Every finding on record at Medilodge of Campus Area

Based on observation, interview and record review, the facility failed to ensure the code status was accurate and reflective of the resident's wishes for one (R7) of two reviewed.Findings include: Review of the medical record reflected R7 admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes, legal blindness and presence of an artificial eye. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had impaired vision without corrective lenses and no natural teeth or tooth fragments (edentulous). According to the medical record, R7 was her own responsible party. On [DATE] at 2:52 PM, R7 was observed seated in a wheelchair, in her room. R7's medical record included a document titled, Advanced Directives Acknowledgements / CPR Consent, which was marked for, No Resuscitation: In the event of a cardiac arrest I am requesting a DNR [do not resuscitate/no CPR] order be issued (must fill out state appropriate form). R7's name was signed on the document, which was dated [DATE]. R7's medical record reflected a Physician's Order for full resuscitation (cardiopulmonary resuscitation/CPR). A Social Services Progress Note, dated [DATE], reflected R7 was self-responsible and a full code. A Physician Progress Note, dated [DATE], reflected, .After our discussion, patient expresses understanding regarding the course of illness and prognosis. Personally confirmed that the patient's code status is DNR . In an interview on [DATE] at 10:16 AM, Social Worker (SW) F reported the Admissions Department completed Advance Directives for those with a full code status upon admission. SW F reported she was responsible for DNRs and tried to see new admit residents on the day of admission or the following day. Upon discussion of R7's code status, SW F reported R7 was a full code. Upon review of R7's medical record documents, during the interview, SW F stated there was a problem. SW F reported R7's document (Advanced Directives Acknowledgements / CPR Consent) was marked for no resuscitation. SW F indicated that was the incorrect form for DNR code status. SW F stated she spoke to R7 after admission, and R7 chose to be a full code. SW F reported she would need to clarify code status with R7. A Social Services Progress Note for [DATE] at 11:11 AM reflected code status was reviewed with R7, and she elected DNR.

Based on observation, interview and record review, the facility failed to conduct a care conference after admission for one (R7) of two reviewed.Findings include: Review of the medical record reflected R7 admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes, legal blindness and presence of an artificial eye. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/17/26, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had impaired vision without corrective lenses and no natural teeth or tooth fragments (edentulous). According to the medical record, R7 was her own responsible party. R7's medical record reflected a prior admission on [DATE] and discharge home on 1/30/26. R7's MDS history included a discharge return not anticipated MDS, with an ARD of 1/30/26. On 04/28/2026 at 2:52 PM, R7 was observed seated in a wheelchair, in her room. R7 reported the facility did not involve her in the plan for her care, and she did not really have a care conference after admission. R7's medical record did not reflect that a care conference had been held since admission to the facility on 2/11/26. On 04/29/2026 at 10:16 AM, Social Worker (SW) F reported 72-hour care conferences were held after admission, then quarterly. SW F reported R7 did not have a care conference after admission on [DATE] because she had not been discharged from the facility for 30 days. SW F reported R7 was not due for a quarterly review until 5/20/26. In an interview on 04/30/2026 at 11:13 AM, Director of Nursing (DON) B reported a care conference should have been held after R7's admission for 2/11/26.

This citation pertains to Intake 2989711.Based on observation, interview, and record review, the facility failed to 1) identify and treat a new wound for one (R70) and 2) treat earwax buildup for one (R58) of 17 reviewed.Findings include: Resident #70 (R70) Review of the medical records reflected that R70 was admitted to the facility on [DATE] and readmitted on [DATE] following hospitalization. Diagnoses of Diabetes Mellitus with Diabetic Polyneuropathy, Peripheral Vascular Disease, left side weakness from previous stroke and a new diagnosis of acute osteomyelitis- right ankle and foot. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/12/2025 revealed R70 had a Brief Interview of Mental Status (BIMS) of 15 (Cognitively Intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R70 was independent to minimal assistance with bed mobility, transfers, toileting. R70 is able to make his needs known. During an interview on 04/28/2026 at 2:39 PM, R70 stated he had his right foot big toe amputated last summer. R70 stated his second toe got a pressure ulcer on the top on it and the third toe developed a pressure ulcer under it and tunneled through. R70 stated the staff never identified it and did not treat it appropriately, and it could have been prevented. During an observation and interview on 04/29/2026 at10:53 AM, Wound Care Nurse H was setting up wound care supplies for wound care on R70's right foot. Wound Care Nurse H gowned and gloved for care, hand hygiene performed. Wound Care Nurse H removed soiled dressing from right foot, disposed of soiled dressing, hand hygiene performed. Wound Care Nurse H stated all of his toes on the right foot were amputated; incision is intact with steri-strips, performed hand hygiene, applied clean gloves, cleaned with wound wash on gauze dressing, hand hygiene completed, applied new gloves, completed dressing change. On 04/29/2026 at 2:10 PM, writer asked DON B for documentation on R70's right foot wounds prior to his amputation of all toes. Nursing Progress notes did not reveal any details on the right foot third toe, other than daily dressing changes to the incision where he had his great toe amputated. On 04/29/2026 at 4:31 PM, DON B came into the conference room where survey team was working, writer asked again for documentation on R70's right foot third toe concerns. DON B stated they had a different program to document that in so she would print it off for this writer, brought in right foot, great toe surgically removed and following care, but nothing regarding the condition of the 2nd and 3rd toes. During an interview on 04/30/2026 at 8:24 AM, Wound Care Nurse H stated R70's 2nd toe was bend/hammer head, and it had a Diabetic Ulcer on it. Writer asked about the 3rd toe, Wound Care Nurse H stated she did skin assessments every Monday and there was nothing there on that specific Monday of 03/09/2026, she was told he went to the hospital that following Saturday 03/15/2026 with a new wound. Writer asked Wound Care Nurse H if she knew when this new wound was identified, she stated she did not, added the 2nd toe concern was documented in the (Electronic Medical Records) EMR, not on the 3rd toe that she was aware of. Writer asked wound Care Nurse H what the process was for any staff would have noticed concerns with skin breakdown. Wound Care Nurse H stated they would come and get her, if it's not on a Monday, she was doing wound care rounds then the staff would address it with the floor nurse. Record review of a wound care note and picture of his right foot dated 03/09/2026, completed by wound care nurse H showing black/brown eschar on the tips of the 3rd and 4th toes on the right foot. Record review of the spread sheet that is used as a communication tool between the wound care nurse H and NP O revealed R70 had a new wound identified on 02/24/26 on his right foot, 2nd digit, in house acquired, length .75 x width 1.02 x depth of 0. Treatment of Povidone iodine. Record review of this same spread sheet dated 03/02/26 revealed R70's right foot, 2nd digit, in house acquired, length .77 x width 1.08 x depth 0.1. Treatment of Povidone iodine. Record review of this same spread sheet dated 03/09/26 revealed R70's right foot, 2nd digit, in house acquired, length 1.25 x width 1.54 x depth 0.1. Treatment of soap and water, Povidone iodine. Record review of this same spread sheet dated 03/09/26 did not include the new wound on right foot, 3rd toe as it was in the picture of his right foot dated 03/09/26 where it shows eschar on the tips of toes 3 and 4. During an interview on 04/30/2026 at 9:30 AM Interview with Nurse Practitioner (NP) O stated she did not make rounds with Wound Care Nurse H here at the facility. NP O stated that Wound Care Nurse H had a spread sheet and would report what was going with the wounds and she wrote orders based on that report. NP O stated they did not have an NP to concentrate on wound care at this time but would within the next week or two. NP O pulled up her visit note for 03/05/26- no mention of 3rd toe skin issues new diabetic ulcer to the right dorsum second digit noted on 02/24/2026. NP O read the wound care documentation from 3/11/2026 13:05 by a unit manager, wound is stable. Continue with active treatment and pain management plan. NP O pulled up her visit note for 3/11/1026, since 3/6/26, R70 had experienced persistent neuropathic pain requiring increased gabapentin (800 mg TID), and ongoing management of a new diabetic ulcer on the right foot second toe, with intermittent refusal of wound care but overall wound stability. NP O read the wound care documentation from 3/12/2026 by floor nurse, location of skin area being documented: 2nd toe of right foot. Continue with plan of care/ Treatment. NP O read the wound care documentation from 3/12/2026 at 9:22 AM by floor nurse, location of skin area being documented: right 2nd toe continues plan of care. NP O read the wound care documentation from 3/13/2026 at 14:19 PM by floor nurse, location of skin area being documented: right 2nd toe, Tx in place. NP O read the wound care documentation from 3/14/2026 at 08:22 AM by floor nurse, location of skin area being documented: right 2nd toe Tx in place. NP O read the wound care documentation from 3/14/2026 at 22:33 PM by floor nurse, location of skin area being documented: right 2nd toe resident on LOA until tomorrow. Was not assessed today. NP O read the wound care documentation from 03/15/2026 at 11:20 AM by Wound Care Nurse H location of skin area being documented: Right foot second toe resident sent out to hospital that today, was not assessed. NP O pulled up her NP visit note for 03/30/2026, over the past three days, the patient has been managed for pain related to a right foot amputation site, with frequent PRN morphine and oxycodone administration. Pain levels have fluctuated, often reaching 8–9/10, but responded effectively to medication, with post-administration scores dropping to 0–3/10. The amputation site remains stable, with wound vac intact and no signs of sepsis; the patient is afebrile and continues on oral antibiotics without adverse reactions. NP O pulled up her NP visit note for 04/01/2026, the surgical site remains intact, with no new signs of infection or sepsis; he is afebrile and has tolerated antibiotics without adverse reactions. The wound vac was removed yesterday. He feels pain management regimen is adequate at this time using oxycodone every 4 hours. During an interview on 04/30/2026 at 12:47 PM, DON B was asked about the 3rd toe wound on his right foot prior to amputation. DON B stated R70 was on Leave of Absence (LOA) on that day, and Wound Care Nurse H couldn't assess him. Regional Director of Clinical D was giving answers prior to the DON B answering and writer asked to have DON B look at his medical record to help identify when that 3rd toe wound was identified. Writer asked DON B what her expectations would be if staff found a new skin concern. DON B stated they would put notes in the EMR, report to the floor nurse, they always put it on the communication board, write new orders, and at daily rounding, it would have been brought up at that time. DON B stated R70 was on LOA on 03/14/26. Assistant Director of Nursing (ADON) C stated R70 would refuse to have nurses do his dressing changes. During a record review of progress note written by Physician's Assistant (PA-C) O for 03/11/2026 at 14:54PM, Inspection: Eschar present on 2nd and 3rd toes on R foot. Patient is status post first toe removal. Incision there is well healed. He has an eschar on his third distal toe that seems to be irritated. +hammer toe second toe. No surrounding erythema. He does have global swelling to the foot which is very evident compared to contralateral side. He is slightly tender to palpation in the foot as well as the distal left lower leg. No streaking, no induration. Record review of nursing progress notes revealed skin assessments/wound care was provided to R70 on 03/01/26, 03/02/26, 03/03/26, 03/04/26 (x4), 03/05/26, 03/06,26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/11/26 at 13:05PM, 03/12/26 (x2), 03/13/26, 03/14/26 done at 8:22 AM before LOA. R70 returned to facility on 03/15/2026 at 15:20 AM from an overnight LOA. Wound care nurse H documented, .there was a new open area to his right foot 3rd toe. Resident wanted to be sent out to the hospital for wound evaluation due to diabetes Type 2. This writer called physician. Awaiting a call back at this time. Record review of R70's care plan intervention was to do a skin assessment weekly. Record review of nursing progress notes revealed R70 was admitted to the hospital on [DATE] through 03/23/2026. Per DC summary, resident underwent amputation of 2nd and 3rd toes and Achilles tendon lengthening on 3/21 of the right foot and started on a 2-week course of oral antibiotics. Resident was wearing a boot to the right foot and had a wound vac to the right foot. Non-weight bearing (NWB) right foot. Resident was alert and oriented x4, able to make needs known. Provider notified of readmission, reviewed meds, orders entered. Record review of hospital coordination from emergency room to admission of R70. Right third toe infected ulcer with subcutaneous gas LRINEC score 3 Recurrent diabetic foot ulcer History of right first toe amputation in June Chronic ulcer on the second toe - CT shows soft tissue swelling and distal subcutaneous air without osteomyelitis - CRP elevated with no systemic signs of infection - Blood cultures show no growth till date follow up on the final blood cultures - Started zosyn and Zyvox - Podiatry consulted for debridement versus toe amputation - Wound care team consulted - HbA1c sent - strict glycemic control Sepsis Documentation: Provider assessment: Infection suspected Suspected source(s) of infection: Skin and Soft Tissue Musculoskeletal Assessment: Negative for back pain and neck pain. Skin: Positive for wound (Right third toe). Negative for rash. Neurological: Negative for dizziness, syncope and headaches. Skin Assessment: General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds. Findings: No rash. Comments: Right foot-great toe has been amputated, second toe has a healing wound, third toe has a wound with surrounding color changes in the toe. Color changes do not extend up the foot, there is no drainage coming from the wound site Clinical Impressions as of 03/15/26 21:32 PM, Wound infection. During an interview on 04/30/2026 at 1:27 PM, RN/Unit Manager E was asked about the wound care, and dressing changes she had completed on R70 dated 03/11/26 at 13:05 PM. RN/Unit Manager E stated she didn't recall, added her memory isn't that good. Writer asked about identifying a new wound on the 3rd toe and she stated she didn't recall. Writer asked what her expectations would be if a resident develops a new skin concern or wound, RN/Unit Manager E stated she would expect the staff to report that to floor nurse, herself as the unit manager or the Wound Care Nurse H. During an interview on 04/30/2026 at 1:47 PM, Registered Nurse (RN) S was asked about the assessment and wound care she provided on R70. RN S stated she remembered doing them but couldn't remember if it was on one toe and two toes. During an interview on 04/30/2026 at 1:54 PM, R70's family member T stated R70 showed her his foot. Family member T told him to go to ER, stated R70 told her he had a wound one on top of 2nd toe, one of bottom of 3rd toe, he was having severe pain, and he shouldn't have had pain due to neuropathy. Family member T stated she called the wound care nurse H who told her she didn't see this new wound a week ago, stated they did his dressing 2 x daily and it should have been identified. During an interview on 04/30/2026 at 2:09 PM, RN U stated she didn't see any new skin opened, he went on LOA and when he came back the next day, he told her he needed to go to the hospital because he had a new wound and it was painful. Writer asked RN U if she had looked at the entire foot when she did his dressing changes, she stated she usually does but didn't think she did so this time. During an interview on 04/30/2026 at 2:44 PM, writer asked wound care nurse H what the dark areas were at the tips of R70's 3rd and 4th toe on the right foot taken during the assessment and wound care pictures on 03/09/26. Wound care nurse H stated it must have been the lighting, writer zoomed in on the picture to show her the dark edges on both toes look like eschar (thick, dry, leathery form of black or brown necrotic tissue (dead tissue) that forms over a wound). Writer commented that it didn't look like poor lighting. Wound care nurse H stated she didn't see any concerns with those toes. R58 Review of the medical record revealed R58 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/26 revealed R58 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had minimal difficulty hearing, and did not wear hearing aids. In a telephone interview on 04/28/2026 at 10:29 AM, R58's Guardian G reported R58 seemed to have an increased difficulty hearing. Guardian G reported they have asked for R58's hearing to be checked, but nothing was done. 04/29/2026 10:39 AM Resident #58 was observed in bed. R58 reported she thought she had earwax buildup and that her ears needed to be cleaned out. Review of the Progress Note-MD History & Physical dated 3/4/26 revealed She [R58] also says her ears need to be cleaned .[Patient] has bilateral age-related hearing loss, uses headphones to hear the TV better, complains of wax and needing her ears cleaned out. Will ask nursing staff about ear lavage [irrigation] vs cerumenex drops. Review of the medical record revealed no indication that R58's earwax had been addressed/treated. In an interview on 04/29/2026 at 10:42 AM, Unit Manager (UM) E reported they were not aware of any concerns with R58's ears. When asked about the Physician's progress note dated 3/4/26, UM E reported the facility typically used Debrox (ear wax removal drops), but she did not see where Debrox was ordered for R58 after the Physician's visit on 3/4/26. UM E reported the Physician's visit was shortly after the facility changed provider groups and the new provider group may not have been aware that they needed to enter the order into the system or delegate to a nurse. In an interview on 04/30/2026 at 11:12 AM, Director of Nursing (DON) B reported the facility changed provider groups on 3/1/26. DON B reported if a provider noted something in their progress notes, they were responsible for entering the order as the facility staff did not read all the provider notes every day. Review of the Physician's Order dated 4/29/26 revealed R58 had an order for Debrox drops for both hears for ear wax and decreased hearing.

Based on observation, interview and record review, the facility failed to obtain vision services for one (R7) of two reviewed.Findings include: Review of the medical record reflected R7 admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes, legal blindness and presence of an artificial eye. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/17/26, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had impaired vision without corrective lenses and no natural teeth or tooth fragments (edentulous). According to the medical record, R7 was her own responsible party. On 04/28/2026 at 2:55 PM, R7 was observed seated in a wheelchair, in her room. R7 stated about one month prior, she had asked to be put on the dental and vision services lists. R7 reported her left eye was a prosthetic, and she had 20 percent vision in her right eye. R7 reported she needed glasses and did not have any. R7's Care Plan reflected visual impairment related to being legally blind and a prosthetic left eye. An intervention, dated 2/11/26, reflected, Arrange a consultation with the eye care provider as needed. An MD History and Physical Note for 3/26/26 reflected R7 would like to see the optometrist and dentist. In an interview on 04/29/2026 at 10:16 AM, Social Worker (SW) F reported the vision services provider visited the facility every four to six weeks and was scheduled to visit on 5/11/26. SW F read the list of residents that were to be seen on 5/11/26, and the list did not include R7. SW F reported she had not been notified of R7's request to see the vision services provider, nor was an order placed in R7's medical record. In an interview with Director of Nursing (DON) B and Regional Director of Clinical (RDC) D on 04/30/2026 at 11:13 AM, it was reported the facility changed provider groups on 3/1/26. With ancillary services, such as vision services, an order was to be placed in the medical record, then SW would add the resident to the list for services. It was reported the providers had not been adding the orders to the medical record.

Based on observation, interview, and record review, the facility failed to properly label medications in one of two medication carts reviewed.Findings include:On 4/30/2026 at 2:16 PM, an observation was made of the 200-hall medication cart with Licensed Practical Nurse (LPN) R. The top drawer was found to contain a vial of Novolog insulin for R27. The vial was observed to have been open and was stored inside a prescription bottle, neither the prescription bottle it was stored in or the vial itself were labeled with an open date or expiration date (based on the open date). LPN R reported the expectation is insulin should be labeled with an open date upon being opened and should be considered expired 30 days after being opened. LPN R reported the vial would need to be disposed up since there was not a way to determine when it was opened/when it expired.On 4/30/2026 at 2:42 PM, during an interview with Director of Nursing (DON), it was reported that the expectation for labeling insulin is that each one is labeled with an open date and each medication cart has a list of medication expirations on it for staff to reference. DON reported that the floor nurses are responsible for cleaning the medication carts and pulling expired medications, management audits them approximately twice per month and pharmacy does once a month.A review of the facilities policy, titled Medications and Biologicals-Labeling of documented in part All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices.Labels for multi-use vials must include: The date vial was initially opened or accessed (needle-punctured); all open or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.According to the U.S. Food and Drug Administration Website (https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency) Insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 F and 86 F for up to 28 days and continue to work.

Based on observation, interview, and record review, the facility failed to obtain dental services for two (R7 and R58) of two reviewed.Findings include: Review of the medical record reflected R7 admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes, legal blindness and presence of an artificial eye. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/17/26, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had impaired vision without corrective lenses and no natural teeth or tooth fragments (edentulous). According to the medical record, R7 was her own responsible party. R7's payor source was listed as Medicaid, effective 3/13/26. On 04/28/2026 at 2:55 PM, R7 was observed seated in a wheelchair, in her room. R7 stated about one month prior, she had asked to be put on the dental and vision services lists. R7 reported having only one tooth and needing dentures. R7's Care Plan reflected they had a dental problem related to no natural teeth and no dentures. An intervention, dated 2/11/26, reflected to refer to dental services as needed. An MD (medical doctor) History and Physical Note for 3/26/26 reflected R7 would like to see the optometrist and dentist. In an interview on 04/29/2026 at 10:16 AM, Social Worker (SW) F reported the dentist visited the facility every four to six weeks and was scheduled to visit on 5/1/26. SW F read the list of residents that were to be seen on 5/1/26, and the list did not include R7. SW F reported she had not been notified of R7's request to see the dentist, nor was an order placed in R7's medical record. In an interview with Director of Nursing (DON) B and Regional Director of Clinical (RDC) D on 04/30/2026 at 11:13 AM, it was reported the facility changed provider groups on 3/1/26. With ancillary services, such as dental services, an order was to be placed in the medical record, then SW would add the resident to the list for services. It was reported the providers had not been adding the orders to the medical record. R58 Review of the medical record revealed R58 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/26 revealed R58 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and did not have broken or loosely fitting dentures. Review of the Nursing admission Evaluation dated 6/8/24 revealed R58 wore upper and lower dentures. In a telephone interview on 04/28/2026 at 10:28 AM, R58's Guardian G reported R58 had dentures that were too large and therefore she could not wear her dentures. Guardian G reported they had brought this concern up to Social Worker (SW) F, but nothing was done. On 04/29/2026 at 10:39 AM, R58 was observed lying in bed. R58 did not have dentures in her mouth. When asked about her dentures, R58 reported she did not wear them because they irritated her and were uncomfortable. R58 reported her dentures were loose and she could not recall the last time her dentures fit well. Review of R58's care plans revealed R58 had upper and lower dentures and staff was to encourage R58 to wear her dentures. The care plans revealed refer to dental services as needed. In an interview on 04/29/2026 at 10:16 AM, SW F reported the dentist was in the facility every four to six weeks. SW F reported they did not think R58 had ever seen the dentist at the facility. SW F reported they were not aware of any concerns with R58's dentures, but if they were made aware of poorly fitting dentures, they would add R58 to the dentist list. SW F reported they had never seen R58 wear her dentures. In an interview on 04/29/2026 at 10:42 AM, Unit Manager (UM) E reported that according to R58's care plans, R58 had dentures. UM E reported she did not recall R58 wearing her dentures but was unsure why R58 did not wear them. In an interview on 04/30/2026 at 8:21 AM, Certified Nursing Assistant (CNA) Q reported R58 did not wear her dentures, and she was not aware of the reasoning. In an interview on 04/30/2026 at 11:12 AM, Director of Nursing (DON) B reported she was not even sure if R58 had dentures because R58 did not wear dentures. Assistant Director of Nursing (ADON) C and DON B reported they were not aware of any concerns with R58's dentures not fitting properly. On 04/30/2026 at 11:12 AM, ADON C reported they checked R58's room and R58 did have dentures in a denture cup. Review of the Nurses' Note dated 4/29/26 at 11:05 AM revealed Resident reported dentures are uncomfortable/not fitting properly .notified [Social Work] to have resident seen by dentist.

This citation pertains to intake MI000151964. Based on interview and record review, the facility 1) failed to assess and monitor and 2) follow physician orders for one (Resident #500) of three reviewed for quality of care, resulting in a delay in recognition and response to a significant change in condition which progressed to a cardiac arrest and subsequent poor outcome, including CPR, hospitalization , and ultimately comfort care status. Resident #500 (R500) A review of the medical record reflected that R500 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypotension, chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] indicated that R500 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R500 no longer resided in the facility. On [DATE] at 12:01 AM, Resident #430 (R430) was observed seated on the side of his bed. R430 reported witnessing his roommate, R500, experiencing what he described as a heart attack. He stated that R500 was yelling for help, but no one responded. R430 said he also began yelling for help because he sensed something was seriously wrong. He reported that R500 had been ill for two days and felt staff did not assist him in a timely manner when R500 called out. R430 stated that R500 became unresponsive, and that Emergency Medical Services (EMS) performed cardiopulmonary resuscitation (CPR). A review of an Encounter Note dated [DATE] at 1:00 PM indicated that R500 had been seen by Nurse Practitioner (NP) O. The note stated: (R500) seen today for hypoxia (low levels of oxygen in body tissues, causing symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin) and shortness of breath. He is lying in bed and states it came on suddenly. He is hypoxic and is currently being placed on supplemental oxygen. He also complains of shortness of breath . he is hypotensive. At the end of the note, it was documented: Hypotension, unspecified type - will add PRN (as needed) Midodrine and monitor. An order for Midodrine HCl (a vasopressor used to raise blood pressure), 5 milligrams (mg) tablets, to be given by mouth every 8 hours as needed for hypotension if systolic blood pressure (SBP) was less than 90 mmHg, was initiated on [DATE] at 10:15 AM. The same order was discontinued at 10:28 AM. On [DATE] at 10:24 AM, R500's blood pressure was ,d+[DATE] mmHg, and Midodrine 5 mg was administered at that time. His Mean Arterial Pressure (MAP) was calculated to be 51 mmHg. (A minimum MAP of 60 mmHg is generally required to adequately perfuse vital organs.) R500's blood pressure was rechecked at 10:26 AM and was ,d+[DATE] mmHg, with a MAP of 50 mmHg. At 12:24 PM, it was recorded at ,d+[DATE] mmHg, and at 1:23 PM, it improved to ,d+[DATE] mmHg. Additionally, an order for Albuterol Sulfate nebulization solution (2.5 mg/3 mL at 0.083%) to be administered via nebulizer every 6 hours as needed for shortness of breath was not given, despite R500 stating he was experiencing shortness of breath. According to the physician's order, R500 was eligible to receive another dose of PRN Midodrine if needed at approximently 6:30 PM. However, no additional vital signs were documented after 1:23 PM. In an interview on [DATE] at 10:38 AM, NP O stated that she assessed R500 on the morning of [DATE]. She acknowledged that while R500 was chronically ill, on that day he was acutely hypoxic and short of breath, prompting her to order PRN Midodrine and Albuterol. NP O said that at minimum, R500's blood pressure should have been rechecked at the 8-hour mark to assess if another dose of Midodrine was indicated. She added that vital signs, including oxygen saturation, should have been monitored. NP O stated that if R500's blood pressures remained low, staff should have contacted her and an additional dose of Midodrine could be administered. In an interview on [DATE] at 11:53 AM, RN I confirmed she was assigned to R500 on [DATE]. RN I stated R500 was declining during her shift, so she administered PRN Midodrine, communicated with NP O, and followed through with diagnostic orders. A review of physician orders revealed an order for daily vital signs initiated on [DATE]. However, documentation showed no vital signs were assessed or recorded on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. A nurse's note dated [DATE] at 9:45 PM stated: Date of incident [DATE] at 8:25 PM. Outgoing nurse reported that resident had a change of condition - hypoxia - and was placed on 2L (liters) oxygen via nasal cannula. This nurse assessed the resident and noted moderate acute distress due to generalized weakness and fatigue. All vital signs were within normal limits except a temperature of 102 F. Nurse requested CNA to clean and assist resident with feeding while notifying the DON. While on the phone, CNA reported the resident had become unresponsive. Nurse immediately contacted EMS. An EMS team already present in the facility responded and initiated CPR until a second team arrived. Resident was transferred to [local] hospital. In an interview on [DATE] at 1:03 PM, CNA E confirmed he was assigned to R500. He described R500 as appearing lethargic and not quite himself. He stated R500 was nonverbal and only able to make gestures. CNA E said R500 continued to decline and was present when R500 became unresponsive and went into cardiac arrest. CNA E stated at baseline, R500 was able to verbalize needs and get around the facility without difficulty. In an interview on [DATE] at 1:59 PM, RN G stated she was on duty when R500 became unresponsive. She noted that at the start of her shift around 6:00 PM, R500 did not look well. The outgoing nurse, RN I, informed her that R500 was declining and advised her to keep an eye on him. RN G did not know R500's baseline, so she contacted DON B, who instructed her to transfer R500 to the hospital. RN G said she called 911, and shortly after, R500 went into cardiac arrest. EMS personnel who were already in the building responded immediately. A review of hospital documentation dated [DATE] showed that R500 was brought to the Emergency Department by EMS after experiencing cardiac arrest shortly before arrival. EMS reported he had been difficult to arouse and underwent 10 minutes of CPR with no shocks advised. He received epinephrine and vasopressin in the field. His last recorded BP was ,d+[DATE] mmHg with a pulse of 111 bpm. R500 had a history of ESBL E. coli bacteremia ( Escherichia coli bacteria in the bloodstream) secondary to a complicated UTI (urinary tract infection) and was being treated for MRSA pneumonia and likely bacteremia. He had lactic acidosis secondary to hypoperfusion and circulatory shock due to sepsis. He was placed on comfort care on ,d+[DATE]. R500 was nonresponsive-his eyes were open, but he did not track or respond to commands. Pupils were non-reactive, and no corneal, cough, or gag reflexes were present. In an interview on [DATE] at 1:23 PM, DON B stated she had spoken with RN G on [DATE]. RN G reported that R500 did not look well and planned to transfer him to the hospital. DON B confirmed that the expectation was to follow physician orders, including rechecking R500's blood pressure to determine if another dose of Midodrine was needed. According to the Elsevier Emergency Nursing Core Curriculum, 7th edition, shock is a clinical manifestation of the body's inability to adequately perfuse tissues. It is a systemic response to illness, resulting in decreased oxygen delivery to cells and potential end-organ damage. Septic shock causes vasodilation and maldistribution of blood volume, particularly in peripheral vessels, leading to hypotension. It is essential to collect and monitor objective data, including level of consciousness and vital signs.

