she heard Resident #3 was on 8L of oxygen and felt she could probably come down but now knows she needs orders to titrate the oxygen on a resident and has since received education. RN E reported she also was written up for poor documentation and felt she learned a lot from this situation. When queried about using the non-rebreather oxygen mask on Resident #3 the week prior, RN E reported that was all the facility had at the time, and there were no extra nasal cannulas available, and Resident #3 remained on the non-rebreather until the next day when the day shift arrived. RN E reported the bag did not inflate at first but then pulled it apart and heard the air blowing and the bag blew up (inflated with air). RN E had the CNA get oxygen supplies but brought back several supplies like the non-rebreather and nebulizers. When queried about combining [MEDICATION(S)] and [MEDICATION(S)] together for Resident #3, RN E reported she had asked a Hospice nurse before who told her she can crush the pill and add [MEDICATION(S)] and a dash of water for residents who cannot swallow, every nurse does that. RN E reported that around midnight, Resident #3 was different in her breathing and was heavier with her oxygen and was starting to decline a little more. RN E reported she called her daughters and encouraged them to talk to their mom. The resident was on her right side and RN E said she laid the phone next to her ear so she could hear them and opened her eyes a little bit. In an interview on [DATE] at 1:13 p.m., the Hospice Nurse (HN) DD reported she expects the facility to reach out to them if a hospice resident is in pain, has shortness of breath, or is unresponsive. HN DD reported she saw Resident #3 on [DATE] and could not tell she was declining but did talk to her and she made sense. There was no indication the resident was going to die this day and did remember she was on oxygen via nasal canula but did not remember how much oxygen. HN DD reported she does not tell staff to mix [MEDICATION(S)] with [MEDICATION(S)] tablets together to administer to the residents. HN DD reported she was not notified of any concerns or changes in condition until [DATE] at 4:20 a.m. when the resident had died . In an interview on [DATE] at 3:24 p.m., the facility Nursing Educator (RN) H reported RN E had a new staff training on [DATE] and again for their skills fair on [DATE]. RN H reported there are wound care books at the nurse's station. RN H reported she tells nurses they need a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She does review what hospice protocols with new staff and what they are to do for residents on hospice. In an interview on [DATE] at 2:09 p.m., the Nurse Practitioner (NP) JJ reported that if a resident who needs oxygen via nasal cannula typically does not have oxygen above 5 liters, but certain circumstances they may need ,d+[DATE] liters such as end of life care. NP JJ reported that a non-rebreather is not used often but utilized it occasionally. It is not appropriate to remove the oxygen from a resident who is on ,d+[DATE] liters to nothing but room air. It is a drastic change and the appropriate thing to do is to wean the resident down off the oxygen slowly. If oxygen order changes are needed, NP JJ would expect the nurse to call the physician or if the resident is on hospice, then they are to contact hospice. If a resident needed to use a non-rebreather, then an oxygen tank could be used short term, but a concentrator should not be used at all. In an interview on [DATE] at 2:40 p.m., RN O reported when she charts oxygen saturations in the computer, there is no place to document how many liters of oxygen a resident is on. RN O reported the facility has standing orders for all residents and the standing orders include oxygen administration and provided this surveyor with a copy. In an interview on [DATE] at approximately 2:45 p.m., the DON denies the facility utilizing standing orders and said they do not exist. Resident #3 Review of a Face Sheet revealed Resident #3 is a [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was diagnosed with COVID-19 on [DATE]. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility, transfers, and toileting. Resident #3 had limited range of motion (ROM) impairment on one side of her upper and lower extremities, at risk for pressure ulcers, none upon admission. Review of Hospital Discharge Summary to the facility dated [DATE] for Resident #3 revealed she had oxygen saturations of ,d+[DATE]% on room air. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #3 revealed no assessment of the resident's respiratory status and one plan for the resident revealed: Standing order sheet signed. Review of Standing Orders signed by the Physician on [DATE] for Resident #3 revealed: Skin issue-skin tear, abrasion, minor laceration - see wound protocol - Barrier cream for excoriation, Stage I wounds. Oxygen- ,d+[DATE] liters per nasal cannula for oxygen saturation below 88% until physician can be contacted for further orders. Review of handwritten orders dated [DATE] for Resident #3 revealed admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record (MAR) dated [DATE] for Resident #3 revealed no orders for oxygen administration until [DATE] for ,d+[DATE] liters via nasal canula and oxygen monitoring every shift ordered [DATE] and no documentation noted. Standing orders not noted on the MAR. [MEDICATION(S)] Sulfate Solution 10 mg/ml (milligrams/milliliter) ordered, give 0.25 ml by mouth every 2 hours as needed for pain/dyspnea, start [DATE] and discontinued on [DATE]. Resident #3 has 3 doses documented on [DATE] only, one of those doses documented by RN E at 10:19 p.m. with a documented pain level of 0. [MEDICATION(S)] Sulfate Tablet sublingual 0.125 mg, give 1 application sublingually every 4 hours as needed for secretions, start date [DATE] and discontinued on [DATE], 2 total doses documented on [DATE] and the last dose documented as given at 4:34 p.m. Review of the [MEDICATION(S)] Narcotic Log Sheet for Resident #3 revealed she received a total of 4 doses of 0.25 ml of [MEDICATION(S)]. On [DATE] she received [MEDICATION(S)] at 8:30 a.m. and 4:35 p.m. which correlate with the MAR and given by the day shift nurse. On [DATE] at 11:00 p.m. and then at 2:00 a.m. on [DATE], the [MEDICATION(S)] given by RN E does not correlate with the MAR. Review of a list of documented oxygen saturations for Resident #3 dated [DATE] to [DATE] does not indicate how many liters of oxygen the resident was on or what actions the nurse took when oxygen saturations fell below the normal of 92 - 100%. Six entries noted below 92% with the lowest of 84% on [DATE]. On [DATE], the documentation on Resident #3 shows she had saturations of 95% vial nasal cannula which is contradictory to the Admission assessment dated [DATE]-[DATE]. Review of a Nursing Admission assessment dated [DATE]-[DATE] for Resident #3 revealed Most recent O2 (oxygen) sats 95% room air . Resident able to answer questions appropriately. No difficulty with speech, and able to understand questions. She was educated to call light and bed control. A&O (alert and oriented) X3. Assessment complete, and compliant with cares and help from staff. The resident has no dentures and voiced she is able to brush her own teeth . On [DATE] at approximately 3:45 PM, the Nursing Home Administrator (NHA) was informed of an Immediate Jeopardy (IJ) that began on [DATE] when the facility staff failed to report, investigate, and operationalize abuse policies and procedures regarding the suspicious resident death of Resident #3 when during an investigation there were allegations of a nurse, RN (Registered Nurse) E, removing oxygen from Resident #3 to hasten her death; and when the facility administration was made aware of allegations surroundin [TRUNCATED]

This citation pertains to MI 589 and M 6435. Based on interview and record review, the facility failed to operationalize policies and procedures to notify the physician and/or hospice nurse for changes in condition for Resident #3 and Resident #12 resulting in an Immediate Jeopardy that began on [DATE] when the facility failed to assure residents were receiving care in accordance with professional standards when: on [DATE] RN E failed to contact the physician when Resident #12 had an acute change in condition and they subsequently died and then on [DATE] RN E failed to contact Hospice and/or the physician when Resident #3 had an acute change in condition and they subsequently died . The failure of the facility to implement established procedures to notify the physician/hospice nurse for changes in conditions puts all 106 vulnerable residents at a high risk for serious harm, injury and/or death. Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . COVID diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility, transfers, and toileting. Resident #3 had limited range of motion (ROM) impairment on one side of her upper and lower extremities, at risk for pressure ulcers, none upon admission. Review of a Facility Reported Incident reported to the State Agency on [DATE] revealed an allegation of neglect of Resident #3 reported to the facility on [DATE]. Certified Nursing Assistant (CNA) F alleged Registered Nurse (RN) E removed Resident #3's oxygen on [DATE] causing her to expire sooner than she may have done naturally. CNA F reported the incident to Detective (DT) U at the police department prior to informing the facility on [DATE]. On [DATE] the facility interviewed RN E who reported Resident #3 was on 8 liters of oxygen and admitted she unplugged the oxygen tubing from the oxygen concentrator to complete a nursing assessment when she passed medications at 9:30 p.m. ([DATE]) and replaced the oxygen before she left the room. During that time, CNA F walked into the room and saw the oxygen tubing disconnected from the concentrator. RN E felt the need to explain to CNA F the reason for disconnecting the oxygen tubing from the concentrator and that it was necessary for a nursing assessment. RN E reported she did remove the oxygen for approximately 10 minutes and the resident maintained oxygen saturations of ,d+[DATE]%. At 12:00 a.m., RN E reported Resident #3 starting abdominal breathing. RN E checked on Resident #3 several times from 12:00 a.m. to 4:00 a.m. ([DATE]). At 4:20 a.m. Resident #3 passed away and hospice was contacted at 4:30 a.m. On [DATE] at 2:30 p.m., the facility interviewed CNA F again who reported she was taking Resident #3's vital signs on [DATE] at 10:00 p.m. and noted her respirations were in the 30's and reported it to RN E who indicated she expected the resident to pass during the night. CNA F reported she saw the pulse oximeter monitor several times and the lowest oxygen saturation was 76%. CNA F reported RN E left Resident #3's room at 4:00 a.m. and took a break. At 4:20 a.m., CNA F entered Resident #3's room and reported the resident appeared she had passed. CNA F then went to get RN E who called the time of death at 4:20 a.m. On [DATE], RN O reported when her shift ended at 9:30 p.m. ([DATE]), Resident #3 was stable, however expected her to pass within the next couple of days. RN E was suspended [DATE] pending investigation. The facility reported they were unable to substantiate the allegation based on the fact that CNA F and RN E were on the COVID Unit and there were no other employees on the unit. The facility was unable to substantiate that actions by the nurse contributed to the resident's death. Review of several handwritten statements/timelines obtained from the facility from staff who cared for Resident #3 revealed: On [DATE] at 2:30 p.m. CNA F started working on the COVID unit at 10:00 on ([DATE]-[DATE]) and around 10:30 p.m. she noticed Resident #3 had respirations between ,d+[DATE] per minute (normal is ,d+[DATE] breaths per minute) and RN E told her she expected the resident to pass this night and she stayed with Resident #3 through the night even though she had too much to do. CNA F popped in and out of the room throughout the night and RN E stayed in the room until the resident passed away. RN E was noted to be in Resident #3's room from 10:30 p.m. until 4:30 a.m. CNA F reported Resident #3's door was closed but not shut and the curtain was pulled with the bed light on. RN E told CNA F she took Resident #3's oxygen off several times and was maintaining. The lowest oxygen saturation CNA F noticed was 76%. After the first rounds, RN E came out of the room to medicate with Roxinol ([MEDICATION(S)]) and gave Roxinol, (pics were sent via text at 12:30 a.m.) and the oxygen saturations were 65% and 76%. RN E told CNA F she gave the resident more [MEDICATION(S)] than she needed but no one would notice because more is in the bottle than should be. RN E told CNA F that she did not want Resident #3 to pass away on the next shift because that nurse was a [OBSCENITY] and wanted her pass with people who cared for her. CNA F reported she went to Resident #3's room and with her phone propped on (Resident #3) watching YouTube videos with one hand holding the residents' hand and her face in the residents face. At 4:00 a.m., RN E left the residents room and went to the Green Room (a community room down the hall). CNA F reported she went to Resident #3's room and the resident had no oxygen on and (the tubing) was laying on top of the concentrator and the concentrator was on, and the oxygen saturation monitor was not on her finger, and Resident #3 had passed. CNA F reported she went to tell RN E. CNA F reported RN E and another CNA removed oxygen from Resident #12 so he would pass. On [DATE], RN E reported she passed medications to Resident #3 at 9:30 p.m. and mixed a medication for secretions with [MEDICATION(S)]. At 10:00 p.m. and assessed the resident. Resident #3 was awake, right eye open, right hand good grip, no verbalization, VS (vital signs assessed), HR (heart rate) within normal limits, oxygen saturations ,d+[DATE]% on 8 liters, respirations within normal limits. RN E assumed 8 liters was ordered and unplugged the oxygen tubing by disconnecting it from the concentrator for 10 minutes and sat there the entire time and said there was no gasping or change of condition. Then plugged the oxygen back in before leaving the room. The facility asked why, and the documented response was she did not know why and wanted to question the doctor if Resident #3 needed to be on it. RN E reported CNA F walked into the room to relay a message to the nurse and noticed the oxygen was unplugged and RN E reported she plugged the oxygen back in and left the room. The facility asked if she documented the events and RN E said no and did not know why. RN E reported she sat with Resident #3 at 12:20 a.m. and passed midnight medications. RN E checked on Resident #3 (,d+[DATE]= )10 times (peek, assess) and 5 minutes at a time tops. At 3:45 a.m. RN E reported breathing and oxygen saturations were up and down constantly and at 12:07 a.m., the resident had oxygen saturations of 65% and a pulse of 47 and she called her daughter. At 12:29 a.m. the resident was at 76% oxygen saturations and pulse of 99. At 3:45 a.m. oxygen saturations were ,d+[DATE]%. The facility asked her if she called hospice and she said no. At 4:20 a.m., she opened the door, cracked open, curtain pulled [NAME] and she had passed away. On [DATE] 12:00 p.m., Licensed Practical Nurse (LPN) RR reported that CNA F told her on [DATE] she had concerns with Resident #3's oxygen prior to her death. LPN RR told CNA F she needed to report it and if she did not, then LPN RR would. On [DATE] LPN RR asked CNA F if she reported the situation yet and CNA FF said she did not but I will. LPN RR reported she did not know who RN E was. On [DATE] at 12:00 p.m., RN KK reported she received a text message on [DATE] from RN E at 12:10 a.m. that said Resident #3 was going to pass, currently waiting at bedside for it, 65% pulse ox (oxygen saturations) - We're close (12:07 76%), she is fighting, she won't stop. At 12:40 a.m., RN KK texted she sure is, pulse doubled also. RN E texted yes, she won't stop. On [DATE], CNA QQ reported to the facility that CNA F told her that RN E was in Resident #3's room for 3 hours the night she passed and was messing with the resident's oxygen and told her the resident had oxygen saturations of 76%, which is low. CNA QQ said CNA F told her that RN E said she was removing oxygen so she would pass while RN E was there because she didn't want her (Resident #3) to pass with RN O because she didn't think RN O cares (about) residents. On [DATE] at 11:30 the facility revealed RN O took report from RN E that morning ([DATE]) and RN E was frazzled and stated she sat in the room with Resident #3 when she had time, so she was not alone and left the room to pass medications and that was when Resident #3 passed. RN O took care of that resident the day before and reported Resident #3 was alert and oriented throughout her shift and her vital signs were pretty stable, nothing alarm, no need to call doc (doctor). RN O reported she worked as an aide on the same unit ([DATE]) after her shift until 8:30 -9:00 p.m. and Resident #3 did not have any difficulty breathing. Review of the Police Report with a documented interview on [DATE] revealed the detective was contacted via email from a person who claimed to have received a text message from a friend that said, I saw someone end a life and that is was the second time. CNA F told the Detective that an RN told her that a resident (Resident #3) was going to pass away soon and did not want the resident to pass away on a shift other than hers and she did not care for the nurse working the following day shift. CNA F said this RN removed the resident's oxygen, she passed away and this situation was [OBSCENITY] ed up. CNA F said she learned the same thing happened with a resident 2 weeks ago named (Resident #12). CNA F .CNA F said RN E sent her pictures of Resident #3's O2 stats from her Pulse Ox while she was doing the med passes and vital assessments of other residents and this seemed strange RN E was sharing pictures and then Resident #3 passed away. CNA F also mentioned RN E admitted to giving Resident #3 more [MEDICATION(S)] than she was supposed to. Review of a Police Report with a documented interview on [DATE] around 12:30 p.m., Dt U interviewed the daughters of Resident #3 who reported RN E told them she would take their mother off her oxygen. RN E told them 10 minutes before Resident #3 died , she grabbed her hand and squeezed it Both (daughters) explained their mother was able to communicate until the day she passed away. Both said their mother died quicker than they expected. (Daughter) reported RN E told her (Resident #3) maintained after she removed her oxygen then mentioned her taking a 10 minute break. when she returned from break, (Resident #3) had passed away. she (RN E) would tell them how she would lay with their mother and stroke her hair. They (daughters) said the last call they received from (RN E) was from her personal phone before midnight the night she passed away and was told their mother was fading and they should tell her it was time to go. At 4:20 a.m. on [DATE] they were informed Resident #3 passed away. The daughters had concerns that during the last phone call with their mother (Resident #3), they could not hear the oxygen concentrator in operation. They explained the loud swoosh of this machine could always be heard, but not the night she passed away. Review of a Police Report with a documented interview on [DATE] at 3:00 p.m., RN E reported she crushed a medication for secretions and liquid [MEDICATION(S)] together and dripped it into Resident #3's mouth. (Resident #3) obviously was passing. RN E reported the resident was on 8 liters of oxygen and was alert, opening one eye like she always did and reported the resident would squeeze her hand really tight during this shift, like she knew what was happening. RN E reported she kept (Resident #3's) door closed during her shift because she didn't want other people to be looking in at the resident. RN E revealed text messages and screen shots she exchanged with another nurse and other residents about Resident #3's stats. RN E showed on her phone she called the family of Resident #3 at 11:44 p.m. on [DATE] because she felt Resident #3 was declining even though her stats were not changing yet and wanted them to talk to the resident and tell her it was time to let go. RN E could not recall events between midnight [DATE] and 4:20 a.m. RN E reported she found out later that Resident #3 was on 8 liters oxygen as needed and Administration told her she needed to be sure and read her orders before caring for residents. RN E reported I assume when someone is on oxygen we are going to keep it on. RN E said when she went in Resident #3's room earlier in the night the resident seemed fine, failed to look at the order, and wondered if the resident really needed to be on oxygen. RN E said she removed the nasal canula from the residents' face and watched her stats which did not change. RN E wanted to know if the resident could maintain without oxygen and kept it off for a few then she left the residents room and told CNA F how the stats maintained without oxygen. RN E reported she went back into the resident's room and put the canula back on after talking with CNA F. DT U asked RN E if she ever unplugged (Resident #3s) oxygen from the concentrator as well and she said yes. RN E reported CNA F saw Resident #3's oxygen unplugged from the concentrator and that is when she went back into the room to plug it back in. RN E reported she should not have done this and it is something she could lose her license over. RN E reported she entered Resident #3's room a 4:19 a.m. and knew she was dead, touched the resident and turned the concentrator off and removed her canula. She felt for signs of life. RN E reported Resident #12 went so fast and his O2 (oxygen) stats were down to 47 when they were trying to adjust his canula. his death was quick, but she cranked his oxygen on the night he died . The Detective (DT) U met with the facility on [DATE] around 10:00 a.m., the Director of Nursing (DON) contacted RN E via text and asked her what happened. RN E reported Resident #3 was actively dying when she arrived on her shift and struggled on night long. The DON asked RN E about removing her oxygen and she said this did occur and she wanted to assess the resident to see how her body would maintain without the 8 liters of oxygen she was being administered and confirmed Resident #3 was on 8 liters of oxygen via nasal cannula. Review of a Police Report with a documented second interview at the facility, CNA F reported RN E expected Resident #3 to pass away sometime during the night. Throughout the night RN E decided she was going to stain the Resident #3's room and not complete her charting. CNA F reported RN E was in Resident #3's room up until around 15 minutes before she passed away. CNA F reported she went in to Resident #3's room and found her passed away around 4:20 a.m. on [DATE]. CNA F said RN E was in the room with her all the entire shift except the last 15 minutes of her life and never lest the room to care for other residents and refused to come out to assist with another resident that fell . CNA F said again that RN F was in Resident #3's room all night with the door closed but not completely shut. CNA F reported RN E removed Resident #3's oxygen numerous times . CNA F reported she saw Resident #3 at least a dozen times throughout the shift and saw on the pulse ox was 76%. RN E took picture of the pulse ox monitor and showed CNA F Resident #3 had a pulse ox below 70% and then above it. CNA F reported RN E said she was giving Resident #3 [MEDICATION(S)] every hour and no one would know how much she gave because of how it is registered. CNA F reported they (RN E) talked about assisted suicide and RN E reported she could be prosecuted and did not want the resident to pass away on any other shift than her because the oncoming nurse was a [OBSCENITY] and did not think she cared for the residents. RN E told CNA F what the risks could be and that she was removing oxygen. CNA F reported she was the first to see Resident #3 deceased and she was not on oxygen and the canula was laying on top of the concentrator and the pulse oximeter was not on her finger. CNA F called RN E to the room and RN E who told CNA F that Resident #3 had passed away. Review of a Police Report with a documented interview at the facility revealed LPN KK reported RN E taking off (Resident #3's) oxygen was a big deal and not the best care we are to give, saying that's causing harm to one of our residents. LPN KK became aware of the incident from coworker and was going to tell the administration of CNA F did not. LPN KK reported that Resident #12 would get frustrated wearing his nasal canula but for the most part left it on. LPN KK reported she received text messages from RN E showing Resident #3's pulse ox readings of 65% and that RN E was at Resident #3's bedside waiting for her to pass. LPN KK reported RN E did not follow proper procedures. Review of a Police Report with a documented interview at the facility revealed LPN RR was notified by CNA F on [DATE] around 6:30 a.m. of RN E removing the oxygen from Resident #3 and the resident passed away. CNA F was very upset and LPN RR told CNA F she needed to report it and if she did not, she was going to. Review of a Police Report with a documented second interview at the facility revealed RN E reported her shift started at 6:00 p.m. on [DATE] and received report from LPN KK that Resident #3 was now COVID positive and on hospice now and aware the resident was on 8 liters of oxygen via nasal canula and oxygen concentrator. RN E said the resident would probably pass during the night or the next shift or soon according to LPN KK. RN R passed medications around 9:30 p.m. and mixed a crushed pill in with [MEDICATION(S)] and gave it to the resident via dropper in the back of her cheek and said Resident #3's oxygen saturations were ,d+[DATE]% on 8 liters of oxygen