Every finding on record at Medilodge of Clare

Based on interview and record review, the facility failed to ensure professional standards of practice were followed regarding 1) administration of blood pressure medication with parameters and 2) treatment of hypoglycemic episodes for 2 residents (R6 and R85) of 7 residents reviewed. Findings include: Resident #6 (R6) Review of a Face Sheet revealed R6 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and congestive heart failure. Review of R6's active Physician's Orders on 4/13/2026 revealed midodrine HCI tablet 2.5 mg (a medication that increases blood pressure), started 3/19/2026, give 1 tablet by mouth every 8 hours as needed for hypotension (low blood pressure) give if SBP (systolic blood pressure, the top number in the reading that measures the maximum pressure in your arteries when your heart beats) is less than 100 mmHg (millimeters of mercury). Further review of the Electronic Medical Record (EMR) revealed that R6's blood pressure had not been checked three times a day from 3/19/2026 to 4/13/2026. During this time frame R6's blood pressures were checked sporadically, sometimes once a day, sometimes twice a day, and other times it was not checked. Review of R6's Medication Administration Record (MAR) from 3/19/2026 to 4/13/2026 revealed midodrine was given only once in this timeframe, on 4/8/2026 at 7:22 PM. Review of R6's blood pressure readings between 3/19/2026 and 4/13/2026 revealed the following SBP readings below 100 mmHg with no documentation midodrine was administered-3/25/2026- 98/543/27/2026- 98/563/28/2026- 94/593/29/2026- 99/613/29/2026- 92/584/7/2026- 98/54 In an interview on 4/13/2026 at 3:33 PM, Licensed Practical Nurse (LPN) Unit Manager A reviewed R6's midodrine order and blood pressure readings and reported the order had been entered incorrectly. LPN Unit Manager A reported the report should have been written for the medication to be given 3 times a day unless the SBP was above 100 and corresponding blood pressure readings should have been ordered. LPN Unit Manager A reported it appeared R6 had missed doses of midodrine. Resident #85 (R85) Review of an Face Sheet revealed R85 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure, atherosclerotic heart disease (plaque buildup within artery walls), and type II diabetes. Review of R85's After Visit Summary revealed hospital discharge orders on 4/6/26 which included midodrine (a medication that increases blood pressure) 5 milligrams (mg), take 2 tablets 3 times a day as needed and hold if systolic (the top number in the reading, measuring the maximum pressure in your arteries when your heart beats) blood pressure is greater than 100 mmHG (millimeters of mercury). Review of R85's Order Summary on 4/13/26 at 10:00 AM revealed the parameter (limit or boundary) for midodrine to hold medication if systolic blood pressure was greater than 100 mmHG was missing. In an interview on 4/14/2026 at 10:00 AM the Director of Nursing (DON) reviewed the midodrine order and confirmed the parameters recommended by the hospital should have been within the order. Review of facility policy/procedure Medication Administration, revised 1/17/2023, revealed staff were directed to obtain and record vital signs, when applicable or per physician's orders. Review of R85's Progress Note dated 4/10/26 at 12:05 PM revealed R85's blood glucose (main sugar found in the blood stream) was 39 mg/dl (milligram per deciliter) (normal range 70-100 mm/dl) and reflected R85 was given an 8-ounce orange juice and had been eating her lunch. Further review indicated R85's blood sugar would be rechecked after lunch. Review of R85's Order Summary Report revealed an active order If blood sugar less than (60) administer OJ, Food or glucose gel per manufacturer recommendation. Recheck in 15 minutes if no improvement notify MD as needed. Review R85's Electronic Medical Record (EMR) on 4/14/26 revealed her blood sugar on 4/10/26 at 5:11 PM was 74 mg/dl. The EMR did not reveal any further documentation. In an interview on 4/14/2026 at 10:07 AM Licensed Practical Nurse (LPN) L reported that a follow up blood sugar was obtained for R85 but not documented. LPN L reported she forgot to chart it. LPN L reported the primary physician was not notified of R85's blood sugar result of 39 mm/dl at 12:05 PM. LPN L reported that a blood sugar should have been obtained within 15 minutes from the first one with physician notification as indicated. In an interview on 4/14/26 at 10:10 AM the DON reported R85's blood sugar should have been rechecked as the physician order stated within 15 minutes and the nurse should have notified the physician if indicated. Review of facility policy/procedure Hypoglycemic Management, no revision date, revealed if the blood glucose reading is 70 mg/dl or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucoses as indicated, and notify the practitioner of the results as ordered.

This citation pertains to intake #2978434.Based on interview and record review, the facility failed to report an allegation of abuse to the state agency within 2 hours for 2 residents (R9 and R25) of 3 residents reviewed for abuse.Findings include:Review of a Face Sheet revealed R9 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety.Review of a Face Sheet revealed R25 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety.Review of the facility reported incident (MI-FRI #63868) revealed R25 struck R9's left arm with the back of his open hand on 3/11/2026 at 10:20 AM. Further review revealed this incident was reported to the state agency on 3/11/2026 at 1:52 PM.In an interview on 4/14/2026 at 10:15 AM, the NHA reported this allegation of abuse was not reported to the state agency within 2 hours because the day was very busy working through the incident.Review of facility policy/procedure Abuse Prevention Program, revised 2/22/2018, revealed .When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility. will immediately. no later than 2 hours if the event is an allegation of abuse. notify the following persons or agencies of such incident. the State licensing/certification agency responsible for surveying/licensing the facility.

Based on interview and record review, the facility failed to ensure timely follow up for the monthly drug regimen review recommendations for 1 resident (R46) of 5 residents reviewed for unnecessary medication.Findings include:Review of an Face Sheet revealed R46 admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease, chronic kidney disease, and dementia. Review of R46's Pharmacist Monthly Medication Review dated 1/5/26 revealed a recommendation to evaluate the risks versus benefits and consider a gradual dose reduction to primidone (used to treat seizures), 50 milligrams (mg) give 0.5 tablet every day for 1 week, then discontinue. Physician response noted on 1/6/26 for hospice to evaluate the recommendation. Review of R46's Order Summary on 4/15/26 revealed an active order for primidone 50 mg to give 0.5 tablet by mouth twice daily. In an interview on 04/15/2026 at 9:48 AM, the Director of Nursing (DON) stated that he was unable to confirm that hospice had been notified to evaluate the recommendation dated 1/5/26 and the recommendation had not been evaluated.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for residents. Findings include:On 04/13/2026 at 10:47AM, observed a trash can sitting under a leaking pipe in the basement area. The trash can was serving as a container and was overflowing with water; the overflow was running down the hallway towards a drain in the floor. When observation was pointed out to Certified Dietary Manager (CDM) R, CDM R stated that the maintenance department is aware of the leak, as they had told CDM R that the leak was coming from the ice machine drain line. On 04/13/2026 at 2:30PM observed that the water in the trash can, under the leaking pipe in the basement area, continued to overflow onto the floor. Maintenance Director (MD) H when asked who is responsible for emptying the water from the container, MD H responded that the maintenance department is responsible for emptying the water out. MD H proceeded to explain that the leak is coming from the metal pipe, which needs to be replaced to repair the leak. On 04/13/2026 at 2:31PM observed water dripping off the metal beam next to the pipe that is leaking. MD H stated the water is coming from the leaking pipe and running along the block ceiling and coming out at that point on the metal beam. MD H also stated repairs are on order to repair the leak to include partial removal of the block wall and ceiling to be able to access, remove and replace the piping and there is a needed tool on order to remove the block and cement wall and ceiling.On 04/14/2026 at 9:36AM, observed a green mold-like substance on the face of the mini-split (air conditioning) unit in the McKeevers dining room. Mini-split unit was not in use at time of observation. On 04/14/2026 at 10:01AM, interviewed Housekeeping Manager (HM) S, regarding who is responsible for cleaning the mini-split unit; HM S stated it is the responsibility of the maintenance department because they would have to physically remove the front of the unit to clean it. On 04/14/2026 at 12:53PM, interviewed MD H regarding procedures to bring the mini-split units back in use, MD H stated the maintenance crew removes the front of the unit, uses a foaming cleaner to clean the unit prior to turning on the mini-split units. On 04/14/2026 at 12:54PM, during interview with MD H, MD H was asked for a timeline for the repair of the leak in the basement. MD H stated there currently isn't a timeline for repair because they are waiting for the tool, needed for the removal of the ceiling and wall, before starting repair of the leak.

Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided according to professional standards of practice for 1 resident (R104) of 5 residents reviewed for incontinence care. Findings include: Review of an Admission Record revealed R104 admitted to the facility on [DATE] with pertinent diagnoses which included altered mental status, urinary tract infection, and muscle weakness. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R104, with a reference date of 2/17/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13, out of a total possible score of 15, which indicated R104 was cognitively intact. Further review of same MDS assessment revealed R104 required assistance with toileting and was incontinent of urine. Review of a current incontinence Care Plan intervention for R104, initiated 2/11/2025, directed staff to apply barrier cream after incontinence care. In an observation on 3/26/2025 at 10:25 AM in R104's room, Certified Nursing Assistant (CNA) G cleaned feces from R104's buttocks and anus and then cleaned R104's vaginal area without changing gloves or performing hand hygiene in between. CNA G did not apply barrier cream to R104 after incontinence care was complete. In an interview on 3/26/2025 at 10:47 AM, CNA G reported she was not aware that she should perform hand hygiene and switch gloves in between going from cleaning feces to cleaning the vaginal area. CNA G reported she was not taught this during her CNA certification or at the facility. CNA G reported she forgot to apply barrier cream to R104 after incontinence care. In an interview on 3/26/2025 at 10:55 AM, Unit Manager I reported staff were expected to change gloves and perform hand hygiene when going from a dirty area to a clean area during incontinence care. Review of facility policy/procedure Hand Hygiene, revised 12/13/2023, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . The use of gloves does not replace hand hygiene . Further review of the Hand Hygiene Table revealed staff were instructed to perform hand hygiene when, during resident care, moving from a contaminated body site to a clean body site.

Based on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all residents residing in the facility. Findings include: Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 4 2024 (July 1 - September 30)revealed the metric Excessively Low Weekend Staffing Triggered In an interview on 2/05/25 at 10:28 AM., Registered Nurse/Staff Scheduler (RN/SS) E reported there was a possibility that the Excessively Low Weekend Staffing had Triggered on the PBJ report from CMS because nurses who are salaried position often work the floor and do not punch in on a time clock. RN /SS E reported as for Certified Nurse Aides (CNA's) this could also be true, because the Activity Director (AD) and the facility Transportation staff do not punch in either to her knowledge. RN /SS E reported both of those staff members work the units as CNAs when the facility runs short. RN /SS E reported she was a salaried staff but often will pick up and work the units performing nursing duties. RN /SS E reported there was also a Glitch in their time clock systems a few months back when the facility changed their payroll/timekeeping system. In an interview on 2/6/25 at 2:00 PM., Nursing Home Administrator NHA reported they had some issues with their PBJ reporting and the timekeeping system which had changed over, and this may be the reason the facility triggered for Excessively Low Weekend Staffing.

This citation pertains to intake #: MI00140715 Based on observation, interview, and record review, the facility failed to accommodate the needs of 2 residents in a timely manner (Resident #178 and Resident #227) out of 3 residents reviewed for accommodation of needs, resulting in delays in care provided to residents. Findings: Review of a Face Sheet revealed R178 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of pneumonia, diabetes mellitus type 2, history of falls, morbid obesity, and need for assistance with personal care. R178 was her own decision maker and cognitively intact. During an observation on 01/08/24 at 12:15 PM, R178's call light was on, staff entered the room at 12:20 PM, and the call light was turned off. Staff exited the resident's room. During an observation on 01/08/24 at 1:09 PM, R178's call light was activated. During the same time, R178 stated that the call light was activated an hour ago, staff came in and turned off the light, and told R178 that staff would be in shortly to assist getting her brief changed. Staff had not yet returned to assist her so R178 activated the call light again. I need to be changed, it's been an hour. During an observation on 01/08/24 at 1:13 PM, staff entered R178's room and the call light was turned off. Staff exited the room. Two aides returned at 1:17 PM to assist resident with a brief change. During an interview on 01/09/24 at 10:18 AM, the Administrator indicated that the expectation for answering call lights was that they were left on until the resident's needs were met. Review of the facility policy Call Lights: Accessibility and Timely Response reflected: Any staff member who sees or hears an activated call light is responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The policy does not direct staff to leave the call light on until the resident's needs are met. 39056 Resident #227 (R227) Review of an Admission Record revealed R227 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: aftercare following explanation of knee joint prosthesis (knee replacement). Review of a Minimum Data Set (MDS) assessment for R227, with a reference date of 11/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R227 was cognitively intact. During an interview on 01/09/24 at 10:26 AM, R227 reported that while she was a resident at the facility, she required ice for her knee following a knee replacement. R227 stated, They (facility staff) would come in and shut off the call light and then 2-3 hours later they'd come back with my bag of ice for my knee. Review of R227's Quality Assistance Form dated 10/26/23 revealed, .CNA (Certified Nursing Assistant) never came back after saying she would be back .Plan/Actions: Call light audits being initiated to assure there is not an unknown concern of call lights not being answered timely. Message to nursing staff to assure if they tell a resident they will be back that they do come back to address any needs, and to not turn off call light until needs are met . Review of the Resident Council Meeting Minutes revealed: Date of Meeting: 7/3/23 .New Business Review/Action Plan .Call light wait times long .Outcome-Not Resolved-Action Needed . Date of Meeting: 9/5/23 .New Business Review/Action Plan .Call light wait times too long on all shifts . Date of Meeting: 1/2/24 .New Business Review/Action Plan .Call lights not being placed within reach .Outcome-Resolved-Still Monitoring .

Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 2 of 8 residents (Resident #4 and #33), reviewed for the provision of nursing services, resulting in blood pressures not being assessed prior to medication administration and medications administered outside of the physician ordered parameters, and the potential for an unsafe elevation of blood pressure and the worsening of a medical condition. Findings: Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: orthostatic hypotension (low blood pressure that happens when you stand up from sitting or lying down). Review of R4's Physician Order dated 9/15/23 revealed, Midodrine HCl Tablet 2.5 MG Give 1 tablet by mouth three times a day for vasopressor (constrict blood vessels) hold if systolic blood pressure (top number) is greater than 120. Midodrine is a medication to treat low blood pressure. Review of the Medication Regimen Review dated 10/2/23 and signed by facility provider on 10/3/23 revealed, Midodrine 2.5 mg TID (three times a day) hold if SBP (Systolic Blood Pressure/top number) is greater than 120. A review of the MAR (Medication Administration Record) shows a few doses administered outside parameters. Review of R4's December 2023 Medication Administration Record revealed the following: On 12/1/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 121/65. On 12/3/23 R4's 10:00 PM dose of midodrine was administered following a blood pressure of 130/66. On 12/4/23 R4's 6:00 PM dose of midodrine was administered following a blood pressure of 130/85. On 12/5/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 121/80. On 12/13/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 123/78. On 12/15/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 136/70. On 12/17/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 127/62. On 12/19/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 154/90. On 12/22/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 138/83. On 12/23/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 126/75. On 12/24/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 133/88. On 12/25/23 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 138/76. On 12/25/23 R4's 6:00 PM dose of midodrine was administered following a blood pressure of 129/63. On 12/26/23 R4's 6:00 PM dose of midodrine was administered following a blood pressure of 134/90. On 12/27/23 R4's 6:00 PM dose of midodrine was administered following a blood pressure of 142/79 Review of R4's January 2024 Medication Administration Record revealed the following: On 1/2/24 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 123/70. On 1/3/24 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 152/83. On 1/4/24 R4's 10:00 PM dose of midodrine was administered following a blood pressure of 130/68. On 1/5/24 R4's 10:00 PM dose of midodrine was administered following a blood pressure of 147/79. On 1/6/24 R4's 11:00 AM dose of midodrine was administered following a blood pressure of 122/67. On 1/8/24 R4's 6:00 PM dose of midodrine was administered following a blood pressure of 136/74. Resident #31 (R31) Review of an Admission Record revealed R31 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: orthostatic hypotension. Review of R31's Physician Order dated 12/1/23-12/28/23 revealed, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for bp (blood pressure) hold if systolic blood pressure is greater than 120. Review of R31's December 2023 Medication Administration Record revealed the following: On 12/2/23 R31's 8:00 PM dose of midodrine was administered following a blood pressure of 124/86. On 12/8/23 R31's 7:00 AM dose of midodrine was administered following a blood pressure of 123/59. On 12/8/23 R31's 11:00 AM dose of midodrine was administered following a blood pressure of 123/59. On 12/9/23 R31's 7:00 AM dose of midodrine was administered following a blood pressure of 149/85. On 12/9/23 R31's 11:00 AM dose of midodrine was administered following a blood pressure of 149/85. On 12/10/23 R31's 7:00 AM dose of midodrine was administered following a blood pressure of 147/75. On 12/10/23 R31's 11:00 AM dose of midodrine was administered following a blood pressure of 147/75. Confirmed using R31's Blood Pressure Summary that R31's blood pressure was not assessed prior to the midodrine administration at 11:00 AM on 12/8/23, 12/9/23, and 12/10/23. Review of R31's Physician Order dated 12/28/23-1/4/24 revealed, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for bp hold if systolic blood pressure is greater than 110. Review of R31's January 2024 Medication Administration Record revealed the following: On 1/1/24 R31's 8:00 PM dose of midodrine was administered following a blood pressure of 114/61. On 1/2/24 R31's 7:00 AM dose of midodrine was administered following a blood pressure of 156/79. On 1/2/24 R31's 11:00 AM dose of midodrine was administered following a blood pressure of 156/79. On 1/2/24 R31's 8:00 PM dose of midodrine was administered following a blood pressure of 121/65. On 1/3/24 R31's 7:00 AM dose of midodrine was administered following a blood pressure of 116/66. On 1/3/24 R31's 11:00 AM dose of midodrine was administered following a blood pressure of 116/66. On 1/3/24 R31's 8:00 PM dose of midodrine was administered following a blood pressure of 127/68. Confirmed using R31's Blood Pressure Summary that R31's blood pressure was not assessed prior to the midodrine administration at 11:00 AM on 1/2/24 and 1/3/24. During an interview on 1/10/24 at 9:11 AM, Licensed Practical Nurse (LPN) D reported that medications with ordered parameters should be administered within the prescribed parameters. LPN D reported that medications with ordered parameters should be held if outside given parameters and a physician notified unless otherwise stated. If a medication should have parameters and does not, the physician should be contacted for clarification of the order. During an interview on 01/10/2024 at 10:26 AM, Unit Manager (UM) F reported that the pharmacist reviewed the resident's physician orders monthly (Monthly Medication Review) and provided recommendations for follow-up related to the ordered medications such as laboratory testing, dose reductions, discontinuations, irregularities, and identified concerns. UM F reported that if the pharmacist identified a concern during the Monthly Medication Review (MRR) a report would be sent to the Director of Nursing (DON). The DON would then send the report to the provider for review at which point the provider would make order changes and or new orders. UM F reported that during the morning interdisciplinary team meetings the MRR's with recommendations and/or concerns were discussed, and the clinical nurse team/unit managers would then follow-up and implement order changes if required. UM F did not recall an identified concern of medications administered outside of ordered parameters. During an interview on 01/10/24 at 09:45 AM, Nursing Home Administrator (NHA) reported that she was not aware that there had been a concern with failing to follow physician ordered parameters as identified by the consultant pharmacist. Review of the facility policy Medication Administration dated 1/1/22 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines .8. Obtain and record vital signs, when applicable or per physician orders. when applicable, hold medication for those vital signs outside the physician's prescribed parameters . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Use vital sign measurements to determine indications for medication administration. For example, give certain cardiac drugs only within a range of pulse or BP (blood pressure) values .Know the acceptable vital sign ranges for your patients before administering medications . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 467-468). Elsevier Health Sciences. Kindle Edition.