Based on observation, interview, and record review the facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. Findings Include: Review of the facility policy entitled QAPI Plan with a date of implementation of 10/24/22 demonstrated in the purpose statement, It is the policy of this facility to systemically collect date as part of the QAPI program to ensure the care and services it delivers meet acceptable standard of quality in accordance with recognized standard of practice. Key components, listed in the policy, include: 1. Tracking and measuring performance 2. Establishing goals and thresholds for performance improvements 3. Identifying and prioritizing quality deficiencies 4. Systematically analyzing underlying causes of system quality deficiencies. 5. Developing and implementing corrective action or performance improvement activities. 6. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as need. In an interview on 03/03/2025 at 03:55 p.m. Licensed Nursing Home Administrator (LNHA) C explained that the facility has a Quality Assurance and Performance Improvement committee that followed the Policy entitled QAPI Plan. LNHA C was asked what QAPI projects have been implement since last survey. LNHA C explained that projects included staff retention, food tray pass, water pass, tray removal and noise level. When asked to explain the specifics for each project he explained that he would have to ask his team. This surveyor asked if the Quality Assurance Committee had identified concerns about med storage, cell phone usage, foot temp and palpability, issues with grievances, issues with smoking, issue with Activities of Daily Living, issues with influenza or pneumococcal vaccination. LNHA C responded that he did not know about any of these issues until during the State Survey Process. LNHA C was asked to provide any projects or monitoring that he had for any projects. In an interview on 03/03/2025 at 04:31 LNHA C returned with temperature logs obtained by the dietary department. When requested to see actual Performance Improvement plan for food temperatures including identified concerns and plan of corrections, LNHA C explained he had no other information other than the temp logs form dietary services. No other performance improvement projects presented by time of exit.

This citation pertains to MI00146912, MI00150426 Based on observation, interview, and record review the facility failed to effectively clean and maintain the physical plant for resident rooms 200, 211,214, 301,303, 400 and maintain a homelike environment regarding noise and phone usage for Resident #318 and Resident Council. Findings Included: On 02/25/2026 at 08:50 a.m. in room [ROOM NUMBER] bathroom the laminate that covered the counter of the sink appeared to be coming off the countertop. Gripper strips only the right side of the bed for 200-1 were observed to be torn and coming off the floor. On 02/25/2025 at 09:13 a.m. room [ROOM NUMBER]-2 was observed to have a hole in the closet door. On 02/25/2025 at 10:19 a.m. observed room [ROOM NUMBER] to be unclean. Dust balls were observed on the floor. Review of the bathroom between room [ROOM NUMBER] and 402 sink counter was observed to lose on the wall and able to be moved up and down with ease. [NAME] caulk on sink counter was cracked and not present the entire length of the back wall. On 02/25/2025 at 09:23 a.m. room [ROOM NUMBER]-B was observed to have a wheelchair at bedside that had visibly torn vinyl arm rest, on both sides of the wheelchair. R41 in that room explained that it was his wheelchair, and he used it daily. During a tour on 03/03/2025 at 10:07 a.m. conducted with Maintenance Supervisor (MS) V room [ROOM NUMBER]-bathroom laminate that covered the countertop appeared to still be coming off counter. MS V explained that he had not received a work order to fix the laminate. room [ROOM NUMBER] gripper strips where still observed to be coming off the floor. MS V explained that he had not received a work order to fix the gripper strips on the floor. room [ROOM NUMBER] sink counter was observed to still be loose on the wall. MS V explained that he had not receive a work order to fix the sink counter. room [ROOM NUMBER]-2 closet was observed to still have a hole in the closet door. MS V explained that he had not received a work order to fix the closet door. room [ROOM NUMBER]-B was still observed to have a wheelchair had visibly torn arm rest on both sides of R41's wheelchair. MS V explained that he had not received a work order to fix R41's wheelchair arm rest. Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). The most recent Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 02/18/2025, revealed R318 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 10:25 a.m. R318 was observed sitting on the side of his bed. R318 explained that he felt the facility did not honor his dignity because frequently he could hear the nursing staff yelling in the hallway at each other. R318 also explained that he could hear staff talking on their phones and swearing at their children to get to bed. R318 explained that he did not feel that this behavior was respectful to his desire for a peaceful environment. Review of resident council minutes form 11/26/2024 demonstrated phones: The staff is on their phones at the nurse's stations and in common areas. Review of resident council minutes from 12/27/2024 demonstrated staff is on their phones at the nurse's station and in common areas this remains ongoing. And Noise level: .the noise level is loud. This happens during the 6p-6a. The staff speak loud in the halls and at the nurse's stations when the staff walk down the halls around 4 a.m. Review of resident council minutes from 01/16/2025 demonstrated old Business that stated, .noise level is loud. This happens during 6p to 6a. The staff speak in a loud tone when they walk up and down the halls. also reported when the staff is sitting at the nurse's station they speak loudly. This remains ongoing. A concern form completed. The same minutes also demonstrated a section entitled phones: The staff is on their phones at the nurse's station and in common areas this remains ongoing. A concern form completed. 27306 On 02/25/25 08:36 AM upon entering room [ROOM NUMBER] there was an pungent urine odor permeating the room, the same odor was detected at the same time in room [ROOM NUMBER] that shared the same bathroom. The same overwhelming urine odor was detected again on 2/26/25 at 12:28 pm and again on 02/27/25 at 10:25 am. On 02/27/26 at 10:26 am, during an interview with Certified Nursing Assistant F and K both reported rooms [ROOM NUMBERS] always have a strong urine odor. On 03/03/25 at 10:24 AM, during an interview with Housekeeping Supervisor Q, he agreed both room [ROOM NUMBER] and 303 have a strong urine odor. Housekeeping Supervisor Q reported he personally had tried multiple products to get rid of the odor but cant get rid of it. It never goes away no matter what I do, maybe its just soaked into the floor.

This citation pertains to intakes MI00150119, MI00146912 and MI00150426. Based on interview and record review, the facility failed to maintain sufficient staffing levels to ensure adequate and timely resident care for four (Resident #6, #32, #50 and #318) from a total census of 65. Findings include: During an interview on 02/27/25 at 3:54 PM, Scheduler J reported staffing levels were primarily based on facility census. 27306 On 02/25/25 09:11 AM, during an interview with Certified Nursing Assistant (CNA) W reported that today she was assigned 13 residents, will at times have 16 residents which was very difficult but impossible to complete all the assigned tasks in caring for that many residents. During an interview with CNA X on 02/25/25 at 09:37 AM, it was reported 13 residents were assigned today. CNA X elaborated on many occasions closer to 20 residents have been assigned, and it was not possible to provide the care needed for 20 residents. On 02/27/25 at 10:26 AM, CNA's E and K reported they normally have 12 or 13 residents assigned to care for but the facility experiences a lot of staff that call in sick and when this happens they will have 20 residents assigned to them and this was not doable. When queried if the Nurses help them answer call lights, toilet residents etc both CNA E and CNA K stated it depended on what nurse was working. On 03/03/25 at 10:59 AM, during the Resident Council (RC) meeting 4 of 5 participants reported the facility was routinely short staffed and call light response time could take an hour or more. RC members agreed staffing concerns get reported monthly and will slightly improve for a few weeks and then slides back into extended wait periods for help. One participant reported call light response time was great while State Agency was in the building. 45038 Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 10/17/2019 with diagnoses that included chronic obstructive pulmonary disease (COPD), atrial fibrillation, peripheral vascular disease (PVD), atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), chronic respiratory failure, depression, anxiety, urinary incontinence, lack of coordination, nausea, dysuria (discomfort, pain, or burning when urinating), muscle spasm, metabolic encephalopathy (impaired brain function), thrombocytopenia (low number of platelets), low back pain, generalized edema (excess fluid buildup in the body's tissues), chronic pain, psychotic disorder (mental disorder characterized by a disconnection form reality), developmental disorder of speech and language, obesity, hypertension, absence of left leg above the knee, nicotine dependence, insomnia, epilepsy (seizure disorder), and asthma. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2024, revealed R6 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 03:50 p.m. R6 was observed sitting in the dining room in her wheelchair. R6 explained that the facility never has enough staff because she always sees them sitting at the nurse's station. R6 explained that it took 3 hours to answer her call light the other night. Resident #32 (R32) Review of the medical record revealed R32 was admitted to the facility 04/18/2019 with diagnoses that included multiple sclerosis, paraplegia (paralysis that occurs in the lower half of the body), neuromuscular dysfunction of bladder, type 2 diabetes, obesity, diabetic neuropathy (nerve damage caused by diabetes), cardiomegaly (enlarge heart), muscle spasm, anemia (low red blood cells), hyperlipidemia (high fat content in blood), chronic obstructive pulmonary disease (COPD), chronic pain, altered mental status, metabolic encephalopathy (impaired brain function), insomnia, edema, anxiety, major depression, migraine, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 0f 10/12/2024, revealed R32 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 R32 was observed lying in bed. R32 explained that his call light is frequently on for an hour to an hour and a half. R32 explained that he is bedridden and when he placed his call light on it is mostly to assist with getting a drink of water or having items handed to him that he can not reach. Resident #50 (R50) Review of the medical record revealed R 50 was admitted to the facility 06/14/2024 with diagnoses that included acute respiratory failure, cerebral infarction (stroke), type 2 diabetes, anemia (low red blood cells), encephalopathy (impaired brain function), acute kidney failure, hyperkalemia (low potassium), atrial fibrillation, bipolar disorder, acquired absence of Right leg below the knee, depression, hypothyroidism (low thyroid hormone), muscle weakness, and unsteady gait. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2025, demonstrated a Brief Interview of Mental Status (BIMS)of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 03:11 p.m. R50 was observed sitting up in her wheelchair at her bedside. R50 explained that it sometimes takes over an hour for staff to answer her call light. R50 explained that it usually occurs on the night shift. R50 explained when she placed her call light on she usually is in need to use the bathroom. Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/18/2025, revealed R318 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 10:27 a.m. R318 was observed sitting on the side of his bed. R318 explained that he has had times where it will take over 45 minutes for staff to answer his call light. He explained that recently he had diarrhea and had been incontinent of his bowels. R318 explained that he walked himself to the bathroom and cleaned himself up and that staff did not come to answer his call light until he was head back to bed. R318 explained that that event had occurred longer than an hour for someone to answer his call light. In an interview on 02/25/25 at 09:24 a.m. Unit Manger (UM) P explained that she frequently works as a nurse manager and a nurse caring for residents. UM P explained that the facility is very short staffed. UM P explained that many times during the day shift there is on four certified nursing assistants for entire building. UM P explained that yesterday she had worked the floor, taking care of residents, for nine hours and four minutes and then was relieved by the MDS coordinator. During an interview on 02/27/2025 at 08:22 a.m. Certified Nursing Aide (CNA) X explained that she had worked at the facility a little over two months. CNA X explained that she usually worked the first shift (6 a.m. to 6 p.m.) and that she works 36 hours per week. She explained that staff call-in frequently and no one comes in to replace them. CNA X explained that they are supposed to have six CNA's working in the building, but they frequently only have three to four CNA's. CNA X explained that when they are short staff, she could have to provide care for twenty residents and all of the resident care can not be completed. CNA X explained that working short staff occurs approximately two times per week. When asked if managerial staff assisted when the units are short staffed, CNA X explained that management does not help. CNA X explained that she observed Maintenance Supervisor V passing trays and that is only been observed when State Surveyors are in the building. 46954 In an interview on 2/27/25 at 2:05 PM, Certified Nursing Assistant (CNA) K stated that staffing at the facility sucks and most management doesn't assist on the floor when needed. CNA K stated that she does not get time for her breaks that she is entitled to and has witnessed other CNA's ignoring call lights. CNA K stated that she often comes in to her shift and discovers residents being saturated in their briefs. CNA K stated she had to do a complete bed change that morning because her resident was discovered saturated in urine, and the linens on the bed were soaking wet with urine. CNA K stated that it is heartbreaking to observe staff ignoring the screams for help from the residents. In an interview on 2/28/25 at 8:27 AM, Licensed Practical Nurse (LPN) E stated that the nursing workload is extremely heavy during the day due to the amount of medications to administer, the treatments that need completed, and assisting with meals. LPN E stated staffing becomes a bigger issue with call ins. In an interview on 2/28/25 at 10:01 AM, Registered Nurse (RN) P stated staffing is not good and has personally witnessed time and time again care not being completed such as showers, oral care, nail care, brief changes, and turning and repositioning. RN P stated she has observed call lights being activated for over an hour, and has discovered residents saturated and soiled in urine and feces. In an interview on 2/28/25 at 11:49 AM, CNA F stated staffing at the facility is bad enough that they had recently decided to leave the facility. CNA F stated that there had been times when they were the only CNA in the facility for 66 residents, and on another occasion recently, they were one of two CNA's in the building, leaving them responsible for over 30 residents. CNA F stated that the management does not assist when staffing is short. CNA F stated, this place is horrible, the staffing is horrible, and we are never fully staffed.

This citation pertains to Intake: MI00149724, MI00150426 Based on observation, interview, and record review the facility failed to maintain preferred food temperature and acceptable palatability for three residents (R11, R41, and R318) out of ten residents reviewed for food palatability and food preferred temperatures. Findings Included: Resident #41 (R41) Review of the medical record revealed R41 was admitted to the facility 10/27/2021 with diagnoses included chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), alcoholic liver disease, emphysema (chronic lung disease that permanently damages the lungs making his difficulty to breath), anemia (low red blood cells), alcoholic fatty liver, polyneuropathy (a peripheral nerve disorder that causes multiple nerves throughout the body to malfunction simultaneously), hypertension, hypotension, hyperlipidemia (high fat content), acquired absence of right leg above the knee, acquired absence of left leg above the knee, muscle spasm, chronic pain, anxiety, nicotine dependence, alcohol abuse, and dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/03/2025, revealed R41 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During observation and interview on 02/26/2025 at 08:33 a.m. R41 was observed lying down in bed. R41 explained that the food is always cold. In an interview on 02/27/2025 at 07:54 a.m. Dietary Manager (DM) Y explained that try carts are insulated and it is necessary for the staff the keep the doors on the carts shut. She explained that dietary staff bring the food carts to the units then nursing staff would deliver the dietary trays to the Residents rooms. On 02/27/2025 at 08:03 a.m. the food cart was observed to arrive on the hall that R41 resides. At 08:10 a.m. R41's food tray arrived in his room. Dietary Manager (DM) Y was asked to test food temperatures of R41's food. Food cover was removed from the tray. Oatmeal had temperature of 137.4 F (Fahrenheit), scramble eggs 105.2F, Coffee 150.4F. When asked what temperature of eggs should be, DM Y responded that it was to the palatability of the Resident. DM Y left the room and R41 was asked to taste his scrambled eggs. R41 sampled scrambled eggs and stated they taste cold to me. Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). The most recent Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 02/18/2025, revealed R318 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 10:09 am. R318 was observed sitting up on the side of the bed. R318 explained that his food is always cold. R318 explained that he had told the facility about his concern and their response was that he needed to come to the dining room if he wanted warm food. On 02/27/2025 at 11:45 a.m. is was observed the delivery of food cart that contained part of the east hall and part of the west hall. Staff were observed passing trays to the east and west halls. At 11:52 a.m. is was observed that the food cart was delivered for the remainder of the west hall and staff where observed passing trays. At 12:05 p.m. it was observed that all trays had been passed to the west hall. R318 still did not have his lunch tray. Dietary Manager (DM) Y was asked where R318's lunch tray was and she could not answer. At 12:09 p.m. R318's tray was located on the first food cart that contained part of the east hall and part of the west hall. DM Y was asked to test temperatures of the tray before the tray was provided to R318. DM Y determined temp of coffee 134.2F (Fahrenheit), temp of Pizza was 112F, temp of salad was 68.8F (told by DM Y salad need to be below 40F), and temp of peaches were 54.2F (told by DM Y peaches needed to be below 40F). R318's lunch tray as discarded and another lunch tray was provided to R318. 46954 Resident #11 (R11) On 2/25/25 at 1:15 PM, R11 was observed in her room, watching television. R11 reported that she dislikes the food, stating that the food is not appetizing and is often cold. On 2/28/25 at 12:03 PM, a lunch tray was requested. The tray contained lemon baked tilapia, roasted potatoes, and steamed broccoli. The steamed broccoli was tasteless and was so overcooked and mushy, that it could not be picked up with a fork. The lemon baked tilapia was not flavorful and did not contain any lemon flavor.

This Citation Pertains to MI00146912 and MI00150426 Based on observation, interview and record review, the facility failed to preserve the dignity of 3 of 4 residents (Resident #2, #318, #32) reviewed for dignity and 4 of 5 residents for residents that attended the confidential group meeting. Findings include: Resident #2 (R2) Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE], revealed Resident # 2 (R2) was admitted to the facility on [DATE] with a readmitted [DATE] with diagnoses that include congestive heart failure, chronic obstructive pulmonary disease. R2 scored 15 out of 15 (cognitively intact) on the Brief Interview Status (BIMS). On 02/25/25 at 09:58 AM during an interview with R2 it was reported that staff complain chronically about their work load and are continuously talking and complaining about Resident 32 (R32) and how frequently R32 pushes the call light for help. R2 elaborated that staff were observed frequently texting or talking on their personal cell phones. R2 elaborated it was uncomfortable to hear staff complain about other residents, their work load and it was frustrating when the call light was on and you can see staff on their phones. When queried if a concern form was filed or if management staff was aware of the concern R2 stated these issues were common knowledge and treated as acceptable behavior. Resident Council On 03/03/25 at 11:00 am during the confidential group meeting 4 of the 5 participants reported the observe staff on a daily basis on their personal cell phones, the participants reported this angered them particularly when their call light was on and they're waiting for help. Five of 5 of the participants reported staff are very noisy at night while they are trying to sleep and again noise level gets unbearable again about 6:00am and wake up due to yelling, screaming and laughing from staff. All 5 participants reported overhearing laughing and conversations about staff personal lives, their upcoming events etc . 5 of 5 participants reported they felt staff have no respect or consideration for residents need for sleep or just peace and quiet. 45038 Resident #32 (R32) Review of the medical record revealed R32 was admitted to the facility 04/18/2019 with diagnoses that included multiple sclerosis, paraplegia (paralysis that occurs in the lower half of the body), neuromuscular dysfunction of bladder, type 2 diabetes, obesity, diabetic neuropathy (nerve damage caused by diabetes), cardiomegaly (enlarge heart), muscle spasm, anemia (low red blood cells), hyperlipidemia (high fat content in blood), chronic obstructive pulmonary disease (COPD), chronic pain, altered mental status, metabolic encephalopathy (impaired brain function), insomnia, edema, anxiety, major depression, migraine, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 0f 10/12/2024, revealed R32 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 11:30 a.m. R32 was observed lying in bed. R32 explained that staff are very loud while providing his personal care and rude in the way that they communicate with me. Review of R32's Quality Assistance Form, dated 1/13/2025 revealed, Nurse was upset that resident used call light 4 times, nurse was talking rudely to resident . (name of nurse) on Sunday night. The Quality Assistance Form, dated 1/13/2025, demonstrated that issue was resolved and description: DON (Director of Nursing) provided nurse education. In an interview on 03/03/2025 at 11:28 a.m. Licensed Nursing Home Administrator (LNHA) B explained that he could not demonstrate that the nurse named in R32 Quality Assistance Form, dated 01/13/2025, had received any education regarding being rude with R32. LNHA B could not explain why the re-education was not completed as stated on R32's Quality Assistance Form, dated 01/13/2025. Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). The most recent Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 02/18/2025, revealed R318 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 10:25 a.m. R318 was observed sitting on the side of his bed. R318 explained that he felt the facility did not honor his dignity because frequently he could hear the nursing staff yelling in the hallway at each other. R318 also explained that he could hear staff talking on their phones and swearing at their children to get to bed. R318 explained that he did not feel that this behavior was respectful to his desire for a peaceful environment. R318 also explained that while voicing concerns about his therapy services, the did not feel that the Director of Therapy was listening to his concerns and treating him with dignity and respect and R318 felt that he only wanted to argue. Review of the facilities Quality Assistance Form completed for R318, with a completion date of 2/16/2025 and 2/17/2025 revealed that R318 had voiced concerns regarding noise level at the facility. The Quality Assistance Form dated 02/16/2025 and 02/16/2025 did not demonstrate that the issue had been resolved to the satisfaction of R318.

Based on interview and record review the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for 5 of 5 residents that participated in the Resident Council (RC) meeting and Resident #2. Findings include: Review of the Resident Council (RC) minutes dated 9/17/24 reflected concerns with staff not wearing name tags, delayed call light response times, noise levels. RC Minutes dated 10/22/24 reflected the Nursing Home Administrator on record (NHA) A attended the meeting and reported inservices were done with staff in relation to concerns brought forth from the 9/17/24 meeting. Residents reported noise level at night continued to be a problem. RC minutes dated 11/26/24 reflected concern related to staff being on their phones in common areas and at the nurses station. RC minutes dated 12/27/24 reflected the concern with staff being on their personal phones continues, call light response time was an issue and staff being loud at night/noise level was a concern. RC minutes dated 1/16/25 reflected call light response time, staff being on their phones, staff being loud/noise levels, staff not wearing name tags and a concerns that RC concerns were not being addressed. Concern forms generated from the RC meetings dated 1/16/25 reflected the NHA A would meet with RC members every two weeks. RC minutes dated 2/20/25 reflected education was provided to staff on the previous months concerns. Resident #2 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE], revealed Resident # 2 (R2) was admitted to the facility on [DATE] with a readmitted [DATE] with diagnoses that include congestive heart failure, chronic obstructive pulmonary disease. R2 scored 15 out of 15 (cognitively intact) on the Brief Interview Status (BIMS). On 02/25/25 at 09:58 AM during an interview R2 voiced multiple concerns pertaining food, call light response time, noise, staff on their cell phones and lack of help from Social Services Director N. When R2 was queried if concern forms were generated or if the concerns were reported, R2 responded he regularly attends RC meeting and month after month the same issues are brought up and never resolved. Of note R2 did not attend the RC meeting on 03/03/25. On 03/03/25 at 10:59 AM, during the RC meeting , all 5 participants reported the staff were very noisy at night, they scream up and down the hall at each other they gather at the nurses station and laugh and giggle in the middle of the night and often residents will be woken up due to noise level. RC participants stated this had been a long standing problem with no resolution. Four of 5 RC participants reported they routinely observe staff on their personal phones in the hall and while sitting at the nurses station, this too they reported gets discussed every month with no resolution. 5 of 5 participants further reported Social Services Director N was not responsive to their needs and concerns, ignored them, refused to meet with them and was frequently rude. RC members stated this had been brought up in RC meetings many times but never makes it into the RC minutes. When queried about staffing and call light response time 4 of 5 participants stated this too gets reported monthly and will slightly improve for a few weeks and then slides back into extended wait periods for help. One participant reported call light response time was great while State Agency was in the building. When queried if the Ombudsman or the Director of Nursing (DON) C or the self identified Nursing Home Administrator (NHA) B ever attended the RC meetings , it was reported the DON C never comes, the NHA B was new and the Ombudsman was invited to the March 2025's RC meeting due to the high volume of concerns, lack of accurate documentation of concerns, lack of follow through and lack of resolution of resident concerns. On 03/03/25 at 11:31 AM, Discussed concerns with self reported NHA B whom has been employed at the facility for one week and was unable to offer any explanation for ongoing concerns and lack of resolution.

Based on interview and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) were provided to two (R323 and R325) of three residents reviewed for beneficiary notification, resulting in the potential for residents and/or representatives to be uninformed of the potential private pay charges of continued services at the facility and inability to file an appeal. Findings include: On 3/3/25 at 12:10 PM, Self-identified Nursing Home Administrator (NHA) B was asked to provide beneficiary notification information including NOMNC and/or SNF-ABN for three residents. A review of the documents provided revealed R323 was missing a SNF-ABN and the NOMNC for R325 was missing the second page, which is where the resident/resident representative would sign, acknowledging receipt and understanding. On 3/3/25 at 3:17 PM, during an interview with social services director (SSD) N, when asked when a resident should receive a SNF-ABN she reported that she gives one for every NOMNC issued. When asked why one was not provided to R323, she reported that she didn't know. When asked where the second page of the NOMC form (that would include a signature) was for R325, she reported that she would attempt to locate it. On 3/3/25 at 3:55 PM, Self-identified Nursing Home Administrator (NHA) B was notified of the missing beneficiary documents. He reported that he was aware. On 3/3/25 at 4:14 PM, SSD N reported that they could not find any of the 2024 beneficiary documents.

This citation pertains to Intake: MI00150426 Based on observation, interview, and record review the facility failed to accurately record and make a prompt effort to resolve grievances for one resident (#318) of one resident reviewed for grievances. Findings Included: Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). The most recent Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 02/18/2025, revealed R318 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 10:09 a.m. R318 was observed sitting on the side of his bed. R318 explained that he had concerns that he had not received his medication as ordered. R318 explained that he had not received his valium until 02/18/2025. R318 explained that he keeps receiving his medication Protonic after his meals instead of prior to meals as it is to be given. R318 explained that he did not receive his Pregabalin until 02/17/2025. R318 also explained that he had a concern regarding that his food was continually cold. R318 also explained that he had concerns about the cleanliness of his room. R318 also explained that he had concerns regarding the noise level at the facility. R318 explained that someone at the facility had filled out a grievance form but he refused to sign the form because they did not record the correct information. R318 denied that any of his concerns had been addressed or that those concerns had been corrected to his satisfaction. Review of the facility Quality Assistance Form for R318, dated 02/17/2025, demonstrated details: Concerns with food temperature, noise level, medication concerns. Plan/Actions: meds addressed- billing issues resolved; noise level addressed with staff. The section Describe demonstrated I have been visiting (resident name) daily and often giving delivering his meal trays. I had suggested he come to the dining room, when he found it to difficult, I would bring him his food hot off the steam table. He has commented that food temps are improving. The Quality Assistance Form dated 02/17/2025 does not have a completion date or a resolved. The document does demonstrate someone wrote on the document Resident refused to sign. Review of the facility Quality Assistance Form for R318, dated 02/16/25, demonstrated details Noise level, Food temp., Housekeeping. Plan/Actions: noise addressed with staff, housekeeping deep cleaned room. The section Describe demonstrated I have been visiting (resident name) daily and checking in on his food temps. I will deliver his trays as he can't come down to the dining room. He has comment that the temps are improving. The Quality Assistance Form dated 02/16/2025 does not have a completion date or a resolved. The document does demonstrate someone wrote on the document Resident refused to sign. During an interview on 03/03/2025 at 08:44 a.m. Director of Nursing (DON) C was asked to review the Quality Assistance Form, dated 02/16/2025 and 02/17/2025. DON C' was asked to provide detail as to what the issues was regarding R318's medication and R318's concern with noise level. DON C could not provide any detail regarding R318's concerns. During an interview on 03/03/2025 at 10:02 a.m. Licensed Nursing Home Administrator (LNHA) B was asked to explain his expectation of the grievance process. LNHA B explained that he expected that a resident completes a Quality Assurance Form or that a staff member could assist them to complete the form. LNHA B explained that once the Quality Assurance Form is completed that he would review the concern and talk with the resident. LNHA B explained then he would give the Quality Assurance Form to the appropriate department to address the issue. LNHA B explained that he would then expect to see a date that the issue had been completed. The Quality Assurance Form for R318, dated 02/16/2025 and 02/17/2025, were reviewed by LNHA B. LNHA B could not explain why each Quality Assurance Form did not include more detail and did not demonstrate a satisfactory conclusion of the issues.

Based on observation, interview, and record review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#6) of 16 residents reviewed for accurate assessments. Findings Included: Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 10/17/2019 with diagnoses that included chronic obstructive pulmonary disease (COPD), atrial fibrillation, peripheral vascular disease (PVD), atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), chronic respiratory failure, depression, anxiety, urinary incontinence, lack of coordination, nausea, dysuria (discomfort, pain, or burning when urinating), muscle spasm, metabolic encephalopathy (impaired brain function), thrombocytopenia (low number of platelets), low back pain, generalized edema (excess fluid buildup in the body's tissues), chronic pain, psychotic disorder (mental disorder characterized by a disconnection form reality), developmental disorder of speech and language, obesity, hypertension, absence of left leg above the knee, nicotine dependence, insomnia, epilepsy (seizure disorder), and asthma. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2024, revealed R6 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 03:45 p.m. R6 was observed sitting up in her wheelchair in the dining room. R6 explained that she usually wears glasses but she recently needed to have them replaced. R6 was not observed to be wearing glasses during the interaction. R6 explained wore glasses for a very long time. Review of R6 medical record demonstrated a progress note, dated 02/13/2025 at 11:20 a.m. which stated, Resident seen by (name of eye Physician and address). Exam completed and glasses ordered. Review of R6's picture in the medical record demonstrate that she was wearing glasses when the picture was obtained. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2024, section B1200. Corrective Lenses- Corrective Lenses (contacts, glasses, or magnifying glass) used was marked as no. During an interview on 02/26/2025 at 04:20 p.m. Minimum Data Set (MDS) Coordinator Z was asked to review R6's picture in the medical record. MDS Coordinator Z explained that she had personally never seen R6 wearing glasses. MDS Coordinator Z explained that she had completed R6's MDS, with an Assessment Reference Date (ARD) of 11/14/2024, section B1200 and had documented that R6 did not have corrective lenses. MDS Coordinator Z explained that MDS Section B1200 was documented a no in error.