and her respirations were good. RN E said she had a pulse ox on the resident from 9:45 to 10:00 p.m. and thought the 8 liters of oxygen was quite high as she sat in a chair next to her bed. (RN E) said she unplugged the oxygen tubing from the concentrator and held it in her hand, and said the resident maintained her stats as I sat there for no longer than 10 minutes. RN E said the residents breathing did not change and she wasn't gasping and didn't' hear a death rattle or anything like that, and plugged the oxygen back in when she walked out of the room. Staff asked RN E why she would plug (Resident #3's) oxygen back in when she left her room if her body was maintaining. (RN E) replied she did not want to question the doctor or the orders. She was asked why if she thought there was an order would she remove oxygen. RN E replied, I just don't have an answer. RN E said CNA F walked into the room when the oxygen tubing was unplugged from the concentrator. When asked about documenting the things she did, RN E said she did not know she was supposed to. Staff asked (RN E) what she learned in nursing school and she replied, basically if you didn't chart it, it didn't happen. RN E reported she told CNA F she removed Resident #3's oxygen and she was maintaining her stats pretty well. RN E reported around midnight Resident #3 started abdominal breathing when she checked on her and her oxygen was being administered at this time. RN E reported she called the residents daughter to encourage the resident to go and then sat with the resident for a little bit but not too long and checked on her quite a few more times until she was found deceased . RN E reported she checked on Resident #3 around 3:45 to 3:50 a.m. and she was on her oxygen but was fighting and that the oxygen sats were changing. In an interview on [DATE] at 9:56 a.m., the Regional Nurse Consultant (RC) M and the Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported CNA F came to the administrators 7 days after the incident with Resident#3 but had told other staff about it before hand and felt it was just a she said, she said incident and had to look at the facts. RC M reported she spent a lot of time on this reported incident and felt CNA F does not usually come forth to Administration with concerns and instead talks about problems with staff and thinks she tells everyone else in the facility about things instead. RN E told them she did take off the oxygen off Resident #3 only once and put it back on. RC M reported E was a new nurse and who provided compassionate care for her residents and during the care of Resident #3, she contacted LPN KK for support. RN E changed her story about the resident's oxygen being on or off and found there is even discrepancies on who found Resident #3 dead. Resident #3 had been in and out of the hospital 4 times since admission. Both RN E and CNA F kept changing their story. They reported they re-educated RN E and gave redirection and verbal counseling to CNA F. The facility reported they re-educated staff on several things including abuse and oxygen. The facility reported RN E has a lawyer now and may not talk to this surveyor without the attorney present and would not allow the attorney at the facility. RN E is still employed and actively working at the facility. In an interview on [DATE] at 3:00 p.m., CNA F reported the night of [DATE] was her second time to working with RN E. CNA F reported she did not tell the management about her concerns with Resident #3 and RN E because people get in trouble and they don't' do anything. CNA F said the night started out normal and she started taking vital signs around 10:30 p.m. Resident #3 was laying on her side facing the doorway with oxygen on but not sure how many liters and her saturations were low around 80% (normal is ,d+[DATE]%) and respiratory rate was round 30 breaths per minute (normal is ,d+[DATE]). CNA F went to tell RN E who said the resident was actively passing, so CNA F reported that is what she was expecting. RN E told CNA F that she was going to sit with Resident #3 until she passed because that is what she told the family she would be there. CNA F reported she checked on the resident and RN E about every half hour and once saw RN E laying her head down next to Resident #3 with face towards the resident who was COVID positive. Another time she looked into the room she saw RN E prop a phone up on the body of Resident #3 reviewing social media and videos. Around 4:00 a.m., RN E came out of Resident #3's room and went down the hall to the Green Room (a community room on the unit) where CNA F was. Before the resident passed, RN E told CNA F that she did not want the oncoming nurse to help Resident #3 because she was such a [OBSCENITY] and did not care. RN E said she knew Resident #3 was ready to die and told CNA F that she could get into trouble and lose her license and that what she is doing is negligent homicide. CNA F reported that when she looked in on Resident #3 during the night, she sometimes had her oxygen on and sometimes did not but was not alarmed because the nurse told her she wanted to see how Resident #3 was maintaining. The pulse ox was on the resident the whole time and did not think anything was wrong until after RN E went to the Green Room and had a conversation with CNA F about the negligent homicide conversation. When RN E came into the green room around 4:00 a.m., CNA F said 15 minutes later she went to do her rounds on her residents. At 4:20 a.m., she entered Resident #3's room and noticed the nasal canula was draped over the concentrator, the resident was still on her side and was unable to get a pulse ox reading. Then RN F came in and said, oh look she died with one eye open looking for me. RN F never went back into the room. CNA F reported the facility told her prior to this interview if this is substantiated, they could lose thousands of dollars. CNA F said she had been employed at the facility 4 months and they just started calling her references at the time of this investigation. In an interview on [DATE] at 9:17 a.m. Detective (DT) U reported the incident with Resident #3 is a death investigation and the report was not complete at this time. In an interview on [DATE] at approximately 10:30 a.m., LPN S reported she would not take oxygen off a resident that is ordered by a physician, and especially not if they are dying. During an observation and an interview on [DATE] at 11:00 a.m., this surveyor inquired to RN X about dressing changes that were to be done on her hall. When RN X specifically asked this surveyor who's dressing needed to be observed, this surveyor did not want to reveal at this time and wanted to know when the next dressing was to be done. RN X then threw her hands up in the air and stormed down the hall saying, I do not have time to play games and then entered a resident's room. This surveyor reported it to the DON and at that time RN X entered the office raising her voice and talking in circles overpowering the conversation. In an interview on [DATE] at 11:15 a.m., RN E is working this day at the facility and was in the DON's office. She reported she has an attorney and is not sure if she can talk to this surveyor at this time and is to let this surveyor know. In an interview on [DATE] at 12:02 p.m., the DON reported RN E's attorney will not let her talk to this surveyor without their presence but is willing to talk via zoom or in person at their site. In an interview on [DATE] at 3:43 p.m., RN E reported her nursing documentation on residents has been poor but is getting better at it and that this surveyor will not find that she put oxygen on Resident #3 in the charting. There are standing house orders though and the physician signs the standing orders after looking at the patient. RN E felt she did not have enough training or good training with the nurses she was paired up with. She remembered being the only nurse on the COVID unit and had 2 deaths and one fall in one night. A male resident was having a death rattle and sounded like he was ready to die and died at 9:04 p.m., then (Resident #3) was hanging upside down on her bed and was hanging off her bed like she was looking under her. RN E believes Resident #3 called out when RN E reported she asked the resident what she was doing when she lowered her and got her back into bed and started working on paper when the CNA came to tell her that another male resident (Resident #12) had low oxygen saturations and she told the CNA to put his oxygen back on. RN E reported how she kept finding Resident #12's oxygen off him and would remind him to keep it on. Then the CNA told her his oxygen levels were still very low, but she was in the middle of doing a tube feeding. Once RN E finished with the tube feeding, she went to Resident #12 and noticed he was at 2 liters and the CNA did not do it. So she turned the oxygen up to 5 liters and his oxygen saturations kept dropping. RN E reported she did not call the doctor when Resident #12's oxygen saturations were low. RN E reported she only had one CNA that night to a potential 19 residents and thinks there were ,d+[DATE] of those residents that were COVID positive. Staffing was hard because nobody wanted to work the COVID unit. RN E reported she worked 6 p.m. to 6 a.m. that next morning and did not do respiratory assessments, just looked at the vital signs and documents them. RN E reported she only listens to the resident's lungs if needed. RN E reported she gave Resident #12 his evening medications and had a great conversation, constantly reminded him to put on his oxygen, but did not expect him to go downhill. RN E reported she did not remember Resident #3 wearing oxygen that night she went in to see her and cannot remember is she put oxygen on her that night but remembered her hacking a lot. RN E reported she put a non-rebreather oxygen mask on her because her oxygen dropped when she hacked. RN E reported she put a non-rebreather on at 1 liter and her oxygen saturations came up to around 94% or so. RN E reported the non-rebreather was in a closet in someone's room and grabbed it and connected it to the oxygen concentrator. RN E reported the CNA that was working with her that night before 10:00 p.m. when the CNA observed Resident #3 trying to lean over to reach something in the window and maybe that is what she did. She just rolled like she was looking for monsters under the bed. The bed was low and RN E reported Resident #3's feet were tangled in the blankets that held the top half of her body on the bed. When queried what RN E did once she saw Resident #3 hanging over the bed dangling, she reported she slowly untangled her feet from the blankets while she was hanging over the side and fell to the floor. Once the resident was on the floor, the CNA came to help her get the resident back up. RN E reported she thinks the incident with Resident #3 happened around 9:30 p.m. RN E then reported she called Resident #3's daughter and told her their mom had a spider man fall but no injuries were noted. RN E reported Resident #3 did not have oxygen on when she put her back in bed at that time. RN E reported she put the non-rebreather oxygen mask on Resident #3 after her fall but could not say the specific time. RN E reported she could call her managers anytime if she needed or had concerns. When queried about the date Resident #3 died , RN E said she heard that Resident #3 was COVID positive and on hospice. Resident ## was not that responsive and kept her left eye closed, and could squeeze her hand if she held it, but did not talk at all. Resident #3 was on 8 liters of oxygen via nasal canula. RN E reported she was not in the room when Resident #3 died and was the first one to find her lying in bed on her side. She had like a yellow hue, which seems to happen with residents with COVID. RN E reported when she saw Resident #3, she was stiff and her chest was not moving and she just knew and called the time of death, then took off her oxygen tubing and turned off the concentrator. The CNA then walked in and asked if she was dead and RN E told her yes. RN E reported she was only in Resident #3's room the night she died for ,d+[DATE] minutes at a time. One time RN D held her hand and laid her head next to Resident #3 on the bed even though she knew she had COVID with her N95 mask and a personal protective equipment (PPE). RN E reported earlier that night she was passing medications and gave Resident #3 her [MEDICATION(S)] and [MEDICATION(S)] for secretions by crushing the [MEDICATION(S)] and mixing it with the [MEDICATION(S)] and water, then drew it up in a syringe and put it in her mouth slowly in the back of her cheek. RN E reported she signed the [MEDICATION(S)] out in the narcotic book but not the MAR and remembered she gave Resident #3 more than one dose that night. When queried about Hospice, RN E reported she did not know she needed to contact Hospice if there are significant changes because she is a new nurse but know now that if there is a huge change she needs to call. RN E reported 3 other nurses started working at the facility after her, but they are not float nurses like her and

This citation pertains to MI 589 and M 6435. Based on observation, interview, and record review, the facility failed to investigate and operationalize abuse policies and procedures when it was alleged two Residents (Resident #3 and Resident #12) passed away after alleged nursing misconduct, abuse and neglect (intentionally removing physician ordered oxygen for extended periods of time and over-medicating with narcotics) while under the care of a Registered Nurse (RN E) resulting in an Immediate Jeopardy (IJ) that began on [DATE] when a Certified Nurse Aide (CNA) and other licensed nursing staff aware of the situation failed to immediately investigate and report alleged abuse to facility administration and when local police detectives made the facility Administration aware of an open investigation into a report of suspicious circumstances surrounding the death of Resident #3 who passed away on [DATE] on [DATE]; and when it was discovered during the police investigation Resident #12 also passed away under similar suspicious circumstances while under the care of the same RN (RN E) on [DATE]. This deficient practice has the high likelihood to cause serious harm, serious injury and/or death for all 106 residents living at the facility. Findings include: Review of the facility Abuse Prevention Program last revised [DATE] revealed policies and procedures consistent 42 CFR Part 483, Requirements for Long Term Care Facilities for the screening, training, prevention, identification, investigation, protection, reporting and response following any alleged abuse, neglect, exploitation or misappropriation for residents living in a long-term care facility. Review of a Facility Reported Incident (FRI) dated [DATE] reflected the facility learned of an allegation of neglect of Resident #3 reported to the facility on [DATE]. Certified Nursing Assistant (CNA) F alleged Registered Nurse (RN) E removed Resident #3's oxygen on [DATE] causing her to expire sooner than she may have done naturally. CNA F reported the incident to Detective (DT) U at the police department prior to informing the facility on [DATE]. Details in the FRI indicated RN E admitted to unplugging the oxygen tubing from the oxygen concentrator to complete a nursing assessment for approximately 10 minutes. The FRI indicated the facility was unable to substantiate the allegation (of abuse) based on the fact that CNA F and RN E were on the COVID Unit and there were no other employees on the unit. The facility was unable to substantiate that actions by the nurse contributed to the resident's death. Review of a [Local Police Department] Field Case Report, Case# ,d+[DATE] dated [DATE], reflected that on [DATE] an associate of Certified Nurse Aide (CNA) F emailed the public safety department to report that CNA F sent a text message the night before, saying I saw a person end a life and this is the second time. The report indicated CNA F alleged RN E had removed physician ordered oxygen from two residents (Resident #3 and Resident #12) and had given more narcotics than was ordered for one resident (Resident #3) possibly hastening their deaths. The interviews documented in the report included an admission from RN E that she had removed oxygen from Resident #3 and reflected multiple licensed nurses and CNA staff corroborated CNA F's claims and were aware of RN E's alleged abuse and misconduct perpetuated against Resident #3 and Resident #12 days before the local public safety detective made contact with the facility on [DATE]. Review of RN E's employee file reflected a Performance Improvement Form dated [DATE]. RN E had been issued a Counseling/Corrective Action that revealed During (an) investigation of (an) allegation, there were a few areas of opportunity identified for improvement, including documentation of assessment, changes of condition, and medication administration, and oxygen administration. Review of RN E's timecard revealed she was suspended on [DATE] and returned to work on [DATE]. RN E worked 13 shifts between [DATE] and [DATE]. During an interview on [DATE] at 10:10 AM, the Nursing Home Administrator (NHA) said a Facility Reported Incident (FRI) was not submitted to the State Agency regarding Resident #12's death because they did not feel an allegation had been made to warrant a FRI. Resident #12 Review of the Electronic Medical Record (EMR) revealed Resident #12 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 died in the facility on [DATE]. Review of a Progress Note documented by Registered Nurse (RN) E dated [DATE] at 2:02 AM reflected approx. 12:30am a CNA (Certified Nurse Aide) came to me and told me [Resident #12's] O2 (oxygen) saturation was 47% with oxygen on and at 5L (liters per minute). [Resident #12] was unresponsive in his bed with declining vitals. I called family to update them, no answer. The family called after the resident passed away. Time of death was 12:52am. Dr ordered body to be released. [Funeral home] was called at approx. 1:30am Review of transcripts from interviews conducted at the facility after it became aware of the open police investigation into alleged abuse/neglect and misconduct obtained from the facility reported incident investigation file revealed the following: CNA F: reported: -On [DATE] at 2:30 p.m. CNA F started working on the COVID unit at 10:00 p.m. on ([DATE]-[DATE]) and around 10:30 p.m. she noticed Resident #3 had respirations between ,d+[DATE] per minute (normal is ,d+[DATE] breaths per minute) and RN E told her she expected the resident to pass this night and she stayed with Resident #3 through the night even though she had too much to do. CNA F popped in and out of the room throughout the night and RN E stayed in the room until the resident passed away. RN E was noted to be in Resident #3's room from 10:30 p.m. until 4:30 a.m. CNA F reported Resident #3's door was closed but not shut and the curtain was pulled with the bed light on. -RN E told CNA F she took Resident #3's oxygen off several times and (Resident #3) was maintaining. The lowest oxygen saturation CNA F noticed (on Resident #3) was 76%. After the first rounds, RN E came out of the room to medicate with Roxinol ([MEDICATION(S)]) and gave Roxinol, (pics were sent via text at 12:30 a.m.) and the oxygen saturations were 65% and 76%. -RN E told CNA F she gave the resident more [MEDICATION(S)] than she needed but no one would notice because more is in the bottle than should be. -RN E told CNA F that she didn't want Resident #3 to pass away on the next shift because that nurse was a [OBSCENITY] and wanted her to pass with people who cared for her. -CNA F reported she went to Resident #3's room and with her phone propped on (Resident #3) watching YouTube videos with one hand holding the resident's hand and her face in the resident's face. At 4:00 a.m., RN E left the resident's room and went to the Green Room (a community room down the hall). -CNA F reported she went to Resident #3's room and the resident had no oxygen on and (the tubing) was laying on top of the concentrator and the concentrator was on, and the oxygen saturation monitor was not on her finger, and Resident #3 had passed. -CNA F reported she went to tell RN E about Resident #3's passing. -The investigation statements also indicated that CNA F reported to facility administration that RN E and another CNA removed oxygen from Resident #12 so he would pass. According to another statement included in the facility investigation related to the allegation made by CNA F about RN E's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -On [DATE], RN E reported she passed medications to Resident #3 at 9:30 p.m. and mixed a medication for secretions with [MEDICATION(S)] at 10:00 p.m. and assessed the resident. Resident #3 was awake, right eye open, right hand good grip, no verbalization, VS (vital signs assessed), HR (heart rate) within normal limits, oxygen saturations ,d+[DATE]% on 8 liters, respirations within normal limits. -RN E assumed 8 liters was ordered and unplugged the oxygen tubing by disconnecting it from the concentrator for 10 minutes and sat there the entire time and said there was no gasping or change of condition, then plugged the oxygen back in before leaving the room. The facility asked why RN E didn't document the insufficient oxygen and Resident #3's response and the documented response was she didn't know why and wanted to question the doctor if Resident #3 needed to be on it. -RN E reported CNA F walked into the room to relay a message to the nurse and noticed the oxygen was unplugged and RN E reported she plugged the oxygen back in and left the room. The facility asked if she documented the events and RN E said no and didn't know why. -RN E reported she sat with Resident #3 at 12:20 a.m. and passed midnight medications. RN E checked on Resident #3 (,d+[DATE]= )10 times (peek, assess) and 5 minutes at a time tops. -At 3:45 a.m. RN E reported breathing and oxygen saturations were up and down constantly and at 12:07 a.m., the resident had oxygen saturations of 65% and a pulse of 47 and she called her daughter. -At 12:29 a.m. the resident was at 76% oxygen saturations and pulse of 99. At 3:45 a.m. oxygen saturations were ,d+[DATE]%. The facility asked her if she called hospice and she said no. At 4:20 a.m., she opened the door, cracked open, curtain pulled back and she (Resident #3) had passed away. The facility investigation revealed that on [DATE] 12:00 p.m., Licensed Practical Nurse (LPN) RR reported the following: -CNA F told her on [DATE] she had concerns with Resident #3's oxygen prior to her death. -LPN RR told CNA F she needed to report it (her concerns with RN E's conduct regarding Resident #3) and if she didn't, then LPN RR would. -On [DATE] LPN RR asked CNA F if she reported the situation yet and CNA FF said she did not but I will. -LPN RR reported she did not know who RN E was. Review of an interview documented by the facility on [DATE] at 12:00 p.m. revealed RN KK reported the following: -RN KK reported she received a text message on [DATE] from RN E at 12:10 a.m. that said Resident #3 was going to pass, currently waiting at bedside for it, 65% pulse ox (oxygen saturations) - We're close (text message sent at 12:07 indicating Resident #3's pulse ox was at 76%), she is fighting, she won't stop. At 12:40 a.m., RN KK texted she sure is, pulse doubled also. RN E texted yes, she won't stop. The facility investigation reflected that On [DATE], CNA QQ reported the following: -CNA F told her that RN E was in Resident #3's room for 3 hours the night she passed and was messing with the resident's oxygen and told her the resident had oxygen saturations of 76%, which is low. -CNA QQ said CNA F told her that RN E said she was removing oxygen so she would pass while RN E was there because she didn't want her (Resident #3) to pass with RN O because she didn't think RN O cares (about) residents. On [DATE] at 11:30 the facility investigation revealed RN O reported the following: -RN O took report from RN E that morning ([DATE]) and RN E was frazzled and stated she sat in the room with Resident #3 when she had time, so she was not alone and left the room to pass medications and that was when Resident #3 passed. -RN O took care of that resident the day before and reported Resident #3 was alert and oriented throughout her shift and her vital signs were pretty stable, nothing alarming, no need to call doc (doctor). RN O reported she worked as an aide on the same unit ([DATE]) after her shift until 8:30 -9:00 p.m. and Resident #3 did not have any difficulty breathing. During an interview on [DATE] at 9:56 a.m., the Regional Nurse Consultant (RC) M, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported CNA F came to administration 7 days after the incident (on [DATE]) with Resident#3 but had told other staff about it before hand and felt it was just a she said, she said incident. RC M reported she spent a lot of time on this reported incident and felt CNA F does not usually come forth to Administration with concerns and instead talks about problems with staff and thinks she tells everyone else in the facility about things instead of reporting alleged abuse/neglect. RC M said that during their investigation RN E told them she did take off the oxygen off Resident #3 only once and put it back on. RC M reported RN E was a new nurse and who provided compassionate care for her residents and during the care of Resident #3 (on [DATE]), she contacted LPN KK for support. RN E changed her story about the resident's oxygen being on or off and found there is even discrepancies on who found Resident #3 dead. Resident #3 had been in and out of the hospital 4 times since admission. RC M indicated both RN E and CNA F kept changing their story. The facility reported they re-educated RN E and gave redirection and verbal counseling to CNA F. The facility reported they re-educated staff on several things including abuse and oxygen. The facility