This citation pertains to intake #: MI00135530 Based on interview and record review, the facility failed to 1.) ensure licensed nurses were competent in the provision of care for a diagnosis of [NAME] Syndrome, 2.) identify a change in condition, 3.) perform a comprehensive assessment following a change in condition, and 4.) ensure complete and accurate documentation for 1 resident (Resident #102) reviewed for quality of care, resulting in a delay in medical treatment and R102's subsequent death. Findings: Resident #102 (R102) Review of an Admission Record revealed R102 was a [AGE] year-old male, originally admitted to the facility on [DATE] and readmitted on [DATE], with pertinent diagnoses which included: [NAME] Syndrome. R102 was listed as a Full Code Status (all medical interventions including cardiopulmonary resuscitation to be provided in the event of a medical emergency). Review of a Minimum Data Set (MDS) assessment for R102, with a reference date of 2/14/23 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R102 was severely cognitively impaired. Review of the Functional Status revealed that R102 required extensive 2 person assist for bed mobility, dressing, toileting, and personal hygiene, and total dependence of 2 persons for transferring. [NAME] Syndrome wwww.pwsausa.org Review of the [NAME]-[NAME] Syndrome Association/USA booklet titled [NAME]-[NAME] Syndrome Medical Alerts last revised 2022 revealed, This booklet was developed to alert medical practitioners in emergency departments, urgent care facilities and primary care practices to severe medical complications that can develop rapidly in individuals with [NAME]-[NAME] syndrome (PWS). The booklet highlights medical issues that occur in some patients with PWS and hopefully assists in the recognition and management of problems that are uncommon in the general population but do occur with increased frequency among individuals with PWS. These findings may present at various ages and result in serious, sometimes urgent or even fatal outcomes. Common problems during hospitalization and medical procedures are also discussed. The booklet also serves to alert families and other caregivers to potential PWS complications requiring specific management. Emergency and Acute Medical Issues .Severe Gastrointestinal Concerns: Vomiting - Decreased ability to vomit. Vomiting occurs infrequently in many people with PWS. Emetics may be ineffective, and repeated doses may cause toxicity. This characteristic is of particular concern in light of hyperphagia and the possible ingestion of uncooked, spoiled, or otherwise unhealthful food items. The presence of new onset vomiting or vomiting accompanied by loss of appetite or lethargy may signal a life-threatening illness and may warrant immediate treatment. (See below and pages 24-25 as well as foldout on the last page of this booklet for more information on this topic.) Severe Gastric Illness: Gastric problems are very common in PWS due to decreased motility and gastroparesis. Abdominal distension or bloating, pain and/or vomiting may be signs of life-threatening gastric dilation, inflammation or necrosis. Rather than localized pain, there may be a general or vague feeling of being unwell. Anti-diarrheal medications may also cause severe colonic distension, necrosis and rupture and should be avoided. Any individual with PWS with these symptoms needs immediate medical attention. An X-ray, CT scan or ultrasound can help with the diagnosis and confirm if there is gastric necrosis and/or perforation. If distension is noted, these individuals need close clinical monitoring on an ongoing basis, to be made NPO, and may need decompression with an NG tube. Gastric necrosis or perforation is a medical emergency requiring exploratory laparotomy or emergent surgery. Individuals with PWS may not have tenderness, rigidity or rebound normally associated with an acute abdomen. Please see additional information on Gastric Necrosis on pages 24-25 of this booklet and see an algorithm for evaluation of GI complaints in people with PWS at the end of this booklet . Pain Tolerance A high threshold for sensing pain is common and may mask the presence of infection or injury. Someone with PWS may not complain of pain until infection is severe or may have difficulty localizing pain. Parent/caregiver reports of subtle changes in condition or behavior should be investigated for medical cause. Any complaint of pain by a person with PWS should be taken seriously . Temperature Abnormalities . fever may be absent despite serious infection . Hyperphagia and Food Seeking Individuals with PWS have a nearly constant drive to eat and must be continuously supervised in all settings to prevent access to excess food .There are currently no treatments for this constant urge to eat. Insatiable appetite may lead to life-threatening weight gain, which can be very rapid and occur even on a low-calorie diet. III. Evaluation and Treatment of Special Issues-Risk of Stomach Necrosis and Rupture A Cause of Death from Sepsis, Gastric Necrosis or Blood Loss Signs and symptoms of stomach necrosis and rupture: *Vomiting-Atypical vomiting accompanied by decrease in appetite or lethargy is unusual in PWS *Loss of appetite (ominous sign) *Lethargy *Complaints of pain, usually non-specific. Pain sensation appears to be abnormal in PWS due to high pain threshold; affected people rarely complain of pain *Pain is often poorly localized *Peritoneal signs may be absent *Abdominal/stomach bloating and gastric dilation *Fever may or may not be present *Guaiac positive stools (chronic gastritis) . https://www.pwsausa.org/wp-content/uploads/2022/04/MedicalAlertsBooklet-GIChart-2022.pdf Review of R102's Care Plans revealed no specific Care Plan for [NAME] Syndrome with interventions and/or observations to assists in the recognition and management of potential medical complications and/or problems. Review of the Facility Assessment last updated 09/2022 revealed, .Decisions regarding caring for residents with conditions not listed above-1.3 A referral packet is received and reviewed by facility staff from the hospital or referring agency to ensure we can meet the needs of the resident before admission to the facility. If additional training is needed it will be completed prior to admitting the resident to ensure we are able to accommodate their needs. If we are unable to meet the needs of the resident, then we will not proceed with admission to the facility . Review of R102's admission documentation revealed the facility received a fax from the local hospital on 2/7/23 with pertinent information regarding R102. The Inquiry-Admission Worksheet included the following information: R102 was a full code and required skilled nursing care. R102 had a history of anemia, anxiety, arthritis, cataracts, kidney disease, (unknown abbreviation), [NAME]-[NAME] Syndrome, sleep apnea, and seizure. Confirming the facility was aware of the diagnosis of PWS prior to admission. Review of R102's Nursing Evaluation Summary dated 2/8/23 revealed, .Active bowel sounds x4 (in 4 quadrants of the abdomen). Abd (abdomen) distended and edema to left leg and bil (bilateral) hands with contractions in hands that guardian states is his baseline .Res. (resident) is a pureed diet with nect (nectar) thick liquids and no straws. Pain is a 2 at this time (no location or type of pain identified) . Confirming R102 had active bowel sounds at the time of admission and nausea and/or vomiting was not identified as a baseline symptom. There were no other Progress Notes regarding R102's abdominal distention. Review of R102's Provider Progress Note dated 2/9/23 revealed R102 had a normal abdominal assessment with no documentation that R102 experienced nausea or vomiting and did not have abdominal distention. Review of R102's Provider Progress Note dated 2/14/23 revealed, patient is seen today to review plan of care .Patient is here for therapy purposes . Patient has a history of [NAME]-[NAME] syndrome . GASTROINTESTINAL: Negative for abdominal pain, nausea, vomiting, diarrhea + constipation . ABDOMEN: Soft & non-tender. BS (bowel sounds) active x 4. No pain with palpation . There was no documentation of chronic abdominal distention and a history of nausea and/or vomiting. Review of R102's Provider Progress Note dated 2/21/23 revealed, patient is seen for a follow-up visit .Patient had an orthopedic consult February 18 .REVIEW OF SYSTEMS . GASTROINTESTINAL: Negative for abdominal pain, nausea, vomiting, diarrhea + constipation . GENERAL: patient is in his bed in his room he is alert he does not appear to be in any acute distress . ABDOMEN: Soft & non-tender. BS (bowel sounds) active x 4. No pain with palpation . EXTREMITIES: No peripheral edema. Pulses are equally palpable x4 . There was no documentation of chronic abdominal distention and a history of nausea and/or vomiting. R102 was not seen by a provider again prior to his transfer to the hospital on 3/16/23. Review of R102's RAI (Resident Assessment Instrument) Progress Note dated 2/20/23 revealed, (R102) admitted for skilled services d/t (due to) having a fracture of the distal end of his left femur (with no known trauma), pneumonia, encephalopathy, anemia, [NAME]-[NAME] syndrome, seizure disorder, hypothyroidism, thrombocytopenia, hyperkalemia, cognitive communication deficit, dysphagia, GERD (reflux), narcolepsy with cataplexy, sleep apnea with CPAP use, generalized weakness and debility. Information obtained through resident and staff interview, chart review and direct resident observation in collaboration with therapy .(R102) has cognitive impairment AEB (as evidence by) his BIM's score of 06/15, he takes antipsychotic medications on a regular basis, and will continue per his home routine, licensed staff monitor for side effects/efficacy, see SW (social work) notes for behaviors/cognition. (R102) is able to hear normal vocal tones during conversation with no hearing aids, his vision is adequate without glasses, his speech is clear and he is able to understand and makes himself understood .(R102) has his own natural teeth in fair repair with no noted difficulty chewing noted. Review of his Hydration Risk UDA reveals he has no s/s (signs or symptoms) of dehydration and is not at risk for dehydration .K Nutrition: See nutritional status CAA (care area assessment) . Confirming R102's diagnosis of [NAME]-[NAME] Syndrome was known prior to his admission on 2/8/23 and he did not have a history of nausea and/or vomiting documented. Review of R102's Nutritional Care Plan (Care Area Assessment) revealed, The resident has potential for nutritional deficits r/t (related to) Left femur fx (fracture), encephalopathy, anemia, [NAME] syndrome, seizure disorder, hypothyroidism, hyperkalemia, GERD, dysphagia, hx (history) falls, Vitamin D deficiency, hyperparathyroidism, depression, bipolar disorder, anxiety, CKD (kidney disease), OA (osteoarthritis). BMI >30 (body mass index greater than 30), obese. Date Initiated: 02/14/2023 .The resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs or symptoms) of malnutrition and consuming at least 75% of meals daily through review date .Administer medications as ordered. Monitor/Document for side effects and effectiveness.Monitor weight as ordered .Notify nurse/MD PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals .Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated .Provide and serve diet as ordered. Monitor intake and record q (every) meal. No concentrated sweets, NDD (dysphagia/difficulty swallowing) diet: level 1/pureed texture, nectar thick liquids. No double portions/snacks between meals. No straws. 2 handle cup, scoop plate at meals .RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed) .Staff to provide assistance at meals, refer to tray card for food preference choices. Confirming R102 did not have a history of nausea and/or vomiting and the potential medical emergency of nausea/vomiting was not addressed under the nutritional care plan. Review of the Complaint Submission to the State Agency revealed, (R102) .was admitted to (facility) on 2/8/23 for rehabilitation from orthopedic surgery for a fracture femur .When I visited (R102) on Tuesday, 3/14/23, he complained of nausea and vomiting. He did not eat his lunch. He was excessively thirsty. He was having difficulty staying awake without prompting. I reported this to the nurse on shift. A nurse listened to his abdomen and lungs, took his temperature and stated that nothing was of concern based on this cursory exam. I was assured that they would keep an eye on him by taking his vitals and conferring with the Nurse Practitioner in charge as to whether any further testing was warranted. Evidently, no labs were ordered as there are no test results for 3/14/23 or 3/15/23. Wednesday, 3/15/23, I made a phone call to (facility) at 3:42 pm to inquire about (R102's) condition. I was told by the nurse on shift that he was, eating ice cream, not having any behaviors and that (R102) was better than he was the day before. Her message was solely of re-assurance that he was well. As I wrote above, no vitals were taken, no labs were ordered, nothing was recorded of his rapidly worsening health . From about 2:00 pm Tuesday, 3/14/23, when I alerted nursing staff to (R102's) symptoms, at least 40 hours passed before there was any notice that he was failing rapidly. By this time, his condition was so critical that his life was in jeopardy with no medical alternatives to change the course of his health; the result being (R102's) preventable death . During an interview on 08/23/2023 at 1:06 PM, Family Member (FM) S reported she was also R102's legal guardian. FM S reported that upon admission to the facility on [DATE] she reported to the facility management and staff that R102 had [NAME] Syndrome and provided the facility with an alert book that contained specific information and an algorithm to reference if R102 was displaying and changes from his baseline. FM S reported the alert book was a booklet produced by [NAME] Association of the US and she would give a copy to all of R102's providers, Community Mental Health, his Adult Foster Care, Hospital, and the facility. FM S stated, it (the booklet) was a fast way to look through and see if there was a problem and pursue it. FM S reported she had visited R102 on 3/14/23 during lunch and became concerned when R102 did not eat his lunch which immediately raised concerns because of his diagnosis of [NAME] Syndrome he had an insatiable appetite. FM S reported R102 was telling her he couldn't eat, and his stomach was bothering him. FM S reported that R102 also drank 5 drinks while she was with him, and she was concerned with his excessive thirst. Additionally, FM S reported she was having difficulty keeping R102 awake and stated he had narcolepsy, but this was different. He just was very out of it. FM S stated, That's why I alerted the nurse on duty at the time. I saw all these signs of something being very wrong and was told they would obtain vital signs and keep an eye on him. FM S stated R102's nausea should have raised concerns. People with his concern develop digestive issues. They lack the mechanism of vomiting so vomiting would be very unusual for someone with [NAME] Syndrome. FM S reported that on 3/15/23 she called the facility for follow up on R102's condition and spoke to the 2nd shift nurse, the same nurse she reported concerns to on 3/14/23, who reported that he was fine and eating ice cream and was assured that R102 had improved and was at his baseline. FM S stated, I made it clear that I had significant concerns about his symptoms with his [NAME] Syndrome. FM S stated that from 3/14/23 until his transfer to the hospital (R102) wasn't as verbal and not as behavioral. and were not identifying that those changes were additional signs of his system failing and a medical emergency. During an interview on 08/24/2023 at 10:58 AM via phone and on 8/24/23 at 3:23 PM via email, FM S verified the booklet provided to the facility staff via a picture of the book in R102s belongings at the facility and stated she alerted staff to the information contained within it (the booklet). At that point in time, I expected that if issues occurred while he was admitted there, they would be able to use it for reference. (The specific booklet provided to the facility can be found at https://www.pwsausa.org/wp-content/uploads/2022/04/MedicalAlertsBooklet-GIChart-2022.pdf) During an interview on 08/25/2023 at 2:45 PM, during exit conference, Regional Nurse (RN) T confirmed that there was a [NAME] Syndrome book in his room for reference and Unit Manager (UM) U confirmed there was a [NAME] Will Syndrome reference sheet hanging up at the nurses' station. Review of R102's Progress Notes revealed no documentation that R102 experienced nausea and/or vomiting from time of admission on 2/8/23 until 3/14/23. Confirming the presence of nausea and/or vomiting was a new symptom for R102. Review of R102's Progress Notes revealed no documentation that R102 had emesis (vomiting) on 3rd shift between 3/13/23 and 3/14/23 and no documentation that the provider was notified. There was a Pertinent Charting-Behavior note written on 3/14/23 at 2:45 AM which revealed Resident displayed several behaviors this shift, from constant use of the call light and some yelling out and an Orders-Administration Note completed at 12:52 AM with a follow up pain scale entry at 3:28 AM both of which contained no additional documentation regarding R102's condition or comprehensive pain assessment. Review of R102's Nurses Note dated 3/14/23 at 1:55 PM revealed, Resident sitting up in w/c at this time, bowel sounds x 4, active, abdomen nontender, lung sounds CTA (clear to auscultation), no resp distress observed, temp 97.1, resident had emesis x 1 per report during the night, no further emesis this shift. There were no Nurses Notes written from 3/11/23 until a Late Entry note written for 3/14/23 at 12:30 PM. Review of R102's Skilled Daily-Medically Complex documentation dated 3/14/23 at 11:59 AM revealed R102s Cardiac and Respiratory Systems were assessed with a blood pressure and pulse obtained on 2/27/23 and respirations and oxygen level obtained on 2/26/23. R102's skin was identified as having no surgical wounds or abnormal skin conditions. There were no new labs and/or tests ordered, and the physician was not notified of any changes, abnormal vital signs, and/or test/lab results. R102's emesis noted on the previous shift was not documented. Review of a Late Entry Nurses Note written on 3/17/23 at 10:32 AM and dated for 3/14/23 at 12:30 PM revealed, Resident alert and oriented. Very pleasant and polite today. Did call and talk to former home care givers this AM and sister on phone today. No difficulties with meals, no N/V (nausea and vomiting). Review of R102's Vital Signs obtained on 3/14/23 at 3:05 PM revealed a blood pressure of 131/68. R102's pulse, temperature, and oxygen saturation were not assessed/documented. Review of R102's Pertinent Charting-Behavior note dated 3/15/23 at 5:58 AM revealed, resident has been in bed all of night shift with no behaviors noted. Review of R102's Skilled Daily-Medically Complex documentation dated 3/15/23 at 12:43 PM revealed R102s Cardiac and Respiratory Systems were assessed with vital signs obtained on 3/15/23 at 2:09 AM. R102's skin was identified as having no surgical wounds or abnormal skin conditions. There were no new labs and/or tests ordered, and the physician was not notified of any changes, abnormal vital signs, and/or test/lab results. R102's Guardian's concerns were not documented in the assessment. Review of a Late Entry Nurses Note written on 3/17/23 and dated for 3/15/23 at 1:32 PM revealed, No difficulties with meals today, no N/V. Very pleasant with all staff today, no outbursts or yelling. Did talk to former home care givers and sister today on telephone. Review of a Late Entry Nurses Note written on 3/18/23 at 12:30 AM and dated for 3/15/23 at 8:26 PM revealed, No nausea or vomiting. Resident drinking fluids and requested ice cream to eat. Vitals within norm. Review of R102's Electronic Health Record revealed no documentation that the provider was notified of R102's vomiting on 3rd shift between 3/13/23-3/14/23 and was not notified of the guardians voiced concerns during her onsite visit on 3/14/23 (excessive thirst, lethargy, nausea and vomiting, and lack of appetite.) The Electronic Health Record revealed no diagnostic testing or laboratory testing were ordered/completed from 3/14/23-3/16/23. Review of R102's Orders-Administration Note dated 3/14/23 at 12:52 AM revealed R102 complained of pain 2/10 and was administered Tylenol Oral Tablet 325 MG (Acetaminophen) 2 tablets. To be administered every 6 hours as needed for pain/fever. There was no description of the location or characteristics of R102's pain. Last dose of as needed Tylenol was not administered on 3/7/23. (Review of R102's Pain Assessments revealed that from 3/9/23-3/16/23 consistently scored 0/10 for pain with a rating of 1/10 on 3/11/23 at 7:30 PM and 3/14/23 at 4:57 PM and a rating of 2/10 on 3/10/23 at 8:05 PM and 3/14/23 at 12:52 AM.) Review of R102's Vital Signs revealed: *Oxygen was last assessed on 2/26/23 *BP, Pulse, and temperature were last assessed on 2/27/23 *3/14/23 at 3:05 PM a BP of 131/68 *3/15/23 at 2:09 AM a BP of 125/72, Pulse of 85, Oxygen 92%, Respirations 18, Temperature 97.5 (There was no Nurses Note written regarding the rationale for obtaining R102's vital signs at 2:09 AM.) *3/16/26 at time of transfer BP of 100/53, Pulse of 103, Oxygen 91%, Respirations 21, Temperature 97.5 During an interview on 08/25/2023 at 10:48 AM, Director of Nursing (DON) reported that R102's Guardian (FM S) visited R102 often and would provide education to the facility staff regarding [NAME] Syndrome. DON reported that if FM S was uncomfortable with anything or had concerns she would report it to facility staff. During an interview on 08/24/2023 at 9:10 AM, Licensed Practical Nurse (LPN) E reported that R102 was previously at the facility (April 2021-September 2021) and was familiar with [NAME] Syndrome at that time. LPN E reported that if a resident is admitted with a diagnosis/syndrome she is unfamiliar with she will review the diagnosis/syndrome to ensure she is aware of what she needs to know as a nurse to ensure proper care. LPN E reported R102 had behaviors which were typically related to making multiple phone calls to his AFC (adult foster care) and his sister. If he was unable to reach them his behaviors would increase. During an interview on 08/24/2023 at 9:49 AM, UM U reported she was the Unit Manager for the unit that R102 was on during his stay. UM U had not been made aware that R102 had nausea and vomiting, changes in his behaviors, and/or lethargy between 3/13/23 and his transfer to the hospital on 3/16/23. UM U reported that R102's guardian was a great guardian for him and was knowledgeable with [NAME] Syndrome (PWS). UM U reported that when R102 was initially admitted to the facility in April 2021 there was a dietician that provided extensive education to the facility staff. UM U reported that during his second admission to the facility (2/8/23) management did not provide education as they did previously because most of the facility staff had been educated prior. UM U reported there was a printout the sister/guardian had pinned up at the nurses' station for staff to reference but could not recall what was included on the printout. During an interview on 08/24/2023 at 9:30 AM, LPN I reported he was the nurse for R102 and recalled his diagnosis of [NAME] Syndrome. LPN I reported that prior to his transfer to the hospital he did not observe any changes in R102's condition. LPN I reported that facility management had asked if R102 had any episodes of nausea and/or vomiting prior to his transfer to the hospital over the last couple shifts LPN I worked, which was why he documented 2 late entry notes on 3/17/23. LPN I reported that 1 episode of emesis would be documented on the 24-hour report sheet unless there were other significant concerns or conditions in addition to the emesis, in which case, the provider would be notified. LPN I reported that if a resident is admitted with an unfamiliar disease/syndrome/condition management will provide education in the form of a printout and/or verbal education for important points to know for nursing staff. LPN I reported that he believed there was a printout distributed at the time of R102's admission. During an interview on 08/24/2023 at 1:07 PM, LPN C reported that R102 was the first patient she had cared for with [NAME] Syndrome. LPN C reported there was a brief education regarding PWS but there was no in-depth education but reported she did recall a printout pegged to the board at the nurses' station. LPN C reported she was R102's nurse on the 3rd shift between 3/13/23-3/14/23. LPN C stated, I believe he had vomited that night and reported she assessed his vital signs, and they were within normal limits. LPN C reported the CNAs had informed her that R102 had vomited, and she did not visualize it. LPN C reported that she did not perform a physical assessment, did not auscultate bowel sounds, and did not palpate abdomen on R102 after he had emesis but went in and talked to him and stated the situation wasn't something that really grabbed my attention or something that needed to be reported to the provider. LPN C did not report what time during the shift R102 vomited. LPN C reported that if R102 would have had an additional episode of vomiting she would have notified the provider but reported that with just 1 episode of vomiting, the outcome of the conversation with R102, and vital sign results, she would have just passed it along in report and documented it on the 24-hour report (not part of a resident's permanent medical chart). LPN C reported if a resident has 2 episodes of emesis in 24 hours and definitely 2 episodes of emesis in 1 shift the provider is to be called. When asked why on 3/14/23 there was no progress note written and informed that the vital signs were not documented, LPN C reported a progress note should have been written and the vital signs should have been documented. LPN C reported there were no other concerns identified during her shift and stated, he was actually a little less needy and exhibited less behaviors from his usual. During an interview on 08/25/2023 at 1:12 PM, ADON H reported she worked a brief shift on 3/14/23 from approximately 1PM to 2 PM. ADON H reported that she had seen on a 24-hour communication form that R102 had had emesis on the previous night shift, so she completed a physical assessment but did not identify any concerns. At that time, R102 had active bowel sounds and no abdominal distension. ADON H reported that FM S did not report any concerns regarding R102's condition to her at that time but did have concerns regarding his wheelchair. During an interview on 08/25/2023 at 9:24 AM, CNA P reported she was R102's 2nd shift CNA on 3/14/23 and 3/15/23. CNA P reported that the last 2 days she provided care for R102 he was more tired. CNA P reported that on 3/15/23 she observed his stomach was distended and stated, (R102) was sitting in his chair (in his room) and his belly looked bigger than usual and he reported he wasn't feeling well. CNA P reported that she notified the nurse on duty (LPN G), and she went in the room to talk to him. CNA P reported she and another CNA put R102 to bed at that time and I believe we got vitals. CNA P reported she was concerned for R102 because he never complained, he never complained about nothing and on 3/15/23 he looked ill and complained of generally feeling unwell which was not normal for R102. During an interview on 08/24/2023 at 11:59 AM, LPN G reported that she had not been provided education on [NAME] Syndrome and was not employed at the facility during R102's first stay in April 2021. LPN G stated, there may have been one (printout at the nurses' station) to keep an eye out for nausea. LPN G reported that she was R102's nurse on 2nd shift on both 3/14/23 and 3/15/23. LPN G reported that R102 had many behaviors and if he got worked up he would sometimes cough up clear secretions but reported it wasn't food, it was clear and if it was more (emesis) I would have called the doctor. LPN G reported that on 3/15/23 R102 went to bed earlier than usual, slept a lot one night, and stated, I did notice him not being so fussy. LPN G reported that looking back that (sleeping more) was bad and reported that in hindsight he was more lethargic than his baseline stating, (R102) was always complaining and vocalizing. And that night he wasn't after me LPN G stated, Looking back, a behavioral patient not being behavioral, that's a sign of a change in condition. LPN G stated, the highest risk patient is the hypochondriac and the behavioral person because they constantly complain or display behaviors, but a full assessment should still be completed because one of those times (not performing an assessment) something is going to happen. LPN G reported that on 3/15/23 she did not complete a comprehensive physical assessment because at that time she felt R102 was just tired but she did have the Certified Nursing Assistants CNAs obtain a set of vital signs and did not recall the vital signs out of range. When asked why the vital signs were not documented in the Electronic Health Record, she reported that the CNAs were responsible for inputting the information into the resident's chart. LPN G was unable to recall R102's vital signs on 3/15/23 or the time the vital signs were obtained. LPN G reported that although she missed a sign of lethargy in R102, the night shift nurse should have been able to identify any additional signs of a change in condition because R102 was a check and change every 2 hours and required turning every 2 hours to prevent skin breakdown. LPN G reported the nightshift nurse was required to do rounds and check on patients throughout the night and reported the nurses should at least assess breathing during their rounds. LPN G reported it was difficult to perform her job duties including performing assessments on residents with a potential change in condition because of the number of residents she was responsible for. LPN G reported she was responsible for approximately 30 residents each shift and frequently felt like I couldn't do enough and was burned out. LPN G stated, I missed (R102's) assessment because I was run ragged and couldn't spend the time I needed caring for assigned residents. LPN G reported that sepsis was always in the back of my head but R102 didn't have any signs of sepsis and reported his temperature wasn't abnormally high or low. LPN G reported she was unaware that a person with [NAME] Syndrome had temperature regulation abnormalities. LPN G reported that she was aware that R102 was medically fragile and reported she was pressing management about discharging him back to his AFC before something happens. LPN G reported that she was told R102 was outside the normal range of lifespan for PWS. LPN G reported that Assistant Director of Nursing H asked her to put in addit[TRUNCATED]

This citation pertains to intake #: MI00137844 Based on interview and record review, the facility failed to 1.) ensure controlled substances were accurately documented and 2.) ensure narcotic medications were administered following the physician order for 4 residents (Resident #108, #109, #110, and #111), reviewed for controlled substances, resulting in narcotic medications not being administered and the potential for drug diversion of controlled substances and pain not being adequately controlled. Findings include: Resident #108 (R108) Review of an Admission Record revealed R108 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle spasms. Review of R108's Physician Order dated 2/10/23 revealed, KlonoPIN Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth two times a day related to OTHER MUSCLE SPASM. Review of R108's Controlled Substance Record revealed no Klonopin was not administered on 8/16/23. Review of R108's Incident Audit Report dated 8/25/23 revealed, Floor nurse signed out clonazepam at 0702 (on 8/16/23) but did not sign it out of the narcotic book or pull the medication from the med (medication) cart .Education provided to floor nurse on rights of medication pass and administering medications per MD (medical doctor) order . Resident #109 (R109) Review of an Admission Record revealed R109 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety. Review of R109's Physician Order dated 2/20/17 revealed, CLONAZEPAM 1 MG TABLET Give 1 tablet orally two times a day related to ANXIETY DISORDER. Review of R109's Controlled Substance Record revealed clonazepam was only administered 1 time on 8/21/23. Review of R109's Incident Audit Report dated 8/24/23 revealed, Floor nurse signed out clonazepam at 0833 (8:33 AM) on 8/21 but did not sign out med in narcotic book .upon investigation floor nurse stated she must have forgotten to pull medication from cart, education provided to nurse on rights of medication pass . Resident #110 (R110) Review of an Admission Record revealed R110 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: seizures. Review of R110's Physician Order dated 7/30/23 revealed, Diazepam Tablet Give 1 tablet by mouth three times a day for seizures. Review of R110's Controlled Substance Record revealed diazepam was administered only 1 time on 8/11/23 and only 1 time on 8/20/23. Review of R110's Incident Audit Report dated 8/24/23 revealed, Floor nurse signed out diazepam but did not sign it out in the narcotic book .Nurse practitioner notified of missed medication on 8/11 and 8/20 .education provided to nurse on importance of med pass and rights of med pass . Resident #111 (R111) Review of an Admission Record revealed R111 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Schizophrenia. Review of R111's Physician Order dated 2/3/20 revealed, diazePAM Tablet 5 MG Give 1 tablet by mouth two times a day related to SCHIZOPHRENIA. Review of R111's Controlled Substance Record revealed no documentation of the date or time R111's diazepam was administered on 8/22/23. During an interview on 08/24/2023 at 3:30 PM, Assistant Director of Nursing (ADON) reported that a medication error report would be completed for R109 and R111 and the missing documentation was completed for R110. During an interview on 08/25/2023 at 1:15 PM, ADON reported that a medication error report would be completed for R108. Review of the facility policy Controlled Substance Prescriptions dated 09/2018 revealed, Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations .The Director of Nursing and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications .IX. Security and Recordkeeping- 1. Controlled substances are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents. The pharmacy will include an individual resident controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident unless directed otherwise by the facility . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered .Never document that you have given a medication until you have actually given it. Document the name of the medication, the dose, the time of administration, and the route on the MAR. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 609-610). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.