Based on interview and record review the facility failed to notify the local state mental health authority of Pre-Admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) changes for one (Resident #33) of two reviewed for PASARR. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE], reflected Resident 33 (R33) was admitted to the facility with diagnoses that included end stage renal disease, developmental disorder of scholastic skills, and bipolar disorder. Review of R33's clinical record reflected R33 scored 12 out of 14 (cognitively intact) on the Brief Interview Mental Status (BIMS). Review of R33's level one screening/3877 dated 12/28/23 reflected R33 had a mental illness and was learning disabled, the level II screen dated 12/29/23 reflected that R 33 was on a 30 day exemption and expected to be discharged from the facility within 30 days. The next 3877 was dated 9/12/24 and reflected R33 had a diagnosis of bipolar disorder, developmental disorder of scholastic skills and was prescribed an anti-depressant medication. On 02/26/25 02:54 PM, during an Interview with Social Service Director (SSD) N reported she did not complete 3877's that the corporate Social Worker did that and that person was out of the country and not available for an interview. SSD N then stated delay obtaining a level II assessment was due to Omnibus Budget Reconciliation Act (OBRA) refused do a level II assessment until a significant change in status was established related to R33's level of capacity and potential need for a guardian. When queried why there was no documentation in R33's medical record that OBRA opted not to complete a level II due to R33's capacity being in question, SSD N stated she could not document everything all the time, and although it was not documented she did communicate with (Licensed Master Social Worker (LMSW) R from Community Mental Health Authority who instructed SSD N hold off on submitting a 3877 until R33's capacity and guardianship was established. During a phone interview with LMSW R from Community Mental Health Authority on 02/27/25 08:46 AM, she reported a level II screening was in fact on hold until the determination of capacity /decision making ability was completed for R33. Review of R33's clinical record reflected the court appointed a legal guardian for R33 on 6/06/24 and R33's significant change 3877 was not completed until 9/12/24. LMSW R reported over 3 months from the time guardianship was granted and the 3877 was submitted to Community Mental Health was not timely. During a follow up interview on 02/27/25 01:53 PM with SSD N she offered no explanation as to why it took over 3 months to complete the significant change PASARR.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for one resident (#32) of 16 reviewed. Findings Included: Resident #32 (R32) Review of the medical record revealed R32 was admitted to the facility 04/18/2019 with diagnoses that included multiple sclerosis, paraplegia (paralysis that occurs in the lower half of the body), neuromuscular dysfunction of bladder, type 2 diabetes, obesity, diabetic neuropathy (nerve damage caused by diabetes), cardiomegaly (enlarge heart), muscle spasm, anemia (low red blood cells), hyperlipidemia (high fat content in blood), chronic obstructive pulmonary disease (COPD), chronic pain, altered mental status, metabolic encephalopathy (impaired brain function), insomnia, edema, anxiety, major depression, migraine, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 0f 10/12/2024, revealed R32 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 01:30 p.m. R32 was observed lying in bed. R32 explained that he wore upper dentures but that he currently could not find them and was waiting for the facility to replace them. R32 could not recall if he had told any staff that he could not find his upper denture. R32 further explained that he had just received new upper dentures in the fall of 2024. Review of R32's plan of care did not have any information that he wore upper dentures. R32's Kardex (document explaining necessary resident care to be used by Certified Nursing Aides) did not demonstrate that R32 wore upper dentures. Review of R32's medical record demonstrated a document entitled Dental Group with a date of 11/20/24 which stated, Inserted upper flexible partial denture. Adjusted buccal flanges on right side to make insertion easier. Partial was stable and occlusion was good. Patient thought it felt comfortable . Review proper care of partial with the patient. Dispensed denture case and denture brush obtained from the staff. Advised patient that will do any needed adjustment at my next visit. During an interview on 03/03/2025 at 01:29 p.m. Social Service Director N explained that she was not aware that R32 was missing his dentures. She explained that she had just assisted him with obtaining his upper dentures several months ago. Social Services Director N explained that she would go to R32's room and attempt to locate his dentures. During an interview on 03/03/2025 at 01:42 p.m. Minimum Data Set (MDS) Coordinator Z explained that she was the person that was responsible to update the plan of care if a resident had dentures. MDS Coordinator Z was asked if R32 had partial dentures and she responded that he did. MDS Coordinator Z confirmed that R39's partial upper dentures where not included on his plan of care or Kardex. During an interview on 03/03/2025 at 01:50 pm. Social Services Director N explained that R39's dentures were located in this closet and provided back to R39.

Based on observation, interview and record review the facility failed to include one resident (R#29) in care plan development of 16 residents reviewed for participation in care planning. Findings include: Resident #29 (R29) Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 29 (R29) was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, schizophrenia and seizure disorder. R29 scored 10 out of 15 (mild cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 02/25/25 at 09:04 AM, R29 was observed sitting in her room and was observed to have sad facial expressions. When queried about her mood R 29 reported she did not like living at the facility and wanted to be discharged back to the community. R29 elaborated that she was admitted to the facility last spring or summer and was discharged to an adult foster care in August 2024 with in home services from the community. R29 reported during her initial stay she had a care conference and was included and involved in her plan of care, R29 stated since her readmission last September, she has not had a care conference and was not included in her plan of care. When queried if she had met with Social Service Director (SSD) N to discuss her concerns R29 stated she tried on more than one occasion but SSD N was always very short and always has an attitude. R29 further stated she was well aware her brother was her guardian but did not think having a guardian made her lose her voice related to wants, needs, and desires be completely bypassed. R29 stated she just wanted to have a care conference and discuss her discharge plans. On 02/27/25 at 01:45 PM, SSD N verified that R29 was discharged in August of 2024 to an Adult [NAME] Care (AFC) and was not expected to return to return to the facility. Review of R29's clinical record including the MDS the admission to the facility on [DATE] was new. When queried why there was no patient care conference held in September 2024 upon R29's admission, SSD N stated there was a care conference held in December 2024. When reiterated why there wasn't a care conference in September 2024 while treated as a new admission with a new MDS , SSD N stated R29 Wasn't gone that long. When queried why the interdisciplinary team wouldn't meet with R29 to discuss what occurred at AFC , reason for returning to the facility and what current goals were SSD N stated she knew R29 was going to stay long term and didn't need to have a care conference. Review of R29's medical record with SSD N present, reflected a form titled Care Plan Conference Summary dated 12/31/24 the form indicated neither R29 or R29's legal guardian attended. There was no documentation that R29 or the R29's guardian was invited to the care conference held on 12/31/24. Page 1. question 1. of the care plan conference summary form asks what attempts were made to involve the resident or resident representative if they did not attended , several options were available to check off i.e.; different day, different time, via phone or written correspondence. None of which were checked. When SSD N was queried about the 12/31/24 care conference she reported R29's guardian attended, when queried why that was not documented on the attendance form or else where in R29s medical record SSD N stated she didn't know. When queried if R29 was invited to the 12/31/24 care conference SSD N stated she couldn't recall, but remembered the guardian attended. SSD N elaborated that R29 seeks her out several times a week and these conversations were discussed. When queried where this was documented or care planned SSD N stated she could have documented better.

This citation pertains to intake: MI00150426 Based on observation, interview, and record review the facility failed to follow physician orders for three residents (R11-brace application, R41-prosthetic fitting appointment, and R318-medication administration time) of sixteen residents reviewed for quality of care. Findings Included: Resident #41 (R41) Review of the medical record revealed R41 was admitted to the facility 10/27/2021 with diagnoses included chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), alcoholic liver disease, emphysema (chronic lung disease that permanently damages the lungs making his difficulty to breath), anemia (low red blood cells), alcoholic fatty liver, polyneuropathy (a peripheral nerve disorder that causes multiple nerves throughout the body to malfunction simultaneously), hypertension, hypotension, hyperlipidemia (high fat content), acquired absence of right leg above the knee, acquired absence of left leg above the knee, muscle spasm, chronic pain, anxiety, nicotine dependence, alcohol abuse, and dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/03/2025, revealed R41 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During observation and interview on 02/26/2025 at 08:54 a.m. R41 was observed lying in his bed. R41 explained that he did not have lower limbs bilaterally and was waiting to receive prosthetics. R41 explained that his stump incision had healed, and he was looking forward to being able to walk again. Review of R41's medical record demonstrated Appointment/Transportation Note, 12/23/2024 at 08:33 a.m. Note Text: Wound RN (RN) contact [NAME] Heart and Vascular office regarding staples to L(left) AKA (Above the knee) incision. Incision is healed and appears that staples are beginning to push outward and causing resident discomfort. No s/s (signs and symptoms) of infection observed by writer verbal order received for OK to remove staples to incision ok to schedule resident to return in 1 week to clinic to office if resident is wishing to pursue a prosthesis. Wound RN disgusted with resident during staple removal. Resident wishes to move forward with prosthesis . Review of R41's medical record demonstrated an order entered 01/29/2025, Order Summary: Referral for prosthetic fitting. Review of R41's medical record demonstrated a Social Services Progress Note, 02/03/2025 at 02:49 p.m. Note Text: . Utilizes a wheelchair for all motivation, recent orders placed for prosthetic fitting. Resident is eager to ambulate again. To follow up with both Endocrinology and Cardiology per facility NP/Physician . No other documentation in R41's medical record demonstrated that an appointment for prosthetic fitting had occurred. During an interview on 02/27/2025 at 09:30 a.m. Assistant Director of Nursing (ADON) T explained that when an order is received for an appointment that the facility scheduler would call the service provider and schedule an appointment. ADON T verified the R41 had a referral for prosthetic fitting. ADON T explained that she would have to verify if the appoint had been made yet. During an interview on 02/27/2025 at 09:58 a.m. Assistant Director of Nursing (ADON) T returned and explained that R41's appointment for the referral for prosthetic fitting had not bee completed yet. ADON T explained that the Manager of Therapy was calling today to schedule that appointment. ADON T could not explain why the appointment had not been requested before this date. Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). The most recent Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 02/18/2025, revealed R318 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 10:41 a.m. R318 was observed sitting at the side of his bed. R318 explained that he was supposed to receive his medication Protonix prior to his meals. R318 explained that he had expressed his concerns to the facility but it still keeps occurring that he does not receive his Protonix until after his meals. R318 explained that he still had not received his Protonix today and it is currently 10:15 a.m. - clearly after breakfast. Review of R318's medical record demonstrated an order, written 02/17/2025, Pantoprazole Sodium (Protonix) Oral Tablet Delayed Release 40 mg (milligrams) (Pantoprazole Sodium) Give 1 tablet by mouth two times a day for GERD (Gastro-esophageal reflux disease). During an interview on 02/27/2025 at 04:29 p.m. Director of Nursing (DON) C was asked when the medication Protonix was supposed to be given to residents. DON C explained that Protonix usually is given before meals. Requested DON C to provide report that demonstrated what time Protonix had been given to R318. Review of R318's Medication Administration Record (MAR) for the month of February 2025 revealed that Pantoprazole Sodium oral tablet delayed release 40 mg (milligrams) was ordered 02/14/2025 to be given as a liberal med pass (once on day shift and once on night shift). The MAR revealed that the Pantoprazole order was discontinued 02/17/2025 and rewritten on 02/17/2025 to be given at 06:00 a.m. and 04:00 p.m. Review of the facility of mealtimes demonstrated that R318s meals were delivered before his breakfast and dinner mealtimes. Review of R318's EMAR (electronic medication administration record)- Resident Details report revealed Pantoprazole was given on the following date and times (after meals): 02/14/2025 at 07:45 p.m., 02/15/2025 at 09:46 a.m. and 08:03 p.m., 02/16/25 at 09:25 a.m. and 07:53 p.m., 02/21/2025 at 09:21 a.m., and 02/25/25 at 07:39 p.m. In an interview on 03/03/2025 at 08:44 a.m. Director of Nursing (DON) C review R318's EMAR (electronic medication administration record)- Resident Details report for Pantoprazole. DON C could not provide an explanation why the medication had not been provided before meals. 46954 Resident #11 (R11) Review of the medical record reflected R11 was admitted to the facility on [DATE], with diagnoses that included generalized anxiety disorder, dependence on renal dialysis, depression, legal blindness, and major depressive disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/24, reflected R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 2/25/25 at 1:15 PM, R11 was observed in bed watching television. R11 had lidocaine patches applied to her neck. R11 reported that the lidocaine patches were for pain control and that she was supposed to be wearing a neck brace at all times, however the neck brace was not observed on R11. The cervical spine collar (neck brace) was observed on the bedside table, out of reach from R11. Review of an active Physician Order dated 11/29/24 reflected CT [cervical spine] collar at all times, remove every shift for skin checks and bathing. On 2/28/25 at 1:54 PM, R11 was observed in her room watching television. R11 did not have the cervical spine collar on. The cervical spine collar remained in the same spot as the previous observation. In an interview on 2/28/25 at 2:00 PM, Certified Nursing Assistant (CNA) X stated that she did not know the purpose of the cervical spine collar, but R11 is supposed to be wearing it. CNA X stated that R11 was not able to apply or remove the cervical spine collar herself. Review of the medical record revealed no documented refusals for the cervical spine collar.

This citation pertains to intake MI000133948. Based on observations, interviews, record review, the facility failed to protect two of three resident's (Residents #5 and 6) right to be free from verbal and physical abuse resulting in R5 and R6 causing injury to each other. Findings included: Record review of a Facility Reported Incident (FRI) dated 1/4/2023, revealed R5 and R6 were roommates. The report revealed that on 1/4/2023, R5 and R6 had begun to fight when R5 was exiting the bathroom and R6's wheelchair was in his way. R5 pushed R6's wheelchair which hit R6 on his shin resulting in an abrasion on R6's right shin. The report further revealed R6 grabbed his four legged cane and hit R5 in the his face resulting in R5 loosing a tooth. An attempt was made on 2/9/2023 at 8:40 AM, to interview R5, however R5 did not want to talk about the incident, and said nothing happened. In an interview on 2/9/2023 at 9:43 AM, R6 stated that while he was sitting on the edge of his bed R5 was exiting the bathroom, and stated R5 shoved his wheelchair towards him hitting his right shin causing skin to come off his shin which bled a lot. R6 then stated that he pushed his wheelchair back at R5, then R5 stood up and said now I am going to f-xxx you up, and raised and pulled back his fist. R6 said that was when he picked up his cane with the intent to put it on R5's chest to push R5 back away from him, however stated R5 sat down and his cane hit him in the face. R6 further stated he was moved to a different room as a result, but also stated that he had asked to be moved about one week prior to the incident because R5 was verbally abusive to him. R6 said R5 would say to him that he was stupid and called him names all the time. R6 stated he had reported the verbal abuse to several different staff members. R6 said R5 would bully all the residents, and if R5 would get near other residents he would tell the resident to move the F*uck out of his way. Review of a Skin assessment dated [DATE] revealed, R6 had a small abrasion to his right shin. During the same interview R6 said approximately two to three months ago while he was in the middle of the activities room R5 approached him and asked him to move, but said he told R5 he could go around him. R6 said R5 then kicked his wheelchair in the wheel which shoved his wheelchair sideway about two feet or more. In an interview on 2/9/2023 at 9:00 AM, Director of Nursing (DON) B said R5 was coming out of the bathroom and R6's wheelchair was in his way so R5 pushed the wheelchair which hit R6 on his shin cause an abrasion. DON B said R6 then hit R5 on his face, with his cane, which caused R5 to lose a tooth. DON B said she found the tooth on the floor. DON B said there was no history of either resident being abusive to other residents. In an interview on 2/9/2023 at 9:30 AM, Social Services (SS) D stated R5 had no history of abuse towards other residents just staff. In an interview on 2/9/2023 at 12:40 PM, Certified Nurse Aid (CNA) E and F stated that when R5 would be painful he would will lash out at residents telling residents to get out of his way and would cuss at the residents. Review of a Physician's progress notes dated 9/28/2022, revealed R5 was seen by the physician for evaluation of a .resident-to-resident interaction today. The note revealed that R5 kicked another resident's wheelchair from behind. Review of a Social Services Progress Notes dated 9/28/2022, revealed R5 was seen regarding a resident to resident incident that occurred with R6. The note revealed R5 admitted he was inpatient ad kicked the wheelchair from behind because the activity door was blocked. Record Review of R5's active care plans revealed no care plan was in place that addressed R5's physical and verbal aggression towards his roommate or other residents.

Based on observation, interview and record review, the facility failed to 1) implement hospital discharge recommendations for one (Resident #4) of four reviewed for quality of care; and 2) assess and monitor a change in condition for one (Resident #263) of four reviewed for quality of care, resulting in the potential for unrecognized changes in condition and delayed care and treatment. Findings include: Resident #4 (R4): Review of the medical record reflected R4 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R4 performed most activities of daily living with independence to limited assistance of one person. During an interview on [DATE] at 12:15 PM, R4 stated he was sent to the hospital a while back and returned to the facility three days later. According to Progress Notes, during a Psychiatric visit on [DATE], R4 expressed that he wanted to kill himself and ran a metal butter knife along his throat. R4's medical record reflected he was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the undated Hospital Discharge Summary reflected discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the document, a Comprehensive Metabolic Panel (CMP/blood test) was to be drawn on approximately [DATE], plus or minus 2 days. Additionally, the document reflected R4 was to follow up with [Surgical Group] within one week. R4's medical record did not reflect documentation of a CMP blood test or an appointment with the surgical group, as recommended. There was no documentation or rationale pertaining to why the recommendations were not acted upon. During an interview on [DATE] at 10:52 AM, Regional Director of Clinical (RDC) M stated she could not find documentation of the recommended blood test or follow-up appointment, nor rationale for why they were not done. Resident #263 (R263): Review of the medical record reflected R263 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:31 AM, R263 was observed lying in bed, alert and verbal, with the head of the bed elevated and oxygen via nasal cannula (NC) in place. Bruising that extended above and below the left shoulder was observed. On [DATE] at 11:51 AM, R263 was observed in bed, with the head of the bed elevated. A meal tray was observed on the overbed table at the right bedside. R263's eyes were closed, and she was not observed to be making attempts to consume food. On [DATE] at 11:58 AM, R263 was hollering out. Upon entrance into R263's room, she stated she was sicker than a dog but could not describe how she felt sick. She then stated she was going to get sick. She put her call light on, and a staff member promptly responded. R263 was heard stating she did not feel well, and the staff member stated she was going to find the nurse. On [DATE] at 12:02 PM, a male nurse knocked on R263's door and entered the room to address her complaint of not feeling well. She was overheard stating she could not breathe, and the rest of the conversation was unable to be heard. The nurse was overheard stating he was going to get some vital signs. Review of R263's oxygen saturation levels reflected: [DATE] at 5:56 PM: 98% on oxygen via NC [DATE] at 9:47 PM: 95% on room air [DATE] at 8:12 AM and 10:26 PM: 96% on room air [DATE] at 9:01 AM: 95% on oxygen via NC [DATE] 11:03 PM: 95% on room air [DATE] at 9:40 AM: 92% on oxygen via NC [DATE] at 2:24 AM: 93% on oxygen via NC [DATE] at 4:19 AM: 92% on oxygen via NC [DATE] at 7:41 AM: 83% on oxygen via NC [DATE] at 2:09 PM: 83% on oxygen via NC [DATE] at 2:30 PM: 91% on oxygen via NC [DATE] at 5:33 PM: 89% on oxygen via NC R263's Progress Notes did not reflect assessment or follow-up for oxygen saturation levels of 83% on oxygen via NC on [DATE], nor that the Physician had been notified at the time of the findings. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .At the time of my evaluation, the patient appears short of breath. She is hypoxic. Pulse ox in 80s. She reports feeling shortness of breath and notwell [sic] .Ill looking, elderly female, lying in bed, in mild distress .Bilateral coarse breath sounds. Apneic breathing. Decreased breath sounds in bases bilaterally .Awake, alert, oriented x2, responsive .ASSESSMENT AND PLAN .[CONDITION(S)] and shortness of breath. We will obtain stat chest x-ray 2 view. We will give [MEDICATION(S)] [diuretic] 40 mg [milligrams] stat and we will start [MEDICATION(S)] 40 mg daily. We will give her a dose of [MEDICATION(S)] [steroid] 40 mg stat and we will start [MEDICATION(S)] course. We will scheduled [sic] [MEDICATION(S)] [breathing treatment] q.6h. [every six hours] for relief of breathing. The patient at [sic] high risk for rapid decompensation; if no improvement in her condition, we will transfer her to the hospital for further evaluation .Continue to monitor respiratory status and oxygen saturation closely. We will obtain stat labs, CBC [Complete Blood Count], CMP [Comprehensive Metabolic Panel], and BMP [Basic Metabolic Panel] . On [DATE] at 3:25 PM, Registered Nurse (RN) E reported R263's lungs were wet, and [MEDICATION(S)], [MEDICATION(S)] and a chest x-ray were ordered. During an interview on [DATE] at 12:11 PM, Senior Director of Nursing (DON) G stated RN E reported the lab was unsuccessful in drawing R263's labs (on [DATE]). They (lab) were going to dispatch another person out. An .Overdue Standing/Future Orders List ([DATE]) reflected notation for [DATE] at 3:46 PM with a comment of, Not able to get severely dehydrated veins are blown made unit nurse aware. A Progress Note for [DATE] at 2:31 PM reflected a claim number for the chest x-ray (approximately two hours after R263 was evaluated by the Physician, who ordered a STAT chest x-ray). During an interview on [DATE] at 9:38 AM, Certified Nurse Aide (CNA) C reported caring for R263 on [DATE] and after she arrived on shift at 12:00 PM on [DATE]. CNA C described R263 as being a little confused on [DATE] and complaining of having a hard time breathing throughout the day. R263 would take her oxygen off and say she was having a hard time breathing. On [DATE], they ordered a chest x-ray and labs before she came in for her shift. As soon as she arrived at 12:00 PM, they started monitoring R263 and rotating her. According to CNA C, R263's left hand was swollen on [DATE] but not on [DATE]. CNA C stated that at 2:30 PM on [DATE], while with Senior DON G, R263 was talking to them, both hands were cold, and her left hand was puffy. They had to change vital signs machines, and R263's oxygen saturation was at 91% on three liters/minute of oxygen. CNA C reported she was in R263's room with the Phlebotomist at 3:30 PM. The Phlebotomist said they could not stick R263, and every time she poked R263, the vein blew. CNA C stated the Phlebotomist tried to draw blood from R263's foot and could not get a vein in the leg. At that time, R263 was kind of groggy, did not really say anything and stared into space. CNA C stated R263 had a couple of medications prior to that, and she was not sure if R263 was trying to rest. When asked if she knew if the nurse was aware of that, CNA C stated she was not sure but thought the nurse was made aware that the lab could not draw blood. At 4:00 PM, she was going to do rounds and a bed check on R263, when she was asked to get another set of vital signs on her. R263 was described as being cold to the touch with a low blood pressure. The machine then stopped recording blood pressure. A sternal rub was done on R263, CPR was initiated and 911 was called, according to CNA C. Upon further discussion, CNA C then said she had not noticed the swelling in R263's hand at the start of her shift. It was not until she went to switch hands when the oxygen saturation was not reading. CNA C believed that to be around 4:00 PM. During an interview on [DATE] at 9:59 AM, Physical Therapist (PT) D reported that on Monday ([DATE]), R263 was tired and stating she did not feel well. Monday was a [CONDITION(S)] day for R263, which made her tired, according to PT D. She reported working with R263 the morning and afternoon of [DATE], and R263 stated she was not feeling well. R263 would talk to her, open her eyes, then close them. PT D stated she informed the nurse that R263 was not feeling well, and that was around 2:00 PM. RN E said the Physician saw R263, ordered a chest x-ray and labs. During a phone interview on [DATE] at 10:42 AM, RN E reported when R263's oxygen was low, they had the Physician look at her, who prescribed [MEDICATION(S)], [MEDICATION(S)] and ordered an x-ray and labs (bloodwork). Around 1:00 PM or 2:00 PM, R263's oxygen saturation had gone up to 91%, then went back down again, which RN E stated was not a surprise to her. When the oxygen saturation went back down, it went to 81% or 83%, according to RN E. When asked around what time R263's oxygen saturation was in the 80's, she stated around 4:00 PM or 4:15 PM. She reported checking on R263 around 2:00 PM, and she was really about the same at that time. RN E stated she believed R263's oxygen saturation went up to the 90's, then back down again to the 80's. Around 4:00 PM, R263 was starting to change, and they coded [initiated CPR efforts] her around 4:15 PM. When queried if the ordered labs or chest x-ray had been completed, RN E stated she went back and the person from the lab was there (with R263). RN E was unsure if they were able to draw R263's labs, as she was told R263 was dehydrated. RN E reported walking into R263's room while the Phlebotomist was there, and R263 was quiet and not in distress. When queried on how often R263 was being reassessed for a change, RN E stated she was sure everyone was in there about every hour or so. If she was not in there, the CNA was. RN E reported being told R263's lungs were wet, but she had not personally assessed R263's lungs because other nurses had. Upon administering R263's nebulizer treatment on the afternoon of [DATE], R263 seemed to get better, and her oxygen saturation levels improved, according to RN E. RN E denied performing an assessment of R263's lung sounds before or after the nebulizer treatment. During an interview on [DATE] at 10:33 AM, RN K reported that when administering nebulizer treatments, she listened to lung sounds before and after the medication was given. During a phone interview on [DATE] at 10:57 AM, RDC F reported going in with Physician H around 12:30 PM on [DATE] to see R263. RDC F reported listening to R263's lungs. R263 did not admit or say she was having a hard time breathing, but she was, per RDC F's report. RDC F reported the nurse administered a breathing treatment around 12:30 PM to 12:40 PM, and RDC F stayed in the room until R263's oxygen saturation level came into the 90's. Upon checking on R263 (at 4:16 PM), R263 was awake, and her color did not look good. Vital signs were obtained, additional staff were requested, and the crash cart was obtained. When 911 was called, R263 was still able to shake her head to answer questions. The AED [automated external defibrillator] was applied preemptively, and R263 was informed of what they were going to do and that her spouse would be notified. R263's eyes glassed over, staff checked for a pulse and initiated CPR. During a phone interview on [DATE] at 3:39 PM, Physician H reported seeing R263 on [DATE] for an admission visit. When queried about when she became aware of R263's condition and shortness of breath, Physician H reported staff notified her while she was at the facility that day ([DATE]). According to Physician H, the nurse also wanted her to see R263 because she was having some shortness of breath. When she went to see R263, she was not keeping her oxygen on, her oxygen saturation would drop, and R263 was a little short of breath at that time and seemed uncomfortable, per Physician Hs report. STAT labs, a STAT chest x-ray, [MEDICATION(S)] and [MEDICATION(S)] were ordered. Once the bloodwork returned, they were going to modify management based on the bloodwork and chest x-ray results. Nebulizers (breathing treatments) were also ordered, and R263 was told to keep her oxygen on to avoid becoming hypoxic, according to Physician H. Physician H reported speaking to RDC F and Senior DON G to let them know that R263 was at high risk for rapid decompensation, was hypoxic and short of breath, that labs and chest x-ray were ordered, and if she continued to deteriorate, to send her to the hospital. Physician H reported the facility was going to closely monitor R263, check vital signs and make sure she was not taking her oxygen off. Regarding the frequency of the monitoring, Physician H reported at least every two hours, including doing vital signs if possible. When queried if the labs were drawn successfully, Physician H reported when talking to staff, they were going to call the lab and get the x-ray done. She made everyone aware that they were going to follow-up on that. Physician H reported being notified later on that R263 coded and was sent to the hospital. Physician H was unsure if the facility was able to get anything done before R263 left the facility. When queried on if anyone was in contact with her between her visit with R263 on [DATE] and the time that she coded that day, Physician H stated the facility may have called the on-call service. She was not personally on call that day. The facility usually called the on-call service when she was not there, but they also had her direct phone number. According to a Progress Note for [DATE] at 5:29 PM, upon entering R263's room at 4:16 PM to assess her condition, she was in bed, appeared pale and was responsive to verbal stimuli. R263 was able to shake her head yes or no. Her blood pressure was ,d+[DATE], respirations were shallow at a rate of six breaths per minute, heart rate was 44 beats per minute and pulse was palpable [able to be felt]. Her oxygen saturation was 89% on three liters per minute of oxygen. 911 was called, the crash cart was obtained and the AED was applied. At 4:22 PM, there was no carotid pulse, and CPR was initiated. Emergency Medical Services arrived on scene at 4:29 PM. A pulse and spontaneous breathing returned prior to transferring to the hospital at 4:47 PM, according to the note.