reported RN E has a lawyer now and may not talk to this surveyor without the attorney present and would not allow the attorney at the facility. RN E is still employed and actively working at the facility. During an interview on [DATE] at 3:00 p.m., CNA F reported the night of [DATE] was her second time working with RN E. CNA F reported she did not tell the management about her concerns with Resident #3 and RN E because people get in trouble and they (facility administration) don't' do anything. CNA F said the night started out normal and she started taking vital signs around 10:30 p.m. Resident #3 was laying on her side facing the doorway with oxygen on but not sure how many liters and her saturations were low around 80% (normal is ,d+[DATE]%) and respiratory rate was around 30 breaths per minute (normal is ,d+[DATE]). CNA F went to tell RN E who said the resident was actively passing, so CNA F reported that is what she was expecting. RN E told CNA F that she was going to sit with Resident #3 until she passed because that is what she told the family. CNA F reported she checked on the resident and RN E about every half hour and once saw RN E laying her head down next to Resident #3 with face towards the resident who was COVID positive. Another time she (CNA F) looked into the room she saw RN E had propped a phone up on the body of Resident #3 reviewing social media and watching videos. CNA F reported that at around 4:00 a.m., RN E came out of Resident #3's room and went down the hall to the Green Room (a community room on the unit) where CNA F was. Before the resident passed, RN E told CNA F that she didn't want the oncoming nurse to help Resident #3 because she was such a [OBSCENITY] and didn't care. CNA F reported RN E said she knew Resident #3 was ready to die and told CNA F that she could get into trouble and lose her license and that what she is doing is negligent homicide. CNA F reported that when she looked in on Resident #3 during the night, she sometimes had her oxygen on and sometimes did not but was not alarmed because the nurse told her she wanted to see how Resident #3 was maintaining. The pulse ox was on the resident the whole time and didn't think anything was wrong until after RN E went to the Green Room and had a conversation with CNA F about the negligent homicide. When RN E came into the green room around 4:00 a.m., CNA F said 15 minutes later (at 4:15 a.m.) she went to do her rounds on her residents. At 4:20 a.m., she entered Resident #3's room and noticed the nasal canula was draped over the concentrator, the resident was still on her side and was unable to get a pulse ox reading. According to CNA F, when RN E came into the room she said, Oh look she died with one eye open looking for me. CNA F reported RN E never went back into the room after Resident #3 died . CNA F reported the facility told her prior to this interview if this is substantiated, they could lose thousands of dollars. CNA F said she had been employed at the facility 4 months and they just started calling her references at the time of this investigation. During an interview on [DATE] at approximately 10:30 a.m., LPN S reported she would not take oxygen off a resident that is ordered by a physician, and especially not if they are dying. During an interview on [DATE] at 12:02 p.m., the DON reported RN E's attorney will not let her talk to this surveyor without their presence but is willing to talk via zoom or in person at their site. During an interview on [DATE] at 3:43 p.m., RN E reported her nursing documentation on residents has been poor, but she is getting better at it and that this surveyor will not find that she put oxygen on Resident #3 in the charting. There are standing house orders though, and the physician signs the standing orders after looking at the patient. RN E felt she did not have enough training or good training with the nurses she oriented with. She remembered being the only nurse on the COVID unit (on [DATE]) and had 2 deaths and one fall in one night. A male resident was having a death rattle and sounded like he was ready to die and died at 9:04 p.m., then (Resident #3) was hanging upside down on her bed and was hanging off her bed like she was looking under her. RN E believes Resident #3 called out (on [DATE]) when RN E reported she asked the resident what she was doing when she lowered her and got her back into bed and started working on paperwork when the CNA came to tell her that another male resident (Resident #12) had low oxygen saturations and she told the CNA to put his oxygen back on. When asked about Resident #12, RN E reported how she kept finding Resident #12's oxygen off him and would remind him to keep it on. Then the CNA told her his oxygen levels were still very low, but she was in the middle of doing a tube feeding. Once RN E finished with the tube feeding, she went to Resident #12 and noticed he was at 2 liters of oxygen and the CNA did not do it, so she turned the oxygen up to 5 liters and his oxygen saturations kept dropping. RN E reported she did not call the doctor when Resident #12's oxygen saturations were low. RN E reported she only had one CNA that night to a potential 19 residents and thinks there were ,d+[DATE] of those residents that were COVID positive. Staffing was hard because nobody wanted to work the COVID unit. RN E reported she worked 6 p.m. to 6 a.m. that next morning and did not do respiratory assessments, just looked at the vital signs and documents them. RN E reported she only listens to the resident's lungs if needed. RN E reported she gave Resident #12 his evening medications and had a great conversation, constantly reminded him to put on his oxygen, but did not expect him to go downhill. RN E reported she did not remember Resident #3 wearing oxygen that night she went in to see her and cannot remember if she put oxygen on her that night ([DATE]) but remembered her hacking a lot. RN E reported she put a non-rebreather oxygen mask on her because her oxygen dropped when she hacked. RN E reported she put a non-rebreather on with 1 liter of oxygen running into the mask and the resident's oxygen saturations came up to around 94% or so. RN E reported the non-rebreather was in a closet in someone's room and grabbed it and connected it to the oxygen concentrator. RN E reported the CNA that was working with her that night before 10:00 p.m. when the CNA observed Resident #3 trying to lean over to reach something in the window thought maybe that is what she did. She just rolled like she was looking for monsters under the bed. The bed was low and RN E reported Resident #3's feet were tangled in the blankets that held the top half of her body on the bed. When queried what RN E did once she saw Resident #3 hanging over the bed dangling, she reported she slowly untangled her feet from the blankets while she was hanging over the side and fell to the floor. Once the resident was on the floor, the CNA came to help her get the resident back up. RN E reported she thinks the incident with Resident #3 happened around 9:30 p.m. RN E then reported she called Resident #3's daughter and told her their mom had a spider man fall but no injuries were noted. RN E reported Resident #3 did not have oxygen on when she put her back in bed at that time. RN E reported she put the non-rebreather oxygen mask on Resident #3 after her fall but could not say the specific time. RN E reported she could call her managers anytime if she needed or had concerns. When queried about the date Resident #3 died , RN E said she heard that Resident #3 was COVID positive and on hospice. Resident #3 was not that responsive and kept her left eye closed, and could squeeze her hand if she held it, but did not talk at all. Resident #3 was on 8 liters of oxygen via nasal canula. RN E reported she was not in the room when Resident #3 died and was the first one to find her lying in bed on her side. She had like a yellow hue, which seems to happen with residents with COVID. RN E reported when she saw Resident #3, she was stiff and her chest was not moving and she just knew and called the time of death, then took off her oxygen tubing and turned off the concentrator. The CNA then walked in and asked if she was dead and RN E told her yes. RN E reported she was only in Resident #3's room the night she died for ,d+[DATE] minutes at a time. One time RN E held her hand and laid her head next to Resident #3 on the bed even though she knew she had COVID with her N95 mask and a personal protective equipment (PPE) on. RN E reported earlier that night she was passing medications and gave Resident #3 her [MEDICATION(S)] and [MEDICATION(S)] for secretions by crushing the [MEDICATION(S)] and mixing it with the [MEDICATION(S)] and water, then drew it up in a syringe and put it in her mouth slowly in the back of her cheek. RN E reported she signed the [MEDICATION(S)] out in the narcotic book but did not document the administration in the MAR (Medication Administration Record) and remembered she gave Resident #3 more than one dose that night. When queried about Hospice, RN E reported she did not know she needed to contact Hospice if there are significant changes because she is a new nurse but know now that if there is a huge change she needs to call. RN E reported 3 other nurses started working at the facility after her, but they are not float nurses like her and had different training. RN E reported at one point there were not enough aides to help and it was stressful and a lot of mandated hours that nurses complained about. In a second interview on [DATE] at 11:42 a.m., RN E denied being in the room with Resident #3 for more than ,d+[DATE] minutes at a time. RN E said she broke HIPAA (Health Insurance Portability and Accountability Act) by having her phone in the room and texting her pulse oximeter pictures to RN KK. RN E reported Resident #3 was on 8L nasal canula and had orders for ,d+[DATE] liters nasal canula but is not sure who gave the orders. RN E reported she did take off the oxygen from Resident #3 to get a baseline oxygen saturation and tried to get her on room air for about ,d+[DATE] minutes and felt it was a mistake but was at her bedside the whole time. The ,d+[DATE] liters of oxygen gave Resident #3 an oxygen saturation of 86%, but when she removed the oxygen the resident oxygen saturations stayed at 86% and felt she could have turned her down to 6L but kept her at 8 L. RN E reported that during report at shift change, she heard Resident #3 was on 8L of oxygen and felt she could probably come down but now knows she needs orders to titrate the oxygen on a resident and has since received education. RN E reported she also was written up for poor documentation and felt she learned a lot from this situation. When queried about using the non-rebreather oxygen mask on Resident #3 the week prior, RN E reported that was all the facility had at the time, and there were no extra nasal cannulas available, and Resident #3 remained on the non-rebreather until the next day when the day shift arrived. RN E reported the bag did not inflate at first but then pulled it apart and heard the air blowing and the bag blew up (inflated with air). RN E had the CNA get oxygen supplies but brought back several supplies like the non-rebreather and nebulizers. When queried about combining [MEDICATION(S)] and [MEDICATION(S)] together for Resident #3, RN E reported she had asked a Hospice nurse before who told her she can crush the pill and add [MEDICATION(S)] and a dash of water for residents who cannot swallow, every nurse does that. RN E reported that around midnight, Resident #3 was different in her breathing and was heavier with her oxygen and was starting to decline a little more. RN E reported she called her daughters and encouraged them to talk to their mom. The resident was on her right side and RN E said she laid the phone next to her ear so she could hear them and opened her eyes a little bit. In an interview on [DATE] at 1:13 p.m., the Hospice Nurse (HN) DD reported she expects the facility to reach out to them if a hospice resident is in pain, has shortness of breath, or is unresponsive. HN DD reported she saw Resident #3 on [DATE] and could not tell she was declining but did talk to her and she made sense. There was no indication the resident was going to die this day and did remember she was on oxygen via nasal canula but did not remember how much oxygen. HN DD reported she does not tell staff to mix [MEDICATION(S)] with [MEDICATION(S)] tablets together to administer to the residents. HN DD reported she was not notified of any concerns or changes in condition until [DATE] at 4:20 a.m. when the resident had died . In an interview on [DATE] at 3:24 p.m., the facility Nursing Educator (RN) H reported RN E had a new staff training on [DATE] and again for their skills fair on [DATE]. RN H reported there are wound care books at the nurse's station. RN H reported she tells nurses they need a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She does review what hospice protocols with new staff and what they are to do for residents on hospice. In an interview on [DATE] at 2:09 p.m., the Nurse Practitioner (NP) JJ reported that a resident who needs oxygen via nasal cannula typically does not have oxygen above 5 liters, but certain circumstances they may need ,d+[DATE] liters such as end of life care. NP JJ reported that a non-rebreather is not used often but utilized it occasionally. It is not appropriate to remove the oxygen from a resident who is on ,d+[DATE] liters to nothing but room air. It is a drastic change and the appropriate thing to do is to wean the resident down off the oxygen slowly. If oxygen order changes are needed, NP JJ would expect the nurse to call the physician or if the resident is on hospice, then they are to contact hospice. If a resident needed to use a non-rebreather, then an oxygen tank could be used short term, but a concentrator should not be used at all. In an interview on [DATE] at 2:40 p.m., RN O reported when she charts oxygen saturations in the computer, there is no place to document how many liters of oxygen a resident is on. RN O reported the facility has standing orders for all residents and the standing orders include oxygen administration and provided this surveyor with a copy. In an interview on [DATE] at approximately 2:45 p.m., the DON denies the facility utilizing standing orders and said they do not exist. In an interview on [DATE] at 2:55 p.m., RN KK reported she is a newer nurse and remembered Resident #3 was declining and called hospice to let them know her oxygen saturations were declining, and hospice had her increase the oxygen to ,d+[DATE] liters. RN KK reported when Resident #3 was admitted to the facility, she was on 2 liters nasal canula and had always had at least 2 liters on. RN KK reported if this resident were rapidly declining, she would have reached out to hospice and learned she needed to do that in nursing school and during the new hire orientation. RN KK is not sure about how much about the use of a non-rebreather oxygen mask but if she needed to use one, she would reach out to someone for more guidance. She would not completely remove oxygen from a resident to get a baseline reading. When queried about RN E sending her texts of Resident #3's oxygen levels, RN KK reported she remembered the oxygen levels were in the 70's and that RN E may have been a little nervous because she had 2 deaths on a previous shift. RN KK reported that RN E sent another message later to her that said the resident was still fighting and her oxygen saturations were slightly up. RN KK reported she did not work with that resident the day she died . In an interview and record review on [DATE] at 3:20 p.m., the DON reported Resident #3 did have a 30 milliliter (ml) multidose bottle of [MEDICATION(S)] prescribed to her, but when she died , the left-over [MEDICATION(S)] in the bottle was destroyed and verified with another nurse. There were 29 milliliters left in the bottle when it was destroyed. The DON provided this surveyor with the narcotic log. The narcotic log for Resident #3 revealed [MEDICATION(S)] 20 MG (milligrams)/1ML concentrate, take 0.25 ML by mouth every 2 hours if needed for severe pain. Resident #3 received 4 total doses administered and the last two doses documented by RN E revealed 11:00 p.m. on [DATE] and the last dose on [DATE] at 2 a.m. Resident #3 Review of a Face Sheet revealed Resident #3 is a [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was diagnosed with COVID-19 on [DATE]. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility, transfers, and toileting. Resident #3 had limited range of motion (ROM) impairment on one side of her upper and lower extremities, at risk for pressure ulcers, none upon admission. Review of Hospital Discharge Summary to the facility dated [DATE] for Resident #3 revealed she had oxygen saturations of ,d+[DATE]% on room air. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #3 revealed no assessment of the resident's respiratory status and one plan for the resident revealed: Standing order sheet signed. Review of Standing Orders signed by the Physician on [DATE] for Resident #3 revealed: Skin issue-skin tear, abrasion, minor laceration - see wound protocol - Barrier cream for excoriation, Stage I wounds. Oxygen- ,d+[DATE] liters per nasal cannula for oxygen saturation below 88% until physician can be contacted for further orders. Review of handwritten orders dated [DATE] for Resident #3 revealed admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3 revealed no orders for oxygen administration until [DATE] for ,d+[DATE] liters via nasal canula and oxygen monitoring every shift ordered [DATE] and no documentation noted. Standing orders not noted on the MAR. [MEDICATION(S)] Sulfate Solution 10 mg/ml (milligrams/milliliter) ordered, give 0.25 ml by mouth every 2 hours as needed for pain/dyspnea, start [DATE] and discontinued on [DATE]. Resident #3 has 3 doses documented on [DATE] only, one of those doses documente [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure nursing staff (Registered Nurse (RN) E, RN H, Director of Nursing (DON)) were trained, competent, and could effectively conduct and fulfill their assigned duties in a manner consistent with the facility's job description and standards of practice for four residents (Resident #12, Resident #3, Resident #8, Resident #2), resulting in substandard care from staff, either by direct care, ineffective training, or by the lack of supervisory proficiency to ensure competent care of a vulnerable population. Findings: On [DATE] at approximately 10:10 AM interview was completed with training supervisor Registered Nurse (RN) H regarding training protocols for new staff. RNH stated that orientation with her would usually take 2 days and they would go through a competency checklist and typically would go over some items on day one, review what was learned on day two and complete the checklist and sign everything the next day. RN H stated the training would consist of discussing topics and demonstrating competencies on each other or on a mannequin. Staff would then complete ,d+[DATE] shifts with another nurse before being on the floor on their own. The checklist for RN E was reviewed with RN H and it was noted to RN H that there were a significant number of items that were included encompassing general organizational topics, documentation, abuse and neglect, medication administration and time-consuming care topics such as wound care, [CONDITION(S)] care, and other skilled nursing care procedures (97 topics). RN H reiterated it was a 2-day process and they do go over every item. Review of RN E's orientation checklist revealed every item was signed on [DATE], RN H stated they would have started RN E's training on [DATE] and signed the second day. Annual competency checklists were also reviewed with RN H. RN H stated annual competency training is a day long process and staff rotate through different stations to cover different sections of the checklist. Review of RN E's employee file as well as facility provided staff list revealed a hire date as [DATE]. RN E had not previously worked in a long-term care facility or worked as a nurse post degree per the resume. A review of RN E's orientation checklist revealed ninety-seven (97) different areas of competency were evaluated and marked as completed on [DATE] under the column Review/Demonstration Date and initialed by RN H and RN E. A review of RN E's Annual Competency Checklist revealed ninety-seven (97) competency items were dated for [DATE] under the column Review/Demonstration Date. In an interview on [DATE] at 3:43 p.m., RN E reported her nursing documentation on residents has been poor but is getting better at it and that this surveyor will not find that she put oxygen on Resident #3 in the charting. There are standing house orders though and the physician signs the standing orders after looking at the patient. RN E felt she did not have enough training or good training with the nurses she was paired up with. She remembered being the only nurse on the COVID unit and had 2 deaths and one fall in one night. A male resident was having a death rattle and sounded like he was ready to die and died at 9:04 p.m., then (Resident #3) was hanging upside down on her bed and was hanging off her bed like she was looking under her. RN E believes Resident #3 called out when RN E reported she asked the resident what she was doing when she lowered her and got her back into bed and started working on paper when the CNA came to tell her that another male resident (Resident #12) had low oxygen saturations and she told the CNA to put his oxygen back on. RN E reported how she kept finding Resident #12's oxygen off him and would remind him to keep it on. Then the CNA told her his oxygen levels were still very low, but she was in the middle of doing a tube feeding. Once RN E finished with the tube feeding, she went to Resident #12 and noticed he was at 2 liters and the CNA did not do it. So, she turned the oxygen up to 5 liters and his oxygen saturations kept dropping. RN E reported she did not call the doctor when Resident #12's oxygen saturations were low. In the same interview, RN E reported she only had one CNA that night to a potential 19 residents and thinks there were ,d+[DATE] of those residents that were COVID positive. RN E reported staffing was hard because nobody wanted to work the COVID unit. RN E reported she worked 6 p.m. to 6 a.m. that next morning and did not do respiratory assessments, just looked at the vital signs and documents them. RN E reported she only listens to the resident's lungs if needed. RN E reported she gave Resident #12 his evening medications and had a great conversation, constantly reminded him to put on his oxygen, but did not expect him to go downhill. RN E reported she did not remember Resident #3 wearing oxygen that night she went in to see her and cannot remember if she put oxygen on her that night but remembered her hacking a lot. RN E reported she put a non-rebreather oxygen mask on her because her oxygen dropped when she hacked. RN E reported she put a non-rebreather on with 1 liter of oxygen running into the mask and the resident's oxygen saturations came up to around 94% or so. RN E reported the non-rebreather was in a closet in someone's room and grabbed it and connected it to the oxygen concentrator. RN E reported the CNA that was working with her that night before 10:00 p.m. when the CNA observed Resident #3 trying to lean over to reach something in the window and maybe that is what she did. She just rolled like she was looking for monsters under the bed. The bed was low and RN E reported Resident #3's feet were tangled in the blankets that held the top half of her body on the bed. When queried what RN E did once she saw Resident #3 hanging over the bed dangling, she reported she slowly untangled her feet from the blankets while she was hanging over the side and fell to the floor. Once the resident was on the floor, the CNA came to help her get the resident back up. RN E reported she thinks the incident with Resident #3 happened around 9:30 p.m. RN E then reported she called Resident #3's daughter and told her their mom had a spider man fall but no injuries were noted. RN E reported Resident #3 did not have oxygen on when she put her back in bed at that time. RN E reported she put the non-rebreather oxygen mask on Resident #3 after her fall but could not say the specific time. RN E reported she could call her managers anytime if she needed or had concerns. When queried about the date Resident #3 died during the same interview, RN E said she heard that Resident #3 was COVID positive and on hospice. Resident #3 was not that responsive and kept her left eye closed, and could squeeze her hand if she held it, but did not talk at all. Resident #3 was on 8 liters of oxygen via nasal canula. RN E reported she was not in the room when Resident #3 died and was the first one to find her lying in bed on her side. She had like a yellow hue, which seems to happen with residents with COVID. RN E reported when she saw Resident #3, she was stiff and her chest was not moving and she just knew and called the time of death, then took off her oxygen tubing and turned off the concentrator. The CNA then walked in and asked if she was dead and RN E told her yes. RN E reported she was only in Resident #3's room the night she died for ,d+[DATE] minutes at a time. One time RN D held her hand and laid her head next to Resident #3 on the bed even though she knew she had COVID with her N95 mask and a personal protective equipment (PPE). RN E reported earlier that night she was passing medications and gave Resident #3 her [MEDICATION(S)] and [MEDICATION(S)] for secretions by crushing the [MEDICATION(S)] and mixing it with the [MEDICATION(S)] and water, then drew it up in a syringe and put it in her mouth slowly in the back of her cheek. RN E reported she signed the [MEDICATION(S)] out in the narcotic book but did not document the administration in the MAR (Medication Administration Record) and remembered she gave Resident #3 more than one dose that night. When queried about Hospice, RN E reported she did not know she needed to contact Hospice if there are significant changes because she is a new nurse but know now that if there is a huge change she needs to call. RN E reported 3 other nurses started working at the facility after her, but they are not float nurses like her and had different training. RN E reported at one point there were not enough aides to help and it was stressful and a lot of mandated hours that nurses complained about. In an interview conducted [DATE] at 3:28 PM the Director of Nursing (DON) reported the facility does not have Standing Orders. Resident #12 Review of face sheet and electronic medical record (EMR) for Resident #12 revealed he had admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 died in the facility on [DATE]. Per review of resident #12's progress notes on their EMR, a note was entered on [DATE] at 2:02 AM by RN E: approx. 