This citation pertains to intake # MI00129347 Based on observation, interview, and record review, the facility failed to ensure resident safety by 1.) providing accurate assessments, 2.) implementing care planned interventions, 3.) monitoring residents, and 4.) implementing safety interventions for residents on leave, for 5 residents (Resident #8, #223, #26, #54, and #48) reviewed for accidents, hazards, and supervision, resulting in falls for Resident #223 and Resident #26, a clavicle fracture for Resident #8, and the potential for further falls, serious injury, and a deterioration in health status. Findings: Resident #8 (R8) Review of an Admission Record revealed R8 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, left arm fracture, and history of falling. Review of a Minimum Data Set (MDS) assessment for R8, with a reference date of 12/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated R8 was severely cognitively impaired. Review of the Functional Status revealed that R8 required extensive 2 person assist for transferring and toileting. Review of R8's Hospital Record dated 6/23/22 revealed a diagnosis of closed fracture of proximal end of left humerus . Review of R8's Activities of Daily Living Care Plan revealed: TRANSFER: sit to stand ax2 (assist with 2 persons), do not bare weight to left arm Dated/revised 07/21/2022 TRANSFER: ax2 with gait belt, do not bare weight to left arm Dated/revised 07/25/2022 TRANSFER: ax2 with gait belt/total lift as needed if resident exhibits weakness, do not bare weight to either arm . Dated/revised 07/31/2022 During an interview on 01/05/2023 at 3:22 PM, Occupational Therapist (OT) T reported that R8's transfer status was changed on 7/25/22 from using the sit to stand with 2 person assist to using the gait belt with 2 person assist because the sit to stand placed too much stress on R8's left arm (from left humerus fracture). OT T reported that when the therapy department made recommendations for treatments/care, no order was written but the therapy department would communicate directly with the facility nurses/Unit Manger to ensure the resident's Care Plan was updated. Review of R8's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note dated 7/30/22, written by Licensed Practical Nurse (LPN) V revealed, .Evaluation of right shoulder related to pain .Resident was transferred by the CNA (Certified Nursing Assistant) to bed with the use of sit stand (sit to stand lift). She attempted to clean and change her (R8). When she c/o (complained of) pain on her right shoulder, the CNA lowered her to the bed. Upon assessment of this writer, I observed that the right shoulder protruded. Pain noted on ROM (Range of Motion). Called the on call supervisor and (Nurse Practitioner name omitted). (Nurse Practitioner name omitted) ordered to send her to the ER (emergency room ) for evaluation. Review of R8's Physician Order dated 7/30/22 at 8:31 PM revealed, Send patient to ER for evaluation of right arm. Review of R8's Nurses' Notes dated 8/1/22 at 10:27 AM revealed, Nurse practitioner aware of x ray results showing .acute mildly displaced right midclavicular fracture . Review of R8's NP/PA (Nurse Practitioner/Physician Assistant) Progress Note dated 8/2/2022 at 4:13 PM revealed, Chief Complaint (Reason for Patient Visit): pain, subsequent encounter for palliative care-History of Present Illness .94 y/o female per staff patient has been having right shoulder pain. this has been ongoing 2-3 days. did have frequent (recent) xray showing clavicle fx (fracture). today patient reports she has been having pain however is unable to specify where or when. staff does report they have been using PRN (as needed) norco (pain medication) with improvement of pain . Review of R8's Orthopedic Consult Note note dated 8/30/22 revealed, (R8) is a 94 y.o. (year old) female who is here today for evaluation of a new right clavicle fracture and old left proximal humerus fracture (left upper arm). She is here today with her family. Her family notes that she sustained a right clavicle fracture sometime around the end of July. She was being positioned with a lifter at her nursing facility and the nursing aides heard a crack. She apparently had pain in the right clavicle. She was seen in an emergency department in Mount Pleasant where x-rays revealed a possible clavicle fracture. She was placed in a figure-of-eight type brace and eventually referred to my office for further evaluation . These hospital records/consult notes were obtained from the hospital medical records department on 1/5/22 by onsite surveyors and were not located in R8's Electronic Health Records (EHR). During an interview on 01/04/2023 at 1:50 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) E reported that R8's right clavicle fracture on 7/30/22 resulted from a facility aide improperly transferring R8 to bed and was not the result of a fall. UM/LPN E was unable to recall details from the incident and reported that the incident would have been documented in R8's EHR. UM/LPN E was unable to locate documentation (incident report, progress notes, hospital records) from R8's right clavicle fracture in the EHR. During an interview on 01/04/23 at 02:29 PM, LPN V reported that she was the nurse on duty at the time of R8's clavicle fracture on 7/30/22. LPN V reported that the aide (identified as Former Waiver Care Aide (FWCA) W) was questionable and she had concerns with her ability to provide quality care to the residents. LPN V reported that she entered R8's room to supervise FWCA W's while she transferred R8 to bed but didn't assist. LPN V reported that she intervened when she identified that R8 was injured but reported she was not able to identify what caused R8's right clavicle fracture. LPN V reported she called the provider immediately following the transfer to have R8 sent to the hospital for evaluation. Confirming that R8 was not transferred following the Occupational Therapists recommendation and Care Planned intervention resulting in a right clavicle fracture (Care Planned to transfer using a gait belt with 2 staff assist and was transferred using a sit to stand with 1 person.) During an interview on 01/05/23 at 09:09 AM, Assistant Director of Nursing (ADON) U reported that the LPN V had immediately notified her of R8's injury on 7/30/22 and subsequent transfer to the hospital. ADON U reported that she had completed an investigation into the incident but was unable to locate any of the documentation from the investigation or from R8's emergency room evaluation. ADON U reported that FWCA W was maneuvering R8 in the sit to stand and LPN V was present in the room. ADON U reported that an Incident Report was not completed and are only completed if there is a fall or a skin tear. ADON U reported that typically hospital records are scanned into the resident's EHR and investigation notes would be available for review but (I) just don't know where that information is. ADON U reported that a thorough investigation was completed and reviewed by management and it was determined that abuse was not substantiated and the root cause for the fracture was osteopenia and not anything we (facility staff) had done to cause the injury. ADON U reported that all staff received retraining on the use of a sit to stand even though I didn't feel it caused it. ADON U reported that she would document an outline of the investigation in writing for review. On 01/05/2023 at 11:16 AM, an outline of R8's 7/30/22 investigation was received via email.On 7/31/22 (incorrect date of incident) staff were transferring resident from w/c (wheelchair) back to bed with sit to stand r/t (related to) resident was feeling weak. Resident did not have pain prior to transfer and then stated she had pain in right clavicle area while up in sit to stand, she was then layed (sic) down in bed. The nurse observed her right clavicle appearing protruded and pain with ROM. The nurse notified the nurse practitioner who gave order to send to ER for evaluation. Resident returned from ER visit with x-ray report showing right shoulder osteopenia, acute mildly displaced right clavicular fracture, superior migration of right humeral head, consistent with chronic rotator cuff disease .Resident had been sit to stand for transfers in care plan and was changed to Ax2/gaitbelt on 7/25/22. Staff used sit to stand to transfer resident on 7/31/22 r/t weakness. Upon investigation, 2 staff were with resident and this nurse spoke to resident and abuse was ruled out. On 8/1/22 resident was changed to total lift for transfers until therapy re-evaluated. Staff were evaluated and re-competencied (sic) on use of sit to stand and it was determined that sit to stand was used correctly and according to manufacturer guidelines. Root cause of fracture r/t resident has diagnosis osteopenia and r/t having left arm in sling and additional pressure on right side of body a fracture resulted. Confirming R8's care planned intervention/Occupational Therapists recommendation for transfers was not followed resulting in R8's right clavicular fracture. During an interview via email on 01/05/23 at 08:25 AM, Director of Nursing (DON) reported that there was no Incident Report completed for R8 regarding the right clavicle fracture on 7/30/22. Review of R8's Progress Notes revealed no documentation of R8's injury/incident, transfer to the hospital, or return from the hospital. Review of R8's Electronic Health Record revealed no hospital records and/or diagnostic (xray) records from R8's 7/30/22 emergency room visit. Former Waiver Care Aide (FWCA) W Review of FWCA W's Employee File revealed she was hired as a WCA on 03/23/22. (Waiver Care Aide- waiver allowed facilities to employ individuals beyond four months, in a nurse aide role, without the completion of a state approved Nurse Aide Training and Competency Evaluation Programs (NATCEP). The individual could continue to work if the nursing home ensured that the nurse aide could demonstrate competency in skills and techniques needed to care for residents during the pandemic.) FWCA W received a Performance Improvement Form on 5/13/22 which revealed: .Reason for Counseling/Corrective Action: Multiple concerns from supervisors/co-workers: -stating a resident was changed and when checked resident was soaked/soiled -not giving care per Kardex (individualized care plan summary) -not able to keep up with charting and care with a minimized work load . Counseling sessions/corrective actions: Spoke with and offered opportunity for any skills or education that she feels like she may need. Spoke with her previously a couple weeks prior to this date regarding some of same concerns, stated she is was (sic) just now getting better orientation that (sic) she was . Expected Level of Performance: Will follow kardex as written, will be able to keep up with work load given, will follow all policy and procedure . Corrective Action Plan: Offered opportunity in building for more orientation, education, and skills training. Continues to go through CNA class currently. Spoke to her to bring awareness to concerns being brought to DON after extensive orientation, told her she needs to feel comfortable asking (for) extra training if she does not feel confident with skills, work load. CNAs she has been paired with the last two weeks have specifically been working with her on time management and will continue while on orientation. DON did educate on expectation after this orientation is complete to be able to complete all tasks and follow kardex's (sic) of residents when given a standard work load . Follow Up Review Date: (no date documented for follow up review) It is essential that immediate steps are taken to improve and maintain performance to the required level. If demonstrated material improvement is not made during this time frame, or if performance deteriorates during or after this time, further action, up to and including discharge, may be taken before the end of this time period or after this time period . Indicating FWCA W had known care concerns without documented follow-up ensuring FWCA W followed resident plans of care and could demonstrate competency in skills and techniques (approximately 11 weeks prior to R8's right clavicle fracture.) FWCA W was not terminated following R8's transfer using a sit to stand with 1 person assist. FWCA W resigned her position with her last day of work documented on the resignation letter as 9/2/22. 37577 Resident #223 (R223) Review of an Admission Record revealed R223 was a [AGE] year old male, admitted to the facility on [DATE] for short term rehabilitation services following a left total hip replacement on 05/18/22. R223 had pertinent diagnoses of high blood pressure, type 2 diabetes mellitus, and need for assistance with personal care. R223 was his own responsible person and scored 15/15 on the Brief Interview for Mental Status (BIMS) completed 06/02/22, which indicated he was cognitively intact. During an interview on 01/02/23 at 10:15 AM, R223 recounted the following details regarding a fall sustained on 05/22/22 while residing at the facility: (a) (R223) needed to go pee, put on the call light, and after a long wait time, staff came in to assist (R223) to the bathroom, (b) (R223) started to pee before getting to the bathroom because of the long wait time, and peed on the floor while heading to the bathroom, (c) after using the bathroom, was assisted back to bed by staff who did not use a gait belt to steady (R223), and (d) (R223) slipped in the puddle of pee that was still on the floor and fell , fracturing his left acetabulum (the socket part of the hip) and spraining his left ankle. Review of a facility Incident/Accident Report for R223, dated 05/22/22 at 9:30 PM, revealed the following information related to the fall: (a) brief description: urinated on floor-grippers (socks) wet, slipped and fell while returning to bed with staff assist, (b) a walker was being used, (c) initial blood pressure obtained after the fall was 100/62 lying, 99/59 sitting, and 90/50 standing, and (d) resident received a diuretic (a medication that removes fluid from the body through increased urine output) and narcotic pain medication at approximately 6 PM, prior to the fall. Review of a Fall Investigation Report for R223 regarding the fall on 05/22/22, the report revealed the following: QUESTION-what appears to be the initial root cause of the fall? ANSWER-urgency to void, recent surgery, and socks wet from urine (slipped). QUESTION-describe initial interventions to prevent future falls. ANSWER-urinal and gait belt. Resident #26 (R26) Review of an Admission Record revealed R26 was an [AGE] year old female, admitted to the facility on [DATE] for short term rehabilitative services, following a right total hip replacement on 12/06/22. R26 had pertinent diagnoses of type 2 diabetes mellitus, high blood pressure, generalized muscle weakness, unsteadiness on feet, need for assistance with personal care, and was her own responsible party for medical decisions. Review of a Physician Progress Note, dated 12/08/22, revealed the following findings on the physical exam: Lungs + for rhonchi (gurgling/bubbling sounds heard while breathing), and extremities 1+ edema (no specific location noted). R26's recent right total hip replacement and surgical incision site were not addressed in the progress note. Review of an Occupational Therapy Evaluation, completed 12/08/22 for R26, reflected the following assessment: (a) safety awareness=impaired, (b) follows 1 step directions=independently with prompts/cues, (c) ability to understand others=usually understands, and (d) decision making ability for routine activities=modified independence. Review of a Physician Progress Note, dated 12/09/22, revealed the following findings during the review of systems: (a) positive for fatigue, fever, chills, and sweats, (b) positive for dyspnea (difficulty breathing), and (c) positive for dizziness, headaches, and weakness. Review of a facility Incident/Accident Report, dated 12/11/22, revealed R26 had an unwitnessed fall in her room. Review of a Nurse Progress Note for R26, dated 12/14/22 at 1:13 PM, reflected .resident is alert and oriented and can make her needs known. After her shower, resident showed signs of pain and distress. Resident had a fall yesterday (12/13/22). Resident was sent out for further evaluation. No record of a fall on 12/13/22 was provided to the surveyor during the survey process. No additional information was obtained regarding the circumstances surrounding the shower received 12/14/22. Review of a facility Transfer to Hospital form, dated 12/14/22, revealed R26 was sent to the emergency room to be evaluated for fall-right hip pain. Review of an emergency room document, dated 12/14/22 at 11:37 AM, reflected .resident to emergency room from local nursing home with chief complaint of a fall. Patient states she fell this morning, the staff report that she fell last night. Patient has shortening and rotation of her left leg. X-ray confirmed a left displaced intertrochanteric femur fracture. After review of all available medical records related to fall(s), it remained unclear as to sequence of events leading to the left femur fracture. Review of a facility Policy-Fall Prevention Program, last reviewed/revised 01/01/2022, revealed the following: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Policy Guidelines: (2) Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. (3) The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. Resident #54 (R54) Review of an Admission Record revealed R54 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of dementia, high blood pressure, type 2 diabetes, muscle weakness, use of a foley catheter (tube that drains urine from the bladder into a closed collection system), and chronic kidney disease-stage 3. A Brief Interview for Mental Status, completed 12/9/22, revealed a score of 3/15, indicating severe cognitive impairment. According to R54's MDS (minimum data set) functional status, the resident required extensive assistance from 2 staff persons for bed mobility, transfers, getting dressed, and using the bathroom. R54's ability to move from a seated to standing position and ability to walk were evaluated as: not steady, only able to stabilize with staff assistance. Review of a Kardex (bed side care guide) indicated that the following care measures were needed for R54: (a) be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, (b) Transfer-the resident requires assist x 2 with gait belt, and (c) Cue, reorient and supervise as needed. Review of a facility Incident/Accident Report, dated 12/07/22, indicated R54 had an unwitnessed fall in the dining room following a meal. The root cause analysis included: resident can be impulsive at times, fall related to general weakness and confusion at times, resident to be removed from the dining room as soon as the meal is completed related to poor impulse control and the need for increased supervision. Review of a facility Incident/Accident Report, dated 12/16/22, indicated R54 had an unwitnessed fall in the dining room following a meal. The root cause analysis included: fall related to general weakness and confusion at times, resident to be removed from the dining room as soon as the meal is completed related to poor impulse control and the need for increased supervision. The intervention to remove R54 from the dining room following a meal was implemented after the unwitnessed fall on 12/07/22. During an observation on 01/03/23 at 3:04 PM, R54 laid resting in bed with eyes closed, and two touch pad call lights were positioned under the fitted sheet, out of sight, midway down the bed, and on the left side of the bed. The placement of the two touch pad call lights suggested that the two touch pad call lights were used as an alarm system to alert staff to R54 attempting to get out of bed. During an observation on 01/04/23 at 10:06 AM, certified nurse aide (CNA) P assisted R54 to change her pants. The two touch pad call lights were positioned under the fitted sheet, midway down the bed, and on the left side of the bed. CNA P indicated that (a) the two touch light call pads alerted staff when R54 attempted to get out of bed unassisted and (b) R54 had no call light available, within reach and sight, to alert staff to needs. During an observation on 01/05/23 at 2:18 PM, CNA X transferred R54 from a sitting position on the edge of the bed to the wheelchair. No gait belt was used to 1 person transfer R54. The two touch pad call lights were positioned under the fitted sheet, midway down the bed, and on the left side of the bed. No other call light system available to R54 was observed. During an interview on 01/05/23 at 2:40 PM, the Director of Nursing (DON) indicated not being aware of touch light call pads utilized as an alarm/alert system for staff regarding care for R54. The DON also indicated that R54 was a two person transfer and a gait belt should be used. 29073 Resident #48 (R48) Review of an Admission Record reflected R48 admitted to the facility on [DATE] with diagnoses that included infection following a surgical procedure, peripheral vascular disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), phantom limb syndrome with pain, morbid obesity, hypertensive heart disease, and acquired absence of the right and left leg above the knee. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R48 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15, required set-up help only for bed mobility, transfers, dressing and locomotion on and off the unit. R48 needed one-person physical assistance for personal hygiene and bathing and required extensive assistance from one person for toilet use. The assessment indicated R48 had not had a fall since the last quarterly assessment. UNSAFE MEDICATION ADMINISTRATION During an observation and interview on 1/3/2023 at 11:37 AM, R48 was observed alone in his room, leaning over from his powerchair, his upper body lying on the bed. Two inhalers (Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) and a Spiriva inhaler device) were noted at the foot of the bed within arms reach of R48. R48 reported that he kept the inhalers with him, and staff had assessed him as safe to self-administer the medication. A lock box to secure the medications was not observed in the room. Review of the Electronic Medical Record (EMR) did not reflect a Self-Administration of Medications Evaluation of Resident's Ability had been completed. The Care Plan Report did not reflect R48 was deemed safe to self-administer medications. Physician orders were reviewed and did not indicate R48 was safe to self-administer medications. During an interview on 1/5/2023 at 9:10 AM, Licensed Practical Nurse/Unit Manager (LPN) E reported that she believed R48 did self-administer his inhalers. LPN E reviewed the EMR and agreed that there was not a self-administration of medication assessment on record for R48. LPN E said there should be an assessment and a locking box for storage of medication as well as physician orders and a care plan pertaining to the self-administration of medication.