Based on observation, interview, and record review the facility failed to provide pain medication as ordered for one Resident (#19) of four residents reviewed for pain. This deficient practice resulted in resident unnecessarily experiencing unrelieved pain. Findings include: Resident #19(R19) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R19 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R19's had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with bed mobility, transfers, dressing and one person physical assist with eating, toileting, hygiene, and bathing. Continued review of the MDS reflected R19 had frequent pain with limited day to day activities related to pain. During an observation and interview on 6/08/21 at 8:37 a.m. R19 was laying in bed on his back and appeared well groomed and alert, oriented and pleasant. R19 reported lived at facility related increased need for assistance related [CONDITION(S)]. R19 reported over past weekend had uncontrolled pain over past weekend because he missed several doses of scheduled pain medication. Licensed Practical Nurse (LPN) N entered R19 room and reported R19 had ran out of scheduled pain medication on Friday and did not receive them from the pharmacy until Monday(6/7/21) morning. R19 reported should have received scheduled [MEDICATION(S)] 25 mg three times daily and instead only received [MEDICATION(S)] 5 mg three times daily both Saturday and Sunday. R19 reported by Monday morning pain was out of control and rated pain on pain scale of 0(least pain) to 10(most pain) of at least 8 out of 10 and increased tremors(shaking), increased blood pressure and stated, all I could do was cry. R19 was told by staff over weekend that pain medication was not available to give and pharmacy had not delivered. R19 reported had reported pain scale to staff throughout weekend greater than 8 out of 10 on pain scale and was given as needed pain medication with minimal relief of pain. Review of the Nursing Progress Notes, dated 6/6/21 at 11:24 a.m., for R19, reflected, Resident is out of [MEDICATION(S)] 10 mg Rx was ordered from pharmacy by night shift nurse .Requested a script to allow to pull 25mg from [MEDICATION(S)] 5mg that is in stock. Awaiting return call from physician. Review of the Physician Orders, dated 11/5/20 to current, reflected R19 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19 pain monitoring reflected between 6/1/21 and 6/8/21 reflected R19 had pain less than 7 out 10 prior to 6/5/21 and had three documented times 7 out of 10 or greater. Review of the Pain Care Plans, revised 4/9/21, had interventions that included, Administer pain medications as ordered. Monitor for effectiveness. If not effective contact physician . During an interview on 6/9/21 at 9:40 a.m. Director of Nursing (DON) B reported no medication errors report for R19 for past week. DON B then reported needed to complete medication error for report on Monday(6/7/21) that R19 did not receive [MEDICATION(S)] dose all weekend. DON B reported if [MEDICATION(S)] (controlled pain medication) dose was not available nursing staff would be expected to call physician and if an order was placed STAT medication should have been received within four to six hours or at least 24 hours from the pharmacy. DON B verified nurse on 6/6/21 days had documented that physician was contacted and reported no documentation that reflected nurse on 6/5/21 had contacted physician after last dose of R19's [MEDICATION(S)] had been given at 1:00 p.m. During an interview and record review on 6/09/21 at 10:15 a.m. DON B verified [MEDICATION(S)] 10mg received from pharmacy for R19 on 5/21/21 #90 and verified three completed narcotic control sheets. DON B reported again would expect nurse to call physician, document and if no response from physician to continue to call physician. DON B reported one documented attempt to contact Physician on 6/6/21 with no follow up noted. DON B reported was informed on Monday morning (6/7/21) by Activity Director M, Registered Nurse (RN) O, R19 mother and R19. During an interview and record review on 6/9/21 at 11:45 a.m. DON B reported, after speaking with staff, nurse that worked nights on 6/5/21 had reported to the day nurse on 6/6/21 that R19 had run out of [MEDICATION(S)] 10 mg tablets. Review of R19 Messaging Queue, provided by DON B, reflected communication to pharmacy [MEDICATION(S)] HCL tablet 10mg on 6/6/21 at 8:52 a.m. and on 7/7/21 at 6:51 a.m. During an interview on 6/9/21 at 12:30 p.m. DON B reported all nurses care for R19 four days prior to R19 running out of [MEDICATION(S)] dose on 6/5/21 had an opportunity to re-order medication from the pharmacy. DON B reported would expect staff to call physician for each missed dose and document. During an interview and record review on 6/9/21 at 12:45 p.m., Assistant Director of Nursing (ADON) P verified R19's [MEDICATION(S)] 10 mg tablets were delivered to the facility at 1:28 p.m. on 6/7/21. R19 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/9/21 at 1:25 p.m. LPN N reported had documented on MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN N reported had actually given [MEDICATION(S)] 5 mg five tablets because the 10 mg tablets had not been delivered from the pharmacy yet. During an interview on 6/10/21 at 9:00 a.m. DON B reported Medication Error document had been completed for R19 related to four missed doses of scheduled [MEDICATION(S)]. DON B reported plan to educate staff for what to do when narcotic script scheduled to run out. DON B reported no evidence that R19 [MEDICATION(S)] had been re-ordered prior to running out 6/5/21.

This citation pertains to Intake: MI 102 and MI 933 Based on observation, interview and record review the facility is placed in Immediate Jeopardy (IJ) for its failure to; 1) operationalize the Cardiopulmonary Resuscitation (CPR) Policy for the use of the available Automatic Electronic Defibrillator (AED) for one resident (R202) of one review for CPR; 2) ensure that nurses maintained CPR certification that were current for 2 of 3 nurse staff who performed CPR for R202 on [DATE], resulting in R202, who was a Full Code, expired after going into [CONDITION(S)] on [DATE] and likelihood that all Residents with Full Code statuses would not receive competent basic life-sustaining measures and efforts in an emergency, resulting in the likelihood of harm and/or death. Immediate Jeopardy: On [DATE] at 6:45 p.m. R202 was found in her room unresponsive and not breathing by Non-Certified Nurse Assistant (NCNA) C who summoned CNA F, passing in the hall. CNA F was unable to locate pulse for R202. CNA F summoned Licensed Practical Nurse (LPN) E and Registered Nurse (RN) D from the Nurse Station at approximately 6:50 p.m. who immediately assessed R202 for a pulse and respirations and found none. CNA F arrived with crash cart without available AED from East Nurse Station at undetermined time related to no documentation of recorded code blue time line. LPN E performed rescue breathing for R202 with use of Ambu bag and oxygen and RN D continued chest compressions without use of available AED. Emergency Medical Services arrived 7:01 p.m. and documented no AED in use prior to arrival. Immediate Jeopardy began on [DATE] at 6:45 p.m. Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:00 p.m. The Immediate Jeopardy Abatement/Removal Plan was accepted on [DATE]. The IJ Removal Plan was verified on [DATE] with a Removal Date of [DATE]. Findings Include: Review of the Face Sheet dated [DATE], reflected R202 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet reflected R202 was her own responsible person and was a Full Code. During the facility tour on [DATE] at 9:18 a.m., no crash cart was observed in area of West Nurse Station including cubby area or common area. During the facility tour a crash cart was noted on East/Certified hall located near East Nurse station with an AED located at the East Nurse station. During a telephone interview on [DATE] at 3:32 p.m., R202 family member J reported R202 passed away at the hospital on [DATE] after being transferred from facility the same day. R202 family member J reported had spoke with R202 on phone [DATE] at 8:30 a.m. and complained of leg pain and need to return to bed from wheelchair. R202 family member J reported concerns about if staff were monitoring R202 including for required oxygen use and reported concerns with crash cart not stocked appropriately when needed on [DATE]. Review of the facility Electronic Medical Record Nurse Progress Notes, dated [DATE] at 12:17 a.m., reflected Nurses' Notes Note Text: Approximately 6:55 pm I was called to (named R202) room by waiver care aide stating that resident looked as if she wasn't breathing. Upon entry (named R202) was sitting in wheelchair, 02 concentrator was not on, nor was nasal cannula in place. No pulse detected. Myself, care aide and charge nurse lowered patient to floor and began CPR. 30 compressions to two breaths. EMS was called. Chest compressions continued. Green discharge from nose was witnessed. (Named R202) showed no signs of breathing. EMS arrived and continued CPR approx 7:00 pm. AED was applied. Intraosseous was manipulated to R leg. Failed attempt. IV then placed in R arm. [MEDICATION(S)] 10 ml given. CPR continued. Pulse of 107 detected. Resident was then intubated, transferred to stretcher. 7:25 pm (named R202) in route to (named hospital) ER. (Named daughter) and (named physician) notified of occurrence. During an observation on [DATE] at 4:25 p.m. this surveyor observed area in and around West Nursing Station and did not locate a crash cart or AED machine. During an interview on [DATE] at 11:00 a.m. Non-Certified Nurse Aid (NCNA) K reported R202 required a one person assist with most care. NCNA K reported R202 was able to express needs and reported used call light frequently for request to reposition at least every hour. NCNA K reported R202 required oxygen and never refused to use it. NCNA K reported facility had one crash cart located by East Nurse Station (opposite of 400 hall). During an observation on [DATE] at 1:35 p.m. this surveyor observed one crash cart located in cubby across the hall from the East Nurse Station and one AED located at the East Nurse Station on the wall. During a telephone interview on [DATE] at 3:04 p.m. Licensed Practical Nurse (LPN) E reported worked at facility one day every one to two weeks. LPN E reported on [DATE] was notified by NCNA C that R202 might not be breathing about 6:30 p.m. or 6:40 p.m. LPN E reported she went to R202 room and found R202 in wheelchair unresponsive with no pulse. Staff lowered R202 to floor and Registered Nurse (RN) D started chest compressions. LPN E reported thought someone was keeping record of event but could not recall. LPN E reported the crash cart did not arrive right away so she located a piece of plastic in the room and tore hole in plastic and used as barrier between R202 mouth and her own and administered two rescue breaths and RN D continued compressions for approximately 2 CPR cycles before crash cart arrived. LPN E reported LPN I arrived about the same time as the crash cart and assisted with Ambu Bag and oxygen. LPN I took over chest compressions after ,d+[DATE] cycles of each 30 compressions and 2 breaths and continued until Emergency Medical Services (EMS) arrived. LPN E reported the AED did was not brought to R202 with the crash cart and when the EMS arrived they used their equipment including their AED Defibrillator and delivered a shock and started an Intravenous line for R202. LPN E reported arrived for shift on [DATE] at 6:00 p.m. and reported Staff Coordinator Lwas caring for R202 prior to that but was unsure if she was given shift report. LPN E reported had not observed R202 prior to Code Blue(emergency situation indicated by patient requiring immediate resuscitation) event because had not completed rounds prior to being called to R202 room by NCNA C. LPN E reported she had not received any type of Code Blue, CPR or AED training from the facility and reported only one crash cart located on East Hall by Nurse Station. LPN E reported only documentation of R202 Code Blue on [DATE] was located in progress notes. During an interview on [DATE] at 3:46 a.m., Non-Certified Nurse Assistant (NCNA) M reported had worked at facility for six months and was waiting to take CNA certification testing. NCNA M reported working West hall on [DATE] day shift 6:00 a.m. to 6:00 p.m. and was assigned to R202. NCNA M reported R202 was up in wheelchair when she arrived on shift at 6:00 a.m. and reported not feeling well with complaints of nausea and NCNA M reported transferring R202 to bed for two hour nap. NCNA M reported R202 was up in wheelchair for lunch then therapy with no concerns. R202 had reported leg pain, at site of incision, and reported to LPN H who provided pain medications and [MEDICATION(S)]. NCNA M reported R202 was alert and oriented and able to express needs and had requested to stay in wheelchair until after dinner. NCNA M reported she took R202 to bathroom at approximately 4:30 p.m. and R202 requested to remain in wheelchair afterwards. NCNA M reported R202 was sleeping in wheelchair when dinner tray delivered and during rounds with NCNA C at 6:00 p.m. and reported to Registered Nurse (RN) L, who was R202 nurse from 3:00 p.m. to 6:00 p.m. This surveyor asked where the facility crash cart was located, NCNA M reported cubby by West Nurse Station and cubby by East Nurse Station or in locked Medication room. NCNA M reported had never received Code Blue training from the facility. During an interview on [DATE] at 4:23 p.m. Certified Nurse Aid (CNA) R reported being employed at the facility for six months. CNA R reported was not present for Code Blue for R202 on [DATE] and reported had never experience a Code Blue at facility including a drill. CNA R reported the facility had one crash cart located in cubby by East Nurse Station. During an interview on [DATE] at 4:54 p.m., LPN I reported being employed at the facility for two years and usually worked day shift from 6:00 am to 6:00 pm. LPN I reported working [DATE] day shift and was completing documentation at end of shift on East Nurse Station when at about 6:50 p.m. CNA F was running down hall looking for crash cart for resident on West hall. LPN I reported CNA staff pushed crash cart to R202 room and reported she arrived to R202 room at the same time as the crash cart and observed RN D performing chest compressions for R202 on the floor and LPN I assisted with connecting oxygen to ambu bag and handed to LPN E who was near R202 head. LPN I reported RN D performed about two rounds of 30 chest compressions and LPN I took over compressions and RN D took over ambu bag. LPN I reported should have been someone responsible for documenting Code Blue event. LPN I reported they continued CPR for several cycles but unsure how many and switched again and continued CPR until EMS arrived. This surveyor asked if the facility had a AED defibrillator available to use. LPN I stated, Yes. LPN I reported it was located at the East Nurse Station. LPN I reported a week prior to R202 Code Blue event the crash cart had moved to the cubby located across the hall from the East Nurse Station, where it was located on [DATE]. LPN I reported was unsure why the crash cart moved but not the AED. This surveyor asked, when would you use the AED defibrillator? LPN I reported it should always be used with CPR. LPN I reported the AED was not used during R202 Code Blue event on [DATE] and was not present in the room during the code. LPN I reported after EMS arrived they took over and used AED, placed intravenous line and administered medication. LPN I reported R202 had a pulse prior to leaving facility. This surveyor asked if anyone recognized the facility AED was not used and if education was provided after the Code Blue on [DATE]? LPN I reported she realized after the EMS had arrived that facility AED had not been used and should have been. LPN I reported facility management did not provided any Code Blue or AED use education after R202 Code Blue event on [DATE]. LPN I did not recall receiving Code Blue education prior to [DATE] event. During an interview on [DATE] at 9:18 a.m., RN Staff Development (RNSD) L reported had been employed at facility for nine months and started staff education role [DATE]. RNSD L reported had cared for R202 on [DATE] from 3:00 p.m to 6:00 p.m. and had last observed R202 on [DATE] at 5:55 p.m. and later observed CNA staff giving report in room shortly after. RNSD L reported the facility had two crash carts and one was located at East Nurse Station and unsure of second location. RNSD L reported when a Code Blue is heard overhead staff are expected to obtain crash cart and AED and deliver to Code Blue location as soon as possible. RNSD L stated, AED should be attached to resident as soon as crash cart arrives because patient has better chance to survive with use. RNSD L reported if crash cart not present after 30 compressions staff expected to continue compressions until crash cart arrives. This surveyor asked, Are breathes delivered without use of ambu bag? RNSD L stated, No. RNSD L reported since taking over role as staff educator three months ago there had been no Code Blue drills at the facility or education provided to staff. During an observation on [DATE] at 10:50 a.m. revealed no crash cart located in or around area of West Nurse station including cubby across from nurse station. During an interview and observation on [DATE] at 11:25 a.m. NCNA V reported had been employed at facility as waiver aid for eight months and was not present for R202 Code Blue on [DATE]. NCNA V reported the facility had two crash carts located against wall in each nurse station and when Code Blue is called overhead staff are required to grab crash cart and take to location as well as vital cart. NCNA V reported items included on crash cart were ambu bag, defibrillator that was located inside the crash cart. NCNA V reported as waiver nurse aid not allowed to perform CPR but if witnessed resident unresponsive, required to call out code blue, obtain vitals, move resident to flat surface, attach AED pads as soon as possible to determine if resident has heart rhythm (can place patches but not deliver shock), record notes including times, and call 911. During a tour immediately after interview at 11:45 a.m. NCNA V passed by West Nurse Station and stated, stated maybe we only have one crash cart. No crash cart was none noted at or in area of West Nurse Station. NCNA V pointed out crash cart located by East Nurse Station in cubby and AED located at East Nurse Station. During an interview on observation on [DATE] at 11:50 a.m. CNA U reported had been employed at the facility for eight years and often worked days shift on West hall. CNA U reported R202 alert and oriented resident and able to express needs. CNA U reported the facility had three crash carts located at each the West and East Nurse Station, and one in the Dining Room. CNA U reported 2 AED located at each Nurse Station on the wall and pointed to wall at West Nurse Station but AED was not there and reported one AED located at East Nurse station. CNA U reported if resident found unresponsive staff are required to call Code Blue overhead, nurse would arrive to location, staff would bring crash cart and AED, staff would call 911, nurse would assess resident. CNA U reported was not CPR certified. CNA U reported last Code Blue occurred prior to [DATE] with exception of R202 on [DATE]. During an facility tour immediately after interview at 12:10 p.m., CNA U entered area by West Nurse Station(room with vending machines, entrance to courtyard) and pointed to area that she had thought crash cart was located and reported no longer there and unsure how long it had been gone and verified no longer in that room. CNA U walked to East Nurse Station and reported crash cart was not present and stated, usually under defibrillator on wall at Nurse Station. CNA U continued to walk to last location she was aware of and stated, I hope this last one is in Dining Room. CNA U arrived to Dining Room and reported crash cart was not present and stated it was usually located in the Dining room by outside exit door, inside red tape area. CNA U stated, this is a problem and is embarrassing. CNA U reported was unsure where the crash carts were located. During an interview on [DATE] at 12:30 p.m. this surveyor requested a second time the Code Blue Policy and Procedure from Director of Nursing B. DON B reported the facility did not have Cope Blue Policy and Procedure. This surveyor ask how staff know how to respond to Code Blue? DON B reported staff are educated on different code by Maintenance Director W including crash cart and AED locations. This surveyor requested training provided training. Review of Employee Files, provided by Payroll Coordinator/Human Resource staff (HR) N on [DATE] at 12:48 p.m., reflected no record of CPR certification LPN E or RN D (two of the three nurses that performed CPR on [DATE] for R202). During an interview and record review on [DATE] at 1:13 p.m., Maintenance Director (MD) W reported responsible for providing new employees training on Emergency Codes including Code Blue. MD W reported staff are trained that all staff must stop what they are doing and report to room Code Blue location when announced overhead. MD W reported he always provides new staff tour of facility that includes location of crash carts and AED. MD W reported facility performs drills including Code Blue drills and reported was unsure when and reported DON B or management initiate drills. MD W reported performs routine prevention maintenance monthly that included verification that AED is functioning and documents findings. MD W reported AED located at East Nurse Station and one Crash Cart located in cubby across the hall from East Nurse Station. MD W reported prior to new management in [DATE] facility had two crash carts. This surveyor asked MD W why staff are educated on location of AED and Crash Cart? MD W stated, because we could save a life. MD W verified routine preventative monthly AED checks for past four months in electronic system dated [DATE], [DATE], [DATE] and [DATE] and reported AED had always been in working condition. During a telephone interview on [DATE] at 3:26 p.m., NCNA C reported had was a wavier nurse aid at the time of R202 Code Blue on [DATE]. NCNA C reported had never worked with R202 prior to [DATE] and arrived for shift at 6:00 p.m. and received report form NCNA M during walking rounds in each resident room. NCNA C reported received report that R202 daughter wanted R202 to call after dinner. NCNA C reported R202 was in wheelchair at the time of report sleeping and oxygen was not on resident, but was located on the floor by the bathroom about 6:15 p.m NCNA C reported was not aware that R202 required oxygen at that time. NCNA C' reported returned to R202 room between 6:40 and 6:45 p.m. and found R202 unresponsive in wheelchair after touching R202 shoulder, felt cold, and reported did not appear normal. NCNA C reported he summonsed CNA F who was walking in hall, to assist with R202, who was unable to locate R202 pulse, and reported CNA F left room and summoned LPN E and RN D who immediately arrived in room. NCNA C reported R202 was lowered to the floor from the wheelchair and RN D started chest compressions, CNA F was getting crash cart located by East Nurse Station and he (NCNA C assisted), someone called 911. NCNA C reported crash cart included suction, oxygen, ambu bag and should have had AED but was not located on crash cart at time of R202 Code Blues on [DATE]. NCNA C reported when he return to R202 room nurses continued CPR with LPN E using ambu bag and R202 continued to appear unresponsive. NCNA C reported after EMS arrived they applied AED patches and used. NCNA C reported had never received Emergency Code education including Code Blue form MD W as new employee and had never received Code Blue training prior or after R202 Code Blue on [DATE] including Code Blue Drills. NCNA C reported RN D appeared to be directing R202 Code Blue event on [DATE]. During a telephone interview on [DATE] at 4:14 p.m., LPN H reported had cared for R202 on [DATE] from 6:30 a.m. to 2:30 p.m. on [DATE] and was not present for R202 Code Blue event. LPN H reported common knowledge for staff to bring Crash Cart and AED to Code Blue. LPN H denied Code Blue drills at facility and denied receiving any Code Blue training from facility. During an interview on [DATE] at 4:37 p.m., RN D reported being employed with the facility for five months. RN D reported on [DATE] worked from 6:00 p.m. to 6:00 a.m. on East and Sound hall. RN D reported had just finished report on her hall when Aid yelled they need a nurse, another aid said unsure if resident on 400 hall was breathing. RN D arrived at R202 room and LPN E was already in room. RN D reported R202 was in wheelchair and staff lowered R202 to the floor, R202 did not have heart rate and RN D started chest compressions, sent Aide for crash cart, continued 30 chest compressions to two breaths for two rounds. RN D reported LPN E attempted to make use plastic barrier between R202 mouth and LPN E mouth prior to Crash Cart arrival and after Crash cart arrived CPR continued with 30 chest compressions to 2 breaths with use of ambu bag connected to oxygen. RN D reported thought a Nurse Aide was recording Code Blue but reported had never observed any documentation of events after the Code Blue. RN D reported LPN I took over chest compressions until EMS arrived and she exited R202 room. RN D reported facility AED was not brought to R202 room at time of Code Blue. RN D reported staff had informed her after Code Blue they did not know they needed to bring with crash cart. RN D reported Crash cart by East Nurse station is located in different location than AED and stated, maybe not best idea. This surveyor asked if it was it reported that that the AED was not in the room at the time of R202 Code Blue on [DATE]? RN D reported she did not report to management. RN D reported facility did not provide Code Blue education included proper AED use after R202 Code Blue on [DATE]. During an observation on [DATE] at 8:15 a.m., Crash Cart was located near the West Nurses Station cubby area with the last documented review of inventory noted [DATE]. No AED noted on cart. During an observation on ,d+[DATE] 21 at 8:25 a.m., Crash Cart continued to be located at East Hall cubby with AED located at Nurse Station. Review of the EMS Patient Care Report, dated [DATE], on [DATE] at 11:08 a.m. reflected 911 was called for R202 on [DATE] at 6:54 p.m. and EMS arrived to R202 at 7:01 p.m. The reported reflected, AED use prior to EMS arrival, No. During an interview on [DATE] at 2:55 p.m., HR N reported responsible for keeping track of licensing and certification for staff and able to do so by recording on payroll and runs report every two weeks. During an interview and record review on [DATE] at 3:15 p.m., HR N provided report used to track licenses and certifications. HR N reported RN D did not have copy of CPR certification in employee file and that was her fault because HR N had seen it and recorded it on payroll but must have disposed of paper copy. HR N reported LPN E did not have copy of CPR certification in employee file and payroll report did not capture need to obtain record (report did not capture all staff who required CPR certification). During an interview an observation on [DATE] at 3:30 p.m., Unit Manager (UM) O reported was unsure where crash cart on West Hall was located at prior to today and reported was performing audit at that time and verified last documented audit was [DATE]. During an interview on [DATE] at 3:45 p.m., DON B reported all nurse staff are expected to have current CPR certification. DON B reported was unable to locate LPN E current CPR certification. DON B verified, according to payroll report used to track professional licenses and certifications, reflected UM O CPR certification expired on [DATE], and RN P had no record of CPR certification, nurse Z had no record of CPR certification, and LPN T CPR certification expired. During an interview on [DATE] at 4:40 p.m., DON B reported she would expect a staff member to be responsible for recording (documenting) Code Blue Emergency including times, staff present, resident response and details related to CPR. DON B verified there was no detailed documentation of R202 code blue on [DATE] that reflected those details. Review of New Employee Education and Reliac facility education, on [DATE] at 11:08 a.m., provided for past 12 months for four employees reflected no record of Code Blue Education. During an interview on 12:17 p.m. DON B reported provided staff education related to crash cart and locations on [DATE] and reported was surprised how many staff did not know what the crash cart was or the location. DON B reported would expect all staff to know what a crash cart was and where to locate crash cart and AED and would expect nurse staff to use the available AED at a code blue. During an interview on [DATE] at 1:30 p.m. ADM A and DON B reported the facility had no documented staff education for code blue including relias education. On [DATE] at approximately 2:00 p.m., the Administrator was notified of the Immediate Jeopardy that began on [DATE] and was identified on [DATE], when the facility failed to operationalize the Cardiopulmonary Resuscitation (CPR) Policy for the use of the available Automatic Electronic Defibrillator (AED) for one resident (R202) of one review for CPR On [DATE], the survey team confirmed that the facility implemented the following to remove the Immediate Jeopardy: -The AED was removed from the wall and placed on the crash cart on [DATE]. -Staff present at the time of the Code Blue received 1:1 education starting on [DATE] regarding location of AED and crash cart and that they are to bring both (AED and crash cart) immediately to emergency situations. -The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]). -Facility Medical Director was notified of the incident on [DATE]. -The ADON or designee did a 100% audit of all licensed nurses for up to date CPR certification on [DATE]. - Licensed nurses CPR cards were validated to be current. Licensed nurses with expired CPR cards will not be permitted to perform CPR until their CPR certification has been updated and validated by DON or designee on [DATE]. - The DON or designee completed a chart audit on every resident and compared the advance directives to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -The facility took the following actions starting on [DATE] to prevent an adverse outcome from reoccurring. (Completion Date: [DATE]) -All staff will be educated on Code Blue and the location of the crash carts/AED by the DON/designee by [DATE]. Staff will not permitted to work a shift until education was completed. -The DON or designee educated all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident by the DON/designee by [DATE]. Staff will not permitted to work a shift until education was completed. -The facility will be scheduling CPR recertification classes (call made/left message [DATE]) for all nurses that do not have a current CPR card within their file. -The CPR policy and procedure will be introduced into the orientation process starting [DATE] and will be delivered by a licensed nurse (DON, ADON, UM and/or SDC) to discuss each person's responsibility and answer questions if needed. -A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented on [DATE]. DON to monitor for code status compliance by completing mock code blue drills that evaluates staff knowledge of the facility CPR policy and procedure, as well as assessing the CPR process. Compliance checks will be conducted random weekly audits/drills for three months. Findings will be reported at monthly QAA Committee meeting. -DON or designee will audit new admissions starting [DATE] to compare the resident's advance directives to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings will be reviewed at the monthly QAA Committee meeting. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not been verified by the State Agency.