12:30am a CNA came to me and told me [Resident #12]'s O2 saturation was 47% with oxygen on and at 5L (liters per minute). [Resident #12] was unresponsive in his bed with declining vitals. I called family to update them, no answer. The family called after the resident passed away. Time of death was 12:52am. Dr ordered body to be released. [Funeral home] was called at approx. 1:30am In an interview on [DATE] at 3:24 p.m., the facility Nursing Educator (RN) H reported RN E had a new staff training on [DATE] and again for their skills fair on [DATE]. RN H reported there are wound care books at the nurse's station. RN H reported she tells nurses they need a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She does review what hospice protocols with new staff and what they are to do for residents on hospice. Resident #12 Resident #3 Review of a Face Sheet revealed Resident #3 is a [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . COVID diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Standing Orders signed by the Physician on [DATE] for Resident #3 revealed: . Oxygen- ,d+[DATE] liters per nasal cannula for oxygen saturation below 88% until physician can be contacted for further orders. Review of handwritten orders dated [DATE] for Resident #3 revealed admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3 revealed no orders for oxygen administration until [DATE] for ,d+[DATE] liters via nasal canula and oxygen monitoring every shift ordered [DATE] and no documentation noted. Standing orders not noted on the MAR. [MEDICATION(S)] Sulfate Solution 10 mg/ml (milligrams/milliliter) ordered, give 0.25 ml by mouth every 2 hours as needed for pain/dyspnea, start [DATE] and discontinued on [DATE]. Resident #3 has 3 doses documented on [DATE] only, one of those doses documented by RN E at 10:19 p.m. with a documented pain level of 0. [MEDICATION(S)] Sulfate Tablet sublingual 0.125 mg, give 1 application sublingually every 4 hours as needed for secretions, start date [DATE] and discontinued on [DATE], 2 total doses documented on [DATE] and the last dose documented as given at 4:34 p.m. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3, which is contradictory to the residents' order summary revealed an order to cleanse coccyx with normal saline, pat dry, apply skin prep around wound, apply border foam dressing to pressure area for protection every day shift for coccyx stage 1 (pressure ulcer) not put into the computer until [DATE] and resident #3 did not receive any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Admission Evaluation dated [DATE] for Resident #3 revealed no pressure ulcer on coccyx noted and the left second and third toes had black areas documented. Review of the Hospice Patient Care Plan for Resident #3 revealed on [DATE] at 12:00 a.m., Resident #3 had a wound measurement of 7.6 x 4.2 and to Establish skin care/wound care regimen. Review of a Care Plan for Resident #3 revealed no care plan for pressure ulcers and/or prevention. Resident #8 Review of a Face Sheet revealed Resident #8 is a [AGE] year-old male admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and an interview on [DATE] at 1:29 p.m., RN E in the room with Resident #8 for dressing change. She placed a cloth towel over the bedside table and placed dressing supplies on top. RN E left the room and grabbed 2 trash bags and hand sanitized before re-entering the room. Opened all the supplies and put on gloves. This resident had a wound on his right hip and RN E proceeded to remove the old dressing that was packed. RN E washed her hands and changed her gloves and took the 4X4 gauze and wet it with normal saline and dabbed the wound in the middle with it and then cleaned the surrounding area, then used a dry gauze and repeated the motions. Then pulled the string of [MEDICATION(S)] out of the bottle by hand with the same gloves and cut a piece off with her scissors and proceeded to pack the wound with the [MEDICATION(S)] and her gloved finger, then placed a border foam dressing over the area. The wound on the right hip was approximately dime sized with some depth and the surrounding tissue was red. RN E proceeded to remove the left hip dressing that had a greenish/tan drainage noted. The wound is not round and about a quarter size in width with a large are of redness surrounding the wound. RN E used gauze with normal saline to wipe across the open area and around it then changed her gloves. A collagen powder packet was opened and sprinkled on the area of the wound and used gloved hands to push the collagen from the surrounding skin into the wound then placed a border foam dressing on it. RN E then removed her gloves and washed her hands. No hand hygiene done during the dressing change when gloves were removed. In an interview on [DATE] at 3:31 p.m., RN E reported she did not have a cotton swab to pack Resident #8's wound with [MEDICATION(S)] because it was not available at that moment. RN E reported that the collagen powder is supposed to be in the wound and had not applied it before. When questioning the technique of pushing the powder from the surrounding skin into the wound, RN E reported she could see why that could be a problem, RN E did not see any concern with pushing [MEDICATION(S)] into the wound with a gloved finger. In an interview on [DATE] at 11:03 a.m., the Director of Nursing (DON) reported she did not consider using a wet/dry gauze with normal saline and wiping over a pressure wound to be considered [MEDICATION(S)]. The DON did expect nurses to do hand hygiene when changing gloves during a dressing change going from dirty to clean. When questioned about packing a wound with [MEDICATION(S)] for Resident #8, the DON said he had a 2 cm (centimeter) underway (tunneling). When asked if using a gloved finger to pack a wound with tunneling is appropriate, the DON shrugged her shoulder and looked up then said she personally would use a cotton swab. The DON reported the collagen powder for wounds should be sprinkled into the wound bed, and if it scattered outside the wound, the DON reported she would just wipe the excess away, however, is the surrounding area was just cleansed, pushing the collagen powder into the wound from the surrounding skin would have less potential for an infection. Resident #2 Resident #2 was admitted to the facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #2 dated [DATE], Section O (0100), reflected the Resident required oxygen therapy prior to admission to the facility and while a resident at the facility. The documentation of this section indicated that Resident #2 did not require the use of a Continuous Positive Airway Pressure device (([CONDITION(S)]) a device used to assist with breathing when asleep for those with a diagnosed sleep disorder) prior to admission or during the admission at the facility. Review of the Electronic Medical Record (EMR) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #2 is on oxygen continuously. The Physician's documentation also reflected that Resident #2 was, positive for apnea (obstructive sleep apnea with [CONDITION(S)]. Uses this nightly). Review of the Doctor's Orders for Resident #2 reflected an order initiated [DATE] for oxygen run a 2 liters per minute (2 lpm) continuous every shift. The Doctor's Orders did not reflect an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview conducted [DATE] at 8:30 AM, Family Member (FM) XX reported talking to Resident #2 on the phone one night while at the facility and the Resident complained that she could not breath and that her [CONDITION(S)] device was not working. Review of the EMR revealed a Progress Note documented on [DATE] at 9:41 PM that at approximately 8:45 PM, Registered Nurse (RN) E discovered Resident #2 struggling to breathe and unresponsive. The documentation reflected the resident was wearing a [CONDITION(S)] device but did not indicate supplemental oxygen was in use. The documentation reflected RN E then applied supplemental oxygen and placed the [CONDITION(S)] mask over the device and the Resident's oxygen (O2) saturation (Spo2) changed from 77% to 86%. The Progress Note reflected Emergency Medication Services (EMS) were contacted and the Resident was transferred to the hospital. On [DATE], at 3:34 PM an interview was conducted with RN E. RN E reported during the incident of [DATE] Resident #2 was wearing a [CONDITION(S)] device but not supplemental oxygen. RN E reported she did not believe the [CONDITION(S)] device had a port to attach supplemental oxygen and she did not know what the Doctor's Orders were for oxygen for the Resident. EMS documentation of the incident of [DATE] with Resident #2 reflected that no supplemental oxygen was in use on arrival. The documentation reflected EMS implemented a high-flow oxygen device and the Resident's Spo2 increased to 100% and the Resident was then able to verbalize to EMS staff that she feels ok. Review of the undated document provided by the facility titled Guidelines for Oxygen Safety reflected, Do not use an oxygen cannula in an emergency. Use a mask with high liters flows (sic). Review of a Registered Nurse (RN) job description revealed: One year of nursing experience preferred, . Assesses and documents the resident's condition and nursing needs, accurately and promptly implements physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Reports and records pertinent observations and reactions regarding residents, . Assists with or institutes emergency measures for sudden adverse development in residents. The facility job description reflected an RN should have, Knowledge/skills/abilities: .Ability to react decisively and quickly in emergency situations and have knowledge of training techniques for clinical staff. Review of a Director of Nursing (DON) job description provided by the facility revealed: Manages the facility nursing program in accordance with the Nurse Practice Act, applicable State and Federal regulations, and policies and procedures.Develops and manages systems to assure clinical competencies, . development and continuing education of nursing members, identification of training needs, . investigate and resolve residents/family, employee concerns, .ensures that adequate nursing staff are available based on facility/census requirements, . assures that all clinical protocols and nursing policies and procedures are followed. According to the Code of Ethic for Nurses (American Nurses Association, 2001, pg. 14), the nurse's primary commitment is to the health, well-being, and safety of the patient. The nurse must take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team. The Code of Ethics for Nurses (pg. 17) goes on to state the nurse is accountable to the quality of nursing care given to patients and the delegation of nursing care activities of other health care workers. The nurse is responsible for monitoring the activities of these individuals and evaluating the quality of the care provided. The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). The profession standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated [DATE]). According to [NAME] in Law Every Nurse Should Know 5th edition, (pg. 13), The collection of data about the health status of the patient is systematic and continuous. These data are communicated to appropriate persons, recorded and stored in a retrievable and accessible system. In Legal and Ethical Issues in Nursing by G. [NAME] (2001), it documents that Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse's notes are to be concise, clear, timely, and complete. (pg. 171) It states that A [NAME] can infer that no observation of the patient was conducted if there is no mention of a change in condition of the patient. (pg. 171) According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. (mcmahon & Associates. Nursing Standards of Practice. Hgexperts.com. Retrieved [DATE], from http://www.hgexperts.com/article.)

This pertains to intake M 6435, MI 589, M 3779 and M 6994. Based on observation, interviews, and record review, the facility failed to use its resources to effectively and efficiently administer the facility to attain and maintain the highest practicable physical, mental, and psychosocial well-being for all 106 residents that resided at the facility, resulting in a substandard quality of care survey and the potential for all residents to be impacted. Findings include: Review of facility provided job description for the Director of Nursing (DON) revealed the DON manages the facility nursing program in accordance with the Nurse Practice Act, applicable State and Federal regulations, and policies and procedures. Essential functions include: Manages the Nursing Department with the goal of achieving and maintaining the highest quality of care possible .develops and manages systems to assure clinical competencies .identification of training needs .pro-actively addresses survey and/or standards of care issues .assures that all clinical protocols and nursing policies and procedures are followed . Review of facility provided job description for the Administrator (NHA) revealed the NHA is responsible for the efficient and profitable operation of the facility, facility compliance with .policies and State and Federal rules and regulations and providing the highest quality care possible. Essential functions include: directs and guides the activities of clinical, administrative and service departments .implements control systems to ensure accountability of all departments .monitors performance for achievement of goals and for improvement and for improvement, and takes corrective action when necessary .ensures all employees receive orientation and ongoing training to meet the quality goals of the organization .acts as chairperson of the facility's Performance Improvement Committee. During an abbreviated survey from 12/15/2020-1/14/2021, immediate jeopardy concerns were identified at F607, F609, F610, F684 and F695. Under to authority and oversite of the Director of Nursing (DON) and the Nursing Home Administrator (NHA) the findings of the survey included: Immediate jeopardy of abuse, abuse investigation, and reporting abuse (See 607, 609, 610) that revealed: That the facility had knowledge that RN E removed Doctor Ordered (DO) oxygen from a declining resident (Resident #3) and that the report to the state agency (Facility Reported Incident 35) did not conclude substandard care by skilled staff but did impose education on the reporting staff. Although the survey did reveal a discipline conference of RN E on 12/9/20 the corrective action did not reveal imposition of re-training and monitoring. The survey revealed that the facility, with knowledge of the event of 11/24/20 with RN E and prior to the IJ concerns identified by the survey, did not initiate an investigation into other incidents of resident care (Resident #1, Resident# 2, Resident #12) or how other facility resident were affected. That, with the prior knowledge of the event of 11/24/20, the oversight did not result in facility-wide retraining of skilled staff until identified by the survey. That a review of the process of orientation and competency of skilled staff reflected ninety-seven topics (see orientation checklist for RN E), many skilled procedures, were documented as completed in one day and the unlikelihood skills and competency can be determined in this manner. (F- 726). The failure of a Registered Nurse (RN E) to not document events to reflect resident care, lack of notifying the healthcare provider for changes in condition, and overall negligence of care for 3 Residents (Resident #3, Resident #8, and Resident #12). (F-684). That the process for reviews of falls, as stated by the DON (F - 641, F-689), did not reflect an ardent attempt to determine root cause by review of questionable skilled assessments incongruent with a Physician assessment on the same day for Resident #2. Additionally, not identifying incomplete incident reports that lacked potentially pertinent data. And the facility did not determine/investigate root cause of falls and implement preventative measures for three Residents (Resident #1, Resident #3, and Resident # 8). That review of nursing documentation and review of incidents involving the documented use of oxygen, oxygen devices, and adherence to facility policy (F- 695), which resulted in resident harm or decline were not identified as areas that required immediate correction and retraining. That a process to review plans of care was not revealed during the survey. That lack of a process of review was not identified as a need and resulted in incomplete Care Plans (F 656). That review of pressure ulcers did not reflect measures to prevent, review, monitor and investigate root causes and meaningful interventions. (F-686) That review of social worker documentation and resident review of consents signed by a severely cognitively impaired resident (Resident #1) with nursing oversight, lack of a diligent pursuit of a PASSAR level II (Preadmission Screening /Annual Resident Review) for a resident with behaviors and on facility initiated [CONDITION(S)] medications who has had an over-exceeding number of falls, lack of diligently pursuing guardianship of a newly admitted severely cognitively impaired resident in a timely manner. (F-745). That review of resident records and orders revealed Standing Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON denies and unaware the standing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -In an interview conducted on 1/5/21 at approximately 2:45 PM the DON denied the facility utilizes standing order and indicated they do not exist. -In an interview on 1/5/20 at 2:40 p.m., RN O reported when she charts oxygen saturations in the computer, there is no place to document how many liters of oxygen a resident is on. RN O reported the facility has standing orders for all residents and the standing orders include oxygen administration and provided this surveyor with a copy. -Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . -Review of Standing Orders signed by the Physician on 11/11/20 for Resident #3 revealed: Skin issue-skin tear, abrasion, minor laceration - see wound protocol - Barrier cream for excoriation, Stage I wounds. Oxygen- 2-4 liters per nasal cannula for oxygen saturation below 88% until physician can be contacted for further orders. That infection control practices throughout the facility, especially for the COVID unit and resident equipment (Resident #4), does not show diligent oversight to contain/prevent spread of infections. (F-880). That the facility Quality Assurance program policy reflects An investigation will be conducted on each identified medical error or adverse event to analyze causes .Preventative actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education. An adverse event is defined as: an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses. However, the number and scope of the issues identified during this survey reflect that the practice by the facility of this stated standard is ineffective. The current lack of leadership in critical oversight of nursing practice, documentation, and implementation of facility policy and training is pervasive and establishes an environment of acceptance of substandard care of a dependent and vulnerable population. Additional supporting information includes: Review of handwritten orders dated 11/22/20 for Resident #3 revealed admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Standing orders not noted on the MAR. [MEDICATION(S)] Solution 10 mg/ml (milligrams/milliliter) ordered, give 0.25 ml by mouth every 2 hours as needed for pain/dyspnea, start 11/22/20 and discontinued on 11/24/20. Resident #3 has 3 doses documented on 11/23/20 only, one of those doses documented by RN E at 10:19 p.m. with a documented pain level of 0. [MEDICATION(S)] Sulfate Tablet sublingual 0.125 mg, give 1 application sublingually every 4 hours as needed for secretions, start date 11/22/20 and discontinued on 11/24/20, 2 total doses documented on 11/23/20 and the last dose documented as given at 4:34 p.m. During an observation and an interview on 12/21/20 at 1:29 p.m., RN E in the room with Resident #8 for dressing change. She placed a cloth towel over the bedside table and placed dressing supplies on top. RN E left the room and grabbed 2 trash bags and hand sanitized before re-entering the room. Opened all the supplies and put on gloves. This resident had a wound on his right hip and RN E proceeded to remove the old dressing that was packed. RN E washed her hands and changed her gloves and took the 4X4 gauze and wet it with normal saline and dabbed the wound in the middle with it and then cleaned the surrounding area, then used a dry gauze and repeated the motions. Then pulled the string of [MEDICATION(S)] out of the bottle by hand with the same gloves and cut a piece off with her scissors and proceeded to pack the wound with the [MEDICATION(S)] and her gloved finger, then placed a border foam dressing over the area. The wound on the right hip was approximately dime sized with some depth and the surrounding tissue was red. RN E proceeded to remove the left hip dressing that had a greenish/tan drainage noted. The wound is not round and about a quarter size in width with a large are of redness surrounding the wound. RN E used gauze with normal saline to wipe across the open area and around it then changed her gloves. A collagen powder packet was opened and sprinkled on the area of the wound and used gloved hands to push the collagen from the surrounding skin into the wound then placed a border foam dressing on it. RN E then removed her gloves and washed her hands. No hand hygiene done during the dressing change when gloves were removed. In an interview on 12/21/20 at 3:31 p.m., RN E reported she did not have a cotton swab to pack Resident #8's wound with [MEDICATION(S)] because it was not available at that moment. RN E reported that the collagen powder is supposed to be in the wound and had not applied it before. When questioning the technique of pushing the powder from the surrounding skin into the wound, RN E reported she could see why that could be a problem, RN E did not see any concern with pushing [MEDICATION(S)] into the wound with a gloved finger. According to the Code of Ethic for Nurses (American Nurses Association, 2001, pg. 14), the nurse's primary commitment is to the health, well-being, and safety of the patient. The nurse must take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team. The Code of Ethics for Nurses (pg. 17) goes on to state the nurse is accountable to the quality of nursing care give to patients and the delegation of nursing care activities of other health care workers. The nurse is responsible for monitoring the activities of these individuals and evaluating the quality of the care provided. The profession standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated 6/29/04). In Legal and Ethical Issues in Nursing by G. [NAME] (2001), it documents that Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse's notes are to be concise, clear, timely, and complete. (pg. 171) It states that A [NAME] can infer that no observation of the patient was conducted if there is no mention of a change in condition of the patient. (pg. 171) According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete.

This pertains to intake M 6435 and MI 589. Based on interviews and record review, the facility failed to demonstrate its QAPI program identified and implemented appropriate plans of action to correct quality deficiencies necessary to assure residents attain and maintain the highest practicable level of well-being, resulting in the potential for serious negative physical and psychosocial outcomes for all 106 residents residing at the facility. Findings include: Review of facility provided policy Quality Assurance and Performance Improvement (QAPI) with a last revised dated of 7/28/2020 revealed: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. A Quality Assessment and Assurance (QAA) will meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary and develop and implement appropriate plans of action to correct identified quality deficiencies. Program activities include tracking potential medical errors and adverse events: An investigation will be conducted on each identified medical error or adverse even to analyze causes .Preventative actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education. An adverse event is defined as: an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses. During an abbreviated survey from 12/15/2020-1/14/2021, noncompliance at an immediate jeopardy level were identified at federal regulatory requirements F607, F609, F610, F684 and F695. Per removal plans provided by the facility, the facility QAPI had previously reviewed the identified incidents and had yet to identify the extent of the concerns or make appropriate plans of action to address them to prevent continued noncompliance being identified during the abbreviated survey.