This citation is related to intake #MI00130701 Based on interview and record review, the facility failed to provide quality care for two residents (Resident #222 and Resident #30 ) by (a) failing to identify, assess, and monitor for a change in condition for Resident #222 and (b) failing to notify the physician of, and initiate a new antibiotic order based on culture and sensitivity for Resident #30 , resulting in (a) severe septic shock and death for Resident #222 and (b) rehospitalization with pneumonia, urinary tract infection and sepsis for Resident #30. Findings: Resident #222 (R222) Review of an Admission Record revealed R222 was a [AGE] year old male, admitted to the facility on [DATE] for acute cystitis (bladder infection), with pertinent diagnoses of high blood pressure, chronic obstructive pulmonary disease, morbid obesity, insulin dependent diabetics, and chronic (long term) use of a Foley catheter (a tube inserted into the bladder that drains urine into a closed collection drainage bag). Review of a Nursing Admission Evaluation-Part 1 for R222, admitted [DATE], reflected the following incorrectly documented or omitted information: (a) R222's height, weight, and current vital signs were pulled forward from a previous admission on 11/19/21, (b) in the transfer safety evaluation the question can the resident walk without assistance was not as completed, (c) in the fall risk evaluation question 8 referred to the nurse checking orthostatic blood pressures and assessing if there was a marked drop in blood pressure. The nurse documented no drop in pressure was noted. However, orthostatic blood pressures on admission could not be located in the electronic medical record (EMR) .Nursing Admission Evaluation-Part 2 also reflected information pulled forward from a previous admission on 02/20/2022 and (d) comorbidities- none were checked despite R222 having at least 2 of the concerns, (e) the Sepsis Screen, used to determine if signs and symptoms of an infection are present and require close monitoring, relied on having current vital signs available. The sepsis screen was determined to be negative based on information that was over 60 days old, (f) the cardiovascular/circulatory screen revealed that no edema (swelling) was present at admission, and (g) the urinary continence screen did not correctly reflect that R222 utilized a foley catheter for the elimination of urine. Review of a Nursing Evaluation Summary note for R222, dated 05/03/22, reflected the following: sob (shortness of breath) with exertion .generalized edema to body 3-4+ throughout . and foley in place, draining clear yellow urine. Review of a Nursing Evaluation Summary note for R222, dated 05/04/22, reflected the following: wears oxygen via nasal cannula at 2 liters .and foley catheter in place, patent and draining hematuria (blood in urine) noted. From 05/05/22 through time of discharge to the emergency roiagnom on [DATE], no nursing progress notes discussed or re-assessed the hematuria noted on 05/04/22. No documentation was found in the EMR that assessed (a) if the foley catheter was draining properly, (b) a description of the urine (cloudy, clear, sedement or blood present), (c) whether an odor was noted when the foley bag was emptied, (d) how often the foley bag was emptied, (e) who much urine the resident was making each shift, and (f) how much fluid R222 was taking in each shift. Review of the Electronic Medication Administration Record (Emar) for R222 reflected an order to monitor urine from indwelling catheter for color, odor, and decreased output. Notify provider as needed of any changes. every shift. Start date 05/05/22. The monitoring involved revealed a check mark was placed in a box each shift. No nursing assessments or narratives were located in the EMR. Review of a Physician Progress Note, dated 05/05/22, reflected the following assessment: weight= 460.6 pounds, extremities= 1+ edema (swelling that barely has any pitting), reason for admission= rehabilitation, risk for re-hospitalization =high, and medical conditions= COPD (chronic obstructive pulmonary disease) on oxygen and cluster headaches. The physician note did not discuss the foley catheter. Review of a Physician Progress Note, dated 05/10/22 for R222, revealed the following assessment: positive for significant weight gain, bilateral lower extremity edema, and no assessment or mention of the foley catheter use and urine output. Review of a Physician Progress Note, dated 05/17/22, reflected the following assessment: weight 550.8 pounds, extremities= 3+ edema bilateral lower extremities (both lower legs). No assessment or mention of the foley catheter use and urine output was noted by the physician. The physician note did not discuss the foley catheter and urine. During an email correspondence with the Director of Nursing (DON) on 01/05/23, the DON indicated that the last date R222 was seen by a physician at the facility was 05/17/22. The DON also indicated that R222 transitioned from Medicare to Medicaid on 05/31/22 and the last date for required daily nursing documentation was 05/31/22. Review of a Nursing Progress Note for R222, dated 06/04/22, revealed .resident requesting to be taken to the hospital related to vomiting, chills, sweats, and blurred vision. Resident unable to keep any food or liquids down. Blood sugar was 87. Ambulance was called and resident was transported to the local emergency department. No nursing progress notes leading up to the residents request to be sent to the emergency room were present in the electronic medical record. Review of a Transfer Notice for R222, dated 06/04/22, reflected that the resident was being sent out for emergency medical care due to vomiting, headache, and blurred vision. Review of emergency room Records for R222, dated 06/04/22 revealed the following: (a) patient complains of body aches, headache, blurred vision over the last few days and 6 episodes of vomiting today, (b) patient has scrotal edema, 3+ pitting edema bilaterally in the lower extremities and abdomen as well, (c) (R222) reports dark urine through his foley catheter that has not been replaced for 7-8 weeks, (d) in ER .urine is dark with chunks in the urine, WBC (White Blood Cell) count of 11.6, respiratory rate greater than 20, heart rate 103 (tachycardic), temperature-99.8, severe fluid overload, and (e) REASON FOR hospitalization -Severe Sepsis with shock and organ failure. Despite being admitted to the intensive care unit, R222 was pronounced dead on 06/08/22. 39056 Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and heart disease. Review of R30's Nurses' Note dated 12/7/22 revealed, resident sent to ER (emergency room ) for eval (evaluation) per sons request. Review of R30's Hospital Discharge documentation from emergency room visit 12/7/22-12/8/22 revealed an order for Nitrofurantoin (Macrobid) (antibiotic) 100 mg (milligram) capsule Take 1 capsule by mouth 2 times a day for 7 days. Review of R30's Nurses' Note dated 12/8/22 at 11:27 AM revealed, N.O. (new order) Noted and received for abt (antibiotic) therapy after res. (resident) returned (sic) from ER with new orders for uti (Urinary Tract Infection) . Review of R30's Physician Order dated 12/9/22 at 9:39 AM revealed, Macrobid Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for UTI for 7 days. (Macrobid was not ordered in R30's Electronic Health Record for approximately 22 hours). Review of R30's December Medication Administration Record (MAR) revealed the first dose of Macrobid was administered on 12/9/22 at 6:00 PM and last dose administered on 12/16/22 at 8:00 AM. Review of R30's Nurses' Note dated 12/9/22 at 9:40 AM revealed, Clarification on abt (antibiotic) ordered from ER for UTI. Macrobid 100mg BID (twice a day) x7 days. N.P. (Nurse Practitioner) aware and want him to cont. (continue) with azithromycin for uri (Upper Respiratory Infection . Review of R30's hospital Result Care Coordination note revealed: *Urine Culture and Sensitivity (C&S) result dated 12/9/22 at 8:12 AM >100000 COL/ML ENTEROCOCCUS SP. ENTEROCOCCI CAN BE PREDICTED TO BE SUSCEPTIBLE TO URINE CONCENTRATIONS OF AMPICILLIN (antibiotic) 100% OF THE TIME . The result of R30's urine culture and sensitivity identified ampicillin as the most effective antibiotic to treat R30's UTI. (Culture and sensitivity tests-After a specimen is sent to a laboratory, the laboratory technologist identifies the microorganisms growing in the culture. Additional test results indicate the antibiotics to which the organisms are resistant or sensitive. Sensitivity reports determine which antibiotics used in treatment are effective and need to be ordered for treatment.) *12/9/22 at 8:49 AM written by hospital physician Please call patient back, stop Macrobid, will need a prescription called in for ampicillin 500 mg p.o. (orally) 4 times daily for 1 week. *12/9/22 at 5:05 PM written by hospital Registered Nurse (prior to R30's 1st dose of Macrobid per facility MAR) revealed, Attempted to contact pt. (patient) Left voicemail. *12/11/22 at 8:38 AM written by hospital Registered Nurse Faxed to (facility) with direction to nurse responsible. Review of R30's Electronic Health Record (EHR) revealed no documentation that the provider was notified of the Urine C&S result or the hospital providers order to stop Macrobid and start Ampicillin. Review of R30's EHR revealed no Physician/Provider assessments/notes for R30 since 11/17/22. R30's EHR revealed no documentation that the Physician/Provider was notified of the Urine C&S result or that the Physician/Provider directed facility nurses to continue using Macrobid over Ampicillin. During an interview on 01/05/2023 at 11:24 AM, Registered Nurse/Infection Control Preventionist (RN/ICP) S reported that she had not been made aware of the hospital order to change R30's Macrobid to Ampicillin prior to R30 being sent back to the Emergency Department on 12/16/22. RN/ICP S reported that as the Infection Control Preventionist she would have expected the facility nurses to notify R30's Physician/Provider as well as RN/ICP S of a Urine C&S report with recommended changes. During an interview on 01/05/2023 at 12:18 PM, RN/ICP S reported that she contacted R30's provider regarding the Urine C&S result and recommended antibiotic change following the interview on 01/05/2023 at 11:24 AM. RN/ICP S reported that R30's provider had not been notified by the facility staff of the results/recommendation on 12/9/22 and 12/11/22. RN/ICP S reported there were no Physician/Provider assessments/notes for R30 for the month of December 2022. Review of Hospital Records revealed R30 arrived in the Emergency Department on 12/16/22 at 3:04 PM and was admitted as an inpatient with Principal Problem .Pneumonia, UTI, Sepsis.

Based on interview and record review, the facility failed to thoroughly address grievances for 7 of 13 confidential group interview respondents, resulting in the potential for unmet needs, unresolved concerns and frustration for residents who live at the facility. Findings: Review of the facility policy Quality Assistance Procedure last reviewed/revised 1/1/2022 reflected Resident's, their representatives (sponsors), other interested family members, or resident advocates may file a Quality Assistance Form. The facility will provide a designated staff person who is approved by resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. The facility will consider the views of a resident or family group and act upon the assistance request and recommendations of such groups concerning issues of resident care and life in the facility. The policy specified 1. Any resident, his or her representative (sponsor), family member, or resident advocate may file a Quality Assistance Form concerning treatment, medical care, behavior or other residents, staff members, theft of property, etc. without fear of threat or reprisal in any form .4. Quality Assistance request may be submitted orally or in writing. The administrator may delegate the responsibility of Quality Assistance investigation to appropriate department manager .5. The resident, or person filing the Quality Assistance Form on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. During a confidential group interview on 1/4/2023 at 2:00 PM, 7 of 13 residents in attendance reported they were frustrated with the facility response to reported concerns. Residents in the group interview said they were not sure where to find a Quality Assistance Form. Residents reported that they have had ongoing concerns with call light response times, cold food and a failure to pass out evening snacks. The residents expressed frustration with the lack of facility response and indicated it doesn't do them any good to report concerns. Review of Resident Council Minutes from June 2022-December 2022 reflected that in 6 of the 7 months of meetings, residents reported extended call light response times or reported staff will not return to meet their need after they answer the call light. Cold food was reported as a concern in August 2022 and again in October 2022. Residents reported they were not being offered evening snacks in November and again in December 2022. During an interview on 1/5/2023 at 2:08 PM, the Nursing Home Administrator (NHA) reported that they were aware there were some inconsistencies with the grievance process at the facility. The NHA said they transitioned to an electronic format and that was contributing to missing some follow-through. According to the NHA, the facility did a thorough review of food temperatures in response to the complaints received from the resident council and thought the issue had been resolved. The NHA reported that they completed a call light response audit and did not identify that there was a delay in call light response time. Review of Call Light Function Audit Tool documents from November 2022 and December 2022 (18 pages in total) reflected the majority of call light response times were excellent. However, the call light audit tool was not used consistently by staff observing the activity as evidenced by the majority of audits did not include a time of day and were limited in scope (very few rooms reviewed per day and time frame). The limited audit could contribute to an uniformed conclusion related to the reported concerns and subsequent frustration expressed by residents who reported a lack of facility response to an ongoing issue.

Based on interview and record review, the facility failed to evaluate and arrange for a legal representative for 1 resident (Resident #23) reviewed for decision making capabilities. This deficient practice resulted in R23 demonstrating repeated impaired decision-making ability on assessments and potentially unsafe and uninformed medical decisions. Findings include: The facility provided the policy Residents' Rights Regarding Treatment and Advance Directives dated 10/18/2020 with a revised date of 1/1/2022. The policy reflected, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .4. The facility will periodically assess the resident for decision-making abilities and approach the healthcare proxy or legal representative if the resident is determined not to have decision making capacities. 5. The facility will identify or arrange for an appropriate representative for the resident to serve a primary decision maker if the resident is assessed as unable to make relevant health care decisions. 6. The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate. Resident #23 (R23) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R23 admitted to the facility on [DATE], with a diagnosis that included (but not limited to) cognitive communication disorder (difficulty with thinking and how someone uses language). Brief Interview for Mental Status (BIMS) reflected a score of 2 out of 15 which represent R23 had severe cognitive impairment. The Face Sheet reflected that R23 was his own responsible party for health care and financial decisions. During an interview on 1/4/23 at approximately 11:30 AM, R23 was observed resting in his bed. R23 told this Surveyor that he was hungry. When asked if he had eaten breakfast, R23 stated he could not recall. When asked what he usually likes to have for breakfast, R23 stated, food. When asked if he received his medication timely manner, R23 stated, I guess. When asked about other aspects of care such as vaccines, showers, or skin issues, R23 continued to give vague and nonspecific answers. Review of the MDS and BIMS on 6/3/22 and 9/1/22 both reflected a score of 0 which revealed R23 had severe cognitive impairment for an extended period. R23 had short-term and long-term memory deficits along with deficits in safety awareness and decision-making abilities. Review of the care plan dated 12/2/21, last revised on 12/2/21 with a focus of Self-determination related to advanced directive: resident is his own decision-maker at this time. Petition for Guardianship discussed with resident and brother. The intervention of Document when resident does not have the capacity to make decisions and refer to legal representative dated 12/2/21. During an interview on 1/4/23 at 3:50 PM, Social Worker (SW) F confirmed R23's BIM scores and was asked if a physician had evaluated R23 for competency or if legal action to appoint a legal resident representative was pursued on behalf of the facility, SW F stated not that she was aware of. SW F stated the R23's family member assisted R23 in decision making when needed. During an interview on 1/4/23 at 3:58 PM, Director of Nursing (DON) was asked if the facility followed the policy to have R23 evaluated for competency due to his low BIM's scores and the DON stated he was not able to locate a physician competency evaluation in the electronic health record. When asked if the facility had requested a legal representative for R23, the DON stated the facility had not done that because the staff felt R23 had the ability to make appropriate decisions for himself.