This citation pertains to intake numbers MI 0991 & MI 1076 & MI 1159. Based on observation, interview, and record review, the facility administration failed to ensure 1 Unlicensed Staff Member (ULSM) C, out of 120 licensed and unlicensed staff members had a State issued nursing license to practice as a Licensed Practical Nurse (LPN) in the State of Michigan, who from (MONTH) (YEAR) to 2/6/2019 provided licensed nursing duties for 110 residents, including Residents #1, #55, #58 and #59 resulting in the potential for residents to not maintain their highest practicable physicial, mental, and psychosocial well-being. Findings included: Record review of ULSM C's employee application revealed ULSM C was hired at the facility in (MONTH) of 2014 as a CNA. ULSM C's employee file revealed ULSM's C certification as a CNA was active and had an expiration date of 10/31/2020. Further review of ULSM C's employee file revealed ULSM C had a diploma in Practical Nursing from a health education center program of nursing that was dated 10/3/2013, and a general associates degree from a community college dated (MONTH) 11, 2007. No other college degrees were noted in ULSM C's employee file. Upon review of ULSM C's job application, dated (MONTH) of 2014, it was noted that ULSM C had written in, under the Education section, that her only degree was from the community college for the General Associates degree obtained in 2007, and had not written on the application her diploma in Practical Nursing dated 10/3/2013. Review of a nurse aid registry confirmation letter, dated 9/12/2016, revealed ULSM C was employed at the facility as a CNA for the last consecutive 24 months. Review of ULSM C's employee file also revealed a job description titled, Certified Nursing Assistant, and included duties that applied to this job role such as taking resident's vital signs, providing bathing, dressing, etc ., under the supervision of a licensed nurse. The job description did not include duties of administering resident's their medications, treatments, documenting progress notes, taking physician orders, implementing physician orders, performing resident's assessments, or administering narcotics to residents. The job description was signed by ULSM C on 12/16/2014. A checklist dated 12/24/2014, that was in ULSM C's employee file revealed ULSM C was observed to be competent with CNA duties, and did not include any licensed nursing duties of administering medications to residents, treatments, obtaining and/or implementing physician orders, performing and/or documenting resident assessments, or documentation of resident progress in nurses' progress notes. No other job description was found in ULSM Cs employee file. Further review of ULSM C's employee file revealed a document titled, Personnel Action Request (PAR) form, dated 4/19/2018. The document revealed, under Section 4: Job/Status/Rate Changes, ULSM C had a rate of 19.00, and the reason indicated was, Completed Nursing School-in Training. The document was signed by Administrator A on 4/20/2018. Another Personnel Action Request (PAR) document, dated 12/28/2018, revealed, under Section 4: Job/Status/Rate Changes, Current, Rate for ULSM C was 14.85 Cena (Competency-Evaluated Nursing Assistant, same as ULSM) and NON LPN 19.50, and under, New-Rate ULSM C's rate was, 15.30 Cena, and 20.09 NON LPN. Under, Reason for rate adjustment the document revealed, Yearly Evaluation, and was signed by Administrator A on 1/8/2019. In an interview on 2/7/2019 at 3:00 PM, ULSM C stated she began working at the facility in 2014 and was hired for a CNA position. ULSM C said she received a diploma from a health education school in 2013 and said she could not recall when she started working in a nursing position at the facility, but thought it was approximately 6 months ago that she started in the role of a Graduate Nurse (GN) at the facility. ULSM C said she asked Assistant Director of Nursing (ADON) H if there was a way to receiving some tutoring help because she was not able to pass the National Council Licensure Examination (NCLEX-national exam taken by a graduated nursing student in order to obtain a nursing license to practice as an LPN). ULSM C said the last time she had taken the NCLEX exam was in (MONTH) (YEAR), and said she had failed the exam, and had no other testing date scheduled at the time. ULSM C said ADON H told her she would have to see what she could do and stated approximately 3 weeks later ADON H told her she could move into a GN position. ULSM C said she had to be under supervision of another licensed nurse, but was able to administer medications, including narcotics, provide wound care, check residents' blood sugar via a finger stick, administer insulin to residents per physician's orders [REDACTED]. [REDACTED]. ULSM C said she was able to perform all the duties that a licensed nurse performed, and said she was supposed to have another licensed nurse sign documents alongside her signature, but stated she did not know if a licensed nurse did so. ULSM C said she did not ever receive a Job Description that governed her GN duties, such as the CNA job description that she received upon her hire at the facility, nor did she complete a competency checklist (duties performed while observed, and signed by a licensed nurse indicating ULSM C was competent to perform licensed nursing duties), and ULSM C said again that she was not able to provide any way to prove that any licensed nurse signed documents alongside her signature. ULSM C confirmed that when she arrived at work when she looked at her assignment, she was working as a GN and she did perform licensed nursing duties by herself without a licensed nurse with her. Adding that sometime a licensed nurse would check on her after she completed a duty. ULSM C confirmed medication administration records which reflected that ULSM C started intravenous (IV) antibiotic medication infusions on residents. Yes, I did start intravenous (IV) antibiotic medication infusions on residents. In follow up interview on 2/11/2019 at 10:08 AM, ULSM C said it was approximately 2 months after starting as a GN that she began to perform licensed nursing duties on her own, and said nurses' told her that she could perform the duties on her own. ULSM C further stated that she had told licensed nurses that she could not perform nursing duties on her own, and said the nurses told her that she was great at it and to go ahead and do it anyway. Observation of ULSM C's name badge, during her interview revealed her title as, Graduate Nurse. ULSM C again stated that she never received any instruction, job description, or what was expected of her in the GN position by anyone in management. Interviews with facility staff and residents reflected the following: In an interview on 2/11/2019 at 12:49 PM, CNA K stated she had worked with ULSM C and said ULSM C was a nurse, an LPN she thought. CNA K said ULSM C wore blue scrubs which is what nurses' wore, and added that CNAs wore green scrubs. In a interview with LPN L on 2/11/2019 at 1:04 PM, LPN L stated, that upon hire, a job description pertaining to LPN duties was received, and included an orientation checklist for competencies related to LPN duties that had to be verified by another licensed nurse before LPN L was able to practice nursing independently at the facility. LPN L also stated that ULSM C was an LPN. LPN L said she was not aware that ULMS C was not a licensed nurse. In an interview on 2/11/2019 at 1:43 PM, Housekeeper D said she knew who ULSM C was and said she would see ULSM C at the medication cart by herself getting medications out for residents. Housekeeper D said ULSM C wore blue scrubs and said ULSM C was either an LPN or and RN. In an interview on 2/11/2019 at 1:45 PM, a volunteer N, from an outside agency who would visit residents at the facility regularly, stated she knew who ULSM C was, and said she was a nurse. Volunteer N said she would see ULSM C at the medication cart by herself putting medications into a medication cup. In an interview on 2/11/2019 at 2:02 PM, Registered Nurse (RN) O, who was a contracted [MEDICAL TREATMENT] nurses at the facility, and not an employee of the facility, stated that he knew who ULSM C was, but could not recall if she as an LPN or an RN, although stated she would see ULSM C at the medication cart getting medications for resident administration. In an interview on 2/11/2019 at 4:05 PM, ADON H said ULSM C had approached her and told her that she had just finished school. ADON H said she asked ULSM C if she had completed LPN or RN school, and said ULSM C told her LPN school. ADON H said it was last fall in (YEAR) when ULSM C approached her, but stated that she could not recall the exact date of the conversation she had with ULSM C. ADON H said herself, Administrator A, and DON B were shocked because they did not know ULSM C had been in nursing school. ADON H said ULSM C asked if she could remain a CNA and shadow a licensed nurse at the facility, and said she told ULSM C she would check on it, but told ULSM C she would have to continue to work as a CNA until further notice. ADON H said she did not ask ULSM C where she had finished her schooling, and said ULSM C told her that she had submitted her documents to take the NCLEX exam but did not have a date for her testing yet. ADON H said she was not aware ULSM C had applied to take her NCLEX exam in Ohio, and not in Michigan. ADON H said between herself, Payroll Staff Member/Human Resources (PSM/HR) F, Administrator A, and DON B they had talked about ULSM C's request to shadow a licensed nurse, and said they all agreed ULSM C could work as a GN. ADON H said PSM F contacted Human Resources (HR) M, who was from the regional corporate office and not an employee at the facility, and received an approval to put ULSM C into an GN position. ADON H also stated Administrator A and DON B said they would talk to their contact person about placing ULSM C into a GN position, but stated she did not know who those contact people were for Administrator A, and DON B. ADON H said it was approximately 3 weeks ago that PSM F, Administrator A, and DON B received approval for ULSM C to start in an GN position. ADON H said no direction was received from the corporate office pertaining to what duties a GN was able to perform. ADON H said they looked for a GN orientation check list but was not able to find one. ADON H stated they understood that ULSM C could perform all duties that an LPN did, but was always too have a license nurse with her at all times. ADON H said ULSM C was always scheduled to work with another licensed nurse, but said who the licensed nurse ULSM C was to be with was always determined at the time the daily assignments were made. ADON H said that was the only way ULSM C was monitored by management to always be under supervision of a licensed nurse. In an interview on 2/7/2019 at 10:25 AM, LPN I said ULSM C was a nurse who floated around the facility performing licensed nursing duties. LPN I said ULSM C performed all the duties an LPN did such as, wound dressing changes, and medication administration to residents. LPN I stated she only knew ULSM C to be an LPN. LPN I said ULSM C perform LPN duties independently (alone), and did not ever have a licensed nurse with her when she provided resident treatments and/or administered residents their medications. In an interview on 2/7/2019 at 10:46 AM, Payroll Staff Member/Human Resources (PSM/HR) F, said ULSM C was a CNA, but currently was a GN, who was to shadow a licensed nurse, and stated it was her understanding that ULSM C was only to shadow a licensed nurse, and not perform any licensed nurse duties such as; administrating residents their medications, or providing treatments. Payroll Staff Member/Human Resources (PSM/HR) F, said she was aware ULSM C had not passed her NCLEX exam. Payroll Staff Member/Human Resources (PSM/HR) F, stated she was not aware ULSM C had performed licensed nursing duties, and then confirmed she was scheduled to work as a nurse. Payroll Staff Member/Human Resources (PSM/HR) F was asked to provide a GN job description, and orientation checklist. Payroll Staff Member/Human Resources (PSM/HR) F was not able to provide the requested documents. Review of a, NCLEX Candidate Performance Report received on 2/7/2019 revealed, ULSM C had taken the test on 9/6/2018, but did not pass the test, furthermore the report revealed ULSM C had taken the test in Ohio. In an interview on 2/7/2019 at 12:05 PM, DON B said she, along with Administrator A, and ADON H, had checked with their corporate office. DON B stated she thought she possibly spoke with corporate Human Resource (HR) staff M, but could not recall exactly whom, and was told it was approved to allow ULSM C to work as a GN. DON B stated said ULSM C had approached her sometime last fall of (YEAR) and told her she had graduated with her diploma as an LPN in approximately (MONTH) of (YEAR). DON B stated she had not confirmed with ULSM C her diploma, but stated she thought ULSM C had verbally told her she had passed her NCLEX exam, and again stated she did not confirm this. DON B then deferred to Payroll Staff Member/Human Resources (PSM/HR) F, and stated that Payroll Staff Member/Human Resources (PSM/HR) F, was to confirm all degrees and licenses for nursing staff. DON B said the corporate office approved ULSM C to work as an GN, and that was why ULSM C was working as a nurse. DON B was asked to provide a GN job description, and orientation checklist, but was not able to provide the requested documents. In an interview on 2/7/2019 at 12:40 PM, Nursing Scheduler (NS) E, stated that when she took the scheduler position ULSM C was already working as an GN. NS E said she was told ULSM C was not able to administer narcotic medications without a licensed nurse with her. NS E said she did not specifically schedule ULSM C with a licensed nurse when she scheduled her to work as a GN. NS E was not able to provide a GN job description, policy and procedure that defined a GN position. NS E said she also was not able to confirm ULSM C was always with a licensed nurse when she scheduled her, and said all the, staff just knew what her (ULSM C) job is. In an interview on 2/11/2019 at 3:30 PM, Senior Director of Operations (SDO) P stated no one from the facility contacted him and asked for approval for ULSM C to work as a GN. SDO P said the chain of command requires the facility management team to contact him. SDO P said staff must practice under their scope of practice, and the company did not employee GN's. SDO P said there was no policy and procedure nor job description for a GN job at the facility, and said the facility follows the Public Health Code, and Centers for Medicare and Medicaid Services (CMS) regarding licensed and unlicensed staff scope of practice. SDO P said the facility did not have a GN program, as well as at the corporate level. SDO P also stated ULSM C absolutely would not have been allowed to pass medications. SDO P said he spoke with HR M who told him that he had not recalled any staff member from the facility contacting him regarding ULSM C working as a GN. SDO P said Administrator A, DON B, and ADON H were not able to recall who they spoke too. SDO P also stated to shadow a licensed nurse meant to keep hands in pockets and not perform any licensed duties at all, due to being an unlicensed staff member. In an interview on 2/13/2019 at 11:59 AM, regional corporate HR M stated he was not contacted by any staff member from the facility regarding ULSM C working as a GN, and stated there was no such GN program. HR M said a request for ULSM C to work as a GN would not have been approved. Record review of a staff signature list that contained the username for ULSM C for electronic medical record (EMR) documentation used by the facility, revealed ULSM Cs username was EM36. Record review of an employee list, not dated, revealed ULSM C was listed as an LPN. Record review of a Detailed Census Report, dated (MONTH) 7, 2019 received from the facility, revealed the facility had identified 77 current residents and 33 discharged residents that ULSM C had provided nursing care, under the scope of practice of a licensed nurse, from (MONTH) 1, (YEAR) through (MONTH) 7, 2019. Record review of a list of residents who received IV antibiotics by ULSM C from (MONTH) 1, (YEAR) through (MONTH) 7, 2019, provided by DON B on 2/15/2019, revealed confirmation that 14 residents had received IV antibiotics, and 5 residents had received IV fluids from ULSM C through the month of (MONTH) 2019. Record review of another report dated 12/1/2018 through 12/31/2018 revealed ULSM C had administered medications to 50 residents that included [MEDICAL CONDITION] (TB) tests, medications (multiple routes) and insulin injections. Resident #1 (R1) : In an interview with R1 on 2/11/2019 at 1:21 PM, R1 said she thought ULSM C was a CNA, but stated ULSM C would perform blood sugar checks (accu checks) on her and administer her medications to her. Record review of R1's Medication Administration Record [REDACTED]. The order revealed that the amount of insulin to be given was based on the results of R1's blood sugar level. Record review of a medication administration report dated 1/2/2019 through 1/31/2019 revealed R1 had received insulin from ULSM C 12 times. Resident # 55 (R55): In an interview on 2/11/2019 at 12:30 PM, Resident #55 (R55) stated she knew who ULSM C was and said ULSM C was a nurse; an LPN. R55 said ULSM C had administered her medications to her that included her narcotic pain medications. R55 said ULSM C would remove her pain patch and apply a new one when it was due. Record Review of a Medication Administration Record [REDACTED]. Resident #58 (R58): Record review of an Order Audit Report for R58, dated 12/12/2018 revealed ULSM C had taken a verbal order from R58's physician to discontinue an anticoagulant injection (a blood thinner), which was signed by ULSM C at 3:01 PM as an LPN, and under that order was noted ULSM C had signed, at 3:01 PM, a Supplementary Documentation Details notation as a Certified Nurse Aid. Resident # 59 (R59): Record review of a Medication Administration Audit Report, dated 1/1/2019 through 1/31/2019, revealed ULSM C provided [MEDICAL CONDITION] care (a hole in the front of the neck that provides a way to breath), [DEVICE] care (a tube in the stomach for providing food), and administered food through the [DEVICE], flushed the [DEVICE] with water (pushing water via a syringe into the [DEVICE]) to R59. Record review further revealed: An Immunization Report dated the previous year from 1/01/2018 through 02/28/2019 in which ULSM C had administered immunization injections for pneumonia and immunization injections for flu to 46 residents. Record review of a 24 Hour Nursing Schedule for the dates of (MONTH) 2, 3, and 4, 2019 revealed ULSM C was on the schedule, under Nursing, and no identified other licensed nurse was noted on the schedules to be working directly with ULSM C. Record review of a list of all employees, received on 2/6/2019 from the facility, revealed ULSM C was listed as an Licensed Practical Nurse, LPN. Record review of a facility policy and procedure titled, Administration Medications, dated as revised (MONTH) (YEAR), revealed, on page #1, under Policy Statement, Policy Interpretation and Implementation, #1, Only persons licensed or permitted by this State to prepare, administer and document the administration of medications may do so. Under #2 the policy revealed, The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. NHA A was interviewed on 2-14-19 at 10:30 am regarding using an unlicensed staff to work in the role of a licensed nurse. The process of hiring a potential nurse applicant was outlined by NHA A as the following: The application fills out an application. The decision to interview the applicant is made by the same department who is seeking applicants. The receptionist will then set up an interview with the applicant. The facility utilizes an online software application. This software application is utilized from initial application to hire. The applicant can pick the department you are interested in hiring into. The facility can review the resume and can see if they applied to sister facilities. The applicant is then called to set up an interview. If not done online then they complete the onboarding application. The applicant then will then interview with the department head, sometimes Human Resources sits in with the scheduler. It was conveyed that sometimes the ADON H sits in with the DON B. The facility then checks references and background check. They aim for two references. Front desk then completes file to Human Resources. Once the applicant is offered a position then the facility will set up a time to do orientation. They collect data, either electronic or hard copy. NHA A was asked who validates the applicants information and who trains the facility Payroll Staff Member/Human Resources (PSM/HR) staff. NHA A stated, Human Resources has that information. Corporate HR trains our HR (Payroll Staff Member/Human Resources) staff F. The administrator confirmed that once the nurse has been hired HR (Payroll Staff Member/Human Resources (PSM/HR) F) would have done reference checks, physical, collect license, social security card, items needed for payroll and schedules orientation. NHA A conveyed the DON B lets me know that a nurse has been hired and then they discuss the wage. NHA A was asked how ULSM C was promoted from a nurse aide position to a licensed nurse position. NHA A stated, ULSM C was hired in 2014 as a CNA. At the end of (MONTH) (YEAR), The DON B , and ADON H asked me if we could offer a Graduate Nurse (GN) Program at our facility. ULSM C told them she had finished nursing school and was taking a nursing board test. Even as a scheduler, I have experienced this in other buildings, in other facilities (referring to a GN). I brought HR in and asked can you find out if (Name of Company) offers the GN program. HR (PSM/HR staff F) reached out to Corporate and was told by one of the three corporate HR staff that this GN position was allowed. I was told by both the DON B and ADON H , that as long as she (ULSM C) was supervised, she was ok to work as a GN. I did not know that it was not recent that she had graduated from nursing school. ULSM C told me she took it in (MONTH) (YEAR) and she did not pass. She told me she rescheduled for the NCLEX in Sept (YEAR). She told me she failed it in Sept (YEAR). NHA A stated, My understanding is that when a new hire comes to me upon recommendation from the DON B , then they have been cleared by our HR. If ever any questions, like a flag on a license, then I am made aware. The first time I meet new hires is orientation. NHA A confirmed that no position description to work as an unlicensed nurse was given to ULSM C. In an interview on 2/19/2019, at approximately 12:00 PM, Medical Director/Physician (MD) Q, stated that he always thought ULSM C was a nurse. The State of Michigan website for verification of nursing licenses search conducted during the onsite survey, (MONTH) 2019, revealed ULSM C did not have a license to practice as a nurse in the State of Michigan. On 2/7/2019, at 4:17 PM, the Administrator was notified of the Immediate Jeopardy that was identified on 2/7/2019 that began on 5/1/2018 when ULSM C was identified to have administered medications, and provide treatments to residents of the facility, document in resident medical records using the credentials of a licensed nurse (LPN), a not have a State issued license to practice as a licensed nurse in the State of Michigan, and the facility staff knowingly allowing ULSMC to practice licensed nursing duties without a license to do so. On 2/11/2019 the surveyor verified the facility implemented the following corrective action to remove the Immediate Jeopardy as of 2/7/19: 1). On 2/7/2019 ULSM C was removed from the schedule as a GN, and her access to the EMR was updated to nurse aide only. 2). On 2/7/2019 no other Graduate Nurses were identified to be employed by the facility functioning as a nurse. 3). On 2/7/19, Resident #1 was assessed by the Director of Nursing. No negative outcomes or change from baseline based on their last MDS assessment were identified on 2-7-10. 4). On 2/7/2019 the Payroll Benefits Coordinator/Human Resources F, DON B, and Administrator A were educated on job titles, validation of credentials, job descriptions, and appropriate access to healthcare records based on those titles. The education also included the graduate nurses, an unlicensed person who has graduated from a nursing school and planning to take their boards, are not employed in any type of position which requires a license. 5). On 2/7/2019, Staff PSM/HR F completed an audit of the employee licenses and certifications. This was confirmed by the Administrator on 2/7/2019. There were 9 RNs, 12 LPNs, and 44 CNAs. 6). On 2/7/2019, PCC (EMR) access for current LPNs, RNs, and CNAs was reviewed and confirmed to match the position of employment by PSM/HR F, and confirmed by the Administrator. 7). On 2/7/2019, 8 of 8 residents from West, 22 of 23 residents form East, 20 of 21 residents from Certified, and 27 of 27 residents from South units that received care from ULSM C have been assessed by licensed nurses and no negative outcomes were identified since having received care from ULSM C. 8). Beginning 2/7/2019, re-education was provided by the Staff Development Coordinator/Designee to the licensed nursing staff regarding scope of practice, someone seeking advancement, and how to report concerns. No employee will be allowed to work without receiving the education. 15 out of 21 licensed nurses had been re-educated. 6 of 21 nurses will not work until they have received the education. 9). Beginning on 2/7/2019, new employees will be reviewed by the Administrator during orientation to validate credentials and ensure that their access to the medical records matches their scope of practice of their job description. New employees will also receive educations on how to report a concern if asked to perform a duty outside of that practice. 10). On 2/7/2019, Resident #1 was notified of the concern. 11). On 2/7/2019, it was identified that 97/4% of the residents residing in the facility received care from ULSM C. 12). Beginning 2/7/2019, residents or resident's responsible parties were notified of the care concerns. 13). Beginning 2/7/2019, the physician began to assess residents that received care form ULSM C. 14). On 2/7/2019, the Medical Director was informed of the concern and agreed with the plan. Although the Immediate Jeopardy was removed on 2/7/2019, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the state agency.

This citation pertains to intake MI 426: Based on observation, interview and record review, the facility failed to serve food that accommodated food allergies for one Resident (R203), of one reviewed from a total sample of four reviewed, resulting in R203 having an anaphylactic reaction to a known mushroom allergy that required treatment and an emergency hospital transfer. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R203 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Face Sheet reflected R203 had a food allergy to mushrooms noted from most recent hospital stay 7/15/18 through 7/19/18. The MDS reflected R203 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with ambulation on unit, dressing, hygiene, and setup help only with transfers and toileting. During an observation and interview on 8/1/18 at 4:30 p.m., R203 was sitting in bed watching television with a carry out pizza box noted on the bedside table. R203 reported the facility served a dish with mushrooms in it for lunch and R203 reported an allergy to mushrooms; therefore he placed an outside order for pizza. R203 appeared well groomed, calm and answered questions appropriately. R203 reported on 7/27/18 he had an anaphylactic reaction to mushrooms he was served at the lunch meal by the facility. R203 reported the facility was aware of the allergy since admission on 7/19/18 because all of the meal tickets have had the allergy to mushrooms on them. This surveyor reviewed several meal tickets dated 7/20/18 through 8/1/18 with mushroom allergy noted on meal tickets and 8/1/18 ticket reflected yellow highlighted mushroom allergy. R203 reported being transferred to the hospital on [DATE] and returned to the facility after dinner about 6:00 p.m. Reveiw of the Nutrional Care Plan, dated 7/27/18, reflected no intervention prior to 7/27/18 related to R203's mushroom allergy. Review of the facility Incident and Accident Report, dated 7/27/18 at 12:30 p.m., reflected R203 had an allergic reaction to mushrooms. The Report section titled, description of event, reflected, Resident came into hall. This nurse was in hallway. Res. yelled (Licensed Practical Nurse (LPN) I name) I need you. Went to resident states, ate mushroom & have allergy, Nurse Practitioner was present Tx (treatment) was started. The Report indicated the Nurse Practitioner was present at the time of the allergic reaction and ordered [MEDICATION NAME] 125 mg Intramuscularly injection, breathing treatment, oxygen and call to 911. Review of the facility, Statement of Witness, undated, reflected Registered Nurse (RN) H, Walked in room resident experiencing DIB (difficulty in breathing), consoled with words rubbing back, gave [MEDICATION NAME] 125 mg IM to (L circled) Lateral thigh, placed on 2-3 LNC of O2(oxygen), applied nebulizer mask . The report indicated the results of the investigation included, Resident received food processed with mushrooms. First aid immediately provided. Transferred to acute hospital emergency room . Resident returned same day with no new orders. Immediate education provided to dietary staff with appropriate disciplinary actions. During an interview on 8/2/18 at 4:47 p.m., Registered Dietitian (RD) D reported R203 was served casserole on 7/27/18 for the lunch meal that had mushrooms in it. RD D reported R203 had an [MEDICATION NAME] reaction after the 7/27/18 lunch meal and reported R203 had a known mushroom allergy prior to the incident. RD D reported as soon as she heard what happened on 7/27/18 she came to the facility and reviewed the ticket process with the staff, did education, and spoke with staff involved. RD D reported R203 had the allergy documented on the meal ticket prior to the incident and at the time of the incident. RD D reported the staff should have known not to serve R203 the casserole because it had mushrooms in it. During a second interview and record review on 8/2/18 at 5:15 p.m., RD D returned with education provided to all kitchen staff dated 7/27/18 labeled Dietary in-service on reading tray tickets and reported education was provided shortly after she arrived on 7/27/18 after meeting with Administrator (ADM) A and Director of Nursing (DON) B and working together to resolve the issue. RD D reported the cause of the R203's incident on 7/27/28 was, staff failure. RD D reported the cook and two aides were held accountable for incident and were given verbal counseling. RD D provided copies of facility, Performance Improvement Form, dated 8/2/18, for kitchen staff E, F, and G. The forms reflected the kitchen staff received verbal counseling for, Resident was served improper food items d/t not reading and reacting to the details on the tray ticket. The forms were signed by two of the three staff on 8/2/18. Review of the facility, Dietary In-Service on Reading Tray Tickets, dated 7/27/18, reflected, 1. Read the residents name, texture, special diet and any notes that is located on the left on the tray tickets. 2. On the right side of the tray tickets you will find the location of were a resident eats, their room number, allergies and their dislikes. The alert section you will find if they can't have a straw, or special instruction to the resident's meal tray and if they need assistance. 3. The person serving needs to read the whole tray tickets and double check what the resident can have and not have. And ensure that the meal meets the resident's diet, texture and allergies. 4. Cooks you need to inform the staff of what is in the meals and assist with any questions that the staff serving has. You prepared the meals you need to make sure that you know what is in the meal that may be an allergy or dislike of a resident. 5. It is everyone's responsibility to check the tray tickets. The person who is putting the juices and the tray in the cart need to double check the trays before sending the trays out the window or door .7. The cook needs to highlight all the allergies on the tray tickets before the start of the line to help make sure that the serving staff sees the allergies. The in-service was signed by 10 staff including three that worked during the lunch meal on 7/27/18. During an interview on 8/7/18 at 3:25 p.m., ADM A reported after R203 allergic reaction incident on 7/27/18 she reviewed with RD D the plan to resolve the issue. During an interview on 8/8/18 at 12:05 p.m., DON B reported R203 had an allergic reaction on 7/27/18 to the mushrooms served at lunch by the facility and was sent to the hospital for treatment after being treated with an injection and oxygen for difficulty in breathing at the facility.

Based on observation, interview and record review the facility failed to transfer 1 of 15 sampled residents (Resident #3) with 2 person assistance and assistive devices, resulting in a fall with fracture. Findings include: This citation is related to Intake MI 323 The facility's Assisting a Resident to Walk to the Bathroom policy revised 1/16/11 reflected: The purpose of this procedure is to provide the resident an opportunity to urinate of defecate and to prevent resident falls. The following equipment and supplies will be necessary when performing this procedure: 8. Walk on the resident's weak side. Provide support as necessary. Walk next to the resident with one arm supporting the resident's bent arm and the other arm around the resident's back at waist level. If necessary for support, use a gait belt for safety. (Note: If two (2) assistants are necessary, on should be on each side supporting the resident by placing one hand on the bent arm and the other arm around the resident's back at waist level. If necessary for support, us a gait belt for safety.) According to the activities of daily living care plan, R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan also reflected R3 was non-ambulatory, and needed extensive 2 person assistance for all transfers since 11/10/14. The quarterly Minimum Data Set (MDS resident assessment tool) complete on 1/20/17 reflected R3 had severe cognitive impairment and required extensive assistance of 2 persons for transfers. Resident (R) #3 had an incident on 3/23/1 at 9:50 AM, which reflected the following: R3 had an observed fall in the bathroom, and prior to the incident he was alert. The incident was witnessed by Certified Nursing Assistant (CNA O). The brief description reflected, Per CNA pt was sitting on toilet and tilted to right side and fell off toilet. The record reflected no mobility device was used. The resident complained of right arm pain, an x-ray was ordered, an assessment and neurocheck were performed. Action was taken, was to educate the CNA of 2 person transfer The Quality Assessment & Assurance Investigation Report undated with completion date reflected: Place of fall/accident: Resident room in bathroom List Care Planned Interventions Prior to Fall/Accident: 2 person moderate assist for transfers, anti-roll back on wheelchair, reminder notes to use call light when needing to get out of bed, tennis shoes on AAT (at all times), resident not to be left alone in wheelchair in room. When was resident last seen: 8:00 AM , What were they doing: Toileting Was resident incontinent when incident occurred: No Level of assistance resident requires (1, 2, device): 2 person moderate assist Immediate intervention implemented: Education to CNA to use 2 person assist and to look at Kardex daily for information transferring residents. The x-ray of the right humerus obtained on 3/23/17 resulted in an acute impacted humeral neck fracture. The facility's GAIT BELTS form, completed by all CNA's reflected: GAIT BELTS Gait belts are safety devices that help our resident's move (ex. Bed to chair) or hold them up while they walk. It provides support and helps prevent falls. It also helps you as a staff member decrease your risk for back injury (if used properly). HOW DO I USE A GAIT BELT? you are being issued a gait-belt and must have it on you at all times during your shift. If lost, there will be a $3.00 charge, if you don't have the funds it will be payroll deducted -Put the belt around the person's waist over his clothing with the buckle in front. -Thread the belt through the teeth of the buckle. Put the belt through the other 2 loops to lock it. -Make sure the belt is snug with just enough room to get your fingers under it. -Grip the belt tightly, bend you knees and keep you back straight. -Lift or move the person with your arm and leg muscles. Do not use your back muscles. -Do not twist your body when you move or lift the person. -When you are done moving or walking with the person, remove the gait belt. Please sign below you have received your gait belt an have reviewed gait belt expectations above. Printed Name and Date: Written by CNA O Signature: Signed by CNA O On 4/17/17 At 12:29 PM R3 was interviewed in his room. R3 was laying in his bed, which had a winged mattress and his call light was in reach. His bed was against the wall, low to the ground and 3 black colored floor strips were noted in front of his bed (where he would exit). A blue colored sling was in his bed, but not on his arm. R3 was asked what happened to his right arm. He replied, I don't know, it's messed up down there (pointed at his right lower arm). When asked if his arm was painful R3 replied, Yeah, its pretty painful. R3 was asked to rate his pain using the 0-10 point pain scale, but could not comprehend its use. R3 was then asked if his pain was like a happy face or sad face. R3 replied, Sad face. R3 was observed to keep is right arm in a flexed position, like a 90 degree angle. R3 was asked how he hurt his arm. He replied, I don't know, I don't remember. The nurse who responded to CNA O's request for help on 3/23/17 Registered Nurse (RN S), was interviewed by phone on 4/17/17 at 2:41 PM and revealed the following: I was coming down the hall and CNA O called me to help pick R3 up. He was in the bathroom laying on his right side. I asked her what happened and she said, (I really don't know. He was trying to sit down and lost his balance). She was fumbling with the answer. She put her gait belt on him and we got him back up on the toilet, his pants were down. He was not soiled and appeared to be dry. He was like Ow, Ow, I hurt, I hurt. One side he was weak on. I touched his shoulder and he said Ow. I assessed him once he was on the toilet. CNA O could not tell me how he fell , or if he hit his head. To me there was no way he could not have hit his head. There was barely any space for 2 let alone 3 people in the bathroom. I had to get him up to assess him. There was no gait belt on him. He had on his tennis shoes. She was by herself in the room. After we got him up, I did an assessment with neuro checks, and put him back to bed. Neuro wise he was fine, he was just painful at the right arm. I called (doctor's name), got an x-ray and did neuro checks. Then I medicated him, with pain meds. First assessment around/near his elbow was reddened both right and left. I can't recall which was the weaker arm. The weaker arm he can not fully extend. I ordered x-ray. We called back and ordered it STAT. x-ray came around 4:30 ish. When the results were obtained about the fracture, I called the administrative staff. I made sure I told all staff R3 was a 2 Person Assist (2 PA) assist to transfer. If you are transferring a person who requires 2 people they should have a gait belt that's standard, especially with the weakness he had. I don't know if it's our policy, I think it should be in his care plan. I was really irritated because the CNA could not tell me how he fell , and she was right there with him. CNA O was interviewed by phone on 4/17/17 at 2:59 PM, and asked to recall R3's fall in March 2017. CNA O stated, It was on the 23' d because I was fired. He was in his room and he doesn't use the call light, and he transfers himself. We were on a lock-down like a quarantine. All the fire doors were shut. R3 is on the opposite side of the fire door. He was yelling out for assistance. He was trying to go to the bathroom he was in the wheelchair on his way to the bathroom. I assisted him to the bathroom so he would not fall, and he fell anyway. On his way to the toilet to sit down, his knees buckled or something. He ended up falling against the door in the bathroom. CNA O was queried if R3 was a 1 or 2 person transfer. Apparently he was a 2 PA, they changed it in the computer. They used to write the care plan on papers in the closet in their room. He got switched to a 2 PA , and we were not aware of it. Usually we did him as a 1 person. We have been doing him as a 1 person assist for a while. CNA O was asked if she used her gait belt on R3 during transfer. No, I did not have a gait belt on him. It was like an emergency situation. He had his shoes on. He tends to try to transfer himself. I walked pass and tried to assist him and that's how everything happened. He had already got out of his bed to his wheelchair. They did not communicate to us he was a 2 PA. Apparently we were supposed to check in the computer for ourselves. CNA O denied writing a statement related to he fall when asked. They sent me home under a suspension. A couple days later they fired me over the phone. They did not have any witnesses. CNA O's statement dated 3/23/17 at 10:00 AM was read to her. CNA O stated, I wrote a short paragraph (whereas she denied earlier). That's pretty much what happened. They did not note is was an emergency situation. CNA O was queried if she pulled the call light while assisting R3 to toilet. I don't think I did. We were short staffed anyway. There were times when I had 19 residents to myself with 1 nurse. I told them it was an emergency situation. I reported it to RN S and Assistant Director of Nursing (ADON C). He was dry, I had just taken him to the bathroom. He had a fall a week prior and no test were done. On 4/17/17 at 3:22 PM ADON C was interviewed in person, and queried about CNA O's statement related to R3's fall dated 3/23/17. ADON C stated, she took the statement from CNA O. ADON C was given the incident packet to review and replied, I spoke with her and took that one . We prefer to interview them, however sometimes they do their own also, was ADON C reply to if employees write their own statements. ADON C denied seeing a statement by CNA O, and revealed the nurses did the Kardex's (plan of care for the CNA's) for the CNA's. They are on POC (Point Of Care) and PCC (Point Click Care) on-line. ADON C was queried if hard copies of the Kardex were kept for the CNA's. She replied, No not for a long time. Since June 2016 I have not noticed any paper Kardex. When taking interviews, I ask them what they stated prior to writing. I asked if she would like to change anything written, and she said no. ADON C denied CNA O, stated it was an emergent situation. My understanding was that she was toileting him. CNA's are supposed to check those Kardex's before they give care. As far as I know that is standard of care. They did a Past Non Compliance after this. CNA's need to make sure they are using their gait belt, make sure area is clear, wheelchair wheels and bed are locked, make sure a safe transfer and tell the resident how and what they are going to do. I do know that when they get hired in, they get checked off with restorative aides for transfers. We do training on that. Restorative Aides, are restorative CNA's.