This citation pertains to intake M 1379. Based on observation, interview, and record review, the facility failed to prevent, treat, and maintain pressure ulcer care for 2 (Resident #3 and Resident #8), resulting in pressure ulcers and potential infection of pressure ulcers. Findings include: Resident #3 Review of a Face Sheet revealed Resident #3 is a [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . COVID diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility, transfers, and toileting. Resident #3 had limited range of motion (ROM) impairment on one side of her upper and lower extremities, at risk for pressure ulcers, none upon admission. Review of a Hospice Progress note for Resident #3 dated 11/23/20 revealed a shearing like area noted to bilateral buttocks/coccyx area. Recommendations: Change to barrier cream to bilateral buttocks and coccyx. Review of Standing Orders signed by the Physician on 11/11/20 for Resident #3 revealed: Skin issue-skin tear, abrasion, minor laceration - see wound protocol - Barrier cream for excoriation, Stage I wounds. Review of Hospital Records dated 11/20/20 for Resident #3 revealed upon examination, the resident had an 8 cm (centimeter) stage II decubitus ulcer. Review of an Order Summary report for Resident #3 revealed on 11/22/20 and order to cleanse the coccyx with normal saline, pat dry, and apply skin prep around wound, apply border foam dressing for stage 1 pressure ulcer and discontinued on 11/23/20. An order to Cleanse coccyx with normal saline, pat dry and apply barrier cream every shift for sheering/wound care ordered on 11/23/20 and discontinued on 11/23/20. Orders for the left second, third, and fourth toe to cleanse with normal saline, pat dry, and apply skin prep every day shift and as needed ordered on 11/12/20 and discontinued on 11/13/20. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3 did not receive any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Admission Evaluation dated 11/10/20 for Resident #3 revealed no pressure ulcer on coccyx noted and the left second and third toes had black areas documented. Review of the Hospice Patient Care Plan for Resident #3 revealed on 11/23/20 at 12:00 a.m., Resident #3 had a wound measurement of 7.6 x 4.2 and to Establish skin care/wound care regimen. Review of a Care Plan for Resident #3 revealed no care plan for pressure ulcers and/or prevention. Resident #8 Review of a Face Sheet revealed Resident #8 is a [AGE] year-old male admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] for Resident #8 revealed a BIMS indicated he is cognitively intact and required extensive assistance of 2 people for transfers and toileting, has limited range of motion in bilateral lower extremities. Has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #8 is not receiving Restorative Nursing care for range of motion, splint, or brace assistance. Resident has 1 stage II pressure ulcer, 1 stage III pressure ulcer, and 1 stage IV pressure ulcer. During an observation and an interview on 12/21/20 at 1:29 p.m., RN E in the room with Resident #8 for dressing change. She placed a cloth towel over the bedside table and placed dressing supplies on top. RN E left the room and grabbed 2 trash bags and hand sanitized before re-entering the room. Opened all the supplies and put on gloves. This resident had a wound on his right hip and RN E proceeded to remove the old dressing that was packed. RN E washed her hands and changed her gloves and took the 4X4 gauze and wet it with normal saline and dabbed the wound in the middle with it and then cleaned the surrounding area, then used a dry gauze and repeated the motions. Then pulled the string of [MEDICATION(S)] out of the bottle by hand with the same gloves and cut a piece off with her scissors and proceeded to pack the wound with the [MEDICATION(S)] and her gloved finger, then placed a border foam dressing over the area. The wound on the right hip was approximately dime sized with some depth and the surrounding tissue was red. RN E proceeded to remove the left hip dressing that had a greenish/tan drainage noted. The wound is not round and about a quarter size in width with a large area of redness surrounding the wound. RN E used gauze with normal saline to wipe across the open area and around it then changed her gloves. A collagen powder packet was opened and sprinkled on the area of the wound and used gloved hands to push the collagen from the surrounding skin into the wound then placed a border foam dressing on it. RN E then removed her gloves and washed her hands. No hand hygiene done during the dressing change when gloves were removed. In an interview on 12/21/20 at 3:31 p.m., RN E reported she did not have a cotton swab to pack Resident #8's wound with [MEDICATION(S)] because it was not available at that moment. RN E reported that the collagen powder is supposed to be in the wound and had not applied it before. When questioning the technique of pushing the powder from the surrounding skin into the wound, RN E reported she could see why that could be a problem, RN E did not see any concern with pushing [MEDICATION(S)] into the wound with a gloved finger. Review of the Medication Administration/Treatment Administration Record (MAR/TAR) dated November 2020 for Resident #8 revealed incomplete and non sensical orders, duplicative treatment entries and missing documented treatments for pressure ulcers in the right trochanter, left trochanter, and sacral region. Review of the Medication Administration/Treatment Administration Record (MAR/TAR) dated December 2020 for Resident #8 revealed orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for the left trochanter stage III pressure ulcer ordered 10/3/20 had several missed treatments. Orders to measure the wounds had missed entries. Orders for the right trochanter stage IV pressure ulcer ordered on 11/25/20 and discontinued on 12/8/20 had missed treatments. A new order for the right trochanter stage IV pressure ulcer started on 12/9/20 has treatments not completed in December. Orders to monitor the placements of the dressings of pressure ulcers every shift is not completed several times. Review of Physician Assistant Progress Note dated 12/18/20 for Resident #8 revealed: . Wounds appear to be slowly healing, continue to monitor. Referral made yesterday to wound clinic . Review of the Care Plan for Resident #8 revealed no meaningful interventions for pressure ulcers until 12/17/20. In an interview on 1/13/21 at 11:03 a.m., the Director of Nursing (DON) reported she did not consider using a wet/dry gauze with normal saline and wiping over a pressure wound to be considered [MEDICATION(S)]. The DON did expect nurses to do hand hygiene when changing gloves during a dressing change going from dirty to clean. When questioned about packing a wound with [MEDICATION(S)] for Resident #8, the DON said he had a 2 cm (centimeter) underway (tunneling). When asked if using a gloved finger to pack a wound with tunneling is appropriate, the DON shrugged her shoulder and looked up then said she personally would use a cotton swab. The DON reported the collagen powder for wounds should be sprinkled into the wound bed, and if it scattered outside the wound, the DON reported she would just wipe the excess away, however, is the surrounding area was just cleansed, pushing the collagen powder into the wound from the surrounding skin would have less potential for an infection. Review of a policy titled Dressings, Dry/Clean last revised 1/2020 does not include procedures for packing a wound/pressure ulcer. According to the Fundamentals of Nursing, 6th edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005, page 153), If wound is deep, gently pack dressing into wound base with sterile gloves or forceps until all wound surfaces are in contact with the gauze. If tunneling present, use a cotton-tipped applicator to place gauze into tunneled area. Be sure gauze does not touch the surrounding skin. According to Legal and Ethical Issues in Nursing, 4th Edition, (Guido, G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete.

This citation pertains to intake # MI 194. Based on interview and record review, the facility failed to formulate and implement a personalized, comprehensive Care Plan based on the medical needs of one resident (Resident #2), resulting in no established plan of care that included the need for Doctor Ordered continuous oxygen and a need for a Continuous Positive Airway Pressure device (([CONDITION(S)]) (a device used to assist with breathing when asleep for those with a diagnosed sleep disorder) culminating with hospitalization for respiratory distress and the potential for all facility residents to have incomplete Care Plans not tailored to the specific needs of a vulnerable population. Findings: Resident #2 was admitted to the facility 11/4/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] for Resident #2 was reviewed. The MDS Section O (0100) reflected Resident #2 required oxygen therapy prior to admission and while a resident at the facility. However, this section did not indicate that Resident #2 required the use of a [CONDITION(S)] or [CONDITION(S)] device prior to admission or during the admission at the facility. In a telephone interview conducted 12/15/20 at 8:30 AM, Family Member (FM) XX reported Resident #2 used a [CONDITION(S)] device nightly. Review of the Electronic Medical Record (EMR) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's documentation also reflected that Resident #2 was, positive for apnea (obstructive sleep apnea with [CONDITION(S)]. Uses this nightly). Review of the Doctor's Orders for Resident #2 reflected oxygen continuous was ordered 11/4/20 and the order remained in place throughout the Resident's admission to the facility. Review of the EMR for Resident #2 revealed the document titled, Nursing Skilled Daily Medically Complex evaluation dated 11/6/20. This evaluation was documented the same day as the Physician encounter and was reviewed. The section titled Respiratory was reviewed. Section #8 reflected, Check all respiratory items in use with boxes eligible to be checked included a. Oxygen therapy, and c. [CONDITION(S)]/C-Pap/AVAP. However, the box for none of the above is checked despite current Doctor's Orders for continuous oxygen and documentation by the Physician that Resident #2 uses [CONDITION(S)] nightly. The EMR Care Plan for Resident was reviewed. The use of continuous oxygen Doctor ordered on 11/4/20 was not included in any of the three Care Plan focus topics directly related to respiratory concerns until 11/15/20. The Care Plan focus topic titled The resident has COPD; idiopathic sleep related nonobstructive alveolar hypoventilation was reviewed. The nightly use of a [CONDITION(S)] device was absent from this Care Plan and other respiratory focus topics. Furthermore, this Care Plan topic of sleep difficulties included an intervention of Give aerosol and bronchodiolaters as ordered. This gave further indication that the Care Plan was not personalized for the Resident as no aerosols or bronchodilators were found to ever been ordered for the Resident. Review of the Electronic Medical Record (EMR) revealed a Progress Note documented on 11/16/20 at 9:41 PM that at 8:45 PM, Registered Nurse (RN) E discovered Resident #2 struggling to breathe and unresponsive. The documentation reflected the resident was wearing a [CONDITION(S)] device and did not indicate continuous supplemental oxygen was in use. The documentation reflected RN E then applied a nasal cannula for supplemental oxygen and placed the [CONDITION(S)] mask over the nasal cannula and the Resident's oxygen saturation changed from 77% to 86%. The Progress Note reflected Emergency Medication Services (EMS) were contacted and the Resident was transferred to the hospital. On 12/21/20 at 3:34 PM, an interview was conducted with RN E. RN E reported during the incident of 11/16/20, Resident #2 was wearing a [CONDITION(S)] device but not supplemental oxygen. RN E reported she did not believe the [CONDITION(S)] device had a port to attach supplemental oxygen and she did not know what the Doctor's Orders were for oxygen for the Resident. EMS documentation of the incident of 11/16/20 reflected that no supplemental oxygen was in use on their arrival. The documentation reflected EMS implemented a high-flow oxygen device and Resident #2's oxygen saturation increased to 100%. The Resident was transferred to the hospital. Review of the hospital emergency room Report for Resident #2 dated 11/16/20 reflected, Impression Acute respiratory failure with [CONDITION(S)] (a deficiency of oxygen reaching the tissues). Review of the EMR reflected Resident #2 was tested for the COVID 19 virus on admission, 11/4/20, which indicated the Resident was at risk for contracting the virus. This documentation did not reflect the Resident was informed of the results of the test. Additionally, the EMR did not reveal an at risk for COVID 19 plan of care was entered into the Care Plan until 11/13/20, nine days after admission. Furthermore, Resident #2 tested positive for COVID 19 on 11/13/20, and a Care Plan for active COVID 19 was not in place until 11/15/20.

This citation pertains to MI 752. Based on observation, interview and record review the facility failed to provide adequate staff for resident transfer in 1 of 6 residents (Resident #101) reviewed for falls, from a total sample of 9 residents, resulting in the broken pelvis (pubic rami) of Resident #101. Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a brief interview for mental status (BIMS) score of 0 out of 15 which indicated severe cognitive impairment. Further review of the MDS revealed Resident #101 was a total assist of 2 staff for bed mobility. Review of the Care Plan At risk for falls dated 9/19/13 and updated 2/9/17 revealed Resident #101 was an Assist of 2 with care and transfers. Review of the Resident Care summary dated 10/12/17 revealed Resident #101 was dependent on 2 staff member to do her ADLS (activities of daily living) and transfers. In an observation on 10/30/17 at 1:51 pm, Resident #101 was noted to be laying in bed. In an interview won 10/30/17 at 1:51 pm, Resident #101 stated staff don't take their time when performing care. Review of the Facility Reported Incident revealed on 10/8/17 at approximately 5:45 am Resident #101 rolled off the bed onto the floor as Certified Nurse Aide (CNA) G was assisting resident with incontinence care .Resident (Resident #101) complained of pain 'all over', but was unable to describe pain or any specific locations and later complained of left leg pain .Due to residents fall, risk factors and discomfort, an X-ray of left hip, pelvis and femur ordered related to pain and results indicated age indeterminate left inferior and superior pubic rami (pelvis) fractures (broken bones). Review of the Facility Staff Interview Summary dated 10/9/17 revealed CNA G stated, on 10/8/17 during last rounds of 3rd shift, (CNA G) entered resident's (Resident #101) room to provide incontinence care .She (CNA G) informed resident what she was going to do and raised the bed to abut waist height. She (CNA G) used the incontinence pad to pull resident (Resident #101) over and onto her right side facing away from her .at one point she left go of resident .resident slid off the edge of the bed to the floor. In an interview on 10/30/17 at 4:04 pm, Licensed Practical Nurse (LPN) H stated, on 10/8/17, Resident #101 was on the floor and the aide (CNA G) said she was changing her (Resident #101) and rolled off the bed. Review of the Radiology Results dated 10/8/17 at 9:42 pm, revealed Resident #101's X-ray results were fractures involving the LEFT inferior and superior pubic rami (pelvis) or indeterminate age. Review of the Corrective Action Notice dated 10/16/17, un-timed, revealed CNA G was involved in an incident resulting in a resident fall and Failing to perform duties according to established standards for quality, performance, and quantity. We must then separate you from employment .effective immediately. In an interview on 11/1/17 at 1:10 pm, Director of Nursing (DON) B stated the root cause of Resident #101's fall and fracture was the plan of care wasn't followed, which was 2 assist for (bed) mobility. On 10/9/17, the facility identified an incident of improper transfer resulting in a fall with fracture for Resident #101. -The facility identified and reviewed residents who required 2 person staff assistance for care and transfer for concerns. -The facility began education of staff on implementing plan of care and resident care summary for how many staff members were needed for care and transfer and mobility status of residents. Substantial education of staff was completed on 10/14/17. -Audits were conducted weekly of 5 residents for transfer status and began on 10/13/17 and continued through the survey exit on 11/1/17. There was no ongoing noncompliance in regards to falls at the time of survey.

This citation pertains to intake number MI 496. Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety of 1 of 3 sampled residents (Resident #100), from a total of 3 sampled residents, resulting in an Immediate Jeopardy (IJ) when Resident #100, who was identified as an elopement risk, exited the facility at approximately 7:28 a.m. on 4/10/17, unbeknownst to facility staff and was found at approximately 7:38 a.m. in the employee parking lot, without a walker approximately 100 feet from the building. Findings include: Review of the Clinical Notes effective date/time 4/10/17 at 8:00 a.m., Director of Nursing (DON) B was notified that resident was outside of the north exit, checked resident's wander bracelet on right ankle and notice that the strap was in place, but the device was not on the strap. Resident (#100) stated that 'someone came in during the night and broke it' . Review of the Social Worker Interview with Resident #100 dated 4/11/17, reflected Resident #100 reported that I woke up and it (wander guard) was in my sock and it rubbed on me when I got up. It fell out and I stepped on it. Resident #100 did not know who took the wander guard off and denied messing with the device. Resident #100 reported that he noted the wander guard was off in the morning of 4/10/17 and that he kicked it under the back of his dresser. Resident #100 reported he went outside the building, to the side of the building for maybe 10 minutes. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #100 was a [AGE] year old male, who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Letters of Guardianship date 3/26/12, revealed a guardian was appointed by the court as full guardian of Resident #100. Review of the Court Clinical Psychiatrist Certification dated 3/30/17 at 10:45 a.m., revealed My determination is that the person is mentally ill My [DIAGNOSES REDACTED]. Most recent hospitalization was this year, admitted because of medication noncompliance and increasing hallucinations and delusional thought. During an interview on 4/12/17 at 9:30 a.m., Social Worker (SW) H reported that Resident #100 was not his own person, he had been deemed incapacitated by the courts due to significant mental illness and has a guardian. SW H reported that Resident #100 has paranoid delusions, thinks people are poisoning him, refused antipsychotic medications, bed electrocuting him, which lead to Community Mental Health placement and court mandated Invega injections. SW H reported that Resident #100 refused the monthly injections and get a police escort since the injections are court mandated. Review of the Certified Nursing Assistant Care Guide, reflected Resident #100 was to be provided supervised trips outside 4x/day, have a code alert bracelet to his right ankle, and use of 4 wheeled walker outside. Review of the Clinical Notes dated 3/29/17 at 2:17 p.m., Resident (#100) has a [DIAGNOSES REDACTED]. He is prescribed intramuscular injection of Invega (an antipsychotic medication used to treat schizophrenia) (administered by Community Mental Health (CMH) and Zyprexa (used to treat the symptoms of psychotic conditions such as schizophrenia and bipolar disorder) 10 mg daily. Resident (#100) has refused this oral Zyprexa since his readmission from inpatient psychiatric placement. Resident (#100) remains with a court mandated order for treatment. A officer (police) has been called to the facility 2x to escort resident to his injection appointment. CMH follows resident closely. Resident (#100) remains paranoid delusions , he continues to pace, and remains with the unrealistic expectation that he can live successfully at .Rescue Mission. Social Worker has requested that CMH discontinue residents oral Zyprexa as he is refusing the medication . Review of the Mood Care Plan dated 1/31/17-present, reflected Resident has a [DIAGNOSES REDACTED]. Very suspicious of others at times .paranoid beliefs that staff is poisoning him. Refusal of psychotropic medications. Belief that he can live in the community with his mother. Writes letter to to .Rescue Mission/police offices around the country. Under court ordered treatment mandation. Review of the Clinical Note date 4/13/16 at 3:33 p.m., reflected Social Worker met with resident related to leave privileges. Resident has not been consistent with signing in and out of the facility. Resident has demonstrated poor safety awareness in the community i.e. asking stranger for cigarettes. Social Worker resident and resident guardian has had previous discussion re: resident leave privileges, all parties were informed of resident's failure to comply with signing in and out and the repercussions of that. Social Worker met with DON, Administrator, Nurse Consultant, Clinical Care Coordinator to review resident .Resident is now able to leave with staff 4x/day for a cigarette break. Resident will have full access to facility courtyards for independent use. A wander guard would also be placed on resident and resident walker . Review of the Elopement Risk Care Plan updated 4/26/16, reflected Resident will be provided supervision or redirection with leave of absence decision making to decrease risk for unsafe situations. No Elopement Risk Care Plan was presented to the surveyor for the current admitted d 1/26/17. Review of the List of Residents with Wanderguards presented 4/12/17, reflected 30 residents had been identified as elopement risk, 21 of 30 were identified as independently mobile. Review of the physician progress notes [REDACTED].#100 states he wants to get out of here. Review of the physician progress notes [REDACTED].#100 temporary elopement. His electrical tether apparatus was broken off the band. The patient claims someone did this at night when he was sleeping. During an interview on 4/12/17 at 11:45 a.m., Certified Nursing Assistant (CNA) 'L' (3rd shift CNA) reported that she does not get in Resident #100's personal space. CNA L reported that Resident #100 makes her nervous so she does not go and physically check the wanderguard and he wears his jeans and gripper socks to bed so the wanderguard was not visible on 4/10/17. During an interview on 4/12/17 at 12:20 p.m., CNA N reported that she does not physically check to see if wanderguards are in place and functioning on 3rd shift. During an interview and observation on 4/12/17 at 9:20 a.m., Resident #100 reported that he exited the facility on 4/10/17 in the morning. Resident #100 reported that someone broke the tether in my sleep, I woke up and it was under my foot in my sock so I took the tether off and put it under my chest (pointed to chest of drawer beside the bed). Resident #100 reported he went out the door without his walker to look at the parking lot and after a while someone came for him. During an interview on 4/12/17 at 11:10 a.m. Housekeeping D reported seeing Resident #100 walking with his walker towards the North Hall around 7:30 a.m. on 4/10/17, then sitting across from the northeast exit putting his coat on, then a few minutes later seeing his walker, but not Resident #100 across from the northeast exit door. Housekeeping D reported that she went out the northeast exit door approximately 200 feet to the side walk beside a 2 lane road and did not see Resident #100 either direction on the road or in the employee parking area. During interviews on 4/12/17 at 11:25 a.m. and 12:35 p.m., and 4/18/17 at 9:28 a.m., Director of Environmental Services (DES) E reported that Housekeeper D informed him that we needed to find Resident #100, DES E checked the residents room and the north hall then went out the northeast exit door and walked approximately 50 feet and Resident #100 was coming around the north side of the building on the sidewalk without his walker. DES E reported that the alarm did not go off when Resident #100 was brought back into the building. DES E reported that when Resident #100 was located he was wearing a jacket over a shirt, long jeans that covered his tennis shoes, so that he could not see his socks. During an interview on 4/12/17 at 9:20 a.m., Resident #100 reported that he has been trying to get out of the facility since 2014, but the judge at court yesterday said he had to stay here, keep taking shots that make me sick, make my left ankle numb, hurt my voice, my eyeballs, and take life out of my brain. Resident #100 reported that he woke up the morning of 4/10/17 the tether (wanderguard) was under my foot in my sock and I stepped on it, took the tether off and put it under the dresser (pointed to the side dresser to the right of the head of bed). Resident #100 reported that he suspected someone broke his tether (wanderguard) in his sleep. Resident #100 reported that he went out one of the open door to look at the parking lot and after awhile someone came and got him. During an interview on 4/17/17 at 11:50 a.m., Licensed Practical Nurse (LPN) P reported that on 4/10/17 he observed Resident #100 go from his room to the day sometime between 6:30 and 7:00 a.m., then back to his room, saw him exit the room again after 7:00 a.m. and head towards the north side of the building. LPN P reported that he had not verified that the wanderguard was on Resident #100 that morning and none of the Certified Nursing Assistant (CNA) staff had informed his that they had visualize the wanderguard. LPN P reported Housekeeper D came to check Resident #100's room, stating she saw his walker by the activity room, but that Resident #100 was not in that area. LPN P reported that he and Housekeeper D went out the southeast exit door to the employee parking area, to the 2 lane road approximately 200 feet behind the facility and did not see anyone. LPN P reported that they did not look down the sides of the building, but went back in to look out in front of building since Resident #100 would sit out there at times. LPN P reported they did not find him, but heard he had been located. Review of the April 2017 Treatment Administration Record (TAR), reflected Alarms - Code Alert -Order Date 1/27/17 - Notes: Code Alert. check alarm placement within the first hour of shift. Nurse may check or verbally validate with nursing assistant. TAR initialed by nursing for day shift 4/10/17. During interviews on 4/12/17 at 12:55 p.m. and 4/18/17 at 9:20 a.m., Director of Nursing (DON) B reported that on 4/10/17 she arrived just before 8:00 a.m., and was informed Resident #100 had been outside without staff present. DON B reported that over a year ago Resident #100 had been put on a wanderguard due to calls from local businesses, who had witnessed Resident #100 crossing the double 2 lane highway in front of the building and the lights would change while he was still crossing the road holding up traffic, and Resident #100 would lay down on the local business lawns. DON B reported that the facility felt he was not making safe choices when he was out independently, that he needed to be supervised. DON B reported that Resident #100 needs a wanderguard and a walker when he outside of the facility, and supervision. DON B reported that on 4/10/17 when she went to assess Resident #100 he had on long pants, blue gripper socks, shoes, and that she had to pull up his pant leg to look for the tether (wanderguard), where she found the band around the outside of the gripper socks but the wanderguard device box that communicated with the alarm system was not on the band. DON B reported that Resident #100 stated the wanderguard device broke during the night and it was under the bedside dresser. DON B reported that the wanderguard device box was located under the dresser, with a piece broke off the back, no tools were noted that could pry off the plastic backing, and the broken section was not found in Resident #100's room. During an interview on 4/12/17 at 9:50 a.m., Administrator A reported that when Resident #100 was first admitted he went in/out of the building on his own, then the facility decided it was not safe for him to go in/out on his own and a wanderguard was placed for his safety. Administrator A reported that when Resident #100 was returned to the building after eloping, his wanderguard was replaced, he was put on 1:1 supervision. Administrator A reported that it appeared the back piece from the wanderguard molded plastic was busted off, like a table knife was used to pry it off. Administrator A reported that no metal utensils were found in Resident #100's room. Administrator A was notified of the IJ that began on 4/10/17 at approximately 7:28 a.m., when the facility failed to prevent the elopement of Resident #100. 1. On 4/10/17, Resident #100 was returned to the building and assessed with [REDACTED]. 2. On 4/10/17, at the time of the incident a total resident head count was conducted. 3. On 4/10/17, immediately following the incident all exit doors and the wanderguard system were checked and found to be functioning properly. 4. On 4/10/17, post incident, a new code alert bracelet was applied to Resident #100's ankle. 5. On 4/10/17, Resident #100 was put on 1:1 supervision. 6. On 4/10/17, Resident #100's plan of care was reviewed and interventions remain appropriate. 7. On 4/10/17, the elopement Policy was reviewed and found to be appropriate. 8. On 4/10/17, all residents that were assessed as high elopement risk and wearing a code alert bracelet were checked and it was determined that all bracelets were in place and functioning appropriately. 9. On 4/10/17, Resident #100's direct care nurses received education on elopement protocols. 10. On 4/11/17, 9 of 9 scheduled licensed nurses received education on elopement including assessment, resident orders for wanderguard checks and use of elopement book. Any active licensed nurse who had not received education will not be scheduled to work until education has occurred. 11. On 4/12/17, Certified Nursing Assistant education on elopement was started. 12. In addition to licensed nurses, all staff education on elopement protocols began on 4-12-17. On 4-13-17 at 2 pm 96 out of 156 active staff have been educated. No staff member will be allowed to work without receiving the education. Although the Immediate Jeopardy was removed on 4/12/17, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for minimal harm that is not Immediate Jeopardy due to the fact that the facility had not yet educated all staff and sustained compliance had not yet been verified by the State Agency.