Based on observation and interview, the facility failed to provide a safe and sanitary environment in the laundry, resulting in the potential for the spread of infection and disease transmission to the facilities total census of 70 residents and its staff. Findings include: On 10/6/21, during an environmental tour of the facility the following observations and interviews took place: On 10/6/21 at 3:10 PM, multiple areas of the concrete floor near the metal floor grates of both washing machine discharge lines were observed pitted, cracked, and with sections missing (ranging in size from one inch to eight inches in length, and one half inch to three inches in depth) in the facility's laundry room. Upon observation the surveyor inquired with the Account Manager staff A, on current state of the flooring to which they stated, yeah it's a trip hazard for sure. We don't even step on the grates, we walk over them just in case. It's been like that for some time. On 10/6/21 at 3:15 PM, the number one washing machine was observed with puddle of liquid approximately 22 inches by 14 inches in size in front of the unit. Upon observation the surveyor inquired with staff A on the root cause of the puddle to which they stated, it's probably been leaking for about six months. They came and replaced a line, but they need to seal around the door so the water doesn't come out. Maintenance is aware of it. At this time the District Manager, staff B, stated, we will be talking to Maintenance about the floor and the washing machine today.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) for a level II OBRA evaluation was completed for 1 (Resident #5) reviewed for PASARR, resulting in the potential for the resident to not receive appropriate mental health treatment and services in the most integrated setting appropriate. Findings include: Review of a Face Sheet revealed Resident #5 was a [AGE] year old male originally admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) indicating he is moderately cognitively impaired and is taking antipsychotics and antidepressants. Review of a PASARR form DCH-3877 Hospital Exempted Discharge form dated 6/18/21 revealed Resident #5 has a mental illness and was to have form DCH-3878, level II screening completed and sent to the local Community Mental Health Services Program (CMHSP). Review of a PASARR form DCH-3877 Change in Condition form dated 9/29/21 revealed Resident #5 has a mental illness and was to have form DCH-3878, level II screening completed and sent to the local CMHSP. Review of a Care Plan for Resident #5 revealed he has a care plan for developmental disabilities and has moderate cognitive impairment. He also is care planned for major depressive disorder with [CONDITION(S)] medication use. In an interview on 10/7/21 at 10:42 a.m., Social Worker (SW) P reported that a Hospital Exempted discharge on a PASSAR is only good for 30 days before another form needs to be completed and sent to the local CMHSP for further evaluation. SW P reported OBRA (Omnibus Budget Reconciliation Act) people were at the facility this day and potentially initiating a lower level of care for Resident #5 who was previously residing at an Adult Foster Care (AFC) facility. SW P acknowledged a level II needed to be done and submitted timely and that Resident #5 did need nursing care services to attend to his [CONDITION(S)].

Based on interview and record review, the facility failed to ensure timely Preadmission Screening and Resident Review (PASARR) post Hospital Exempted Discharge were initiated and submitted to the local state agency for evaluation of mental illness and/or intellectual development disability needs for 1 (Resident #5), resulting in the potential for unmet mental health and psychiatric care needs. Findings include: Review of a Face Sheet revealed Resident #5 was a [AGE] year old male originally admitted to the facility on [DATE]with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) indicating he is moderately cognitively impaired and is taking antipsychotics and antidepressants. Review of a PASARR form DCH-3877 Hospital Exempted Discharge form dated 6/18/21 revealed Resident #5 has a mental illness and was to have form DCH-3878, level II screening completed and sent to the local Community Mental Health Services Program (CMHSP). Review of a PASARR form DCH-3877 Change in Condition form dated 9/29/21 revealed Resident #5 has a mental illness and was to have form DCH-3878, level II screening completed and sent to the local CMHSP. Review of a Care Plan for Resident #5 revealed he has a care plan for developmental disabilities and has moderate cognitive impairment. He also is care planned for major depressive disorder with [CONDITION(S)] medication use. In an interview on 10/7/21 at 10:42 a.m., Social Worker (SW) P reported that a Hospital Exempted discharge on a PASSAR is only good for 30 days before another form needs to be completed and sent to the local CMHSP for further evaluation. SW P reported OBRA (Omnibus Budget Reconciliation Act) people were at the facility this day and potentially initiating a lower level of care for Resident #5 who was previously residing at an Adult Foster Care (AFC) facility. SW P acknowledged a level II needed to be done and submitted timely and that Resident #5 did need nursing care services to attend to his [CONDITION(S)].

Based on interview and record review, the facility failed to assess the neurological status in one (Resident #64) resident after a fall. This deficient practice placed Resident #64 at risk for potential neurological changes to go undetected after an unwitnessed fall. Findings include: Resident #64 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #64 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which represents Resident #64 had severe cognitive impairment. Resident #64 required staff assistance for all activities of daily living. The progress note dated 9/11/21 at 5:54 AM reflected Resident #64 had an unwitnessed fall in his room with no acute injuries noted but neurological assessments were initiated to continue to monitor for latent effects. The facility provided a copy of the neurological assessments dated 9/11/21 from 5:40 AM to 9/13/21 at 10:00 PM for review. The facility used a form titled Neurological Evaluation Flow Sheet to record the assessment findings. The form reflected the following frequency to assess, Complete checks: every 15 minutes x 1 hour, every 30 minutes x 2 hours, every 1 hour x 2 hours, every shift x 72 hours. Of the 19 opportunities identified on the flow sheet the resident was assessed only 4 times: 9/11/21 at 5:40 AM and 10:00 PM, 9/12/21 at 10:00 PM, 9/13/21 at 6:00 AM and 9/13/21 at 10:00 PM. The progress notes and orders did not reflect directions to deviate from the suggested frequency resulting in incomplete monitoring and assessing after a fall. On 10/8/21 at 10:38 AM, the Director of Nursing was asked for any other information to review prior to the exit of this survey and no further documents were presented.

Based on observation, interview and record review, the facility failed to implement measures to support 1 resident (Resident #48) who is flaccid and has one sided weakness, resulting in potential to cause further complications. Findings include: Review of a Face Sheet revealed Resident #48 is a [AGE] year old female originally admitted to the facility on [DATE] and has pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had a Brief Interview for Mental Status (BIMS) indicating she is cognitively intact and requires extensive assistance of one person for transfers. During an observation during initial tour on 10/5/21, Resident #48 observed in her wheelchair with her left arm flaccid and hanging down dependent to gravity. The left side of the wheelchair had a padding on it. During an observation on 10/6/21 at 10:13 a.m., Resident #48 was in her wheelchair with her left arm flaccid and hanging down her side between her body and her wheelchair. Resident #48 denied any concerns. In an interview on 10/7/21 at 11:22 a.m., the Rehabilitation Director (RD) N reported Resident #48 was currently in therapy for a couple recent falls. PT N reported the resident had been at the facility for a long time and did not know if the resident had an assistive positioning/supportive device for her left arm. PT N reported flaccid arms are usually elevated for comfort and another therapist in the room reported she thought the resident at one time had a sling but did not like it. They could not provide any documentation indicating Resident #48 had an evaluation for positioning of her left arm or measures implemented to prevent further decline. In an interview on 10/7/21 at 11:41 a.m., Certified Nursing Assistant (CNA) M reported she is unaware of Resident #48 needing any positioning devices for her arm. During an observation and an interview on 10/7/21 at approximately 4:00 p.m., Resident #48 was in the doorway to her room in her wheelchair and her arm was dependent to gravity. When queried about her arm, she reported she would like her arm elevated on a tray or something for comfort. Several times during the survey, Resident #48 was observed supporting her flaccid hand with her right hand. Review of the Order Summary for Resident #48 revealed no orders for positioning devices. Review of the Care Plan revealed no positioning or range of motion interventions for Resident #48's left sided weakness.

Based on observation, interview and record review, the facility failed to ensure a medication administration error rate less than 5%. This deficient practice resulted in two errors made with medication administration out of 26 medication opportunities observed and an error rate of 7.69% which put Resident #16 and Resident #45 at risk for undesired outcomes. Findings include: During an observation of a medication pass on 10/7/21 at 5:00 PM, Nurse H prepared medication for Resident #45. Nurse H crushed two tablets of [MEDICATION(S)] EC 5 mg (medication used to stimulate the bowel), placed it in pudding and administered it to Resident #45. During an observation of a medication pass on 10/7/21 at 5:19 PM, Nurse H prepared medication for Resident #16. Nurse H pulled apart a capsule of Tamsulosin 0.4 mg (a medication used to treat enlarged prostate), placed it in pudding and administered it to Resident #16. The facility provided a copy of Medications Not To be Crushed list from the medication book on the medication cart. The record reflected [MEDICATION(S)] with a reason code 1 and 17 and Tamsulosin with a reason code 2. The record reflected the following, 1. [MEDICATION(S)] coated formulation. 2. Time release formulation .17. Antacids and/or milk may prematurely dissolve the coating of the tablet. On 10/8/21 at 11:25 AM, the Director of Nursing was asked for any other information to review prior to the exit of this survey and no further documents were presented.

Based on observation, interview, and record review, the facility failed to provide complete and adequate Foley catheter care for 1 (#326) Resident reviewed, resulting in the likelihood development of catheter acquired urinary tract infection (CAUTI) and the use of antibiotic. Findings include: Record review of facility 'Catheter Care, Urinary' policy/procedure dated 1/2013, revealed the purpose of this procedure is to prevent infection of the resident's urinary tract. Steps of Procedure: (#26) With non-dominant hand retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure. (#27) Assess the urethral meatus. (#28) For the Male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular [MEDICAL CONDITION] from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. (#29) Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. (#32.) Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. (#33) Reposition the bed covers The U.S. Food and Drug Administration is advising that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with acute sinusitis, acute [MEDICAL CONDITION], and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options. An FDA safety review has shown that fluoroquinolones when used systemically (i.e. tablets, capsules, and injectable) are associated with disabling and potentially permanent serious side effects that can occur together. These side effects can involve the tendons, muscles, joints, nerves, and central nervous system. (https://www.fda.gov/Drugs/DrugSafety/ucm 3.htm) Resident #326: Record review of resident #326's admission Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year-old male. The MDS assessment noted the Resident #326 to need two-person physical assist with dressing, toileting and bathing. Section H bladder and bowel noted an indwelling catheter. Medical [DIAGNOSES REDACTED]. Record review of Resident #326's Medication Administration Record [REDACTED]. In an interview on 09/11/19 at 01:11 PM, Registered Nurse (RN) Infection Control N revealed that Resident #326's catheter acquired urinary tract infection (CAUTI) was a facility acquired UTI, had a catheter in place due to [MEDICAL CONDITION], and had a referral to Urologist. RN N stated that Resident #326 was started on [MEDICATION NAME] mg BID (twice daily) until 9/15/19, due to culture results of pseudomonas aeruginosa (bacteria) over 100,000 organisms. Record review of resident #326's laboratory services urine analysis culture and sensitivity results dated 9/4/19 revealed: pseudomonas aeruginosa greater than 0 and other organisims. Observation on 9/11/19 at 3:16 PM of Resident #326's Foley catheter care provided by Certified Nurse Assistants Q and R, revealed that the certified nurse assistants (CNA) washed their hands and donned gloves, rolled the resident from side to side to lower the pants and loosen the brief. CNA Q then grabbed a washcloth from the bedside table, placed the washcloth into the soapy water basin at bedside and washed the resident from the groin area inward, across the top of the perineum and down the sides. Put the washcloth back into the wash basin and pulled out the washcloth squeezed the cloth and wiped the outside of the uncircumcised foreskin. Put the washcloth back into the basin and squeezed the cloth and wiped the underside of the foreskin and testicular region. CNA Q then put the washcloth back into the water basin and squeezed out the cloth and wiped the catheter tubing from where the foreskin laid over onto the tubing and downward toward the catheter y connection. CNA Q then put the washcloth back into the basin and the squeezed out the cloth and wiped the catheter tube down beyond the catheter y connection site toward the collection bag. CNA R then used a towel to dry the areas off and assisted CNA Q to do up the resident #326's brief and roll the resident from side to side and pull up the pants. Both CNA Q and R placed bed pillows under the resident's feet and pulled the bed covers up over the resident and assisted the resident into a comfortable position. CNA R then came around the bed and emptied the drain bag and alcohol wiped the drain bag spout with the same gloves used during the whole procedure and emptied the graduate container. CNA Q, while wearing the same gloves used during the procedure, collected the water basin and supplies, emptied out the basin, dried it with paper towels, and put the basin in a drawer. CNA Q then walked over and placed the rolling overbed table within reach of the resident and then took off her gloves. In an interview following the catheter care procedure on 9/11/19 at 3:30 PM with Certified Nurse Assistant (CNA) Q she stated that, No he's not circumcised. The State Surveyor asked why not pull the foreskin back and clean the head and site? CNA Q stated that, I usually would, but I just laid him down. I should have done that. The State Surveyor asked if CNA Q knew if Resident #326 had a urinary tract infection? CNA Q stated, I didn't know he had a urinary tract infection. Record review of Resident #326's Medication Administration Record [REDACTED]. In an interview and record review on 09/12/19 at 09:06 AM, Registered Nurse/Assistant Director of Nursing (ADON) and staff Educator V, revealed that the catheter care education was done with the staff on their annual competency. Record review of Certified Nurse Assistant (CNA) Q was a return employee, who came back on or started employment on 7/24/19. Record review of CNA Q's Orientation/Competency Skills Checklist form dated 7/29/19 was signed off on the care by RN V. RN V stated that, We discussed catheter care yesterday about 2:00 PM prior to demonstrating for you. Surveyor asked how uncircumcised penis catheter care is done? RN V stated by pulling back the foreskin, clean it and then replace the foreskin. In the Orientation education materials, we talk about catheter care. We have online orientation materials. I will print those off. I don't have anything on paper, we talk about it, it's on the competency check list. It was only verbal education given. I have nothing written just the return demonstration. No, we just did verbal (education) with CNA Q, also yesterday was verbal (instructions).