This citation pertains to MI 938. Based on interview and closed record review, the facility failed to assess, treat and provide interventions for pain management in 1 of 1 post operative residents (#2) from a total 4 sampled residents, resulting in an unrelieved pain associated with psychosocial ill-being as well as leaving the facility without completing the course of rehabilitative services due to severe pain. Findings include: According to the hospital discharge summary dated 10/16/14 (Thursday) Resident #2 was a [AGE] year old female who had undergone surgical procedure (spinal fusion of Lumbar 4 and 5) on 10/13/14 and was being discharged to the long-term care facility for the short-term rehabilitation services. The list of her medical [DIAGNOSES REDACTED]. The physical therapy (PT) plan of care dated 10/16/14 reflected Resident #2 "was referred to skilled PT due to decline in functional mobility; transfers, ambulation, bed mobility as well as muscle strength, pain, aerobic capacity and balance. Resident states she has pain 8/10 being the most severe pain, at her low back." On 11/2/14 at 10:20 a.m., the physical therapist, (staff "G") stated the resident did not receive PT over the weekend due to her severe pain (9-10) which was communicated to the nursing staff. The listed pain medications upon discharge (10/16/14) from the hospital included: 1) Tylenol 500 mg every 4 hours, 2) [MEDICATION NAME] (narcotic) 5 mg 2-4 tablets every 4 hours as needed, 3) [MEDICATION NAME] (anti-depressant) 5 mg three times daily as needed for muscle spasms. However, the Electronic Medication Administration Record [REDACTED]. Resident #2 was allowed to receive narcotics ranging between 10 mg to 20 mg 6 times daily as needed. Resident #2 's "Pain Assessment " dated 10/16/14 reflected the resident had generalized back pain with moderate to severe intensity and the pain was increased with toileting, transfers, wound treatment, lying down as well as with repositioning. The pain scale recorded on MAR indicated [REDACTED]. The nurse's note dated 10/16/14 reflected Resident #2 had 2 surgical sites on her lower back that were dressed with 4 x 4 gauze and "as needed pain medication given with minimal relief. " The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Furthermore, Resident #2 was not administered [MEDICATION NAME] 5 mg (prescribed for muscle spasms) for the first 2 days, 1/16/14 or 10/17/14, at all. On 11/5/14 at 8:30 a.m., the Director of Nursing, (staff "B") stated the nurses used their discretion to select which tiers of pain medication they would administer, but the above documentation reflected nursing discretion varied greatly from one nurse to another in terms of dosage determination, thus it was not an effective tool to gauge the pain level. The nurse's note dated 10/20/14 reflected Resident #2 "was tearful and complained of pain. Resident says the [MEDICATION NAME] has little effect on her pain. 20 mg of [MEDICATION NAME] given at 6:20 and doctor (doctor' s name) evaluated patient. " The MAR indicated [REDACTED]. There was no documentation Resident #2 was administered [MEDICATION NAME] at 6:20. The social service note dated 10/21/14 (5 days after admission) reflected Resident #2 left the facility against medical advice. On 11/5/14 at 8:30 a.m., the Director of Nursing, (staff " B " ) was asked why Resident #2 left the faciity on Against Medical Advice. Staff "B" stated the resident complained that the amount of pain medications she received were inadequate and ineffective to relieve her post surgical pain. The resident( #2) was unable to be reached during the onsite survey. ( )

This citation pertains to MI 671. Based on observation, interview and record review, the facility failed to identify and provide adequate supervision to prevent falls for 1 of 2 residents (#1) reviewed for falls from a total 4 sampled residents, resulting in repeated injuries. Findings include: According to the physician's orders [REDACTED].#1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Care Area Assessment (CAA) dated 6/24/14 reflected Resident #1 was born in Cuba and spoke Spanish. The MDS assessments since admission (6/18/14) as well CAA documentation (6/24/14) had such incomplete information that it was difficult to determine Resident #1's cognitive patterns, communication skills as well as his overall functional status. Under Falls CAA worksheet dated 6/24/14 Resident #1 was described as having dementia, confusion and used a merry walker during the day. The Fall assessment dated [DATE], 8/25/14 and 10/2/14 reflected Resident #1 was at high risk (10 or above) of falls ranging score between 17 through 19. The Focus (problem statement) of Resident #1, initiated 7/2/14 and revised on 10/30/14 reflected Resident #1 was at risk for falls. There was no risk factors listed to explain what made Resident #1 to be vulnerable for falls. The listed interventions included 1) low bed, 2) fall mattress, 3) bed alarm, 4) room close to nursing station, 5) non skid footwear, 6) follow restraint protocol, 7) lap buddy during waking hours while in wheelchair, and 8)monitor antipsychotic medication. Resident #1 had 2 falls (8/24/14, 10/1/14) related to the use of the merry walker restraint. The first incident report of fall dated 8/24/14 reflected Resident #1 was at nurses station when he tried to turn around and the merry-walker got caught on the corner of wall. When the resident tried to push himself off from being caught the merry-walker tipped over, snapping the handle bar and the resident fell face down, causing 2 inches of eye brow laceration. Resident #1 was taken to hospital for sutures. The physician progress notes [REDACTED].#1 was up ambulating with merry walker and sustained laceration on his left eye brow requiring 6 sutures and contusion in left inferior orbit/cheek. On 10/31/14 at 11:00 a.m., the unit manager, (staff "C") stated the cause of the first fall may have been the antipsychotic medication adjustment. Resident #1 had failed antipsychotic dose reduction attempt and was reinstituted to the original dosage. However, this was not clearly explained in the care plan. Staff "C" could not explain what may have caused the second fall other than the increased agitation of Resident #1's recent behavior. Again this was not clearly explained in the care plan. Staff "C" was also asked what specific interventions the facility had for the residents with high risk fall versus residents with low risk falls. Staff "C" stated the high risk residents would receive physical therapy (PT) screen. Again the fall interventions did not list the PT screen as a care option. The physical therapist screen dated 8/25/14, after the 8/24/14 fall, reflected Resident #1 needed occasional redirection, but it was still safe to use the merry-walker. The second incident report dated 10/1/14 reflected Resident #1 was found face down in the small dining room floor, unwitnessed, bleeding from his nose and mouth. Resident #1 had a cut from a broken denture that caused an injury on his right lower lip, bridge of nose reddened and swollen. Also small scraped area to right knee and left shin noted. It was not clear whether the facility had determined what the cause of incident was. The physical therapist screen dated 10/2/14, after the 10/1/14 incident reflected Resident #1's merri-walker use was no longer appropriate, thus he will have a lap buddy since he continued to stand often, increasing the risk for falls. On 11/5/14 at 11:00 a.m., the physical therapist, (staff "G") who did not conduct the therapy screen for Resident #1, was asked whether the ambulating equipment (merry-walker) was inspected for the structural safety and functioning; and how the nursing staff could have provided redirection/supervision when he was having difficulty with using the merry-walker alone. Staff "G" stated the therapy screen was not the same as therapy evaluation, but from his observation the resident seemed to be able to maneuver the walker well. On 10/30/14 at 12:00 p.m., Resident #1 was observed sitting in a main dining room with the lap buddy on. Resident #1 was wheeled out of the dining room and was being ambulated in the "100" hall by Licensed Practical Nurse, (staff "I") and the nurse's aide, (staff "J") with a gait belt and his wheelchair following behind him. Resident #1 was slightly unsteady on his feet and ambulated fairly well with 2 assists. He was non-verbal and did not appear engaging in any voluntary interactions with staff. ( )

Based on observation, interview and record review the facility failed 1) follow the facility bowel protocol 2) monitor and assess for constipation for 1 sampled resident (#29) of 1 reviewed for bowel records from a total sample of 11, resulting in Resident having an episodes of an impaction, multiple days with no bowel movements and painful bowel movements. Findings include: According to Resident #29's admission Minimum Data Set (MDS) assessment dated [DATE], Resident #29 was a [AGE] year old male with [DIAGNOSES REDACTED]. Weight was documented at 225 pounds on admission. On 5/20/14 starting after lunch around 12:45 pm, Resident #29 was observed to have been yelling, crying with tears running down his cheeks, holding on his stomach with his hand, and yelling "my rectum hurts, nurse, I got to poop." Review of Resident #29's bowel record dated 4/20/14 through 5/20/14 at 6 am revealed Resident #29 had 4 episodes with 5-10 days with no bowel movements dated 4/20/14 through 4/24/14 (5 days), 4/26/14 -5/4/14 (8 days) 5/7/14 - 5/16/14 (10 days) and 5/16/14 - 5/21/14 (6 days). Review of Resident #29's Nursing Daily Skilled Documentation dated 4/26/14 at 6:00 am, revealed "resident restless, resident yells out "my but hurts" resident yells 'nurse' resident begs hands against wall, physician notified via message system @ 9:30 am, large impacted BM (bowel movement) extracted from resident, doctor calls back at 10:00 am, orders on (one)(sp) time dose of 30 ml (milliliter) [MEDICATION NAME], resident no longer yelled out and rested..." Review of Resident #29's Medication Administration Record [REDACTED]. Review of Resident #29's nurse notes revealed no documentation of the physician being notified in Resident #29's nurses' note during the episodes of several days with no bowel movements until there was an impaction on 4/26/14. Resident was not on any other regularly scheduled medication for constipation according to the MAR indicated [REDACTED] Review of Resident #29's MAR indicated [REDACTED]. The facility policy was not followed. On 5/20/14 MOM was administered after this surveyor brought the bowel records to the attention of Unit Manager "C." There was no documentation the physician was notified of the 6 days prior with no bowel movement. On 5/21/14 at 9:45 am, during a conversation with Resident #29 and Registered Nurse (RN) "F,"related to Resident #29's constipation concern and he stated, "I don't like prune juice." Resident #29 reported he did like apple juice. On 5/21/14 at 12:00 pm, Dietary Manager (CDM) "D"and Registered Dietician "I" were interviewed. CDM "D"reported she had notified RD "I" on 4/29/14 of Resident #29's weight loss, and a significant weight loss was documented on 5/8/14. RD "I" reported she had observed resident #29 while he was eating on 5/14/14. Both RD "I" and RD "D were asked if either of them had looked at Resident #29's bowel record and they responded the nurse usually notified the RD of any concerns, use of laxatives but they looked at constipation and GI issues and [DIAGNOSES REDACTED]. CDM "D" reported she had just added prune juice to the tray card (5/21/14). CDM "D" was asked did you ask if Resident #29 liked prune juice? CDM "D"responded, "no." CDM reported the tray cards were updated and prune juice was going to be added. On 5/22/14 at 9:10 am, Unit Manager Registered Nurse "C" reported half of the facility's resident's bowel records were not monitored with the transition of paper to computer and Resident #29 bowel records were missed with the transition along with half of the facility's residents. ( )

Based on observation, interview and record review the facility failed 1) follow the facility bowel protocol 2) monitor and assess for constipation for 1 sampled resident (#29) of 1 reviewed for bowel records from a total sample of 11, resulting in Resident having an episodes of an impaction, multiple days with no bowel movements and painful bowel movements. Findings include: According to Resident #29's admission Minimum Data Set (MDS) assessment dated [DATE], Resident #29 was a [AGE] year old male with [DIAGNOSES REDACTED]. Weight was documented at 225 pounds on admission. On 5/20/14 starting after lunch around 12:45 pm, Resident #29 was observed to have been yelling, crying with tears running down his cheeks, holding on his stomach with his hand, and yelling my rectum hurts, nurse, I got to poop. Review of Resident #29's bowel record dated 4/20/14 through 5/20/14 at 6 am revealed Resident #29 had 4 episodes with 5-10 days with no bowel movements dated 4/20/14 through 4/24/14 (5 days), 4/26/14 -5/4/14 (8 days) 5/7/14 - 5/16/14 (10 days) and 5/16/14 - 5/21/14 (6 days). Review of Resident #29's Nursing Daily Skilled Documentation dated 4/26/14 at 6:00 am, revealed resident restless, resident yells out my but hurts resident yells 'nurse' resident begs hands against wall, physician notified via message system @ 9:30 am, large impacted BM (bowel movement) extracted from resident, doctor calls back at 10:00 am, orders on (one)(sp) time dose of 30 ml (milliliter) [MEDICATION NAME], resident no longer yelled out and rested. Review of Resident #29's Medication Administration Record [REDACTED]. Review of Resident #29's nurse notes revealed no documentation of the physician being notified in Resident #29's nurses' note during the episodes of several days with no bowel movements until there was an impaction on 4/26/14. Resident was not on any other regularly scheduled medication for constipation according to the MAR indicated [REDACTED] Review of Resident #29's MAR indicated [REDACTED]. The facility policy was not followed. On 5/20/14 MOM was administered after this surveyor brought the bowel records to the attention of Unit Manager C. There was no documentation the physician was notified of the 6 days prior with no bowel movement. On 5/21/14 at 9:45 am, during a conversation with Resident #29 and Registered Nurse (RN) F,related to Resident #29's constipation concern and he stated, I don't like prune juice. Resident #29 reported he did like apple juice. On 5/21/14 at 12:00 pm, Dietary Manager (CDM) Dand Registered Dietician I were interviewed. CDM Dreported she had notified RD I on 4/29/14 of Resident #29's weight loss, and a significant weight loss was documented on 5/8/14. RD I reported she had observed resident #29 while he was eating on 5/14/14. Both RD I and RD D were asked if either of them had looked at Resident #29's bowel record and they responded the nurse usually notified the RD of any concerns, use of laxatives but they looked at constipation and GI issues and [DIAGNOSES REDACTED]. CDM D reported she had just added prune juice to the tray card (5/21/14). CDM D was asked did you ask if Resident #29 liked prune juice? CDM Dresponded, no. CDM reported the tray cards were updated and prune juice was going to be added. On 5/22/14 at 9:10 am, Unit Manager Registered Nurse C reported half of the facility's resident's bowel records were not monitored with the transition of paper to computer and Resident #29 bowel records were missed with the transition along with half of the facility's residents. ( )

Based on observation, interview, and record review, the facility failed to honor food preferences, calculate estimated needs, and prevent a significant weight loss in 1 (Resident #5) of 4 reviewed for weight loss, from a total sample of 17, resulting in a significant weight loss for Resident #5 and the potential for continued weight loss. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #5 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #5 scored 2/15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required extensive assistance of 1 person with eating. The MDS revealed Resident #5 did not have a poor appetite, overeating, or a swallow disorder. The MDS revealed Resident #5 weighed 161 pounds, had a significant weight loss, and was on a mechanically altered diet. Review of Resident #5's Weight Change History from 6/27/13 through 3/27/14, revealed the following weights: 7/22/13 186 # 8/3/13 184# (loss of 2 pounds) 9/12/13 168# (loss of 16 pounds) 9/24/13 163# (loss of 5 pounds) 10/3/13 165# (gain of 2 pounds) 10/11/13 165# 10/18/13 162# (loss of 3 pounds) 10/22/13 162# 11/2/13 165# (gain of 3 pounds) 11/12/13 162# (loss of 3 pounds) 11/18/13 159# (loss of 3 pounds) 11/24/13 162# (gain of 3 pounds) 12/2/13 160# (loss of 2 pounds) 12/13/13 161# (gain of 1 pound) 12/26/13 157# (loss of 4 pounds) 12/30/13 161# (gain of 4 pounds) 1/2/14 161# 1/15/14 162# (gain of 1 pound) 1/20/14 162# 1/28/14 157# (loss of 5 pounds) 2/5/14 157# 2/11/14 156# (loss of 1 pound) 2/21/14 156# 2/22/14 156# 3/1/14 155# (loss of 1 pound) 3/12/14 151# (loss of 4 pounds) 3/18/14 151# 3/25/14 154# (gain of 3 pounds) Resident #5 had a total loss of 32 pounds from 7/22/13 through 3/25/14 and had loss greater than 10% of her body weight over an 8 month time period. Review of the Nutritional assessment dated [DATE], revealed Resident #5's usual body weight was 190 pounds. Review of the Condition Change Form dated 10/11/13, revealed Resident #5 had a significant weight loss due to food refusals. Review of Resident #5's "Need for mechanically altered diet..." care plan dated 4/25/13, revealed on 10/11/13, Resident #5 had a significant weight loss due to food refusal/dislike of pureed food. Resident #5's care plan revealed interventions that included: 2 times protein at breakfast, meals served in the assisted dining room, obtain likes/dislikes minimally every 3 months, offer replacements for uneaten food, magic cups, med plus 2.0, and boost (supplements). Review of the Interdisciplinary Nutritional Issues Review dated 10/11/13, revealed Resident #5 had a weight loss of at least 7.5% over the past quarter, and 10% loss over the past 6 months. The review revealed from 9/27/13 through 10/11/13, Resident #5 ate 51% of breakfast, 19% of lunch, 25% of dinner, 0% of supplements with meals, 100% of supplements between meals, and 20% of snacks. The section titled Estimated Needs for Kcal (kilocalorie), protein, fluid, and UBW (usual body weight) was blank. The form was signed by Certified Dietary Manager (CDM) "K". The reverse side of the form had 5 sections titled ID (interdisciplinary) team notes. There was a slash written through all the sections. There was no information in any of the ID team sections. Review of the Physician Notification of Significant Weight Change dated 10/11/13, revealed Resident #5 lost 21 pounds (11%) over the past 90 days. The form revealed "The team suspects significant weight loss or gain may be due to the following factors: refusal to eat-dislike of pureed food and honey thick liquids". In an interview on 3/28/14 at 8:57 am, CDM "K" reported that she filled out the Physician Notification of Significant Weight Change dated 10/11/13. CDM "K" reported that she did not calculate Resident #5's nutritional needs at that time. In a telephone interview on 3/27/14 at 9:05 am, Registered Dietician (RD) "L" reported that nutritional needs were calculated annually and "every time a significant problem" arose. Review of the Dietary Progress Notes, revealed on 7/15/13, Resident #5's diet was changed to pureed with honey thick liquids by speech therapy. The Dietary Progress Notes dated 9/14/13, revealed Resident #5 "is currently on a NAS (no added salt) pureed diet but does not like the consistency of food and will not eat it. Her daughter and family members bring her in regular food that she consumes...2x (two times) protein at breakfast, yogurt at breakfast, cottage cheese" at lunch and supper. The Dietary Progress Notes dated 10/11/13, revealed Resident #5 had a weight loss of 11% in 90 days, loss of 14% in 180 days, and "refuses meals frequently d/t (due to) dislike of pureed diet". The Dietary Progress Note dated 12/5/13, revealed Resident #5's weight was stable since 9/24/13, but down 15% over 180 days. The Dietary Progress Note dated 1/15/14, revealed Resident #5's weight was stable for 30, 90, and 120 days, but down 12% over 180 days. Review of the Videofluoroscopic Swallow Study dated 1/30/14, revealed Resident #5 had severe oropharyngeal dysphagia (difficulty swallowing). The recommendations were Dysphagia I or II diet, honey thick liquids, small bites/sips, no straws, and double swallow slow rate. Review of Resident #5's physician's orders [REDACTED]. Review of the "Feeding Guidelines for (Resident #5)" (undated) found in Resident #5's medical record, revealed Resident #5 was "on a pureed diet and honey thick liquids. However, she is allowed some soft items of her choice. These items are: 1) scrambled eggs 2) cooked green beans-mash them with fork before presentation 3) cooked baked beans-mash them with fork before presentation 4) tuna salad-no celery or onion etc 5) baked potato-no skin 6) cottage cheese" Review of the In-Service/Staff Meeting regarding Resident #5's added soft food items, was signed by numerous staff members between 2/3/14 and 2/12/14. In an interview on 3/26/14 at 11:00 am, CDM "K" reported that Resident #5's intake was "not that great", but she took "supplements well". CDM "K" reported that Resident #5 could now have certain foods that were not pureed and that Resident #5 received scrambled eggs daily at breakfast,cottage cheese twice daily for lunch and dinner, and the other items as available. When queried as to why the other items on the soft food list were not available, CDM "K" stated "They aren't always on the menu". When queried how Resident #5's intake of the soft food items compared to her intake of pureed food items, CDM "K" stated "I'm not in the restorative dining room. I look at percentage of intake. It's not broken down by food (specific items). CDM "K" reported that in February 2014, Speech Therapist (ST) "P" compiled the list of soft food items that Resident #5 preferred. An observation on 3/25/14 at 12:00 pm, revealed Resident #5 was in the assisted dining room and was assisted with eating her lunch with a baby spoon (small bites). Resident #5 was observed to fall asleep multiple times during lunch. Resident #5 was awakened by staff and Resident #5 refused magic cup, pureed potatoes, pureed chicken, and juice. Resident #5 was awakened again by staff and asked if she wanted to eat any more. Resident #5 refused. Staff then cleaned up her tray. Resident #5 was not offered any cottage cheese or any alternates for the food that she refused. She at a total of a few bites of food. An observation on 3/26/14 at 11:35 am, revealed Resident #5 was in the assisted dining room sitting at a table with a Styrofoam cup approximately half full of a supplement on the table in front of her. Residents were engaged in an activity during this time. At no time did a staff member assist Resident #5 with drinking her supplement. At 11:48 pm, Resident #5's lunch tray was served and contained the following items: pureed beef burgundy, pureed mixed vegetables, pureed mashed potatoes, pureed pears, thickened apple juice and grape juice, and a magic cup. There was no cottage cheese on the tray. At 11:57 am, Director of Nursing (DON) "B" sat down next to Resident #5 and assisted her with eating from a baby spoon. Resident #5 was fed 1 bite of pureed beef burgundy and she cringed and reported she did not want any more of that. Resident #5 then refused pureed pears. DON "B" then attempted again and Resident #5 ate 3 bites of pureed pears. Resident #5 was then given a sip of honey thick grape juice and she reported that she did not like the grape juice. Resident #5 was then given 3 sips of honey thick water. DON "B" then offered Resident #5 ice cream (magic cup) and Resident #5 refused. Resident #5 then accepted 2 bites of pears, 2 sips of water, 2 more bites of pears, 1 bite of magic cup, 1 sip of water, 2 bites of magic cup, 3 more sips of water, 1 bite of magic cup, 4 sips of water, 1 bite of magic cup, and 1 more sip of water. Resident #5 then reported that she was finished. There were no items off the soft food list on her tray. Resident #5 was not assisted with consuming the supplement in the Styrofoam cup that was present before lunch. An observation on 3/27/14 at 11:40 am, revealed Resident #5 was sitting at the table in the assisted dining room. At 11:45 am, Resident #5's lunch tray was served and contained the following items: cottage cheese, magic cup, pureed pork veggie stir fry, pureed mandarin oranges, pureed mashed potatoes, honey thick apple juice, and honey thick water. Certified Nursing Assistant (CNA) "N" fed Resident #5 1 bite of pureed mashed potatoes. Resident #5 cringed and stated "What is that?" Resident #5 then accepted 2 sips of apple juice and requested to go back to her room. At 11:51 am, Resident #5 was returned to her room. At 11:58 am, CNA "N" delivered Resident #5's tray to her room. CNA "N" reported that Resident #5 was "not a good eater" and ate better for her daughter. CNA "N" reported that Resident #5's daughter brought in chopped up spaghetti the other night and Resident #5 ate 100% of the spaghetti. At 12:02 pm, CNA "N" left Resident #5's room to get CNA "O" to finish assisting Resident #5 with lunch. CNA "O" stated "her (Resident #5's) daughter will bring food in and smash it up and she (Resident #5) will eat all of it". CNA "O" was able to feed Resident #5 3 bites of magic cup, 2 sips of apple juice, and 4 sips of water. CNA "O" stated stated "I'm looking at this cottage cheese and thinking that's not pureed. I think since she's a pureed and that cottage cheese is chunky, not sure if she can have it" . Resident #5 refused a bite of cottage cheese, but accepted 1 bite of magic cup and 1 sip of water. CNA "O" stated "the only time she (Resident #5) eats is when her daughter brings in food. I think she likes her daughter's food better. She eats it all". Resident #5 was not offered alternatives to the food items she refused. Review of Resident #5's tray card for breakfast revealed "special request 2x (two times) reg scr. egg (regular scrambled eggs), yogurt, magic cup". The lunch tray ticket revealed "special request magic cup, regular cot. (cottage) cheese". The dinner tray ticket revealed " special request magic cup, regular cot. cheese". In an interview on 3/27/14 at 12:47 pm, CDM "K" reported that she did not have a copy of the feeding guidelines that contained a list of soft food items that Resident #5 was able to consume. CDM "K" reported that the restorative CNA's had a copy of the feeding guidelines and they were able to ask the kitchen for those items. When queried why all the feeding guidelines/food preferences were not listed on the tray card, CDM "K" stated it was "hard to convey all that information on the tray card" and the computer system would not allow her to do that. CDM "K" stated "if available, we could make any of that stuff anytime. I'm in the main dining room. The restorative girls can come down and get replacements". When queried if Resident #5 ate the soft food items on the list, CDM "K" stated "I'm mainly in the main dining room. The aides would be better to answer that" and the food acceptance "doesn't break down by food". When queried if she ever asked the CNA's if Resident #5 accepted the soft items over the pureed items, CDM "K" stated "I didn't. I know she likes magic cups and takes supplements better". In an interview on 3/27/14 at 1:17 pm, Speech Therapist (ST) "P" reported that Resident #5 had to change to pureed foods due to difficulty swallowing and choking. ST "P" reported that Resident #5's family requested ST to see her again after some time of being on pureed food. ST "P" reported that she evaluated Resident #5 in December and she was doing a little better with the soft food items. ST "P" reported she spoke with Resident #5's family and came up with the soft food item list that Resident#5 likes and reported to the family that the facility could "probably concentrate on those items". ST "P" reported that the facility did not do dysphagia II diets and therefore, Resident #5 was on a dysphagia I diet (pureed). ST "P" reported that Resident #5 could have any of those soft food items on the list if she would like. ST "P" reported that she notified the kitchen staff, posted Resident #5's feeding guidelines with soft food items in the assisted dining room, held an in-service and put the information in the kiosk for the CNA's to review. In an interview on 3/28/14 at 9:20 am, CNA "M" reported that she assisted Resident #5 with breakfast that morning. CNA "M" reported that Resident #5 ate 100% of the cream of wheat, a few bites of pureed bread, and approximately 240 mL of juice. CNA "M" reported that Resident #5 had pureed eggs on her tray and Resident #5 did not like the way it tasted. CNA "M" reported that she "remembered something" that ST "P" said about Resident #5 being able to consume regular scrambled eggs. CNA "M" reported that she was not sure if that was only when ST "P" was present in the dining room or if it was for every meal. CNA "M" reported that Resident #5 did not receive regular scrambled eggs every day with breakfast. CNA "M" reported that Resident #5 "sometimes" received cottage cheese with lunch and that Resident #5 "really likes that". An observation on 3/28/14 at approximately 9:30 am, revealed a copy of Resident #5's feeding guidelines, with a list of soft foods she could consume, taped to the inside of the cupboard in the assisted dining room. In an interview on 3/28/14 at 9:40 am, Cook "Q" reported that he checked Resident #5's breakfast tray before it was served. Cook "Q" reported that he checked to make sure the circled items on the menu were on the tray. When queried what kind of eggs were served to Resident #5 at breakfast, Cook "Q" stated she "might not have had any this morning", but that Resident #5 usually received pureed scrambled eggs. Cook "Q" reported that he read Resident #5's tray card before the food was served. After Cook "Q" reviewed the surveyor's copy of Resident #5's tray card, Cook "Q" reported that Resident #5 was suppose to receive regular scrambled eggs and that he did not think the aides (dietary aides) were reading the tray card correctly. Cook "Q" stated "obviously she (Resident #5) didn't get regular today. I checked her tray so that's on me". In a telephone interview on 3/28/14 at 10:35 am, when queried if nutritional needs should be reassessed/recalculated after a significant weight loss, RD "L" stated "I go case by case. I do a whole assessment and see if we need to change the needs". RD "L" reported that she was aware that Resident #5 disliked pureed foods. RD "L" reported it was up to the facility to honor food preferences and that she believed it would aide in a weight gain for Resident #5 if the facility offered the soft foods Resident #5 was able to consume. RD "L" stated "goal first is to offer things they love". RD "L" reported that the pureed eggs for breakfast on 3/28/14, "must have been an error...we can't have those errors, especially with someone who is losing weight". Review of Resident #5's food acceptance record dated 12/27/13 through 3/26/14, revealed average meal intake of 32% for breakfast, 17% of breakfast alternate, 27% of lunch, 16% of lunch alternate, 33% of dinner, 4% of dinner alternate, average meal 30.7%, and average alternate 12.3%. ( )