This citation pertains to intakes MI 072, MI 196 Based on observation and interview, the facility failed to ensure: 1.) the resident call light system was fully functional with centralized audible or visual signals, 2.) that staff have functioning devices for the wireless system in their possession and are answering resident call lights, and 3.) that resident call lights were within reach, affecting all resident in the facility, resulting in an Immediate Jeopardy for residents who experienced extensive wait time to have their needs met and the potential for serious harm, injury, and or death for all residents in the facility in the event of an emergent situation. Findings include: During an interview on 2/13/17 at 12:10 p.m., Resident #101 indicated she had a bowel movement in her brief and had not been cleaned up, or bathed this morning, and she couldn't wait any longer. During an observation on 2/13/17 at 12:15 p.m., observed Resident #101's call light button above bed to be turned to red (indicating call light was on). On the outside of Resident #101's room no light indicator above door, and no sound coming from the hallway monitoring system. Resident #101 had dark matter in her fingernails, on her sheets, and top blanket, and a strong smell of urine and feces. During an interview on 2/13/17 at 12:25 p.m., CNA C indicated that morning care includes full bed bath, washing face, hands, chest, upper body, hands and feet. CNA C indicated briefs should be check at least every two hours, and changed as needed. CNA C indicated Resident #101 should have been bathed, and had clean linens, a blue pad, and gown and or clothing put on by now. During an interview on 2/13/17 at 2:45 p.m., Resident #105 indicated response times for call lights are over 20 minutes. Resident #105 indicated she has had to wait over 45 minutes to get assistance from staff after pressing her call light. During an observation on 2/14/17, Resident #106's call light on starting at 7:50 a.m At 8:30 a.m., the call light was observed to have remained on (40 minute wait time). During an observation on 2/14/17 at 9:57 a.m., observed Resident #107 lying in her bed, call light not within reach. Observed call light under Resident #107's bed, stuck under the bed frame. During an observation on 2/14/17 at 10:20 a.m., observed Resident #107's call light to be stuck under the bed in same place as the previous observation at 9:57 a.m. During an observation on 2/14/17 at 10:05 a.m., observed Resident #109's call light on. Time on 9:43 a.m. (22 minute wait time). During an observation on 2/14/17 at 10:14 a.m., observed Resident #109's call light on the floor, Resident #109 indicated she could not find her call light. Resident #109 indicated she thought it was over there on the floor. Resident #109's call light was observed on the floor out of reach. During an interview on 2/14/17 at 10:06 a.m., Resident #108 indicated he has waited a long time when he turns his call light on. Resident #108 indicated he waits at times over an hour. Resident #108 indicated his call light has been on, but he can only use the bathroom with help. Resident #108 indicated he had just had an incontinence episode of bowel movement because he has diarrhea. Resident #108 stated I feel like a burden, but I had to go. During an observation on 2/14/17 at 10:10 a.m., CNA C entered Resident #108's room, turned the call light off and informed Resident #108 I'll be back. CNA C did not ask Resident #108 what he needed. CNA C went out of Resident #108's room, and continued to pass breakfast trays. CNA C did not re-enter Resident #108's room until 10:24 a.m. During an interview on 2/14/17 at 10:12 a.m., CNA C indicated the needs of the resident should be met before turning the call light off. During an observation on 2/14/17 at 10:17 a.m., observed Resident #110's call light on the floor, tucked into a slipper next to bed, out of reach of Resident #110. During an observation on 2/14/17 at 10:23 a.m., observed Resident #104 asleep in her bed, call light underneath wheel near the head of bed on floor. During an interview on 2/14/17 at 10:27 a.m., CNA L indicated residents should always have their call lights within reach, either clipped to their clothing, or bedding. During an observation on 2/14/17 at 11:52 a.m., observed Resident #104 asleep in her bed, call light underneath wheel near the head of bed on floor. (in the exact same spot as earlier observation at 10:23 a.m., 1 hour 29 minutes without reachable call light.) During an interview on 2/14/17 at 11:53 a.m., Licensed Practical Nurse/Clinical Care Coordinator (LPN/CCC) P indicated she does rounds as the supervisor on the unit for Resident #104. LPN/CCC P indicated she enters all the resident rooms, and assesses the room, checks call light placement, hazards, infection control concerns, house keeping concerns, needs of the residents. LPN/CCC P indicated that since 7:00 a.m., today (2/14/17) she had done rounds on her assigned rooms, and found no concerns. LPN/CCC P indicated she had recently been in Resident #104's room, and found no concerns. During an interview on 2/14/17 at 10:50 a.m., Director of Nursing (DON) B indicated call lights are always to be place within residents reach. DON B indicated the unit managers do rounds throughout their shifts and go into each resident room to ensure resident call lights are within reach. DON B indicated if the unit managers find something such as a call light not within reach of a resident, the unit manager will do real time teaching at that moment to the staff on the unit. During an interview on 2/14/17 at 10:15 a.m., Resident #111's call light was noted to be on the monitor. Resident #111 indicated staff takes about 30-40 minutes to come into her room, Resident #111 indicated she needed to be repositioned because her bottom (buttocks) hurt. During an interview on 2/14/17 at 11:10 a.m., Resident #112's Family Member (FM) M indicated staff take at least 30 minutes to answer call lights. FM M indicated that Resident #112 was also recently rolled out of bed by a staff member when the staff member was doing a brief change on Resident #112. FM M indicated Resident 112 is unable to speak, make needs known, and roll over in bed. During an interview on 2/14/17 at 11:20 a.m., Resident #113 indicated she recently fell out of bed because the mattress was the wrong mattress. Resident #113 indicated she was asleep and rolled in her sleep, the mattress to the bed completely tipped her out of bed. Resident #113 indicated her call light was not within reach, and not clipped to her or her bedding. Resident #113 indicated she was unable to get help with her call light. Resident #113 indicated she had to wake her room-mate up to call for help. During an observation on 2/14/17 at 11:29 a.m., observed Resident #114 trying to get this surveyors attention. Upon entering Resident #114's room, he was seated up in a high back wheelchair on the right side of his bed, toward the footboard. Resident #114's call light was clipped to his pillow at the top of the bed, near the head board, approximately 4 feet behind the reach of the resident who was observed to have contracted arms and hands. During an interview on 2/14/17 at 11:29 a.m., Resident #114 was unable to speak verbally, but did nod his head yes and no when asked questions. Resident #114 was asked if he was wet, he responded with a yes head nod, a yes head nod to pain, a yes head nod if he had been waiting for someone for 10 minutes, a yes head nod to 20 minutes, and a yes head nod to over 30 minutes. When this surveyor asked if this happens often, Resident #114 nodded head yes. During an interview on 2/14/17 at 11:35 a.m., LPN N indicated 2 CNA's for the south east unit were on lunch break, and the other CNA is giving another resident a shower. LPN N indicated Resident #114 can make needs known to simple commands, yes and no questions by nodding his head. LPN N indicated Resident #114's assigned CNA is one of the CNA's on lunch break. During an observation on 2/14/17 at 11:36 a.m., along with LPN N Resident #114 was observed. LPN N confirmed the placement of Resident #114's call light clipped to the pillow at the top of Resident #114's headboard. During an interview on 2/14/17 at 11:37 a.m., LPN N indicated the call light would do Resident #114 no good if Resident #114 could not reach it to use, as Resident #114 is non-verbal. During an interview on 2/13/17 at 1:40 p.m., CNA G indicated the call system does not audibly sound at the monitoring boards in the middle of the units (can only be seen if staff walk up to the monitor to view). CNA G indicated the call system does not sound in the charting room either. CNA G indicated that the CNA's are to carry pagers on them, the call light alerts the pager and then CNA's answer the call lights. CNA G indicated she did not have a pager on her. CNA G indicated it is the policy to carry a pager at all times, but the facility is missing many of them, so CNA's are reliant on the monitor in the middle of the unit to check if call lights are on. Observation of the call light monitoring boards revealed the facility was shaped as an letter H and each board was located down the leg of each H and noted to be hanging on the wall in the middle of the H leg, making this board not centralized or easily visualized by facility staff. During an interview on 2/13/17 at 1:45 p.m., Licensed Practical Nurse (LPN) H indicated she had no pager on her. LPN H indicated she had forgotten the pager in the office and that the facility is short of pagers. LPN H indicated management is aware of the pagers for staff being short. LPN H indicated that the pagers have been missing for over a month because staff puts them in their pockets and forget to leave them at the facility at the end of their shifts. During an interview on 2/13/17 at 2:00 p.m., CNA I indicated there have not been available pagers in over a month. CNA I indicated staff have to go to the middle of the hall to see the monitor to check for call lights that are on. CNA I indicated no sound comes from the monitor system. During an interview on 2/13/17 at 2:30 p.m., CNA J indicated when she arrived at work today, there were no available pagers. CNA J indicated the pagers have been short, or unavailable for well over a month. CNA J indicated no sound comes from the monitors, staff just have to look up at the monitor to check for call lights that are on. During an interview on 2/13/17 at 3:15 p.m. LPN O indicated he did not have a pager on him. During an interview on 2/14/17 at 8:40 a.m. Registered Nurse (RN) K indicated pagers for staff (CNA's) are missing, staff take them home and they don't bring them back. RN K indicates management is aware that CNA's are not carrying pagers. RN K reported that 6 minutes after a call light is turned on by a resident and unanswered, the page for assistance then goes to the nurse's pager. RN K indicated there is no sound for the call lights once a resident turns their call light on, the staff must go to the monitors in the middle of the unit to check the call lights that are on. During an interview on 2/13/17 at 3:00 p.m., DON B reported that in January 2017, Administrative staff made changes to the call light system and no longer require CNA's to wear pagers. DON B indicated no sound comes from the monitors where call lights that are turned on are available for staff to see. DON B indicated staff relies on verbal communication to assist with call lights. DON B indicated it takes 6 minutes for the call light page to reach the nurses who carry pagers. On 2/14/17 the Director of Nursing was notified of an immediate Jeopardy that began January 31, 2017 due to the facilities failure to ensure 1.) the resident call light system was fully functional with centralized audible or visual signals, 2.) that staff have functioning devices for the wireless system in their possession and are answering resident call lights, and 3.) that resident call lights were within reach. On 2/21/17, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 2/14/17, an audit was completed to ensure call lights are in place, licensed nurses have pagers per facility practice, and the residents' immediate needs are met. 2. On 2/14/17, an audit of facility pagers was completed to ensure availability and working order. 3. On 2/15/17, the QAPI committee The QAPI committee met to review the call light policy and found it to be appropriate and in accord with the intent of the regulation. 4. Beginning 2/15/17, cctively scheduled Licensed Nurses and CENAs received education for expectations related to use of call light system and ensuring resident needs are met timely. Licensed Nurses and CENAs will receive this education prior to taking his/her scheduled assignment. If education not completed, the Nurse/CENA will not take an assignment. 5. Beginning 2/14/17, Interdisciplinary team member (IDT) will be assigned purposeful rounding rooms M-F and interview current residents with BIMS score of 8 or higher to ensure that needs are being met in a timely manner. Findings will be acted upon at time of identification. Although the immediate jeopardy was removed on 2/15/17, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the for minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed.

This citation pertains to intake MI 072 Based on observation, interview and record review the facility failed to residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being (have a fully functional call system in place) and ensure residents had access to immediate care in the event of an emergent situation for 12 of 15 sampled residents (Resident #106, #107, #109, #110, #113, #104, #105, #111, #112, #114, #101, #108) reviewed for receiving necessary care and services, from a total sample of 15 residents, resulting in an Immediate Jeopardy for the potential for serious harm when, beginning January facility management informed staff they no longer were required to carry pagers to alert them of resident requests for assistance, and residents no longer had consistent means to contact staff so their needs were met. This deficient practice placed 12 residents at risk for potential serious harm, injury, and/or death. Findings include: Resident #106 Review of a facility Face Sheet revealed Resident #106 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#106 was an extensive assist with 1 staff for bed mobility, and toilet use, and transfers. A BIMS revealed Resident #106 was cognitively intact with a score of 15/15. During an observation on 2/14/17, Resident #106's call light on starting at 7:50 a.m At 8:30 a.m., the call light was observed to have remained on (40 minute wait time). Resident #107 Review of a facility Face Sheet revealed Resident #107 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #107 was a limited assist with 1 staff for bed mobility, and transfers. A BIMS revealed Resident #107 was cognitively impaired. During an observation on 2/14/17 at 9:57 a.m., observed Resident #107 lying in her bed, call light not within reach. Observed call light under Resident #107's bed, stuck under the bed frame. During an observation on 2/14/17 at 10:20 a.m., observed Resident #107's call light to be stuck under the bed in same place as the previous observation at 9:57 a.m. Resident #109 Review of a facility Face Sheet revealed Resident #109 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #109 was a limited assist with 1 staff for bed mobility, and transfers, and a total assist with 2 staff for toilet use. A BIMS revealed Resident #109 was cognitively intact with a score of 13/15. During an observation on 2/14/17 at 10:05 a.m., observed Resident #109's call light on. Time on 9:43 a.m. (22 minute wait time). During an observation on 2/14/17 at 10:14 a.m., observed Resident #109's call light on the floor, Resident #109 indicated she could not find her call light. Resident #109 indicated she thought it was over there on the floor. Resident #109's call light was observed on the floor, out of reach. Resident #110 Review of a facility Face Sheet revealed Resident #110 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #110 was supervision with 1 staff for bed mobility, transfers, and dressing. A BIMS revealed Resident #110 was cognitively intact with a score of 12/15. During an observation on 2/14/17 at 10:17 a.m., observed Resident #110's call light on the floor, tucked into a slipper next to bed, out of reach of Resident #110. Resident #113 Review of a facility Face Sheet revealed Resident #113 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated revealed Resident #113 was a limited assist with 1 transfers, and toilet use, supervision with 1 staff for bed mobility and dressing. A BIMS revealed Resident #113 was cognitively intact with a score of 15/15. During an interview on 2/14/17 at 11:20 a.m., Resident #113 indicated she recently fell out of bed because the mattress was the wrong mattress. Resident #113 indicated she was asleep and rolled in her sleep, the mattress to the bed completely tipped her out of bed. Resident #113 indicated her call light was not within reach, and not clipped to her or her bedding. Resident #113 indicated she was unable to get help with her call light. Resident #113 indicated she had to wake her room-mate up to call for help. Resident #104 Review of a facility Face Sheet revealed Resident #104 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #104 was supervision with 1 staff for bed mobility, transfers, and dressing. A BIMS revealed Resident #104 was cognitively impaired. During an observation on 2/14/17 at 10:23 a.m., observed Resident #104 asleep in her bed, call light underneath wheel near the head of bed on floor. During an interview on 2/14/17 at 10:27 a.m., CNA L indicated residents should always have their call lights within reach, either clipped to their clothing, or bedding. During an interview on 2/14/17 at 10:50 a.m., DON B indicated call lights are always to be place within residents reach. DON B indicated the unit managers do rounds throughout their shifts and go into each resident room to ensure resident call lights are within reach. DON B indicated if the unit managers find something such as a call light not within reach of a resident, the unit manager will do real time teaching at that moment to the staff on the unit. Resident #105 Review of a facility Face Sheet revealed Resident #105 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #105 was an extensive assist with 1 staff for bed mobility, toilet use, and transfers. A BIMS revealed Resident #105 was cognitively intact with a score of 15/15. During an interview on 2/13/17 at 2:45 p.m., Resident #105 indicated response times for call lights are over 20 minutes. Resident #105 indicated she has had to wait over 45 minutes to get assistance from staff after pressing her call light. Resident #111 Review of a facility Face Sheet revealed Resident #111 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated ,[DATE] revealed Resident #111 was supervision with 1 staff for bed mobility, transfers, and dressing, and an extensive assist with toilet use, and personal hygiene. A BIMS revealed Resident #111 was cognitively intact with a score of 13/15 During an interview on 2/14/17 at 10:15 a.m., Resident #111's call light was on the monitor. Resident #111 indicated staff takes about 30-40 minutes to come into her room, Resident #111 indicated she needed to be repositioned because her bottom (buttocks) hurt. Resident #112 Review of a facility Face Sheet revealed Resident #112 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated revealed Resident #112 was an extensive assist with 2 staff for bed mobility, transfers, and dressing, and a total assist with 2 staff for toilet use, and personal hygiene. A BIMS revealed Resident #112 was cognitively impaired and unable to complete BIMS assessment. During an interview on 2/14/17 at 11:10 a.m., Resident #112's Family Member (FM) M indicated staff take at least 30 minutes to answer call lights. FM M indicated that Resident #112 was also recently rolled out of bed by a staff member when the staff member was doing a brief change on Resident #112. FM M indicated Resident 112 is unable to speak, make needs known, and roll over in bed. Resident #114 Review of a facility Face Sheet revealed Resident #114 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated revealed Resident #114 an extensive assist with 2 staff for transfers, bed mobility and toilet use, an extensive assist with 1 staff for eating. A BIMS revealed Resident #114 was cognitively impaired with a score of 08/15. During an observation on 2/14/17 at 11:29 a.m., Observed Resident #114 trying to get this surveyors attention as I walked passed his room. Upon entering Resident #114's room, he was seated up in a high back wheelchair on the right side of his bed, toward the footboard. Resident #114's call light was clipped to his pillow at the top of the bed, near the head board, approximately 4 feet behind the reach of the resident who was observed to have contracted arms and hands. During an interview on 2/14/17 at 11:29 a.m., Resident #114 was unable to speak verbally, but did nod his head yes and no when asked questions. Resident #114 was asked if he was wet, he responded with a yes head nod, a yes head nod to pain, a yes head nod if he had been waiting for someone for 10 minutes, a yes head nod to 20 minutes, and a yes head nod to over 30 minutes. When this surveyor asked if this happens often, Resident #114 nodded head yes. During an interview on 2/14/17 at 11:35 a.m., LPN N indicated 2 CNA's for the south east unit were on lunch break, and the other CNA is giving another resident a shower. LPN N indicated Resident #114 can make needs known to simple commands, yes and no questions by nodding his head. LPN N indicated Resident #114's assigned CNA is one of the CNA's on lunch break. During an observation on 2/14/17 at 11:36 a.m., along with LPN N Resident #114 was observed. LPN N confirmed the placement of Resident #114's call light clipped to the pillow at the top of Resident #114's headboard. During an interview on 2/14/17 at 11:37 a.m., LPN N indicated the call light would do Resident #114 no good if Resident #114 could not reach it to use, as Resident #114 is non-verbal. Resident #101 Review of a facility Face Sheet revealed Resident #101 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was an extensive assist with 2 staff for bed mobility, and toilet use, a total assist with 2 staff for transfers. A Brief Interview for Mental Status (BIMS) revealed Resident #101 was mildly cognitively impaired with a score of 10/15. During an interview on 2/13/17 at 12:10 p.m., Resident #101 indicated she had a bowel movement in her brief and had not been cleaned up, or bathed this morning, and she couldn't wait any longer. During an observation on 2/13/17 at 12:15 p.m., observed Resident #101's call light button above bed to be turned to red (indicating call light was on). On the outside of Resident #101's room no light indicator above door, and no sound coming from the hallway monitoring system. Resident #101 had dark matter in her fingernails, on her sheets, and top blanket, and a strong smell of urine and feces. During an interview on 2/13/17 at 12:17 p.m., Certified Nurse Aide (CNA) E indicated she did not think Resident #101 had been cleaned up by her assigned CNA, CNA F During an interview on 2/13/17 at 12:20 p.m., CNA F indicated she did not do Resident #101's morning bath, or brief change because CNA F thought therapy was going to do it. During an interview on 2/13/17 at 12:25 p.m., CNA C indicated that morning care includes full bed bath, washing face, hands, chest, upper body, hands and feet. CNA C indicated briefs should be check at least every two hours, and changed as needed. CNA C indicated Resident #101 should have been bathed, and had clean linens, a blue pad, and gown and or clothing put on by now. Resident #108 Review of a facility Face Sheet revealed Resident #108 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #108 was a extensive assist with 2 staff for bed mobility, transfers, dressing and a total use. A BIMS revealed Resident #108 was cognitively impaired with a score of 07/15. During an interview on 2/14/17 at 10:06 a.m., Resident #108 indicated he has waited a long time when he turns his call light on. Resident #108 indicated he waits at times over an hour. Resident #108 indicated his call light has been on, but he can only use the bathroom with help. Resident #108 indicated he had just had an incontinence episode of bowel movement because he has diarrhea. Resident #108 stated I feel like a burden, but I had to go. During an observation on 2/14/17 at 10:10 a.m., CNA C entered Resident #108's room, turned the call light off and informed Resident #108 I'll be back. CNA C did not ask Resident #108 what he needed. CNA C went out of Resident #108's room, and continued to pass breakfast trays. CNA C did not re-enter Resident #108's room until 10:24 a.m. During an interview on 2/14/17 at 10:12 a.m., CNA C indicated the needs of the resident should be met before turning the call light off. During an interview on 2/13/17 at 1:40 p.m., CNA G indicated the call system does not audibly sound at the monitoring boards in the middle of the units (can only be seen if staff walk up to the monitor to view). CNA G indicated the call system does not sound in the charting room either. CNA G indicated that the CNA's are to carry pagers on them, the call light alerts the pager and then CNA's answer the call lights. CNA G indicated she did not have a pager on her. CNA G indicated it is the policy to carry a pager at all times, but the facility is missing many of them, so CNA's are reliant on the monitor in the middle of the unit to check if call lights are on. During an interview on 2/13/17 at 1:45 p.m., Licensed Practical Nurse (LPN) H indicated she had no pager on her. LPN H indicated she had forgotten the pager in the office and that the facility is short of pagers. LPN H indicated management is aware of the pagers for staff being short. LPN H indicated that the pagers have been missing for over a month because staff puts them in their pockets and forget to leave them at the facility at the end of their shifts. During an interview on 2/13/17 at 2:00 p.m., CNA I indicated there have not been available pagers in over a month. CNA I indicated staff have to go to the middle of the hall to see the monitor to check for call lights that are on. CNA I indicated no sound comes from the monitor system. During an interview on 2/13/17 at 2:30 p.m., CNA J indicated when she arrived at work today, there were no available pagers. CNA J indicated the pagers have been short, or unavailable for well over a month. CNA J indicated no sound comes from the monitors, staff just have to look up at the monitor to check for call lights that are on. During an interview on 2/13/17 at 3:15 p.m. LPN O indicated he did not have a pager on him. During an interview on 2/14/17 at 8:40 a.m. Registered Nurse (RN) K indicated pagers for staff (CNA's) are missing, staff take them home and they don't bring them back. RN K indicates management is aware that CNA's are not carrying pagers. RN K reported that 6 minutes after a call light is turned on by a resident and unanswered, the page for assistance then goes to the nurse's pager. RN K indicated there is no sound for the call lights once a resident turns their call light on, the staff must go to the monitors in the middle of the unit to check the call lights that are on. During an interview on 2/13/17 at 3:00 p.m., Director of Nursing (DON) B indicated in January 2017 Administrative staff made changes to the call light system and no longer require CNA's to wear pagers. DON B indicated no sound comes from the monitors where call lights that are turned on are available for staff to see. DON B indicated staff relies on verbal communication to assist with call lights. DON B indicated it takes 6 minutes for the call light page to reach the nurses who carry pagers. On 2/14/17 the Director of Nursing was notified of an immediate Jeopardy that began January 31, 2017 due to the facilities failure to ensure 1.) the resident call light system was fully functional with centralized audible or visual signals, 2.) that staff have functioning devices for the wireless system in their possession and are answering resident call lights, and 3.) that resident call lights were within reach. On 2/21/17, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 2/14/17, all resident in the facility were reviewed to ensure safety and that their needs were met. 2. On 2/14/17, an audit was completed to ensure call lights are in place, licensed nurses have pagers per facility practice, and the residents' immediate needs are met. 3. On 2/14/17, an audit of facility pagers was completed to ensure availability and working order. 4. On 2/15/17, the QAPI committee The QAPI committee met to review the call light policy and found it to be appropriate and in accord with the intent of the regulation. 5. Beginning 2/15/17, actively scheduled Licensed Nurses and CENAs received education for expectations related to use of call light system and ensuring resident needs are met timely. Licensed Nurses and CENAs will receive this education prior to taking his/her scheduled assignment. If education not completed, the Nurse/CENA will not take an assignment. 6. Beginning 2/14/17, Interdisciplinary team member (IDT) will be assigned purposeful rounding rooms M-F and interview current residents with BIMS score of 8 or higher to ensure that needs are being met in a timely manner. Findings will be acted upon at time of identification. Although the immediate jeopardy was removed on 2/15/17, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the for minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed.