Based on observation, interview and record review, the facility failed to ensure that drug regimens for 3 of 4 sampled residents (#6, 8 and 11) reviewed for antipsychotic drugs and 1 of 2 sampled residents (#8) reviewed for antibiotic use from a total sample of 15 residents, were free from medications used without adequate indications for it's use, without adequate monitoring, with an excessive dose or in the presence of adverse conditions, resulting in a decline in functioning, falls and an unplanned significant weight loss as being caused or contributed to by the use of an antipsychotic drug for resident #6 and an increased risk of side effects from potentially unnecessary drugs for all three residents. Findings include: A review of the face sheet (undated) and the October 2014 physician's orders [REDACTED]. She was admitted to the facility on [DATE]. According to physician's orders [REDACTED].#6 was admitted to the facility receiving 75mg (milligrams) a day of the antipsychotic medication [MEDICATION NAME] for "[MEDICAL CONDITION]". The targeted behaviors listed on the "Mood and Behavior Symptom" Care Plan dated 6/8/14 were "Delusions and Hallucinations and is not easily redirectable.. and Delusions that other men are her husband and she needs to pack her things to go home". There was no documentation in the record that Resident #6 had ever been a danger to herself or others or had delusions or hallucinations that were distressing and impaired her functioning. This was confirmed in an interview with the facility Administrator, staff "A" and the Director of Nursing, staff "B" on 10/28/14 at 1:20 p.m. During this same interview on 10/28/14 at 1:20 p.m. the Administrator, staff "A" and the Director of Nursing, staff "B" confirmed that their behavior monitoring system used by the facility did not allow to identify the time, place and what may have precipitated the behaviors in order to identify the root cause or identify a pattern of behaviors to develop and implement non-pharmacological interventions. The system currently used only allowed for yes and no answers per shift to note when the behaviors occur. Furthermore, it did not allow for the delusions or hallucinations to be specifically described; this made it impossible to note if the resident was distressed. by the delusions or hallucinations. In addition, multiple medications changes were made the same day according to telephone orders dated 8/6/14, "Increase [MEDICATION NAME] to 250 mg po (by mouth) bid (twice a day); increase [MEDICATION NAME] to 1 mg po q (every) 4 (hours) prn (as needed); increase [MEDICATION NAME] to 200 mg po bid and [MEDICATION NAME] 20 mg 1 dose now and [MEDICATION NAME] 10 po 1 dose now". It was difficult to monitor the effectiveness or problems of each individual medication intervention. A physician's note dated 8/12/14 stated, "[MEDICATION NAME] may have added to her aggression as it can do that at times" but he did not change or adjust the dose of [MEDICATION NAME] being used for "behaviors". The [MEDICATION NAME] was increased from 75 mg per day on admission- 5/22/14 to 500 mg per day which was the last dose increase made on 9/4/14. The timeline for the dose changes (increase) of the [MEDICATION NAME] was as follows: 5/22/14 Admission 25 mg AM 75 mg PM Total: 100 mg per day 6/10/14 50 mg AM 100 mg PM Total: 150 mg 7/19/14 75 mg AM 100 mg PM Total: 175 mg Aug. no date 150 mg twice a day 25 mg as needed Total: 325 mg. 8/7/14 200 mg twice a day Total: 400 mg 9/4/14 200 mg twice a day 100 mg every morning Total: 500 mg. The maximum recommended dose according to the State Operations Manual, revision 107 dated 04-04-14 for the elderly was 150 mg of [MEDICATION NAME] per day. Any dose exceeding this should be explained by the physician. There was no individualized assessment to justify the increased dose, the relative risks versus benefits of the use of the antipsychotic medication which addressed either specific targeted behaviors, or addressed the Federal Food and Drug Administration's (FDA) Black Box Warning which stated, " These medications (Antipsychotic medications) are not approved for the treatment of [REDACTED]. A review of the Minimum Data Sets (MDS used to quantify the residents' condition) dated 5/29/14 (Admission MDS) and 8/11/14 (Significant Change in Condition) showed a decline in several Activities of Daily Living and other conditions as follows: From "independent" with transfers and ambulation to "extensive assistance of 2 or more staff" for both transfers and ambulation. From "supervision" to "extensive assistance of 2 or more staff" for locomotion (use of wheelchair). From no falls prior to admission to 3 falls, 2 with no injury and one with minor injury. From 149 pounds to 134 pounds - a 10.1% weight loss in less than 3 months, (Resident #6 continued to lose weight- the last recorded weight on the Weight Details Report was 127.6 pounds for 9/2014 which was a 14.8% unplanned loss since admission. In addition, Nurses' notes of 8/6/14; 8/7/14; 8/16/14; 8/17/14; 8/19/14; 8/29/14; 9/2/14; 9/3/14; 9/4/14; 9/10/14; 9/18/14; 9/23/14; 9/26/14 and 9/27/14 all mention that Resident #6 was "drowsy" and this was not evaluated as a possible side effect of the [MEDICATION NAME]. There was no documentation in the record that the physician, pharmacist or the Consulting Psychiatrist ever evaluated any of Resident #6's decline that may have been (possibly) caused by the excessive dose of the antipsychotic medication in lieu of her medical conditions. In an interview with the facility Administrator, staff "A" and the Director of Nursing, staff "B" on 10/28/14 at 1:20 p.m., they agreed that the facility had "dropped the ball" on this case. ( ) During the review of resident #11's medical record, her admission face sheet dated May 20, 2014 documented a date of birth on September 15, 1976 ([AGE] years old) with [DIAGNOSES REDACTED]. Resident #11's drug regimen on admission to the facility did not include an antipsychotic drug. According to a physician's progress note dated September 12, 2014, resident #11 had increased wandering, passing eye contact, poor attention span, with a gait that was fast paced. Theses notes included the assessment that resident #11 had a change in mental status, [MEDICAL CONDITION], with hypomanic/manic [MEDICAL CONDITION]. Physician's plan of care documented to increase resident #11's [MEDICATION NAME] to 10 milligrams (mg) by mouth daily. According to the physician's orders [REDACTED]. Zyprex is classified pharmacologically as an atypical antipsychotic drug. In addition to starting resident #11 on [MEDICATION NAME] September 11, 2014, the physician's orders [REDACTED]. Also, the physician's orders [REDACTED]. Thus, there were three drugs changed on September 12, 2014 with the addition of [MEDICATION NAME] 5 mg twice daily, [MEDICATION NAME] 250 mg three times daily, and discontinuation of [MEDICATION NAME]. During an interview with staff nurse (S) on October 30, 2014 at 10:00 a.m., she stated that resident #11 had an increase in behaviors just prior to the September 11, 2014 with the addition of [MEDICATION NAME]. Nurse (S) stated that resident #11 was more agitated, wandering into other residents rooms, hovering over residents and getting into their personal space. On October 30, 2014 at 10:20 a.m., resident #11 was observed going in and out of her room independently, walking around the nursing station repeatedly, and going in and out of the activity room. Resident #11 had a blank stare on her face, and never spoke. She was unable to keep her attention span. Yet, with the addition of the antipsychotic drug [MEDICATION NAME], along with [MEDICATION NAME] which is indicated for mood stabilization, and the discontinuation of [MEDICATION NAME] and [MEDICATION NAME], there was no adequate way to monitor the effectiveness of [MEDICATION NAME] in treating her [MEDICAL CONDITION] and manic behavior. ( ) According to a facility face sheet dated 4/7/14, Resident #8 was a [AGE] year old female admitted to the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. Resident #8 experienced an increase in antipsychotic medication without ruling the cause of the [MEDICAL CONDITION] may be caused by a urinary tract infection on 2/6/14. Lab results for Resident #8 dated 2/10/14 at 1:51 p.m., indicated that Resident #8 had a urinary tract infection with white blood cells of 65 to 80 ( increase in cells during an infectious process ). The urine culture indicated Resident #8 had a urinary tract infection from E. Coli. According to facility documents titled, "Progress Notes" dated 2/7/14 at 8:45 a.m. reflected, "Resident (#8) combative with staff. Hit CNA (Certified Nurses Aid) and yelling. Accusations of staff hitting and kicking her. Housekeeping and Restorative (nursing) and CNA in room with resident (#8). False accusations". A Progress Note dated 2/13/14 at 8:30 p.m. reflected "Antibiotic started this shift for UTI". A timeline for antipsychotic medications for Resident #8 presented by Licensed Recreational Therapist on 10/30/14 (no time noted) reflected, "Resident (#8) had increased target behavior, delusions and hallucinations in late January 2014. [MEDICATION NAME], ( antipsychotic medication ) increased 2/6/14 to 5 mg (milligrams)". [MEDICAL CONDITION] "called the acute confusional state, [MEDICAL CONDITION] is a medical condition that results in confusion and other disruptions in thinking and behavior, including changes in perception, attention, mood and activity level. Individuals living with dementia are highly susceptible to [MEDICAL CONDITION]. Unfortunately, it can easily go unrecognized even by healthcare professionals because many symptoms are shared by [MEDICAL CONDITION] and dementia. [MEDICAL CONDITION] may be the first and perhaps only clue of medical illness or adverse medication reaction in the Alzheimer ' s individual. Report such " clues " as a change in bowel or bladder habits, ankle swelling, respiratory symptoms, pain or fever." http://www.alz.org/norcal/in_my_community_ .asp " Urinary tract infection [MEDICAL CONDITION] is a type of infection which is common among older people. Women are more commonly affected than men. If a person with a memory impairment or dementia has a urinary tract infection, this can cause severe confusion known as '[MEDICAL CONDITION]'. UTI can cause confusion in older people and people with dementia. If the person has a sudden and unexplained change in their behavior such as increased confusion, agitation, or withdrawal, this may be caused by a UTI ". http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=1777 According to documentation from a local acute mental care facility dated 8/4/14 at 10:20 a.m. reflected that Resident #8, "Is a [AGE] year old Caucasian female with the known [DIAGNOSES REDACTED]. She (Resident #8) was admitted on a petition and certification only to find out she is currently on deferral status from her recent admission to (name of another acute care mental facility) in June. She (Resident #8) has a durable power of attorney with her son and daughter having the power of attorney. They do not have the guardianship. I spoke with her daughter today who reports that the patient (Resident #8) has not had any mental health difficulties in her life. She (Resident #8) was a very active person until about [AGE] years ago when they noted the first signs of dementia". A timeline for antipsychotic medications for Resident #8 presented by Licensed Recreational Therapist on 10/30/14 (no time noted) reflected, Resident (#8) was diagnosed by a Nurse Practitioner on 6/16/14 with "[MEDICAL CONDITION] disorder". [MEDICATION NAME] is indicated for use in treating [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] with depressive episodes and not approved for treatment of [REDACTED]. http://www.rxlist.com/[MEDICATION NAME]-drug/indications-dosage.htm Resident #8 was not diagnosed with [REDACTED].#8 was noted to have begun exhibiting symptoms of dementia. " WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [MEDICAL CONDITION]: Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. [MEDICATION NAME] ([MEDICATION NAME]) is not approved for the treatment of [REDACTED]. " http://www.drugs.com/pro/[MEDICATION NAME].html A document was presented on 10/30/14 by Director of Nursing "B" titled, "Risk vs Benefit Statement for Antipsychotic Medication Use" for Resident #8 dated 10/29/14. Prior to the entrance date of this survey (10/28/14), there was no Risk vs Benefit completed for Resident #8 given the warning. During an interview on 10/31/14 at 8:20 a.m., Director of Nursing "B" confirmed there was no Risk vs Benefit completed before the beginning of the survey for Resident #8's use of antipsychotic medication. According to a facility policy titled, "Psychoactive Medications", revised last on October 2009 reflected the procedure, "Review of psychoactive medication that may include: ...Care Tracker Mood and Behavior Reports". Review of Resident #8's Care Tracker report found the behaviors were monitored as they were presented in the Minimum Data Set (MDS) assessment: wandering, verbal abuse, physical abuse, social inappropriateness, resisting care, delusions, hallucinations, and suicide/self harm. Review of January 2014 through October 2014 Care Tracker Report for Resident #8 reflected numbers of occurrences for each of these behaviors but no specific date, time, what was occurring before the behavior, specific behavior, specific hallucination or delusion and if the resident found them distressful nor the interventions used to alter these behaviors. The behavior tracking device used for Resident #8 did not identify a root cause (time, date, area, occurrence, specific behavior) and a non-pharmacological intervention to address the behavior. Resident #8 received the full course of an antibiotic; however, the identified organism causing the infection was resistant to the prescribed antibiotic. Review of a facility "Interim Orders" dated 9/25/14 (no time noted) for Resident #8 reflected "Bactrim DS (double strength) 160/800 mg (milligrams) by mouth BID (twice a day) for 3 days Diagnosis: [REDACTED]. This order indicated that an antibiotic was prescribed before receiving the culture and sensitivity. Lab results for Resident #8 dated 9/24/14 at 11:45 p.m., for a urine culture and sensitivity indicated that the organism (E Coli, a bacteria) causing the urinary tract infection for Resident #8 was greater than 320 resistant to Bactrim DS. This organism would not be effectively treated by Bactrim DS ordered for Resident #8 . Another lab results for Resident #8 dated 10/8/14 at 12:06 p.m., for a urine culture and sensitivity indicated that the organism (bacteria) causing the urinary tract infection for Resident #8 was again E Coli. The culture and sensitivity for Resident #8's UTI again indicated that her E Coli was resistant greater than 320 to the Bactrim DS. This time another antibiotic, [MEDICATION NAME] was prescribed to which the E Coli was susceptible. During an interview with Director of Nursing (DON) "B" on 10/30/14 at 1:12 p.m., (DON) "B" noted that when she was handed the Infection Surveillance Report, Resident #8 was treated with an antibiotic that her UTI (The bacteria E Coli) was resistant to during the period of 9/25/14. Review of Resident #8's Medication Administration Record [REDACTED]. Using an incorrect antibiotic could lead to antibiotic resistance. "Antibiotic resistance is the ability of bacteria to withstand the antimicrobial power of antibiotics. Simply put, antibiotics that used to cure an infection do not always work anymore". http://www.drugs.com/article/antibiotic-resistance.html Resident #8 was treated with a resistant antibiotic for her urinary tract infection and was diagnosed for a second time with UTI for the same bacteria. Resident #8 had an increase of the antipsychotic drug, [MEDICATION NAME] without considering whether her increased behaviors may be a result of her UTI and without adequate monitoring of the targeted symptoms. ( )

Based on observations, interviews and record review, the Facility failed to provide medically related social services to attain the highest practicable physical, mental and Psychosocial well-being for 1 of 3 total sampled physically combative Residents (#101), resulting in Resident #101 sustaining a fractured left hand index finger while being showered and displaying behavior problems and the potential for further injuries and abuse due to on-going physically combative behaviors. Findings include: Review of the clinical record face sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old woman, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. and required extensive assistance of 2 with Activities of Daily Living. Review of the Behavior care plan dated as re-written on 12/28/12 for Resident #101 revealed the Facility identified verbal and physical behaviors such as hitting/slapping during care and pounds on lap tray while verbalizing God gestures. The interventions for staff to follow when Resident #101 becomes "combative during care"dated as reviewed on 3/13/13 were to sing, talk about food or drinks, secure safety, leave and return as well as explain all steps of care, talk calmly during care and play music of interest(music of interest not identified).On 5/20/13 an antidepressant was listed as an intervention for depression. There were no other non medicational interventions listed after 3/13/13. Review of the Facility's Incident/Accident report dated 5/1/13 at 6:51 AM, revealed Resident #101 was found with a painful, swollen and bruised Left hand. Resident #101 was sent to the Hospital assessed and treated with a splint for her Fractured Left Hand Index finger. Investigation completed by the Director of Nursing (DON#2), revealed the origin of the injury occurred during a shower on 4/30/13 at 3:00 PM when Resident #101 was reported to have "punched the tile wall while being combative during a shower." The action taken was to shower Resident #101 in the community shower where there is more room for her instead of in her private shower, located in her room. An observation on 6/10/13 at 10:35 SM, revealed Resident #101, in her room, laying in bed, dressed in shirt and a brief, without pants. A blanket covered her legs. Her bed was in a low position. The left side was against the cinder block wall and the right side had a mat on the floor next to the bed. There was no splint on her hand and no obvious bruising or swelling observed. An interview was attempted, however Resident #101 mumbled non-scenical, repetitive sounds. When asked if she was "OK", Resident #101 said,. "yes I am". In an interview on 6/10/13 at 3:15 PM, CNA #6 said she was giving Resident #101 a shower at about 3:00 PM on 4/30/13 and Resident #101 pounded her left hand onto the tile wall in her private bathroom. CNA#6 said she pulled her away from the wall and thought she was fine, but began swelling in the evening. CNA#6 said Resident #101 is combative the "vast majority" of the time and "you always need 2 people because she's not safe." During an interview with the Facility's Social Worker (SW#3) on 6/10/13 at 1:00 PM, SW#3 said Resident #101's behavior log sheets are pulled daily and reported at a meeting, however SW#3 said she has not done any weekly or monthly behavior reviews to determine if the behaviors have decreased or increased or if the interventions were effective. SW#3 said she had only reported the listed behaviors. SW#3 said Resident #101 has not been seen, assessed or evaluated by any outside psychiatric services but thinks Resident #101 should have, however she just started working at the Facility as of 5/1/13. SW#3 said Resident #101 is on the medications Ativan(anti-anxiety) and Remeron (anti-depressant), for her behaviors but was not sure if they had been effective or not. Review of the Facility's Behavior report for Resident #101 revealed the following behaviors were recorded Physical Verbal Other In March 2013: 28 16 6 In April 2013 51 17 13 In May 2013 40 25 15 June 1 through June 9 16 8 6 Review of the Facility's Bowel and Bladder Chart Detail Report dated 5/18/13 revealed Resident #101 was given incontinent care only once on the second (documented at 10:40 AM) and third (7:52 PM), shift. Review of the Facility's Incident/Accident report dated 5/18/13 at 9:00 PM, revealed Resident #101 was being provided care and CNA#8 witnessed CNA#7 use verbal profanity toward Resident #101. After the question, "Was the Resident exhibiting behavior symptoms prior to the incident?" was written, "Resident is combative with care. Resident attempted to grab and hit CNA's during PM ADL cares." In a phone interview on 6/10/13 at 11:00 AM, Certified Nurse Assistant (CNA#8) said on 5/18/13 in the evening, she and CNA#7 were getting Resident #101 ready for bed and Resident #101 was combative, "as usual". CNA#7 held Resident #101's hands down while CNA#8 said she washed her up after an incontinent episode of urine and bowel movement. CNA#8 said CNA#7 let go of Resident #101's hand after she was finished cleaning her and Resident#101 hit CNA#7 who responded with profanity towards Resident#101. CNA#8 said, "For months we have been charting about behaviors of (named Resident #101) and nothing seemed to be done." CNA#8 said the staff are not able to provide proper personal care for Resident #101 because of her combative behavior. In a phone interview on 6/10/13 at 12:35 PM, CNA#7 said on 5/18/13 she held Resident #101's hands down so CNA#8 could clean her up after she was incontinent. CNA#7 said Resident #101 hit her face when she let go of her hands and she "lost it" and swore at her. CNA#7 said Resident #101 has been combative for a long time and nothing is being done. CNA#7 said Resident #101 "bites, claws, pulls the curtains down, hits you. She only gets care once a shift because of her behaviors. She kept hitting the shower wall one day and broke her hand." CNA#7 said they reported it to the Charge Nurse (Registered Nurse #4). In a phone interview on 6/10/13 at 1:25 PM, RN#4 said she was not aware Resident #101 needed her hands held down in order for staff to provide personal care but did know she required 2 staff for care due to her behaviors. In an interview on 6/10/13 at 2:10 PM, Resident #101's attending Physician (MD#5) said he was not aware staff were only changing Resident #101 once a shift due to her behaviors. MD#5 said he thought her main behaviors were that she preferred to stay in her room. MD#5 said he was aware Resident #101 fractured her finger as a result of behavior problems during a shower when she pounded the tiled wall and he was aware staff used verbal profanity toward Resident #101 during her care. #