Based on observation, interview and record review the facility failed to implement and honor food preferences, and prevent a significant weight loss for 1 sampled resident (#29) of 6 reviewed for weight loss from a total sample of 11, resulting in a significant weight loss for Resident #29 and the potential for a continued weight loss and potential in decline in skin issues. According to the facility's plan of correction dated 3/18/14, "Element #2...All nursing staff have been informed that if a resident is not eating well they need to check the residents preferences and offer alternates." According to Resident #29's admission Minimum Data Set (MDS) assessment dated [DATE], Resident #29 was a [AGE] year old male with [DIAGNOSES REDACTED]. Weight was documented at 225 pounds on admission. According to Resident #29's Weight Change History dated 4/21/14 was 225 pounds (#), on 4/29/14 at 211 #, on 5/4/14 at 209 #, on 5/12/14 at 205 # and on 5/18/14 down to 206 # with a total loss of 20 pounds in 30 days. Review of Resident #29's bowel record dated 4/20/14 through 5/20/14 at 6 am revealed Resident #29 had 4 episodes with 5-10 days with no bowel movements dated 4/20/14 through 4/24/14 (5 days), 4/26/14 -5/4/14 (8 days) 5/7/14 - 5/16/14 (10 days) and 5/16/14 - 5/21/14 (6 days). According to the facility's plan of correction compliance dated 4/21/14, "all res (residents) that have had weight loss for the month have been reviewed to ensure they have been addressed per policy, 100 % audit completed on tray cards to ensure special request are up to date on tray cards. All nursing staff have been informed that if a resident is not eating well they need to check the residents preferences and offer alternates." According to an all staff message from caretrackeronline.com dated 4/17/14, "If a resident is not eating well you need to check the residents preferences and offer alternates. If a resident is non-verbal and not eating well please check their preferences, go to the kitchen and get items avail (available) that are on their list and try offering this to them. Please inform the dietary manager or supervisor if you feel a residents preferences need to be assessed." According to Resident #29's Nutritional assessment dated [DATE] food preferences: were listed as Beverages: decaf coffee, tomato and oj (orange juice). Likes: Blank. Dislikes: Spinach. Resident #29's weight was documented as 222 pounds. Review of Resident #29's clinical record revealed there was no preference list (form 5027) according to the facility policy that listed all of his food preferences. On 5/21/14 at 9:45 am, during a conversation with Resident #29 and Registered Nurse (RN) "F,"related to Resident #29's constipation concern and he stated, "I don't like prune juice." Resident #29 reported he did like apple juice. On 5/21/14 at 12:00 pm, Dietary Manager (CDM) "D"and Registered Dietician "I"were interviewed. CDM "D"reported she had notified RD "I" on 4/29/14 of Resident #29's weight loss, and a significant weight loss was documented on 5/8/14. RD "I" reported she had observed resident #29 while he was eating on 5/14/14. Both RD "I" and RD "D were asked if either of them had looked at Resident #29's bowel record and they responded the nurse usually notified the RD of any concerns, use of laxatives but they looked at constipation and GI issues and [DIAGNOSES REDACTED]. CDM "D" reported she had just added prune juice to the tray card. CDM "D" was asked did you ask if Resident #29 liked prune juice? CDM "D"responded, "no." CDM reported the tray cards were updated. On 5/21/14 at 12:05 pm, Certified Nurse Aide "H" was observed to have reported to Resident #29 "there are no peaches available." CNA "H" offered a different fruit and resident declined. CNA "H" was observed to have walked away from Resident #29, no further assistance was offered and Resident #29 had not eaten anything else on his tray. Three residents were observed to have peaches in the large dining room. CDM "D" stated, "I may not have ordered if they are not on the menu (peaches)." CDM "D" was requested to escort this surveyor to the store room. A can of peaches were observed towards the back of the shelf in the store room. On 5/21/14 at 12:10 pm, Assistant Dietary manager reported he had used the peaches from a mixed fruit can for breakfast, and had not seen the can on the shelf at lunch. On 5/21/14 at 12:15 pm, Resident #29's preference list was requested from CDM "D" at 12:25 pm CDM "D" returned and reported she was unable to locate Resident 29's preference list (or piece of paper) from the stack of shredding and "it was probably shredded." CDM "D" reported the preference list was not placed in Resident's 29's chart or any resident at the facility's chart. The information was placed on the tray card. On 5/21/14 at 2:05 pm, during an interview with CDM "D" and DM "J," CDM "D"reported a dietary preference form was used to speak with Resident #29 and reported Resident #29 did not like cranberry juice. CDM "D" reported preferences were often "written on a paper towel or napkin or what ever was available." On 5/20/14 at lunch Resident #29's tray care revealed, "whole milk 8 oz, oj (orange juice) 4 oz, water 8 oz, special request 2 x protein." On 5/21/14 at breakfast Resident #29's tray card revealed, "mix 1/2 prune jc (juice) w/ 1/2 4 oz, water 8oz, whole milk 8 oz, oj 4 oz Special Request 2 x protein, fruit." Attached select menu Resident had chosen orange juice and apple juice, cheese scrambled eggs white toast and milk. Resident #29 had not received any orange juice or apple juice on his tray, and had received prune juice (which he had reported he disliked.). Resident had requested peaches specifically. On 5/21/14 at 2:05 pm, CDM "D" reported Resident #29's neighbor brought in to the facility for Resident #29, chocolate boost and donuts. These food preferences were not placed on the the food preference list or the tray card. CDM reported the food preferences were not placed on the care plan. On 5/22/14 at 8:15 am, resident was observed to have received prune juice on his tray and stated, "I don't like prune juice." On 5/22/14 at 9:10 am, RN "C" and DON "B" reported Resident #29's neighbor brought in to the facility for Resident #29, chocolate boost, donuts and cookies. Both RN "C" and DON"B" reported Resident #29 was diabetic and were ninety nine percent sure the boost was ok for a diabetic. There was no education documented on discussion with the neighbor on appropriate snacks for a diabetic related to the weight loss. On 5/22/14 at 9:40 am, Licensed Practical Nurse (LPN) "M" reported she had not recalled seeing any food preferences in the dietary notes, occasionally some foods were listed on the slips, but she would usually have to go talk to the residents and ask the residents about their preferences prior to getting them something from the kitchen to eat. On 5/22/14 at 9:41 am, Certified Nurse Aide "L" reported she would go to the kitchen or ask a nurse if a resident ask for a snack. On 5/22/14 at 9:50 am, LPN "E" reported she would usually check the chart as dietary was to complete an assessment upon admission of food preferences. Then, LPN "E" reported she ask the resident their food preferences prior to giving them something to eat. LPN "E" reported she usually wrote down a communication to the kitchen of the resident's likes and dislikes. According to the facility policy "Dietary Documentation and Care Planning (diet 214)," dated 5/11/12, "Procedures: 1. Nutritional Assessment A... 1. Complete the Initial Dietary Visitation HCM Diet 5027 form upon the first visit with the resident 2. Make Diet card using this form from resident/family interview. 3. Put in Dietary Section of chart and write a dietary not you have completed it." ( )

Based on observation, interview and record review, the facility failed to implement safety measures during a transfer to prevent a fall with injury for 1 of 4 sampled residents (#101) reviewed for mechanical lift transfers and falls, resulting in a fall with a hematoma and fracture. Findings include: According to the face sheet printed 1/28/14, Resident #101 was a [AGE] year old female who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status score of 06, interpreted as severe cognitive impairment. The cognitive care plan dated 3/16/12 and updated 1/10/14 reflected Resident #101 had cognitive loss as evidenced by impaired decision making skills and long and short term memory loss. The Activities of Daily Living Care plan dated 5/2/11 and reviewed 1/9/14, reflected Resident #101 was to be transferred with a mechanical lift using full body adult sling with two person assist. This same care plan reflected Resident #101 was unable to perform activities of daily living tasks independently related to osteoporosis, multiple sclerosis and lower extremity neuropathy. The facility incident report dated 1/27/14 at 8:10 am, reflected "cna (certified nurse aide) called nurse to room (#) res. (resident) observed laying flat on her back on floor head towards west, feet toward east both legs at mid-calf laying up across mechanical lift foot bar towards rt. (right) side res. A&O x 3, (alert to person, place and time) ... red raised area noted at right crown of head-5 cm across... 0 red areas, 0 edematous areas L (left) foot & leg noted to be extremely rotated L hip abnormally shaped res c/o (complained of) severe pain with light touch 0 ROM (range of motion) attempted res c/o (complained of) RLE (right lower extremity) hip pain..." The nurses' notes dated 1/27/14 6:00 pm reflected the "sling (was) 0 completely under res. (resident), sling on the right side of res. body (within) 2 inches. Under body the rest in a space of 5 inches between body & lift (left) foot Sling inspected 0 broken or frayed areas noted on straps or entire sling areas... to prevent further injury by moving bone positions 911 called - res to go to (name of hospital) emergency room for eval (evaluation) & tx (treatment)..." The nurse aide care plan (undated) reflected Resident #101 needed a mechanical lift with a two person assist, and Resident #101 was non-ambulatory, and needed a large full body sling. The pain assessment dated [DATE] reflected Resident #101 had no pain. Both the nurses notes dated 1/27/14 and the incident report dated 1/27/14 reflected Resident #101 has severe pain to touch. However, the pain assessment dated [DATE] immediately following the fall, also reflected resident had no pain. During an interview with Nurse "H" on 1/30/14 at 3:05 pm she explained the pain assessment she completed on 1/27/14 was marked no pain, when Resident #101 was actually experiencing pain, Nurse "H" stated this was because she knew she was not going to write anything on the care plan. The pain assessment dated [DATE] reflected Resident #101 was in mild pain and the current pain interventions were effective. On 1/30/14 at 3:00 pm Resident #101 confirmed that she was not currently in pain. On 1/29/14 at about 12:20 pm, during an interview with nurse aides "C" and "D" demonstrated what happened during the transfer of Resident #101, which resulted in a fall. Nurse Aide "C" stated she placed the sling underneath Resident #101 and waited for nurse Aide "D" to enter before beginning with the transfer. Nurse Aides "C" and "D" were asked how did they know that was the right sling was used for Resident #101, they replied because she is an average size and the sling they used was for an average weight. Nurse Aide "C" then continue to demonstrate by putting the mechanical lift over the bed, then hooking the middle straps on the mechanical lift all the way around on all four sides. Then Nurse Aide "C" stated she began to lift the resident off of the bed, the sling was observed to have a clearance of about 4 to 5 inches above the bed, then Nurse Aide "C" moved the sling away from the bed. Nurse Aide "C" explained as she was moving the lift away she could feel that it was caught on something underneath the bed, so she jerked the mechanical lift to free it from whatever it was caught on while Resident #101 was in the sling. During this observation on 1/29/14 at about 12:20 pm, it was observed that the sling was caught underneath the bed on a metal bar underneath the head frame on the bed. Nurse Aide "C" stated as soon as the sling cleared the bed Resident #101 fell . Both Nurse Aides "C" and "D" stated they don't know how it happened. On 1/29/14 at about 12:20 pm, during this same interview, Nurse Aides "C" and "D" were asked about their written statements, where they documented that a "cord" was underneath the bed. Both Nurse Aides "C" and "D" said they don't know what was underneath the bed. Nurse Aide "C" added that even if it was a piece of cereal the lift rolled over, that could cause the lift to be off balanced. Then Nurse Aide "C" was asked if everything was executed the way that was just stated, then how could Resident #101 have fallen? Nurse Aide "C" replied "well, when I transferred her her body could have touched the bed, which would have caused her to swing, and the cloth hooks could have come half way off at that time, then when I jerked the lift it could have caused the left front cloth hook to come all the way off," at which point Resident #101 would have slide out of her sling head first unto the floor. During the interview on 1/29/14 at about 12:20 pm, both nurse aides "C" and "D" stated they had been trained on how to use Hoyer lifts during their orientation and they were observed by a nurse. Nurse aide "D" added she had already had prior experience as a nurse aide. According to the employee "CNA Skilled Checklist," dated 3/26/13 and 7/30/13 respectively, Nurse Aide "D" received her orientation training on 3/26/13. Nurse Aide "C" received her orientation training on 7/30/13. The facility had a second mandatory training on resident transfers 9/19/13, in which nurse aide "C" attended. Nurse Aide "D" was re-trained resident transfers on 9/20/13. According to the facility's "Inservice Training Record" on "Hoyer lift training" dated 1/27/14 neither Nurse Aide "C" or Nurse Aide "D" attended that training. On 1/29/14 at 3:30 pm, during an interview with Nurse "G," Nurse "G" explained the she was the nurse who trained the nurse aides on the use of mechanical lifts. Nurse "G" was asked did she follow any written instructions when training the nurse aides, and Nurse "G" replied that Therapy initially trained staff on how to properly use the Hoyer lifts and demonstrates with an employee in the mechanical lift. The facility just had a mandatory training the evening of 1/27/14 and the Therapy staff had to stay late to train us. After Therapy trained the initial group of employees, she trained the remaining employees. Nurse "G" went on to say all nursing staff received mechanical lift training with observation of demonstration on orientation, during the 9/19/2013 training and again on 1/27/14. Nurse "G" explained that the type of sling a nurse aide should use is by the resident weight and there is a color coded weight and type of sling to be used on each mechanical Lift. Nurse "G" stated that the green sling was the right one for Resident #101's weight, and Nurse Aides "C" and "D" stated that was the one that was used. Nurse "G" explained she told the nurse aides during their mechanical lift training to be careful during each transfer, that after a resident was lifted, but before a resident's transfer was started, they should do a "visual check" to make sure everything is place. Nurse "G" also stated they should check underneath the bed before they begin to move the sling, to remove anything that may be in the way. The Operation Manual (undated) for the use of the Hoyer Lift on page 28 warns "When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem - otherwise, injury or damage may occur. Adjustments for safety and comfort should be made before moving the patient...." On 1/30/14 at 3:00 pm, in the Resident #101's room, Resident #101 stated "they dropped me." When asked more detail information about the Hoyer Lift and sling used, Resident #101 again stated "I said they dropped me." At that point she demonstrated with her arms by lifting both of her arms moving them outside her bed, then letting go. Indicating she was physically dropped during a transfer without the use of a Hoyer Lift. Resident #101 was asked why was a mechanical lift used, and Resident #101's reply indicated she did not know why a lift was not used. The hospital history and physical report dated 1/27/14 reflected Resident #101's chief complaint was "fall and left hip fracture." The radiology report of this same report reflected Resident #101 had an x-ray of the left hip showed osteopenia and comminuted minimally displaced fracture ... 2) CT (cat scan) of the hip on 1/27/14, showed tinny (sic) evulsion fracture in addition to the x-ray findings listed above. 3) CT of the head on 1/27/14 showed small right parietal scalp hematoma, atrophy, and small vessel ischemic change." This same hospital history and physical report dated 1/27/14 reflected "the best method of attempting to get up and move about would be with the open reduction and internal fixation using a subcondylar nail that is locked, carries with the risk of infection, blood clots, neurovascular compromise, leg length discrepancy, shortening of the limb, hardware cut out among others. The operative report dated 1/28/14 reflected the operation procedure that took place and added "The patient has MS. She has not been ambulatory for some time. We will maintain her transfers for activity." Although there were discrepancies in Resident #101's account of what took place and Nurse Aides "C" and "D's" account, they both reflect that Resident #101 fell during a transfer with facility staff, which resulted in a scalp hematoma and a left hip fracture that resulted in surgery. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE AND EFFECTIVE CATHETER CARE FOR AN INDWELLING URINARY CATHETER FOR 1 OF 2 RESIDENTS (#5) REVIEWED FOR CATHETERS FROM A TOTAL SAMPLE OF 22 RESIDENTS, RESULTING IN THE DEVELOPMENT OF RECURRENT URINARY TRACT INFECTION AND CATHETER RELATED PAIN, BLEEDING AND URETHRAL EROSIONS. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET RESIDENT #5 WAS AN [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION HISTORY AND PHYSICAL DATED 11/8/11 REFLECTED RESIDENT #5 WAS CONFUSED, HAD SWELLING IN HIS LOWER LEGS THAT WAS FOUND TO BE RELATED TO HAVING BLOOD CLOTS IN BOTH LEGS AND CARRIED THE [DIAGNOSES REDACTED]. THE PHYSICIAN ' S PROGRESS NOTE DATED 2/21/12 REFLECTED RESIDENT #5 WAS BEING SEEN BY A PSYCHIATRIST FOR HIS BEHAVIORAL ISSUES, AGGRESSIVENESS AND WAS BEING TREATED WITH ANTIBIOTIC (BACTRIM) FOR URINARY TRACT INFECTION. THE NURSING NOTE DATED 2/22/12 REFLECTED THE PHYSICIAN HAD ORDERED POST VOID RESIDUAL (PVR), A PROCEDURE TO ASSESS THE AMOUNT OF URINE REMAINING IN THE BLADDER WITHIN 5 TO 10 MINUTES FOLLOWING URINATION. NORMAL PVR IS USUALLY 50 ML OR LESS. A PVR OF 150 TO 200 MAY INDICATE PRESENCE OF A [MEDICAL CONDITION]. PVR MEASUREMENT COULD BE DONE BY HAVING THE RESIDENT VOID INTO A CONTAINER THAT MEASURES URINE OUTPUT, AND THEN CHECKS THE AMOUNT OF LEFTOVER (RESIDUAL) URINE IN THE BLADDER USING A CATHETER OR ULTRASOUND. THE NURSING NOTE DATED 2/24/12 (2-10/SECOND SHIFT) REFLECTED, " ...RESIDENT STRAIGHT CATHED AT THE BEGINNING OF THE SHIFT WITH 1220 CC URINE OUTPUT. RESIDENT DID NOT NEED ANY BRIEF CHANGE, AS HE WAS NOT INCONTINENT OF URINE DURING THIS SHIFT. AT THE END OF THE SHIFT RESIDENT WAS STRAIGHT CATHED FOR URINE OUTPUT OF 260 CC ... " THE NURSING NOTES DATED 2/25/12 (10-6/THIRD SHIFT) REFLECTED, " ...POST ATB (ANTIBIOTIC) DAY 2. NO ADR (ADVERSE DRUG REACTION) NOTED. STRAIGHT CATH AT THE END OF THIS SHIFT WITH 600 CC OUTPUT ... " THE NURSING NOTE DATED 2/25/12 AT 2:00 P.M., " RESIDENT UP IN WHEEL CHAIR PROPELLING SELF AROUND AS DESIRED MOST OF SHIFT. CONFUSED BUT ALERT AND ORIENTED X 1. NO VOICED COMPLAINTS. STRAIGHT CATH OUTPUT 1300 CC YELLOW URINE ... " BOTH NURSING NOTES 2/24/12 AND 2/15/12 REFLECTED RESIDENT #5 HAD BEEN STRAIGHT CATHETERIZED (INSERTING AND REMOVING A SMALL TUBE INTO THE BLADDER IMMEDIATELY AFTER REMOVING THE URINE) 4 TIMES WITH AMOUNT OF URINE RANGING BETWEEN 260 CC AND 1300 CC. THERE WAS NO ASSESSMENT OF THE BLADDER TO SHOW WHETHER THE RESIDENT'S BLADDER WAS DISTENDED OR NOT, WHETHER OR NOT THE RESIDENT HAD COMPLAINED OF ANY URINARY DISCOMFORT AND THERE WAS NO "MEASUREMENT" OF URINE OUTPUT PRIOR TO STRAIGHT CATHETERIZATION. THUS THERE WAS NO EVIDENCE THAT THE PROCEDURES WERE CARRIED OUT CORRECTLY AND ACCURATELY. THE NURSING NOTE DATED 2/25/12 REFLECTED RESIDENT #5 WAS TO HAVE " FOLEY, " A INDWELLING URINARY CATHETER, FOR [MEDICAL CONDITION] AND WAS TO HAVE FOLLOW UP WITH AN UROLOGIST. ON 6/28/12 AT 10:00 A.M., THE EAST WING UNIT MANAGER, (STAFF " H " ) WAS NOT ABLE TO CONFIRM THE UROLOGIST VISIT. THE ONLY AVAILABLE UROLOGIST REPORT DATED 5/31/12 REFLECTED, " RESIDENT IS HERE TODAY BECAUSE HE DEVELOPED ACUTE [MEDICAL CONDITION] WITH NO INFORMATION AND UNABLE TO ANSWER QUESTIONS VERY WELL. A ' FOLEY ' IS IN PLACE. HE WAS LAST SEEN BECAUSE OF THE [MEDICAL CONDITION] BLADDER WHICH HAS BEEN PRESENT SINCE 2009 WHEN HE HAD A STROKE". THE UROLOGIST CONCLUDED HIS FINDING AS, " FAILED TRIAL OF VOIDING FOR 1 MONTH ". HOWEVER, THERE WAS NO EVIDENCE THAT THE RESIDENT RECEIVED ATTEMPTS TO HAVE TRIALS OF VOIDING SINCE HE WAS CATHETERIZED ON 2/25/12. THE NURSING NOTES DATED 2/25/12 THROUGH 6/25/12 REFLECTED RESIDENT #5 HAD BEEN TREATED WITH ANTIBIOTICS 6 TIMES (ON 2/25/12 WITH BACTRIM, ON 3/19/12 [MEDICATION NAME], ON 5/1/12 WITH [MEDICATION NAME] INTRAMUSCULARLY, ON 5/17/12 WITH [MEDICATION NAME], ON 5/21/12 WITH [MEDICATION NAME], ON 6/7/12 WITH BACTRIM AND [MEDICATION NAME]) FOR CATHETER RELATED URINARY TRACT INFECTION [MEDICAL CONDITION] AS WELL AS CATHETER RELATED COMPLICATION. ON ALL OF THESE UTI INCIDENCES THE RESIDENT WAS NOT DOCUMENTED AS HAVING ANY SIGNS AND SYMPTOMS OF UTI OTHER THAN HIS UNDERLYING FLUCTUATING BEHAVIOR ISSUES. THE NURSING NOTE DATED 2/26/12 REFLECTED, " RESIDENT UP IN WHEEL CHAIR AS AD LIB (AS DESIRED), FOLEY PATENT, RESIDENT PULLING ON FOLEY DURING ADL (ACTIVITIES OF DAILY LIVING) CARES, RESIDENT ENCOURAGED NOT TO PULL OUT FOR URINARY HEALTH, RESIDENT STATES ' THEY WRECKED MY PETER, ' RESIDENT DRESSED AND THEN LEFT FOLEY ALONE ". THE NURSING NOTE DATED 2/28/12 REFLECTED, " RESIDENT ATTEMPTING TO GET UP UNASSISTED, RESIDENT CONFUSED, STATES THERE IS ELECTRICITY IN HIS BRIEF ". THE NURSING NOTE DATED 5/17/12 REFLECTED, " RESIDENT HAS BEEN INCREASINGLY AGITATED AND RESTLESS ...HE BECAME COMBATIVE [MEDICATION NAME] (ANTI-ANXIETY) WAS GIVEN ...DOCTOR (PHYSICIAN ' S NAME) WAS NOTIFIED OF PENILE DISCHARGE ...RESIDENT NOTED TO HAVE SORES AROUND HIS FORESKIN [MEDICATION NAME] (ANTIBIOTIC) 500 MG ONCE, THEN 250 MG DAILY FOR 4 DAYS ... " THE NURSING NOTE DATED 5/18/12 REFLECTED, " ...RESIDENT HAVING BLOOD DRIPPING FROM PENIS ... " THE NURSING NOTE DATED 5/20/12 REFLECTED, " ...RESIDENT REFUSED TO LAY DOWN, URINE CLOUDY, GLANS PENIS RED WITH DRAINAGE (PURULENT) ... " THE SPECIMEN FROM THE PENILE DISCHARGE WAS SENT FOR CULTURE ON 5/26/12. THE PENILE CULTURE REPORT DATED 6/4/12 REFLECTED THE RESIDENT HAD 2 MICROORGANISMS (STAPHYLOCOCCUS AUREUS AND PROTEUS MIRABILIS. THE URINE CULTURE FROM 6/2/12 ALSO SHOWED THE RESIDENT HAD [MEDICAL CONDITION] (MRSA) IN ADDITION TO THE PROTEUS MIRABILIS AND PSEUDOMONAS AERUGINOSA. RESIDENT WAS TREATED WITH 2 ANTIBIOTICS (BACTRIM AND [MEDICATION NAME]). THE NURSING NOTE DATED 6/2/12 REFLECTED RESIDENT #5 WAS STILL HAVING BLOOD IN HIS BRIEF. BLOOD FROM URETHRA, TIP OF PENIS SWOLLEN, AS FORESKIN WOULD NOT FULLY RETRACT. ON 6/28/12 IN THE AFTERNOON, THE EAST WING UNIT MANAGER, (STAFF " H " ) WAS ASKED WHETHER THE RESIDENT ' S PENIS AND THE CATHETER COULD BE OBSERVED OR NOT. STAFF " H " STATED THAT THE RESIDENT COULD GET VERY VIOLENT IF SOMEONE ATTEMPTED TO TOUCH THE CATHETER OR EXAMINE HIS PENIS POSSIBLY DUE TO THE PAIN ASSOCIATED WITH HANDLING. DESPITE THE ONGOING REPEATED EPISODES OF treatment for [REDACTED]. RESTORING NORMAL BLADDER FUNCTION TO THE EXTENT POSSIBLE. THERE WAS NO WAY TO VERIFY HOW NURSING STAFF PROVIDED EFFECTIVE CATHETER CARE FOR RESIDENT #5 WHO DEVELOPED COMPLICATIONS AND ACCOMPANYING PAIN. ( )