This citation pertains to intakes MI 072, MI 196 Based on observation, interviews, and record review, the facility failed to prevent serious accidents and ensure resident safety for 5 of 15 sampled residents (Resident #115, #101, #112, #113, and #103) reviewed for falls, rom a total sample of 15 residents, resulting in a fall with fracture in both Resident #115 and Resident #101, a fall from bed for Resident #112 after there were not enough staff present to perform personal care, a fall from bed for Resident #113 without major injury, and multiple falls without major injury for Resident #103. Findings include: Review of a facility Policy & Procedure titled Lippincott Procedures dated 11/11/16 revealed Falls are a major cause of injury and death among elderly people. Each year, one in three adults age 65 or older falls. Falls among long term care facility residents occur frequently. About 1,800 older adults living in long term care facilities die each year from fall-related injuries, and those who survive frequently sustain hip fractures and head injuries that result in permanent disability and reduced quality of life. After a fall-even if the resident shows no sign of distress or has sustained only minor injuries, monitor blood pressure, pulse, and respirations every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every 2 hours for 24 hours or until condition stabilizes. Documentation: After a fall, complete a detailed incident report to help track frequent resident falls so that your facility can implement prevention measures for high-risk residents. Resident #115 Review of a facility Face Sheet revealed Resident #115 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #115 was a limited assist with 1 staff for bed mobility, transfers, ambulation, dressing, and toilet use. A BIMS revealed Resident #115 was cognitively impaired with a score of 06/15. Review of a facility Care Plan report dated 10/21/16 revealed (Resident #115) Potential for injury associated with falls history related to right hip fracture prior to admission (Resident #115 was in the facility for rehabilitation). Review of a facility Incident/Accident report dated 11/23/16 at 6 a.m., revealed: (Resident #115) was observed laying face down in her room with her head close to the hallways door and her body parallel with the bathroom door. (Resident #115) stated that her arm and shoulder on her right side hurt. (Resident #115) Right shoulder had deformity and right anterior wrist was bruising. The document revealed there were no interventions implemented to prevent further falls or a root cause analysis to the cause of the fall. Review of a Emergency Department history and physical dated 11/23/16 revealed This is a [AGE] year old female (Resident #115). According to staff at (facility name) she was found on the floor. The fall was unwitnessed. A CT scan revealed a comminuted intraarticular fracture dislocation of the right humeral head (shoulder fracture) with severe osteoporotic bone. I (ED doctor) recommend a closed reduction to improve the alignment and get the humerous abducted against the body. During an interview on 2/15/17 at 1:00 p.m., Confidential Informant (CI) U indicated Resident #115 was at the facility for rehabilitation for a fall with a hip fracture. CI U indicated Resident #115 was very cautious when walking. CI U stated she (Resident #101) told (CI U) she fell because staff did not come when she turned her call light on, and (Resident #115) didn't want to have an accident (urinate in her pants). CI U indicated Resident #115 was able to make needs known, and (Resident #115) would not have gotten up on her own unless she absolutely had to. CI U indicated Resident #115 has always been continent of urine and bowel, and Resident #115 was fearful of falling again. During an interview on 2/13/17 at 1:40 p.m., CNA G indicated the call system does not sound, at the monitoring boards in the middle of the units (can only be seen if staff walk up to the monitor to view). CNA G indicated the call system does not sound in the charting room either. CNA G indicated that the CNA's are to carry pagers on them, the call light alerts the pager and then CNA's answer the call lights. CNA G indicated she did not have a pager on her. CNA G indicated it is the policy to carry a pager at all times, but the facility is missing many of them, so CNA's are reliant on the monitor in the middle of the unit to check if call lights are on. During an interview on 2/13/17 at 1:45 p.m., Licensed Practical Nurse (LPN) H indicated she had no pager on her. LPN H indicated she had forgotten the pager in the office. LPN H indicated the facility is short of pagers. LPN H indicated management is aware of the pagers for staff being short. LPN H indicated that the pagers have been missing for over a month because staff puts them in their pockets and forget to leave them at the facility at the end of their shifts. During an interview on 2/13/17 at 2:00 p.m., CNA I indicated there have not been available pagers in over a month. CNA I indicated staff have to go to the middle of the hall to see the monitor to check for call lights that are on. CNA I indicated no sound comes from the monitor system. During an interview on 2/13/17 at 2:30 p.m., CNA J indicated when she arrived at work today, there were no available pagers. CNA J indicated the pagers have been short, or unavailable for well over a month. CNA J indicated no sound comes from the monitors, staff just have to look up at the monitor to check for call lights that are on. During an interview on 2/14/17 at 8:40 a.m. Registered Nurse (RN) K indicated pagers for staff (CNA's) are missing, staff take them home and they don't bring them back. RN K indicates management is aware that CNA's are not carrying pagers. RN K reported that 6 minutes after a call light is turned on by a resident and unanswered, the page for assistance then goes to the nurse's pager. RN K indicated there is no sound for the call lights once a resident turns their call light on, the staff must go to the monitors in the middle of the unit to check the call lights that are on. Resident #101 Review of a facility Face Sheet revealed Resident #101 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was an extensive assist with 2 staff for bed mobility, and toilet use, a total assist with 2 staff for transfers. A Brief Interview for Mental Status (BIMS) revealed Resident #101 was mildly cognitively impaired with a score of 11/15. Review of a facility Care Plan report dated 10/3/14 for Resident #101 revealed Potential for injury associated with falls related to history of falls, impaired cognition, incontinence, pain and impaired mobility. Re-admit 1/30/17 with right hip fracture. Review of a facility Clinical Note dated 1/25/17 at 5:32 a.m., revealed (Certified Nurse Aide Q) called this nurse to room (Resident #101's). This nurse observed resident lying on the floor on the left side of her bed. Resident's body was positioned on the left side. (CNA Q) explained that she was trying to help (Resident #101) get cleaned up, when (Resident #101) pulled on assisting bar to turn herself and rolled out of bed onto the floor. During this incident (Resident #101) obtained a 4.5 cm x 2.5 cm skin tear on right forearm. (Resident #101) complained of right hip pain. Review of a facility Incident/Accident report dated 1/25/17 at 4:45 a.m., revealed CNA Q called this nurse to (Resident #101's) room. This nurse observed resident laying on the floor on left side of her bed. (Resident #101's) body was positioned on the left side. CNA Q explained that she was helping (Resident #101) get cleaned up when the resident pulled on side rail to turn herself and rolled out of bed. During an interview on 2/13/17 at 11:15 a.m., Confidential Informant (CI) W indicated Resident #101 fell out of the bed on 1/25/17 because Resident #101 only had 1 staff assisting her. CI W indicated Resident #101 is a 2 person assist with care because Resident #101 in unable to turn herself, or provide care on her own. CI I indicated Resident #101 is in pain due to her medical conditions. CI W indicated there is no way Resident #101 had strength enough to turn, roll or pull/push on a bar, and fall approximately 3 feet from a raised bed onto a tile floor. CI W indicated Resident #101 told CI W that on 1/25/17 the CNA caring for her that morning told Resident #101 not to worry about her foot being stuck under the blankets. CI W stated I just don't understand how Resident #101 who can do next to nothing for herself, falls 3 feet from a bed CI W indicated facility staffing is not responding to resident call lights in a timely manner, and many times CI W has observed call lights out of reach of Resident #101. During an interview on 2/21/17 at 6:00 a.m., CNA Q indicated she was doing care on Resident #101 on 1/25/17 at approximately 4:30 a.m., CNA Q indicated when she rolled Resident #101 away from her to wash her buttock and change her brief, Resident #101 rolled off the bed. CNA Q indicated Resident #101 did not have side rails or a bar on the opposite side of the bed. CNA Q indicated she thinks Resident #101 was holding onto the bed frame and rolled herself out of the bed onto the floor. CNA Q indicated the bed was approximately 3 1/2 feet up in the air. CNA Q indicated she yelled for help. CNA Q indicated she was unaware that Resident #101 was a 2 person assist with cares. During an interview on 2/13/17 at 10:20 a.m., Resident #101 indicated she recently fell out of bed. Staff (CNA Q) wanted her to roll over, and it hurts her to roll over. Resident #101 stated staff tell you what to do, I'm old and I was trying to roll over, but I couldn't get my foot over the other one. I told her (CNA Q) 'I'm slipping, I'm slipping'. I said I'm falling. Resident #101 indicated CNA Q was arguing with her and that they were fighting about her foot/leg the entire time. Resident #101 indicated it hurts her so much to move, and be moved. Resident #101 indicated she went to the hospital after the fall. Resident #101 indicated there were no bars on the side of her bed the morning she fell out of bed. Review of a Hospital History & Physical dated 1/25/17 revealed This is a pleasant [AGE] year old female (Resident #101) who resides at a local nursing facility, I believe, (facility name) who was brought in via ambulance due to hip pain. The patient (Resident #101) was being rolled on her side and being changed in which somehow she fell out of bed during her care. The patient (Resident #101) landed on her right side and had immediate and severe right hip pain. The patient (Resident #101) was found on x-ray to have a right supcapital femoral neck impacted fracture (right hip fracture) and orthopedics was subsequently consulted (for surgical repair). Resident #101 underwent surgical repair of her fractured hip. During an interview on 2/21/17 at 12:35 p.m., Licenses Practical Nurse/Clinical Care Coordinator (LPN/CCC) P indicated Resident #101 should have 2 staff assisting with her brief change on 1/25/17 at the time of the fall. LPN/CCC P indicated Resident #101 was updated to a 2 person assist on the CNA guide, but not until after the fall. LPN/CCC indicated Resident #101's care guide should have been updated prior to the fall, as noted in her MDS assessment from 11/16 and also the MDS assessment prior to the 11/16's where Resident #101 was a max assist with 2 staff for bed mobility, transfers, and toileting. Resident #112 Review of a facility Face Sheet revealed Resident #112 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #112 was an extensive assist with 2 staff for bed mobility, transfers, and dressing, and a total assist with 2 staff for toilet use and personal hygiene. A BIMS revealed Resident #112 was cognitively impaired and unable to complete BIMS assessment. Review of a facility Care Plan report dated 12/21/15 for Resident #112 revealed (Resident #112) is at risk for skin break down/pressure ulcer related to decreased mobility, dependant with bed mobility Review of a facility Incident/Accident report dated 2/9/17 at 12:45 a.m., (CNA R) states that during care and total bed change after vomiting, (CNA R) rolled resident to her right side away from (CNA R) to apply an incontinence pad under (Resident #112) holding (Resident #112) with left hand, and using right hand to put pad down, when (Resident #112) moved and leaned forward and hit right arm to bedside chair and fell on her (Resident #112's) back on the floor. The document revealed Resident #112 sustained a bump and abrasion back of head 2 cm x 1.5 cm slightly red. right foot swollen and contracted. The document indicated that CNA (R) rolled (Resident #112) away from self and when resident moved (CNA R) unable to hold on to her (Resident #112). During an interview on 2/14/17 at 11:10 a.m., FM M indicated that Resident #112 was recently rolled out of bed by a staff member when the staff member was doing a brief change on Resident #112. FM M indicated Resident 112 is unable to speak, make needs known, or roll over in bed. FM M indicated he visits daily, and does some care for Resident #112, and that there is no way Resident #112 rolled herself out of her bed. FM M indicated Resident #112 is suppose to have 2 staff present when care is done. Resident #113 Review of a facility Face Sheet revealed Resident #113 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated revealed Resident #113 was a limited assist with 1 transfers and toilet use, supervision with 1 staff for bed mobility and dressing. A BIMS revealed Resident #113 was cognitively intact with a score of 15/15. Review of a facility Incident/Accident report dated 2/9/17 at 5:15 a.m., revealed (Resident #113) found on floor by her bed when CNA saw her (Resident #113's) roommate by their door notifying staff of (Resident #113) yelling for help. (Resident #113) states she rolled to her left side when the mattress flipped ad she fell on the floor by her window. (Resident #113) states she landed on her left knee. Describe the fall: (Resident #113) was trying to roll to her left side when her mattress flipped over and (Resident #113) went on the floor. Intervetions to prevent further falls wre documented ask maintenance to check on bed and mattress. During an interview on 2/14/17 at 11:20 a.m., Resident #113 indicated she recently fell out of bed because the mattress was the wrong mattress. Resident #113 indicated she was asleep and rolled in her sleep, the mattress to the bed completely tipped her out of bed. Resident #113 indicated her call light was not within reach, and not clipped to her or her bedding. Resident #113 indicated she was unable to get help with her call light. Resident #113 indicated she had to wake her room-mate up to call for help. During an interview on 2/21/17 at 8:40 a.m., Environmental Services Director (ESD) T indicated Resident #113 had a concave mattress on 2/9/17. ESD T indicated he is unaware if on admission appropriate mattresses are part of the assessment of the residents. ESD T indicated Resident #113 rolled over and due to the upward wing on the side of the mattress caused it to flip over. ESD T indicated the mattress was not fastened to the bed, and if Resident #113 would have had a bariatic (larger/wider/flat) mattress, it would not have flipped Resident #113 out of her bed. ESD T indicated the mattress at the time of Resident #113's fall was too small, and with the shape of that mattress, and Resident #113's weight led to it flipping over when she rolled. Resident #103 Review of a facility Face Sheet revealed Resident #103 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #103 was a limited assist with 1 staff for bed mobility, transfers, dressing, and toilet use. A BIMS revealed Resident #103 was mildly cognitively impaired with a score of 10/15. During an observation on 2/13/17 at 1:1:35 p.m., Resident #103 observed laying in his bed, 2 cm laceration above right eye with a steri-strip covering a laceration. During an interview on 2/13/17 at 1:40 p.m., Resident #103 indicated staff at the facility are not helpful with answering his call light. Resident #103 indicated he completes most of his daily care on his own. Resident #103 indicated he had a headache, and is in pain due to a recent fall. Review of a facility Care Plan dated 4/22/15 revealed: (Resident #103) Potential for injury associated with falls related to decreased mobility, seizure disorder, recent history of frequent falls. Review of a facility Incident/Accident reported dated 1/10/17 at 4:40 p.m., revealed: CNA observed (Resident #103) sitting on the floor on his bottom. (Resident #103) was going to brush his teeth and lost his balance. The document revealed there were no interventions implemented to prevent further falls or a root cause analysis to the cause of the fall. Review of a facility Incident/Accident reported dated 1/17/17 at 1:55 p.m., revealed: This nurse observed (Resident #103) sitting on the floor beside his bed. The (CNA-V) was walking (Resident #103) back to his room to his bed from the bathroom, when he sat on the bed he slid off the edge onto the floor. The document revealed obtain a less slippery mattress as an intervention to prevent further falls. During an interview on 2/21/17 at 10:00 a.m., CNA V indicated she was walking Resident #103 back to his bed after morning care on 1/17/17, when he went to sit down, he was not close enough to the center of the bed, and he slid down the edge of the mattress onto his buttocks. CNA V indicated Resident #103 is a 1 person assist with transfers, and the clinical care coordinators are aware of his frequent falls. CNA V indicated she is unaware if any new interventions, or changes to his transfer status, but if staff feels unsafe with transfers, or a resident needs a higher level, staff can always go up a level to a 2 person assist without an order from the therapy department. CNA V indicated she is unaware if other staff is anticipating Resident #103's needs, and addressing the amount of falls he is having. Review of a facility Incident/Accident reported dated 1/30/17 at 11:30 a.m., revealed: Maintenance alerted this nurse. observed (Resident #103) lying on the floor on his right side in bathroom still slightly twitching from what appears to be a seizure, head towards bathroom door and in fetal position. injury: laceration above right eye and laceration to left forehead. X-ray taken: NO, Follow up actions: Not specified. Review of a facility Incident/Accident reported dated 1/30/17 at 12:30 p.m., revealed: CNA walking (Resident #103) back to bed from bathroom. (Resident #103) lost balance and slid down closet door to floor. Review of a facility Incident/Accident reported dated 1/30/17 at 6:30 p.m., revealed: CNA reports found (Resident #103) on floor sitting by his bed. states slid down from bed. The document revealed dycem applied on mattress under sheet as an intervention to prevent further falls. Review of a facility Incident/Accident reported dated 2/6/17 at 7:10 p.m., revealed: observed (Resident #103) on floor at the end of roommates bed on his back. The document revealed there were no interventions implemented to prevent further falls or a root cause analysis to the cause of the fall. Review of a facility Incident/Accident reported dated 2/7/17 at 12:00 a.m., revealed: unwitnessed fall (Resident #103) was trying to get up out of bed and slid off the end of bed onto his bottom. The document revealed there were no interventions implemented to prevent further falls or a root cause analysis to the cause of the fall. Review of a facility Incident/Accident reported dated 2/7/17 at 2:30 p.m., revealed: unwitnessed fall (Resident #103) observed kneeling at the side of his bed, when asked what happened, stated he (Resident #103) rolled out of bed. The document revealed there were no interventions implemented to prevent further falls or a root cause analysis to the cause of the fall. Review of a facility Incident/Accident reported dated 2/10/17 at 6:30 p.m., revealed: unwitnessed fall (Resident #103) observed on floor in his bathroom sitting on his butt. The document revealed there were no interventions implemented to prevent further falls or a root cause analysis to the cause of the fall. Review of a facility Incident/Accident reported dated 2/11/17 at 7:10 p.m., revealed: unwitnessed fall (Resident #103) observed on floor in room between bed and door with walker next to him. The document revealed there were no interventions implemented to prevent further falls or a root cause analysis to the cause of the fall.