This citation pertains to MI# 830 Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive device to prevent an accident in 1 of 3 sampled residents (#103), of a total sample of 8, resulting in Resident #103 sustaining a fall with a head injury with acute intracranial hemorrhage and subdural hematoma after an inappropriate transfer. Findings include: Review of Resident #103's minimum (MDS) data set [DATE] revealed an [AGE] year old female with a brief interview of mental status (BIMs) score of 2 indicating severe cognitive impairment, and noted disorganized thinking. Resident #103's transfer and ambulation functional status was noted as extensive assist with one person physical assist. Assistive device noted the use of walker or wheelchair. Balance during transition and walking were assessed as not steady, only able to stabilize with staff assistance. Resident #103's [DIAGNOSES REDACTED]. Review of Resident #103's 'Fall/Injury Assessment: Prevention and Management Plan of Care', with a re-written date of 5/12 revealed that the resident assessment for fall/injury risk related to: Musculoskeletal unsteady; medical factors of exhaustion, weakness; Cognitive impairment factors of dementia; Sensory impairment factors of visual; Pharmacological factors of cardiovascular meds, narcotics; Poor safety awareness at times. Interventions noted: Ambulation and transfer assist of 1 person, walker, gait belt, non-skid socks/ on 2/15/11shoes were added, hipsters at all times (hip pads). Review of Resident #103's 'ADL (activity of daily living)/Mobility: Plan of Care', with a re-written date of 5/12 revealed that the resident assessed to provide assistitive device as needed for ambulation of gait belt and walker on 8/23/11 and provide assitive device as needed for transfer of gait belt 12/31/11 and walker 2/11/12. Review of Resident #103's 'Living Moments Care Delivery Guide' dated 11/27/12 revealed the resident was assist of 1 person with ambulation and transfers. Fall risk identified as non-skid foot wear. There was no documentation of walker, gait belt, hipsters or shoes noted on the care guide. Review of Resident #103's 'Resident Incident Report' dated 11/16/12 at 3:20 PM revealed that the nurse #6 was at the medication cart when she heard a noise and went down the hall and seen Resident #103 lying on the floor of her room on her back. Physical examination was noted that the resident put her hand on middle backside of head, acknowledged pain and stated 'it hurts little bit'. No wound or abrasion noted. The report noted that certified nurse assistant (CNA) #10 was the supervising staff member to the resident at the time of the fall. Review of Resident #101's 'Resident Incident Report' dated 11/26/12 at 7:15 PM revealed that staff entered the resident's room and that Resident #103 was lying on her back, right next to her bed. Physical examination was noted as 'Bump to the back of head' and a hematoma was noted of 4 centimeters on the parietal (skull). Level of pain was noted: 4-hurts little more. Review of Resident #103's 'Resident Incident Report' dated 12/8/12 at 9:30 PM revealed Resident #103 was walking with staff (CNA #10) when she fell and hit her head. Physical examination was noted as neuro with in normal limits, 122/82 sitting, 112/78 standing, and 160/66 lying. Pain noted to back of head, pain scale 6-hurts even more. Physical examination of injury noted as contusion, laceration and swelling to back of the head. Resident incident description was noted as "I hit my head and it hurts". The Resident #103 was transferred to the emergency room . In an interview on 1/23/13 at 2:05 PM, certified nurse assistant (CNA) #10 reported, "It was about 9:30 PM and I was getting ready to walk her (Resident #103) to the bathroom for last rounds. I didn't have my gait belt on her. I know that I'm suppose too, but I've taken her many times. She's a one person (assist). I was guiding her with my hand and walking backwards with her hand in my hand and she let go to itch her nose or something and she fell . She stumbled backwards onto her but and her head hit her dresser edge. Between the bed and dresser there was a little space between them and thats were she ended up. The CNA #10 stated that she had lost her gait belt a couple of months prior to the fall and did not know that there were gait belts avalable on each floor. The CNA #10 stated that she did not use a walker when ambulating Resident #103 stating that she used her hand to lead the resident. CNA #10 revealed that the resident was not wearing her glasses and that she was not wearing shoes but gripper socks. Record review of the facility 'Falls and Injuries' procedure dated 4/2012 revealed that the facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program, and strives to provide an enviornment that is free from hazards over which the center has control and provides supervision and assistance devices to each resident to prevent avoidable accidents. Record review of Resident #103's 'Certificate of Death' dated 12/22/12 revealed cause of death 1.) Alzheimers disease, approximate interval between onset and death, years. 2.) Acute intra cerebral hemorrhage, approximate interval between onset and death, days. #

This citation pertains to MI# 823 Based on observation, interview and record review, the facility failed to prevent a fall in 1 (#101) of 4 sampled residents, from a total sample of 4 residents, resulting in resident #101 who is mentally impaired has a history of falls from lose of balance and uses a walker to ambulate, fell while bending over to pick up an extension cord that had been strung across her doorway threshold and entangled in her walker wheel, so that she could enter her room and losing her balance causing her to fall and sustain a fracture to her left knee. Findings include: Record review of the minimum data set ((MDS) dated [DATE] revealed a resident #101 was a [AGE] year old female with BIMS' (brief interview of mental status) score of 9 (moderately impaired). Resident #101's was independent with ambulation with use of a walker. Record review of resident #101's cognitive assessment/plan of care dated 10/5/11 revealed a [DIAGNOSES REDACTED]. Interventions included providing cues/direction with care/activities, anticipate needs, and maintain a safe environment. Record review of resident #101's Fall/Injury assessment: prevention and management plan of care dated 1/4/11 revealed that resident #101 was unsteady, and on 10/6/11 independent with walker. It was noted that on 8/26/11 resident #101 was observed on the floor. Record review of the facility accident/incident report dated 8/26/11 revealed that resident #101 sustained a fall from loss of balance, but sustained no injury at that time. Immediate actions to prevent further incidents were to monitor resident #101. Record review of facility accident/incident report dated 11/5/11 at 1:40 PM revealed that resident #101 was heard yelling for help. Resident #101 was found on the floor in her room on her right side with her walker under her side. Resident #101 stated that she was trying to move the (extension) cord out of her way, and then fell . The extension cord was plugged into tools for construction (laid) across walkway and tangled in her walker. Immediate actions to prevent further incidents were to tape cords/secured down by construction crew Record review of a written statement taken by the facility from resident #101 dated 11/6/11 revealed that she saw the extension cord and tried to move the cord because it was tangled in her walker and that she lost her balance and fell . An interview on 11/29/11 at 7:30 AM with resident #101 while she was sitting in room #17, revealed that she was walking with her walker and that she bent over to get the (extension) cord and went down. Resident #101 stated that the cord was across her doorway and that it got tangled in her walker wheels. Resident #101 stated that there were two construction workers in the hall, but that there were no yellow caution signs or yellow tape to block off the area. Resident #101 stated that the cord was not taped down to the floor. Record review of a written statement taken by the facility from construction man #5 revealed that he had an extension cord plugged into the wall of resident room #17. The cord was laid across the door threshold and that the construction crew was working in the hallway when they heard resident #101 fall. The written statement revealed construction crew was instructed to remove the cord and to tape it down in the future. An interview on 11/29/11 at 10:00 AM with construction man #5 revealed that he was working when the resident #101 fell over the extension cord that the construction crew use for their tools. Construction man #5 stated that there was no one in the room #17 when they plugged the extension cord into the wall and laid it across the threshold while they worked drilling holes to secure the hand railing in the hallway. The construction man #5 stated that they were working 7 to 10 feet away from the room #17 doorway. The construction man #5 stated that there were no yellow caution signs placed near the cord or that the cord was not taped to secure it to the floor. An interview on 11/29/11 at 10:20 AM physician #7 revealed that the resident #101 used a walker and that she had a delayed learning process and that it takes her longer to learn new things. Physician #7 stated that the resident #101's gait was not stable due to her obese size and mental retardation and that resident #101 fell to her knees. The physician stated that x-rays were done with results of hair line fracture to left knee. Record review of the facility daily group assignment form dated 11/5/11 for the 6:00 AM to 2:00 PM shift revealed that there were three certified nurse assistants (CNA #6, #7, #8) working the hall. An interview on 11/29/11 at 9:45 AM with CNA #6 revealed that she was not on the floor working at the time of resident #101's fall. CNA #6 stated that she is a smoker and that she was outside smoking on her break at the time of the fall. An interview on 11/29/11 at 9:50 AM of CNA #7 revealed that she was in the dining room feeding residents lunch at the time of the fall and that is where she was suppose to be when meals are served and clean up. An interview on 11/29/11 at 12:49 PM with the registered nurse #4 revealed that it was just after lunch when the resident #101 was walking with her walker to her room. Nurse #4 stated she was sitting at the nursing station and construction men were in the hallway putting bolts up for hand rails when she heard resident #101 yell. Nurse #4 ran to room #17, and found resident #101 on the floor in room near the threshold with a heavy/thick extension cord was plugged into the room #17's wall half way up the wall on the right side of the door and going across the doorway to the left side and down the hallway to the power tools used by the construction men. Nurse #4 stated that she assessed and assisted resident #101 in getting up off the floor. Nurse #4 stated that she spoke to the construction men about securing the extension cord with tape to the floor. Nurse #4 stated that there were no yellow caution signs up or yellow caution tape to block off the area of construction used. Nurse #4 stated that later in the day around she was aware of a fracture to resident #101 left knee and sent the resident out to the hospital for evaluation and treatment. An interview on 11/29/11 at 12:30 PM with the facility maintenance man #9 revealed that he did not work weekends, but took calls from the facility staff. Maintenance man #9 stated that the hallways and resident rooms were in the process of being renovated. Maintenance man #9 stated that he does not supervise the outside contracted construction crew while they are working in the facility building. Maintenance man #9 stated that he was aware of a fall involving a resident and an extension cord but that he was not at the facility on that Saturday when it occurred. A second interview on 11/29/11 at 1:40 PM with the construction man #5 revealed that they did not tape the extension cord down and that he was not sure if caution signs were used. An interview on 11/29/11 at 2:30 PM with the facility staff coordinator #1 revealed that construction started in the late spring which included a sprinkler system and ceiling tiles replaced, knocked out some walls, painting, replaced hand railings and other construction that was needed for the renovation. Staff coordinator #1 revealed that there was no extra staff added during the construction to provide extra supervision of residents while construction was taking place. Staff coordinator #1 stated that she went by the regular budgeted staffing sheets that give her a number of residents and how many staff she can schedule. Staffing coordinator #1 stated that she had not added any extra staff due to construction, just scheduled for the residents care. Staffing coordinator #1 stated that she did not know who supervised the construction crew while they worked in the facility. #

This citation pertains to MI# 142 Based on observation, interview and record review, the facility failed to provide adequate and appropriate supervision to prevent a burn in 1 (#101) of 3 sampled residents, resulting in resident #101 being found on the night shift with a blister/second degree burn of 4 x 2 centimeters of unknown origin. Findings include: Record review of resident #101's accident/incident report dated 3/26/11 at 00:00 revealed: Blister was noted to right leg, above the knee. The certified nurse assistant (CNA) was providing care and noticed the blister. Resident does not know how it happened. The blister was noted to be 4 x 2 centimeters in size. Record review of resident #101's Bladder Data Collection and Assessment form dated 3/14/11 revealed that the resident consumed caffeine and had a [DIAGNOSES REDACTED]. An interview on 4/14/11 at 12:35 PM, with Resident #101 revealed: "It was a cup like this (held-up his coffee cup he was using) maroon one. It was sitting on the edge of the table, and I reached across the table and bumped it with my elbow and it hit the arm on my wheelchair and spilled on my right leg. Yes, it burned, but I finished my meal....it did burn about the size of a baseball, it blistered up...." Observation on 4/14/11 at 2:00 PM, with the attending physician of Resident #101's right leg revealed a dressing above the knee that was pulled back by the physician to reveal a pink area of 4 x 2 cm. The physician stated that it was a second degree burn and healing. An interview on 4/14/11 at 2:40 PM, with the licensed practical nurse (LPN) #8 revealed that she worked 6:00 PM to 6:00 AM (3/25-3/26/11). LPN #8 came in at 6:00 PM and the evening meal is served at 6:30 PM. Around midnight, a certified nurse assistant brought the blister noticed on Resident #101's right leg to her attention. Nurse #8 stated, "I was down stairs working, split between two floors. A down stairs resident was having behavioral issues. I did go look at it, it was a blister 4 x 2 cm. It took me a while to get there. I asked resident #101 how it happened, he didn't know when, how, or what happened. He couldn't recall. It was around 12:00-12:30 AM, the CNA noticed around midnight. I was at the nursing station while he was eating. I was going in and out of the hallway into the dining room. I didn't notice anything spilt on the floor, nothing to clean up". Nurse #8 stated that she had talked with the day nurse who worked the 3/25/11 about the blister and was told there was no blister. Record review of the facility investigation file revealed that written statements were taken from staff members involved. Review of nurse #8's written statement acknowledged that she was in feeding another resident during the meal in the dining room. Resident #101 chooses to have his meals in the hallway. Record review of resident #101's treatment administration record (TAR) for the month of march 2011 revealed that 4 x 4 gauze was applied to the right knee and wrapped with Kerlex for protection on the 2-10 PM shift on 3/26, 3/27/, 3/28 and 3/29/11. Record review of resident #101's skin grid-pressure/venous insufficiency ulcer/other form, dated 3/26/11, identified a stage II- partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. On 3/30/11, it was noted that the area started out as an intact blister, now open, red in color, no slough noted to peri wound tissue, also red in color 0.3 cm from 7 o'clock to 5 o'clock. An interview on 4/14/11 at 1:20 PM, with unit manager RN #3, revealed that the burn was noticed on Saturday 3/26/11 early AM, but she did not know when it happened. The blister on Resident #101 was found on midnight shift by CNA's during their rounds to ensure residents were clean and dry. The unit manager reviewed Resident #101's clinical record with the state surveyor and noted that there was a nurse note written on 3/26/11 at 7:30 AM, which revealed that there was a blister to Resident #101's right knee and that it was fluid filled and covered with a 4 x 4 gauze. A nurse note dated 3/26/11 at 12:10 PM, revealed that the spouse was notified of the blister. There were no nurse notes written on 3/27-3/28/11. The next nurse note written is dated 3/29/11, when an order for [REDACTED]. The unit manager could not explain why a blister/burn was not charted on by nursing staff. There were no notes indicating the color, seeping, sign of infection, warmth to the touch and dressing changes. The unit manager revealed that the physician saw the resident on 3/29/11, and that a Silvadene/Telfa/tape two times daily was ordered. The unit manager RN #3 stated there was no hot liquid assessment done on the resident. RN #3 stated that therapy had worked on/off with the resident but that there was no evaluation for handling hot liquids. Further interview with Unit manager RN #3 revealed that the facility had a Hot Beverage List of residents, which means the residents need lids on hot beverages and monitoring. The unit manager stated that there was no policy or procedure for the Hot Beverage Watch list that she knew of, it was just something that the facility does. Record review of resident #101's Nutrition Progress Note, dated 3/23/11, revealed that the resident was to be on a hot beverage watch. An interview on 4/14/11 at 2:05 PM, with the director of nurse's (DON) revealed that the facility did not have a hot liquid handling assessment. The DON reviewed resident #101's nutrition care plan which identified the resident as a Hot Beverage Watch. The DON stated that the hot beverage watch list means general supervision with hot beverages. The DON acknowledged that facility did not know when the burn to Resident #101 occurred. #