This citation pertains to intake number MI 518. Based of observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 6 residents (Resident #101), from a total of 7 sampled residents, resulting in Immediate Jeopardy (IJ) when Resident #101, who was identified as an elopement risk and at risk for falls, exited the facility at approximately 12:00 PM on 5/12/12, unbeknownst to facility staff. Resident #101 was found at approximately 1:45 PM, 2.33 miles from the facility walking down the sidewalk of a divided six-lane road by a staff member coming to work. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 was severely cognitively impaired for daily decision-making skills, required encouragement, cueing, set up for locomotion on the unit, and his balance was not steady when walking. Review of the Roster/Sample Matrix given to the surveyor on 5/23/12, revealed Resident #101 was not at the facility at the time of the investigation. Review of the Wandering and At Risk for Elopement Assessment, dated 3/1/12, revealed Resident #101 had the physical capability of wandering or elopement, was disoriented and depressed, wandered independently and aimlessly about the facility oblivious to physical and safety needs. Resident #101 had a Wander Guard, required frequent monitoring, and exercise in place for wandering/elopement interventions. The Wandering and At Risk for Elopement Assessment revealed staff was aware that Resident #101 was a wander risk. Review of the Incident Report, dated 5/12/12, revealed the facility was called at 1:30 PM by a staff nurse on his way to work to inform them he had just observed Resident #101 on the sidewalk of a 6 lane divided road, just past the university campus walking by himself. In an interview on 5/23/12 at 4:55 PM, Licensed Practical Nurse (LPN) #3 reported she gave Resident #101 his medications on 5/12/12 at approximately 11:45 AM. LPN #3 reported she did not hear any door alarms sound on 5/12/12 between 11:45 AM and approximately 2:30 PM. In an interview on 5/23/12 at 12:47 PM, Certified Nursing Assistant (CNA) #4 reported Resident #101 was on 15-minute checks and was last observed at 12:00 PM in his room. CNA #4 reported she heard "Doctor Walker" (elopement) paged overhead just before 2:00 PM. In an interview on 5/23/12 at 1:10 PM, CNA #5 reported that on 5/12/12, she picked up Resident #101's empty lunch tray at approximately 12:50 PM, but did not see him. CNA #5 reported that she did not do the 15-minute checks during lunch for any residents at risk for elopement. CNA #5 reported she did not hear any door alarms sound on 5/12/12 between 11:45 AM and approximately 2:30 PM. In interview on 5/23/12 at 2:36 PM, 4:07 PM, and 4:25 PM respectively, Acting Receptionist #8, LPN #9, and Social Worker (SW) #14 reported that there was no elopement book at the front desk to visually identify residents at risk for elopement on 5/12/12 at the time of the elopement. They stated the elopement books were kept at the nursing stations. Acting Receptionist #8 reported that she was working the front desk on 5/12/12, which included opening and closing the front door for visitors. Acting Receptionist #8 stated she did not know Resident #101 was an elopement risk or recall if he exited the facility via the front door. In interviews on 5/23/12 at 1:40 PM and 6/5/12 at 12:15 PM, LPN #7 reported he was coming to work at approximately 1:45 PM on 5/12/12, when he noticed Resident #101 walking down the sidewalk on a six-lane divided road about 100 feet from the intersection of a four-lane road. LPN #7 reported he did a U-turn, parked his vehicle, and borrowed a phone to call the facility to inform them he had found Resident #101 approximately two miles from the facility. LPN #7 ran across the six-lane divided road to intercept Resident #101. LPN #7 reported that it took him a while (approximately 45 minutes) to coax Resident #101 into his vehicle and return him to the facility. LPN #7 reported Resident #101 had a jacket on and appeared dressed appropriately for the day. Resident #101 was returned to the facility at approximately 2:30 PM by LPN #7. In interviews on 5/23/12 at 5:20 PM and 5/30/12 at 3:05 PM, Occupational Therapists (OT) #13 and #15 reported that Resident #101 was not safe to be out of the building on 5/12/12 walking on a sidewalk next to a 6 lane divided road without supervision. OT #13 stated "it is terrifying to think Resident #101 was out by himself", he had poor cognition and memory. Review of the Treatment Administration Record (TAR) for May 2012, revealed from 5/1/12 through 5/11/12, Resident #101's Wander Guard bracelet was checked for placement every shift and function once a day. Review of the Exit Door Alarm Daily Checks for the months of April 2012 through May 12, 2012, revealed all exit door alarms were checked and had functioned properly. An observation on 5/23/12 at 10:30 AM, revealed the front entrance door had 2 sets of Wander Guard alarms, which functioned properly and the remaining exit doors on the resident units were found with key pad locks. In an interview on 5/23/12 at 1:27 PM, Administrator #1 reported that she was not able to identify through which door of the facility Resident #101 eloped on 5/12/12. On 5/25/12 at 8:52 AM, the Administrator was notified of the Immediate Jeopardy that began on 5/12/12, and was identified on 5/23/12, when the facility failed to prevent the elopement and ensure the safety of Resident #101, identified as an elopement risk, who eloped from the facility on 5/12/12 at approximately 12:00 PM, unbeknownst to facility staff. Resident #101 was found on 5/12/12 at approximately 1:45 PM by a staff member on his way to work, approximately 2.33 miles from the facility on a sidewalk of a six-lane divided road. On 5/30/12, this surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 5/12/12 at 2:00 PM, elopement was paged in the facility, a head count was completed and Resident #101 was not present. 2. On 5/12/12 at 2:30 PM, Resident #101 was returned to the facility, a physical assessment was completed, and Resident #101 was placed on 1:1 supervision. 3. On 5/12/12 at 2:45 PM, the Maintenance Director checked all 9 door exits. 8 of the 9 doors have magnetic locks which were intact, the front entrance door had a code alert system which was checked with a code alert bracelet and found to be in working order. The Maintenance Director in-serviced the front door monitor face-to-face on door alarms and code alert. 4. On 5/12/12 at 3:00 PM, the southwest Unit Manager assessed and verified all 13 residents with code alerts for placement and functioning. 5. On 5/12/12, Unit Managers re-assessed 105 residents for elopement risk and verified care plan interventions. All new admissions will be assessed for elopement risk and interventions implemented. 6. On 5/12/12, the 2 elopement manuals at the 2 nursing stations were reviewed and updated. A third manual with pictures of elopement risks was placed at the front entrance door for the front door monitor. Front entrance door guidelines were reviewed, which included: a. Residents, who are there own responsible party, must sign out on a leave of absence at the nurse's station prior to leaving the facility. b. The front entrance door monitor must notify the nurse's station to verify the resident has signed out for a leave of absence prior to allowing the resident to leave the facility. c. If the code alert sounds, immediately assess the area for a resident at risk for wandering or elopement. d. Contact the nurse's station to summon staff to redirect the wandering resident away from the public exit. e. If no resident is in view and the code alert sounds, page the elopement notification code, do not silence the alarm. 7. On 5/12/12 & 5/13/12, face-to-face in-servicing for 65 employees was completed. All on duty staff continue to be in-serviced prior to the start of their shift. The in-service included, Elopement Prevention Procedures, Code Alerts, Elopement Manuals, and Front Door Monitoring. 8. On 5/12/12 at 4:30 PM, the Social Worker interviewed and assessed Resident #101 for any emotional distress or change in psychosocial well being. 9. On 5/12/12, the front entrance door monitor continued from 8:00 AM to 8:00 PM, 7 days per week. 10. On 5/12/12, door checks for 9 of 9 exit doors continued daily. 11. On 5/14/12, the Administrator and Maintenance Director determined the signal light for the front entrance door was not working correctly at all times. 24/7 front entrance door monitoring was implemented, with the additional duty of monitoring the signal light. A Technician was notified and all staff was updated about the code alert system dysfunction. 12. On 5/15/12, the Technician assessed the code alert system and noted electronic noise interference was causing the dysfunction and contacted a Specialist. The technician rewired the bypass buttons so they no longer reset the code alert alarm and the Maintenance Director added 2 addition antennas for code alert bracelets to increase coverage distance from the front entrance door from 3 feet to 6 feet. 24/7 monitoring of the front entrance door will continue until re-inspected by the Technician. 13. On 5/16/12, the Specialist determined cause of interference, which has decreased and the Maintenance Director continues to assess electronic interference. 14. On 5/23/12, the automatic exit for the front entrance door was disconnected to eliminate the door from staying open for any period of time. 15. On 5/23/12, all exit door alarms have been activated in addition to the magnetic lock. 16. On 5/25/12, 16 nursing staff members have been in-servicing on 15 Minute Check Policy, all other nursing staff will be in-serviced prior to beginning work on their next scheduled shift. Although the Immediate Jeopardy was removed on 5/14/12, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance had not yet been verified by the State Agency. #

This citation pertains to intake number MI 494. Based on observation, interview, and record review, the facility failed to provide the necessary treatments and services to prevent pressure sores from developing in 1 of 3 sampled residents (Resident #104) from a total sample of 7 residents, resulting in Resident #104 developing a Stage II pressure sore (loss of skin) on her left heel. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #104 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #104 was severely cognitively impaired for daily decision-making skills, was at risk for developing pressure ulcers, and required assistance of one staff member to transfer, locomotion on the unit, bathing, hygiene, and toileting. Review of the physician's orders [REDACTED]. Change daily and as needed". The physician's orders [REDACTED]. Review of the Physician Telephone Order dated 5/18/12, revealed the weekly skin assessments for Resident #104 were discontinued, Braden Scale 17 (an assessment tool for predicting the risk of pressure ulcers, Braden Scale of 16 and below was considered to be at risk for developing pressure ulcers). The Physician Telephone Order dated 5/21/12, revealed bilateral heel protectors on at all times. Review of the Skin Care Plan dated as reviewed 4/18/12, revealed Resident #104 was at risk for impaired skin integrity related to Chronic Lower Extremity [MEDICAL CONDITION], approaches in place were: * "Skin assessment as needed, Braden Scale quarterly and as needed. * Encourage Resident #104 to elevate legs as much as possible... * Update physician of changes in lower extremities (increased [MEDICAL CONDITION], temperature changes, redness, increased pain) * Pressure relieving/reducing mattress and wheelchair cushion. * Treatment to lower extremities as ordered. * Educate Resident #104 on importance of elevating legs frequently, related to recurrent stasis ulcers". Review of the Nurse's Notes dated 5/20/12 2:00 PM-10:00 PM, revealed that upon further assessment of lower extremities, the left heel of Resident #104 was open with a skin flap hanging from the heel area, is reddish black with maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) noted under the bottom of the foot. The Nurse's Notes revealed the left heel area was cleansed, [MEDICATION NAME] applied, area wrapped with Kerlix, and Resident #104 was place on 24 hours of bedrest, with heel elevated off the mattress. Review of the Documentation Guidelines for Wound Care (no date) revealed, "1. Document daily wound treatment. 2. Assess wound site: Type of wound (stasis or pressure ulcer..), Appearance of wound (amount, color, odor, drainage, slough (dead tissue), or eschar (scab), Frequency of dressing changes, Type of medication and dressing applied, Enzymatic debridement (removal of dead tissue). 3. Assess for signs and symptoms of infection: redness, swelling, warmth, [MEDICAL CONDITION], bleeding,[MEDICAL CONDITIONS], drainage (amount, color, odor). 4. assess for pain related to dressing change: Intensity, need for medication prior to dressing change, non-medication interventions for pain, response to intervention. 5. Assess the need for Physical Therapy intervention: sharps debridement, whirlpool, dressing changes. 6. Document at least weekly: size, evidence of healing, description of surrounding tissue, any changes in wound care. 7. Dietary interventions... 8. Other interventions: positional changes (frequency), special mattresses. In an interview on 6/1/12 at 3:15 PM, Licensed Practical Nurse (LPN) Unit Manager #9 stated when asked where Resident #104's Daily Ulcer Documentation for May 2012, that he was not able to find the documentation. Review of documentation requested by this surveyor on 5/31/12 for all of Resident #104's Wound Treatment Documentation for May 2012 did not reveal the Daily Ulcer Documentation sheet. In an interview on 5/31/12 at 3:14 PM, LPN #20 reported when the dressing change was completed on 5/20/12 to Resident #104's left lower leg, removed Resident #104's sock which appeared wet, and noted the left heel was black, bleeding, and the skin on the heel was "not there, it was bad". In in interview on 5/31/12 at 3:35 PM, LPN #19 reported assisting LPN #20 with the dressing change and noticing a wet bloody spot on the sheets where the left heel was, and when the sock was removed from the left heel the skin from the heel just slid of with the sock. In an interview on 5/31/12 at 4:40 PM, Registered Nurse (RN) #2 reported Resident #104 was noncompliant with laying down, she likes to sit in her wheelchair, and the lower leg dressings were changed when Resident #104 was sitting in her wheelchair so staff may not have noted the change in the left heel. RN #2 was asked how she knew Resident #104 had a broken blister to her left heel when there was no documentation about a blister, she stated the left heel wound edges appeared consistent with a broken blister. Review of the Treatment Administration Record (TAR) dated May 2012, revealed Resident #104 treatment to bilateral lower legs was completed 30 out 31 opportunities, no documented assessment of the wound was noted. The TAR revealed Resident #104 was scheduled for 8 opportunities for a whirlpool to bilateral lower extremities, refused 4 with no reason documented, 3 were completed, and 1 was not offered. The TAR revealed Unna Boot to bilateral lower extremities, on hold and a FYI (for your information) note dated 5/21/12 "heel protectors on at all times". Review of Weekly Skin assessment dated [DATE] (no time), revealed Resident #104 had multiple open areas noted on bilateral buttocks, bilateral upper posterior thighs, and coccyx. The Weekly Skin Assessment did not document findings for the areas to the bilateral lower extremities, which were being treated daily according to the TAR and Physician Orders. Review of the Nursing Notes dated 5/15, 16, 17, 18, 19, and 20 at 1:30 PM/2012 revealed no documentation of a blister or any type of documentation related to Resident #104's left heel. Review of the Weekly Ulcer assessment dated [DATE], revealed Resident #104 had a Stage II 7.0 cm x 7.0 cm x 0.1 cm broken blister, open area with clear drainage to her left heel, reddening in color, and no pain noted. Review of the Care Plan kept in Resident #104's room for Certified Nursing Assistant (CNA)reference for individualized care, revealed under Skin Care NO pressure ulcers was checked, special instructions to change Unna Boots every Wednesday and Saturday after shower were also noted (according to the TAR the Unna Boots are on hold). The Care Plan did not have any documentation to remind staff that Resident #104 had a Physician order [REDACTED]. Observation on 5/31/12 at 3:40 PM of Resident #104's left heal, revealed a darkened area with granulated tissue, open areas to great toe, areas were cleaned and new dressings were applied. The right lower leg dressing was also changed and this surveyor noted open areas to the 2nd toe. In review of the Weekly Ulcer Assessments, TAR, and the Nursing Notes no mention of the open areas to the toes of the right and left feet were noted. On 5/30/12 at 4:45 PM Resident #104 was noted up in her wheelchair with right foot wrapped in gauze to her toes, left foot bare, bilateral heel protectors were not in place. In an interview on 6/4/12 at 2:33 PM, CNA #25 (who did care for Resident #104 prior to 5/20/12) reported Resident #104 sits in the wheelchair all day. CNA #25 reported when Resident #104 was assisted to bed, the dressings to her lower legs were in place, and in general if Resident #104 did not ask to have her socks off she left them on. CNA #25 reported since the nurses were doing dressing to Resident #104's lower legs she assumed they checked Resident #104's feet at that time. #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROTECT ONE RESIDENT (#12) OUT OF 3 RESIDENTS REVIEWED FOR ABUSE AND NEGLECT FROM A TOTAL SAMPLE OF 19 RESIDENTS RESULTING IN PSYCHOSOCIAL HARM. FINDINGS INCLUDE: ACCORDING TO THE JULY 2011'S FACILITY'S "physician's orders [REDACTED]. THE RESIDENT'S MINIMUM DATA SET (MDS) COMPLETED ON 5/27/11 REFLECTED HE WAS AN EXTENSIVE ASSIST WITH TOILET USE (SELF PERFORMANCE), A ONE PERSON PHYSICAL ASSIST (FOR SUPPORT), IMPAIRED ON ONE SIDE (UPPER/LOWER EXTREMITY), FREQUENTLY INCONTINENT OF URINE, AND OCCASIONALLY INCONTINENT OF BOWEL. THE FACILITY'S ADL (ACTIVITIES OF DAILY LIVING) DIRECTIVES CARE PLAN (ONSET DATE 5/27/11) REFLECTED, "...ASSIST OF ONE WITH BED MOBILITY, TRANSFERS, AMBULATION WITH GAIT BELT, WHEELCHAIR LOCOMOTION, DRESSING, TOILETING, PERSONAL HYGIENE, AND SHOWERS..." ON 7/13/11 AT 9:30 AM, RESIDENT #12 REVEALED HE WAS TRAPPED IN HIS BATHROOM ABOUT ONE WEEK AGO. HE STATED HE HAD PULLED HIS CALL LIGHT AND NO ONE CAME, THAT HE COULD NOT OPEN THE DOOR, AND THAT HE TOLD HIS DAUGHTER AND THE NURSING STAFF ABOUT BEING LOCKED IN THE BATHROOM. AS HE RECALLED THE INCIDENT OF HIS ENTRAPMENT IN THE BATHROOM, RESIDENT #12 APPEARED UPSET. HE CLAIMED IN HIS REPORT TO HIS DAUGHTER THAT HE FELT LIKE HE WAS INSIDE THE BATHROOM FOR A LONG TIME. RESIDENT #12'S DAUGHTER WAS CALLED ON 7/14/11 AT 11:40 AM. THE DAUGHTER CONFIRMED HER FATHER TOLD HER HE WAS TRAPPED IN THE BATHROOM LAST WEEK, HE FELT TRAPPED SO LONG THAT HE HAD TO POUND ON THE DOOR. SHE STATED, SOMEONE HAD PUT HIM ON THE COMMODE AND LEFT HIM ON IT. HE GOT HIMSELF OFF THE COMMODE AND POUNDED ON THE DOOR, AND HIS ROOM MATE (RESIDENT # 23) HELPED HIM OUT WITH HIS POWER/ELECTRIC WHEELCHAIR. THE DAUGHTER STATED SHE REPORTED IT TO THE NURSE LAST FRIDAY. RESIDENT #23 WAS INTERVIEWED ON 7/14/11 AT 12:00 PM. THE RESIDENT REPLIED, "YES" AND THAT HE REMEMBERED RESIDENT #12 BEING LOCKED IN THE BATHROOM THE PREVIOUS WEEK AND HE LET HIM OUT. WHEN ASKED COULD RESIDENT #12 HAVE GOTTEN OUT OF THE BATHROOM WITHOUT ANY HELP, RESIDENT #23 REPLIED, "NO". THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 7/14/11 AT 12:08 PM AND WAS INFORMED OF THE CONVERSATIONS WITH RESIDENT #12, RESIDENT #12'S DAUGHTER AND RESIDENT #23. THE DON STATED THAT SHE DID NOT RECALL THE RESIDENT BEING LOCKED IN THE BATHROOM LAST WEEK AND THAT THE FAMILY MAY HAVE TALKED TO THE UNIT MANAGER AT THE TIME (WHO NO LONGER WORKED THERE). THE DON WAS ASKED FOR THE INCIDENT/ACCIDENT (I/A) REPORT RELATED TO RESIDENT #12 BEING LOCKED IN THE BATHROOM, WHICH WAS COMPLAINED BY BOTH THE RESIDENT AND HIS DAUGHTER. THE DON STATED THAT SHE DID NOT HAVE ANY I/A REPORTS FOR THE RESIDENT RELATED TO THE INCIDENT. LATER ON AT 4:25 PM, THE DON STATED THAT SHE HAD TALKED TO RESIDENT #12'S DAUGHTER AND THAT THE DON WAS THE TOLD THE SAME STORY AS THE DAUGHTER RECALLED TO THE SURVEYOR. THE DAUGHTER ADDED THAT SHE REPORTED THE INCIDENT TO THE STAFF, AND THAT SHE WAS IN THE PROCESS OF FOLLOWING THIS UP BY TALKING TO THE STAFF ABOUT IT. APPLYING THE PSYCHOSOCIAL OUTCOME GRID, RESIDENT #12 STILL FELT THE EFFECTS (UPSET) OF BEING TRAPPED IN THE BATHROOM, BEING HELPLESS THAT NO ONE RESPONDED TO HIS CLAIM WHEN HE PULLED THE CALL LIGHT AND WAS FORCED TO POUND THE DOOR BEFORE HIS ROOM MATE RESCUED HIM. ( )

This citation pertains to intake number MI 730. Based on observation, interview, and record review the facility failed to prevent the elopement and ensure the safety of 1 of 6 sampled residents (Resident #500), who was assessed to be a high risk for elopement from a total sample of 6 residents, resulting in an Immediate Jeopardy when Resident #500 cut off her WanderGuard bracelet (code alert alarm that activates if a resident exits through a door) and exited through the front door of the facility on 6/27/2011, at approximately 5:10 PM, without the knowledge of facility staff. Resident #500 was witnessed walking down center of a roadway by an un-sampled resident (Resident "A"). This deficient practice places 18 additional residents, identified as an elopement risks, at a high risk for serious injury, harm, and/or death. Findings include: A review of the facility face sheet and the "Minimum Data Set" (MDS), dated [DATE], revealed that Resident #500 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated that Resident #500 had no impairment with ambulation or mobility. A record review of a facility Competency form, dated 3/11/2011, revealed that Resident #500 was not competent to make health care decisions due to a [DIAGNOSES REDACTED]. Record reviews of the "Wandering and at Risk for Elopement Assessment", dated 2/3, 2/10, 2/17, 4/28, and 6/27/2011, revealed Resident #500 was at risk for elopement. A record review of a facility "Incident Report", dated 6/27/2011, revealed on 6/27/2011 at 5:10 PM Resident #500 exited the facility, was brought back in to the facility by staff, and placed on 1:1 observation. The "Incident Report" revealed that Resident #500 had cut off her WanderGuard alarm bracelet with an emery board. The "Incident Report" revealed that, after Resident #500 was placed on 1:1 observation, she still made attempts to leave the facility. Observation of the facility doors and door alarms was conducted on 7/1/2011 at 10:00 AM with Maintenance Director #11. All door alarms were in working order. The front door WanderGuard alarm (the door that Resident #500 exited) was found to be in working order. The front door was equipped with a second (main) alarm which was not activated until after visiting hours. The main door alarm was activated from 10:00 PM to 6:00 AM daily. Observations of the front door revealed that no alarm would sound between the hours of 6:00 AM and 10:00 PM if anyone walked through the door, unless there was a WanderGuard bracelet on that person. This surveyor observed visitors, staff, and eligible residents coming and going through the facility front door. Accounts Payable Staff Member #12 was interviewed on 7/1/2011 at 10:00 AM. Accounts Payable #12 stated that she sat at the lobby window Monday through Friday until 5:00 PM. Accounts Payable Staff Member #12 said that she did not see Resident #500 exit the facility on 6/27/2011. Observation of the window where Accounts Payable Staff Member #12 sat revealed a direct view of anyone who would go through the facility front door. Record review of a "Care Plan" (untitled), dated 2/9/2011, revealed that resident #500 demonstrated cognitive loss as evidenced by impaired decision making skills and short term memory loss. A "Care Plan" (untitled) related to Depressive Disorder, dated 2/9/2011, revealed Resident #500 had a history of [REDACTED]. The approach included Resident #500 to have 1:1 observation as needed. Record review of the physician "Progress Note", dated 6/23/2011, revealed Resident #500 had been agitated for approximately one week and the physician was asked to evaluate Resident #500 due to Resident #500's agitation. The physician's note revealed Resident #500 had been pacing the halls wanting to leave the facility and had made many phone calls to family members. The physician's note revealed that Resident #500 called 911 (emergency response) on 6/19/2011, because she wanted to leave the facility. Record review of a "Psychiatric Review", dated 6/13/2011, revealed that Resident #500 had been upset, "wanted to leave the facility and called 911". The "Psychiatric Review" revealed Resident #500 would get upset at times over her current placement and often wanted to move and live somewhere else. A second "Psychiatric Review", dated 6/20/2011, revealed Resident #500 had been agitated, pacing, and had made over 50 phone calls in the morning. A third "Psychiatric Review", dated 6/27/2011, (the day of Resident #500's elopement) revealed Resident #500 had been anxious and agitated and that Resident #500's anxiety and agitation had been worse, and she was "very, very edgy". Review of the "Nurses' Notes", dated 6/18/2011- 6/23/2011, revealed Resident #500 was repeatedly very upset, remained agitated, restless, anxious, and slightly paranoid, and was not able to be re-directed most of the time. There was no documentation that Resident #500 received increased supervision. Review of the "Nurses' Notes", dated 6/25/2011 at 4:00 PM, revealed that Resident #500 requested to "go to a friend's house or her son's house". The "Nurses' Notes" indicated Resident #500 was reminded that she could not go out of the facility unless signed out by a family member. There was no documentation that Resident #500 received increased supervision. Review of the "Nurses' Notes", dated 6/27/2011 beginning at 6:00 AM, revealed Resident #500 had used the phone multiple times, was anxious and was pacing the hallways. The "Nurses' Notes" revealed that the Psychiatrist was notified and medication changes were ordered, but there was no documentation of increased supervision. The "Nurses' Notes" revealed that, on 6/27/2011 at approximately 5:10 PM, Resident #500 exited the facility after cutting off her WanderGuard bracelet. Resident #500 was assisted back to the facility by staff members and was placed on 1:1 supervision. Psychiatrist #1 was interviewed on 7/1/2011 at 10:45 AM. Psychiatrist #1 stated Resident #500 had directly stated that she was leaving and going somewhere else. Psychiatrist #1 said that Resident #500 would wander a lot, become agitated, and would use the facility phone up to 50 times a day. Psychiatrist #1 said that Resident #500, on the day of her elopement, was calling a neighbor. Psychiatrist #1 said that Resident #500 had many attempts to leave the facility. Psychiatrist #1 said that Resident #500 knew the WanderGuard bracelet would sound the alarm at the door. Psychiatrist #1 said on 6/27/11, Resident #500 had told him that she was leaving the facility that night. Psychiatrist #1 said that he tried to talk her out of it and made medication changes for Resident #500, but Psychiatrist #1 said that she "did it (eloped) all right". Psychiatrist #1 said that the nursing staff was aware that Resident #500 was planning on leaving that night (6/27/2011). In an interview on 7/1/2011 at 2:30 PM, an un-sampled resident (Resident "A") said that he was sitting in the lobby area of the facility on 6/27/2011 directly facing the front door. Resident "A" said that the WanderGuard alarms on the facility doors would sound falsely at times. Resident "A" stated staff were aware of this and that the staff's response time to the door alarms decreased. Resident "A" stated when Resident #500 exited the front door no alarms sounded and he saw Resident #500 go out the front door. Resident "A" said that he thought it was strange so he went into the dining room, looked out the window, and saw Resident #500 walking down the middle of the road on the yellow line. Resident "A" stated he saw Resident #500 walk to the other side of the street and that was when he went and told Licensed Practical Nurse (LPN) #6. Resident "A" said approximately 3 to 4 minutes had passed since Resident #500 had exited the building. In an interview on 7/5/2011 at 11:40 AM, LPN #6 (Resident #500's primary nurse) stated Resident #500 used the phone several times a day. LPN #6 said that she had seen Resident #500 on 6/27/11 at 5:05 PM but did not notice whether Resident #500's WanderGuard was on. LPN #6 said that Resident #500 had been agitated and wandering the facility. LPN #6 said Certified Nurse Aide (CNA) #5 had come out of the break room and told her Resident #500 was walking outside. LPN #6 said that at the same time Resident "A" also approached her and told her that Resident #500 was outside. LPN #6 said CNA #5 then ran out to get Resident #500 and that CNA #5 caught up to Resident #500 at the end of the sidewalk. LPN #6 stated she did not increase supervision of Resident #500 on the day of her elopement until the elopement had occurred at which time Resident #500 was placed on 1:1 observation. In an interview on 7/5/2011 at 2:10 PM, CNA #5 (Resident #500's primary CNA) stated he was on lunch break sitting in the break room when he saw Resident #500 walking on the other side of the road. CNA #5 said that he got up and ran out the front door to get Resident #500, but when he got outside Resident #500 was approximately 10 feet around the corner of the sidewalk. CNA #5 said that he thought he remembered LPN #6 telling him to be on the look out for Resident #500 and to watch if Resident #500 left the facility. CNA #5 said that he was never told that Resident #500 was to be on 1:1 supervision. CNA #5 stated the CNA's from the previous shift had mentioned to him to watch Resident #500 in case Resident #500 tried to leave the facility. In an interview on 7/1/2011 at 11:14 AM, CNA #2 said that between 2:00 PM and 3:30 PM Resident #500 had her WanderGuard alarm in place because Resident #500 had set off the door alarm that led to the service area of the facility. CNA #2 said that Resident #500 had wandered around the facility a lot on 6/27/11 and that Resident #500 seemed very worried and "worked up". CNA #2 said that when Resident #500 was found outside, she was carrying a laundry bag, a shirt, and a pair of pants. CNA #2 stated asked Resident #500 where her WanderGuard bracelet was and Resident #500 told her that she had cut it off with an emery board. CNA #2 said that, prior to Resident #500's elopement; Resident #500 was not placed on increased supervision. CNA #2 said (Resident "A") had told her Resident #500 was outside. CNA #2 said that when she got outside Resident #500 was at the end of the sidewalk getting ready to turn the corner. Resident #500 was interviewed on 7/1/2011 at 1:30 PM and said that she had gone for a walk on 6/27/11 and was not going anywhere in particular. Resident #500 reported she had cut her WanderGuard bracelet off with an emery board. In an interview on 7/1/2011 at 10:34 AM, Social Worker (SW) #3 reported being at the facility at the time of Resident #500's elopement on 6/27/11. SW #3 said that she asked Resident #500 where she was going and Resident #500 stated she was "headed to a friend's house" about 8 blocks away. SW #3 reported Resident #500 had a pair of pants and a shirt on a hanger with her when Resident #500 was found outside, along with a mesh laundry bag. SW #3 said she asked Resident #500 where her WanderGuard bracelet was and Resident #500 told her that she had cut it off with a pair of scissors and threw it in the garbage. SW #3 reported that it was not uncommon for Resident #500 to go into her (SW#3) office and state she wanted to leave and go live with her son. On 7/1/2011 at 11:14 AM, accompanied by CNA #2, this surveyor observed the environment and route that Resident #500 took when she eloped on 6/27/2011 at 5:10 PM. The front door of the facility faced the road that Resident #500 walked down. The road was a residential road with a speed limit of 25 mph. Several businesses were observed across the street and many cars were noted to access the road from the businesses and the facility. Observation of the route revealed that Resident #500 had walked approximately one half of a block away from the facility and had been heading towards a main busy road which had a posted 45 mph speed limit. On 7/6/2011 the Administrator was notified of the Immediate Jeopardy that began on 6/27/2011 when Resident #500, who was assessed to be at risk for elopement and had exhibited elopement intentions prior to exiting the facility, exited the facility on 6/27/2011, without the knowledge of facility staff. Resident #500 removed her WanderGuard bracelet, and was observed walking down the middle of a roadway, approximately one half of a block away from the facility. This deficient practice places 18 additional residents, identified as elopement risks at a high risk for serious harm, injury, and/or death. On 7/6/2011 the surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1). On 6/27/2011 a new WanderGuard bracelet was placed on Resident #500. 2). On 6/27/2011, Resident #500 was placed on 1 on 1 observation. 3). On 6/27/2011 the physician was contacted and ordered medication changes for Resident #500. 4). On 6/27/2011 all 18 residents, who were assessed to be elopement risks, were audited for WanderGuard bracelet placement and functionality. 5). On 7/1/2011 a one-on-one monitor was placed at the facility's front door to monitor who comes in and goes out of the facility and will remain in place until a new alarm system is approved by the Fire Marshall. 6). On 7/1/2011 Resident #500 was transferred to the hospital for psychiatric treatment. 7). Beginning 7/5/2011 an in-service was conducted for all staff on the facility elopement and wandering policy and procedures to include signs to identify if a resident was making plans for elopement. All staff, who had not received the in-service, due to vacations, medical leaves etc., will not be allowed to work until they have received the in-service. 8). On 7/5/2011 all 90 residents in the facility were assessed for wandering and/or elopement risk. Although the Immediate Jeopardy was removed on 7/5/2011 the facility remained out of compliance at scope of isolated and a severity of no actual harm, but potential for more than minimal harm, that is not Immediate Jeopardy because all staff had not received the in-service and sustained compliance had not been verified by the State agency. ( )