This citation pertains to intakes MI 072, MI 196 Based on observation, interview, and record review the facility failed to develop, update, and implement care plans to prevent falls in 7 of 15 residents (#101, #103, #104 #112, #113, #114 and #115) reviewed for accidents and supervision, from a total sample of 15 residents, resulting in multiple falls, falls with injuries (fractures) and the potential for continued falls with major injury. Findings include: Resident #101 Review of a facility Face Sheet revealed Resident #101 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was an extensive assist with 2 staff for bed mobility, and toilet use, a total assist with 2 staff for transfers. A Brief Interview for Mental Status (BIMS) revealed Resident #101 was mildly cognitively impaired with a score of 11/15. Review of a facility Incident/Accident report dated 1/25/17 at 4:45 a.m., revealed CNA Q called this nurse to (Resident #101's) room. This nurse observed resident laying on the floor on left side of her bed. (Resident #101's) body was positioned on the left side. CNA Q explained that she was helping (Resident #101) get cleaned up when the resident pulled on side rail to turn herself and rolled out of bed. Review of a facility Care Plan report dated 10/3/14 for Resident #101 revealed Potential for injury associated with falls related to history of falls, impaired cognition, incontinence, pain and impaired mobility. Re-admit 1/30/17 with right [MEDICAL CONDITION]. During an interview on 2/13/17 at 10:20 a.m., Resident #101 indicated she recently fell out of bed and Staff (CNA) Q wanted her to roll over, and it hurts her to roll over. Resident #101 stated staff tell you what to do, I'm old and I was trying to roll over, but I couldn't get my foot over the other one. During an interview on 2/21/17 at 6:00 a.m., CNA Q indicated she was doing care on Resident #101 on 1/25/17 at approximately 4:30 a.m., CNA Q indicated when she rolled Resident #101 away from her to wash her buttock and change her brief, Resident #101 rolled off the bed. CNA Q indicated she was unaware that Resident #101 was a 2 person assist with cares. During an observation on 2/13/17 at 12:45 p.m., observed Resident #101's right hip surgical incision. Review of a facility Care Plan report dated 10/3/14 for Resident #101's interventions after a fall revealed no new fall prevention interventions noted. One new addition dated 2/10/17 (2 1/2 weeks after Resident #101's fall) offer Resident #101 personal teddy bear to hold with turning/repositioning due to increased anxiety. Resident #103 Review of a facility Face Sheet revealed Resident #103 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #103 was a limited assist with 1 staff for bed mobility, transfers, dressing, and toilet use. A BIMS revealed Resident #103 was mildly cognitively impaired with a score of 10/15. During an observation on 2/13/17 at 1:1:35 p.m., Resident #103 observed laying in his bed, 2 cm laceration above right eye with a steri-strip covering the laceration. During an interview on 2/13/17 at 1:40 p.m., Resident #103 indicated staff at the facility are not helpful with answering his call light. Review of a facility Care Plan dated 4/22/15 revealed: (Resident #103) Potential for injury associated with falls related to decreased mobility, [MEDICAL CONDITION] disorder, recent history of frequent falls. This document did not show any new interventions that are related to the frequent falls Resident #103 has had (indicated below). This document failed to address person centered interventions, safety, education, root cause. Review of a facility Incident/Accident reported dated 1/10/17 at 4:40 p.m., revealed: CNA observed (Resident #103) sitting on the floor on his bottom. (Resident #103) was going to brush his teeth and lost his balance. Additional review of this document revealed: Post fall question: 1. what could we do together to prevent this from happening again? -narrative: document left blank 2. what is the gap? what was different this time that may have led to the fall? -narrative: document left blank. Review of a facility Incident/Accident reported dated 1/17/17 at 1:55 p.m., revealed: This nurse observed (Resident #103) sitting on the floor beside his bed. The (CNA-V) was walking (Resident #103) back to his room to his bed from the bathroom, when he sat on the bed he slid off the edge onto the floor. Post fall question: 1. what could we do together to prevent this from happening again? -narrative: obtain a less slippery mattress. 2. what is the gap? what was different this time that may have led to the fall? -narrative: sat too close to the edge of the bed and slid out. During an interview on 2/21/17 at 10:00 a.m., CNA V indicated she was walking Resident #103 back to his bed after morning care on 1/17/17, when he went to sit down, he was not close enough to the center of the bed, and he slid down the edge of the mattress onto his buttocks. CNA V indicated Resident #103 is a 1 person assist with transfers, and the clinical care coordinators are aware of his frequent falls. CNA V indicated she is unaware if any new interventions, or changes to his transfer status, but if staff feels unsafe with transfers, or a resident needs a higher level, staff can always go up a level to a 2 person assist without an order from the therapy department. CNA V indicated she is unaware if other staff is anticipating Resident #103's needs, and addressing the amount of falls he is having. Review of a facility Incident/Accident reported dated 1/30/17 at 11:30 a.m., revealed: Maintenance alerted this nurse. observed (Resident #103) lying on the floor on his right side in bathroom still slightly twitching from what appears to be a [MEDICAL CONDITION], head towards bathroom door and in fetal position. injury: laceration above right eye and laceration to left forehead. X-ray taken: NO, Follow up actions: Not specified. Review of a facility Incident/Accident reported dated 1/30/17 at 12:30 p.m., revealed: CNA walking (Resident #103) back to bed from bathroom. (Resident #103) lost balance and slid down closet door to floor. Review of a facility Incident/Accident reported dated 1/30/17 at 6:30 p.m., revealed: CNA reports found (Resident #103) on floor sitting by his bed. states slid down from bed. Post fall question: 1. what could we do together to prevent this from happening again? -narrative: dycem applied on mattress under sheet. 2. what is the gap? what was different this time that may have led to the fall? -narrative: see above. (note 3rd fall on 1/30/17- on reports NO answered to care plan update). Review of a facility Incident/Accident reported dated 2/6/17 at 7:10 p.m., revealed: observed (Resident #103) on floor at the end of roommates bed on his back. Further review of this document revealed Not Applicable answered to care plan update. Review of a facility Incident/Accident reported dated 2/7/17 at 12:00 a.m., revealed: unwitnessed fall (Resident #103) was trying to get up out of bed and slid off the end of bed onto his bottom. Review of this document revealed NO answered to care plan update. Review of a facility Incident/Accident reported dated 2/7/17 at 2:30 p.m., revealed: unwitnessed fall (Resident #103) observed kneeling at the side of his bed, when asked what happened, stated he (Resident #103) rolled out of bed. Review of this document revealed Not Applicable answered to care plan update. (note 2nd fall on 2/7/17). Review of a facility Incident/Accident reported dated 2/10/17 at 6:30 p.m., revealed: unwitnessed fall (Resident #103) observed on floor in his bathroom sitting on his butt. further review of this document revealed Not Applicable answered to care plan update. (note 2nd fall on 2/10/17 another fall occurred at 4:40 p.m., facility indicated the report was stuck in the computerized system unable to be printed for this surveyor to review). Review of a facility Incident/Accident reported dated 2/11/17 at 7:10 p.m., revealed: unwitnessed fall (Resident #103) observed on floor in room between bed and door with walker next to him. further review of this document revealed NO answered to care plan update. This surveyor requested documentation from nursing notes, behavioral logs, 15 minutes checks, 1:1 staffing, vital signs/neuro checks as stated in facility policy after a fall. No documentation was provided to this surveyor by time of exit. Resident #104 Review of a facility Face Sheet revealed Resident #104 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #104 required supervision with 1 staff for bed mobility, transfers, and dressing. A BIMS revealed Resident #104 was cognitively impaired. During an interview on 2/14/17 at 10:21 a.m., CNA L indicated residents should always have their call lights within reach, either clipped to their clothing, or bedding. During an observation on 2/14/17 at 10:23 a.m., observed Resident #104 asleep in her bed, her call light was underneath the bed wheel near the head of bed on floor. During an interview on 2/14/17 at 10:50 a.m., Director of Nursing (DON) B indicated call lights are always to be place within residents reach. DON B indicated the unit managers do rounds throughout their shifts and go into each resident room to ensure resident call lights are within reach. DON B indicated if the unit managers find something such as a call light not within reach of a resident, the unit manager will do real time teaching at that moment to the staff on the unit. During an observation on 2/14/17 at 11:52 a.m., observed Resident #104 asleep in her bed, her call light remained in the same location as the previous observation, underneath the bed wheel near the head of bed on floor. During an interview on 2/14/17 at 11:53 a.m., Licensed Practical Nurse/Clinical Care Coordinator (LPN/CCC) P indicated she does rounds as the supervisor on the unit for Resident #104. LPN/CCC P indicated she enters all the resident rooms, and assesses the room, checks call light placement, hazards, infection control concerns, house keeping concerns, needs of the residents. LPN/CCC P indicated that since 7:00 a.m., she had done rounds on her assigned rooms, and found no concerns. LPN/CCC P indicated she had recently been in Resident #104's room, and found no concerns. Resident #112 Review of a facility Face Sheet revealed Resident #112 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #112 was an extensive assist with 2 staff for bed mobility, transfers, and dressing, and a total assist with 2 staff for toilet use, and personal hygiene. A BIMS revealed Resident #112 was cognitively impaired and unable to complete BIMS assessment. Review of a facility Care Plan report dated 12/21/15 for Resident #112 revealed (Resident #112) is at risk for falls related to high risk assessment, decreased mobility, and dependant with bed mobility Review of a facility Incident/Accident report dated 2/9/17 at 12:45 a.m., (CNA R) states that during care and total bed change after vomiting, (CNA R) rolled resident to her right side away from (CNA R) to apply an incontinence pad under (Resident #112) holding (Resident #112) with left hand, and using right hand to put pad down, when (Resident #112) moved and leaned forward and hit right arm to bedside chair and fell on her (Resident #112's) back on the floor. Review of this document revealed: If injury describe: bump and abrasion back of head 2 cm x 1.5 cm slightly red. right foot swollen and contracted. Post fall question: 1. what could we do together to prevent this from happening again? -narrative: try to roll (Resident #112) toward self for better safety and protection. Post fall question 2. what is the gap? what was different this time that may have led to the fall? -narrative: (CNA R) rolled (Resident #112) away from self and when resident moved (CNA R) unable to hold on to her (Resident #112). During an interview on 2/14/17 at 11:10 a.m., FM M indicated that Resident #112 was recently rolled out of bed by a staff member when the staff member was doing a brief change on Resident #112. FM M indicated Resident 112 is unable to speak, make needs known, or roll over in bed. FM M indicated he visits daily, and does some care for Resident #112, and that there is no way Resident #112 rolled herself out of her bed. FM M indicated Resident #112 is suppose to have 2 staff present when care is done. During an interview on 2/21/17 at 10:30 a.m., RNX indicated Resident #112 should have been a 2 person assist with bed mobility, and cares as noted in the MDS assessment. RNX indicated no care plan interventions were updated to reflect the fall Resident #112 had on 2/9/17. Resident #113 Review of a facility Face Sheet revealed Resident #113 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated revealed Resident #113 was a limited assist with 1 transfers, and toilet use, supervision with 1 staff for bed mobility and dressing. A BIMS revealed Resident #113 was cognitively intact with a score of 15/15. Review of a facility Incident/Accident report dated 2/9/17 at 5:15 a.m., revealed (Resident #113) found on floor by her bed when CNA saw her (Resident #113's) room-mate by their door notifying staff of (Resident #113) yelling for help. (Resident #113) states she rolled to her left side when the mattress flipped ad she fell on the floor by her window. (Resident #113) states she landed on her left knee. Describe the fall: (Resident #113) was trying to roll to her left side when her mattress flipped over and (Resident #113) went on the floor. The document revealed Post fall question: 1. what could we do together to prevent this from happening again? -narrative: ask maintenance to check on bed and mattress. During an interview on 2/14/17 at 11:20 a.m., Resident #113 indicated she recently fell out of bed because the mattress was the wrong mattress. Resident #113 indicated she was asleep and rolled in her sleep, the mattress to the bed completely tipped her out of bed. Resident #113 indicated her call light was not within reach, and not clipped to her or her bedding. Resident #113 indicated she was unable to get help with her call light. Resident #113 indicated she had to wake her room-mate up to call for help. During an interview on 2/21/17 at 8:40 a.m., Environmental Services Director (ESD) T indicated Resident #113 had a concave mattress on 2/9/17. ESD T indicated Resident #113 rolled over and due to the upward wing on the side of the mattress caused it to flip over. ESD T indicated the mattress was not fastened to the bed. ESD T indicated the mattress at the time of Resident #113's fall was too small, and with the shape of that mattress, and Resident #113's weight, led to it flipping over when she rolled. Resident #114 Review of a facility Face Sheet revealed Resident #114 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated revealed Resident #114 was an extensive assist with 2 staff for transfers, bed mobility and toilet use, an extensive assist with 1 staff for eating. A BIMS revealed Resident #114 was cognitively impaired with a score of 08/15. Review of a facility Incident/Accident report dated 11/22/16 at 6:30 a.m., revealed: (CNA S) was removing (Resident #114) from his place at the table when she pulled his wheelchair away from the table (Resident #114) leaned forward and fell head first onto the floor. 3.1 cm laceration noted to right temple are of his forehead. The document revealed Post fall question: 1. what could we do together to prevent this from happening again? -narrative: recline wheelchair back prior to removing (Resident #114) from dinner table. 2. what is the gap? what was different this time that may have led to the fall? -narrative: proper wheelchair seating position. Request made for education/documenting for staffing in regards to Resident #114's fall, anticipation of needs, safety with devices, reclining wheelchair. No documents were provided to this surveyor. Review of a facility Care Plan report dated 8/2/16 for Resident #114 revealed (Resident #114) is at risk for falls related to history of falls, impaired mobility. There were no new interventions put into place or updated after Resident #114's fall on 11/22/16. Resident #115 Review of a facility Face Sheet revealed Resident #115 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed Resident #115 was a limited assist with 1 staff for bed mobility, transfers, ambulation, dressing, and toilet use. A BIMS revealed Resident #115 was cognitively impaired with a score of 06/15. Review of a facility Care Plan report dated 10/21/16 revealed (Resident #115) Potential for injury associated with falls history related to right [MEDICAL CONDITION] prior to admission. Review of a facility Incident/Accident report dated 11/23/16 at 6 a.m., revealed: (Resident #115) was observed laying face down in her room with her head close to the hallways door and her body parallel with the bathroom door. (Resident #115) stated that her arm and shoulder on her right side hurt. (Resident #115) Right shoulder had deformity and right anterior wrist was bruising. The document revealed Post fall question: 1. what could we do together to prevent this from happening again? -narrative: document left blank 2. what is the gap? what was different this time that may have led to the fall? -narrative: document left blank. Review of a Emergency Department history and physical dated 11/23/16 revealed This is a [AGE] year old female (Resident #115). According to staff at (facility name) she was found on the floor. The fall was unwitnessed. A CT scan revealed a comminuted intraarticular fracture dislocation of the right humeral head with severe osteoporotic bone. I (ED doctor) recommend a closed reduction to improve the alignment and get the humerous abducted against the body. General appearance: (Resident #115) is frail, appears very thin, she is pleasant, very conversational although with mild dementia. During an interview on 2/15/17 at 1:00 p.m., Confidential Informant (CI) U indicated Resident #115 was at the facility for rehabilitation for a fall with a [MEDICAL CONDITION]. CI U indicated Resident #115 was very cautious when walking. CI U stated she (Resident #101) told CI U she fell because staff did not come when she turned her call light on, and (Resident #115) didn't want to have an accident (urinate in her pants). CI U indicated Resident #115 was able to make needs known, and (Resident #115) would not have gotten up on her own unless she absolutely had to. CI U indicated Resident #115 has always been continent of urine and bowel, and Resident #115 was fearful of falling again. CI U indicated at times in the facility, residents in the dining room often try to get up on their own because there are no staff present. CI U indicated Resident #115 did not have an alarm in place to notify staff, even after staff had noted Resident #115 trying to get to the bathroom at times. CI U indicated the only reason Resident #115 would attempt to go to the bathroom alone would be due to staff not being present. CI U indicated Resident #115 was aware she was planned to return home the week of the fall, and she (Resident #115) must have had to use the bathroom pretty bad for her to walk unassisted. During an interview on 2/13/17 at 3:00 p.m., Director of Nursing (DON) B indicated in January 2016 Administrative staff made changes to the call light system and no longer require CNA's to wear pagers. DON B indicated no sound comes from the monitors where call lights that are turned on are available for staff to see. DON B indicated staff relies on verbal communication to assist with call lights. DON B indicated it takes 6 minutes for the call light page to reach the nurses who carry pagers. During an interview on 2/15/17 at 2:20 p.m., MDS Nurse Y indicated she does updates to all Residents she is assigned over a look back period at the time of the residents annual or quarterly assessments. MDS Y indicated, any time there is a change in a residents condition, especially a fall, the incident/accident report should be completely filled out, top to bottom all areas filled in with some answer. At the time of the fall, or shortly there after the nurse assessing the resident should go into the care plan and update accordingly. MDS Y indicated this does not always happen. MDS Y indicated care plans are the detailed reports the staff rely on to paint a picture of the resident and their needs, they should be up to date, accurate, and specific to each resident.

This citation pertains to intake MI 399 Based on observation, interview, and record review, the facility failed to ensure proper resident transfer for 1 of 3 (#1) residents reviewed for transfers from a total sample of 6 residents, resulting in a fractured arm. Findings: On 6/8/15, the facility identified an incident resulting in an injury to a resident. The facility reported the incident within 24 hours to the State Agency and started an investigation. The facility completed an investigation within 5 days and reported the results to the State Agency. On 6/30/15, an unannounced on site investigation was initiated for the facility reported incident Review of the medical record revealed Resident #1 was a [AGE] year old female admitted to the facility 12/3/10, with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], revealed Resident #1 was severely cognitively impaired. Review of the facility investigation revealed a bruise was noted on the arm of Resident #1 on 6/6/15. An X-ray revealed a fracture of the arm. The Director of Nursing (DON) B initiated an investigation and discovered on 6/5/15, Certified Nurse Aide (CNA) C had completed an improper transfer. The investigation revealed Resident #1 had been transferred using a EZ Stand mechanical lift (a lift that moves a resident to a standing position) rather than the Hoyer Lift (a lift where a resident is recumbent in a hammock-type sling) as indicated on the facility Resident Summary (a facility document that summarizes a resident's needs and specific care the methods). On 7/2/15, at 11:43 AM, an interview was conducted with DON B. DON B reported during the investigation of a cause for the bruise and fracture of the arm of Resident #1 CNA C was contacted. DON B reported CNA C told her of the improper transfer he performed on 6/5/15. On 6/30/15, at 4:50 PM, an interview was conducted with CNAC. CNA C reported he had provided care for Resident #1, was familiar with her, and she accepted care well. CNA C reported he was not sure if he had checked the Resident Summary that day or in the proceeding days. CNA C indicated if he had not received report of a change he assumed the transfer status was unchanged. CNA C reported on 6/5/15, he pushed Resident #1 in her Rock-N-Go chair from the lounge to her room. CNA C reported he transferred Resident #1 from the chair using an EZ Stand lift. CNA C reported he had applied all of the straps of the EZ Stand lift correctly, lifted the Resident and held her in a standing position while he performed personal care. CNA C reported during this care the Resident's right leg slipped and he immediately spotted (supported) the right side. CNA C was asked if he had grabbed the right arm of the Resident. CNA C stated, I may have, I remember concentrating on her torso. CNA C reported he assisted Resident #1 to a sitting position on the edge of the bed and completed care. CNA C reported he did not consider the event significant as Resident #1 did not do anything that indicated harm. CNA C reported he did not tell the nurse of the incident. CNA C reported he was aware Resident #1 should have been transferred by a Hoyer lift. In an interview conducted 7/1/15, at 12:20 PM, Licensed Practical Nurse (LPN) E reported she absolutely expects CNA's to know the transfer status of a resident before initiating a transfer. LPN E reported the information on transfer status is readily available in the computer. In an observation and interview conducted 7/1/15, at 12:25 PM, CNA F demonstrated how to access the wall mounted computer in the hall and review the Resident Summary for transfer status. CNA F reported staff should always check the status, and to do so, only takes seconds. On 7/1/15, at 11:35 AM, it was observed all resident halls of the facility have wall mounted monitors for resident documentation and review of care records. It was observed staff transferring Resident #1 from the lounge to her room would have passed by a monitor. In an interview conducted 7/2/15, at 9:05 AM, Therapy Manager (TM) D reported the Resident Summary of Resident #1 was modified 1/8/15, to a Hoyer lift for transfers. TM D reported when a resident's transfer status is determined initially or changed the Therapy Department will make the change in the computer. TM D reported prior to the use of computers for resident care in the facility a paper communication was given to the nurse along with a verbal report. TM D reported this process has continued in addition to the computer record as a double safety. TM D reported there is no reason staff could not know a resident's transfer status.