Every finding on record at Medilodge of Gaylord

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for all 70 residents living in the facility. Findings include: During a tour of the dietary department with Registered Dietitian (RD) A and Dietary Manager (DM) Q on 3/17/2026 at 12:18 PM, the following items were noted in the reach in freezer:an opened unsealed plastic bag in a manufacturer's box with beef patties exposed to air, and undated as to opened date and use by (expiration) datea partial bag of frozen formed cookie dough unlabeled and undated as to opened date and use by datea partial bag of frozen premade biscuits unlabeled and undated as to opened date and use by date.a partial bag of frozen hashbrowns unlabeled and undated as to opened date and use by date.The reach-in refrigerator contained an opened thickened apple juice with an opened date of 1/28 and a use by date of 2/3.On 3/17/2026 at 12:49 PM, a tour of the pantry on C Hall with RD A and DM Q, revealed a refrigerator containing an opened quart container of honey thickened orange juice without an opened date, but with a use by date of 2/24/26 and an opened quart container of nectar thickened cranberry juice with an opened date of 2/16 and no use by date.On 3/17/2026 at approximately 1:00 PM, a tour of the pantry on C Hall with RD A and DM Q, revealed a refrigerator with an opened quart container of thickened cranberry juice which was not marked with an opened date or use by date.On 3/18/2026 at 7:33 AM, the reach-in refrigerator in the dietary department was observed to include two containers of honey thickened milk. Each of these quart sized containers were marked as opened 3/10/26 and use by 3/16/26, two days prior. The container included instructions printed on the side which indicated the product must be used within four days of opening, which was four days prior to this observation.The facility provided their policy titled, Food Receiving and Storage dated as reviewed and revised 7/1/2025 which read in part, . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( opened on and use by date).According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat,Time/Temperature Control for Safety Food, Date Marking. (A) Except whenPACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specifiedunder S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated,READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD preparedand held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly markedto indicate the date or day by which the FOOD shall be consumed on the PREMISES,sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E)-(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FORSAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANTshall be clearly marked, at the time the original container is opened in a FOODESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the dateor day by which the FOOD shall be consumed on the PREMISES, sold, or discarded,based on the temperature and time combinations specified in (A) of this section and:(1) The day the original container is opened in the FOOD ESTABLISHMENT shall becounted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENTmay not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .On 3/18/25 at approximately 7:40 AM, the sanitizer bucket containing a wiping cloth floating in the solution in the dietary department was tested for sanitizer concentration. The dietary staff member P stated the bucket contained bleach water. RD A tested the solution, and it measured zero parts chlorine indicating the solution contained no sanitizer.3-304.14 Wiping Cloths, Use Limitation. (A) Cloths in-use for wiping FOOD spills from TABLEWARE and carry-out containers that occur as FOOD is being served shall be: (1) Maintained dry; and (2) Used for no other purpose. (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; and. Wiping Cloths, Use Limitation. Soiled wiping cloths, especially when moist, can become breeding grounds for pathogens that could be transferred to food. Any wiping cloths that are not dry (except those used once and then laundered) must be stored in a sanitizer solution of adequate concentration between uses. Wiping cloths soiled with organic material can overcome the effectiveness of, and neutralize, the sanitizer. The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit.

Based on observation, interview and record review, the facility failed to ensure correct implementation of transmission-based precautions (TBP) for one Resident (#87) of one resident reviewed for TBP and to ensure infection prevention and control policies were reviewed on an annual basis with the potential to affect all 70 residents living in the facility.Findings include:Resident #87 (R87) Review of the electronic medical record (EMR) revealed R87 was admitted to the facility on [DATE] and had diagnoses including sepsis due to methicillin susceptible staphylococcus aureus (MSSA) and osteomyelitis of the left ankle and foot. On 3/17/2026 at 1:42 p.m. R87 was observed self-propelling in a wheelchair toward his room from the entry of D-Hall, near the nurses' station. R87 was not wearing a protective gown. Upon observing R87 enter his room, it was noted there was a Center for Disease Control and Prevention (CDC) Contact Precaution sign adhered to the front of R87's door and a cart containing personal protective equipment (PPE) positioned in the hall next to the Resident's doorway. Further review of the CDC Contact Precaution sign revealed the following: Stop. Contact Precautions. Everyone Must . put on gloves before room entry . Put on gown before room entry . On 3/17/2026 at 2:33 PM, Licensed Practical Nurse (LPN) S was observed preparing R87's medications for administration and was accompanied to the Resident's room. Upon entering R87's doorway, LPN S was asked if a protective gown and gloves was required to enter R87's room. LPN S stated, No, he can come out of his room now. That was from before. LPN S entered R87's room without donning a protective gown or gloves. It was noted the CDC Contact Precautions sign remained adhered to the door of R87's room at the time of the observation. LPN S proceeded to prepay R87's intravenous antibiotic for administration, assisted R87 to lay down in bed per his request, and assisted the Resident to remove his long-sleeved sweatshirt. R87 was observed to have a right upper arm PICC line. LPN S cleansed the port of R87's PICC line, flushed the line and attached the IV tubing to administer the Resident's medication. LPN S did not wear a protective gown while caring for R87's PICC line. An observation on 3/19/2026 at 9:14 AM revealed the CDC Contact Precaution sign remained adhered to R87's door and the PPE supplies were in hall next to the Resident's doorway. During an interview outside R87's room on 3/19/2026 at 10:55 AM Certified Nursing Assistant (CNA) T explained the Contact Precaution sign adhered to R87's door was, Because he has an IV and wounds on his foot. CNA T reported she gowned up when performing close contact care activities with R87. CNA T was asked what the difference between Contact Precautions and Enhanced Barrier Precautions (EBP). CNA S reported she considered the utilization of Contact Precautions was to be used as EBP. During an interview on 3/19/2026 at 11:05 AM, the facility's Infection Preventionist, Registered Nurse (RN) N was queried regarding the status of R87's infection and requirement for TBP. RN N stated R87 was placed in Contact Precautions due to, An infection in his spine. RN N reported staff were to wear a protective gown and gloves when providing high-contact care activities. When asked to explain the differences in Contact Precautions and EBP, RN N replied, They're basically the same. Review of the facility policy titled, Transmission-Based Precautions, with a review date of 12/31/2025, revealed the following: The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact and droplet precautions . Residents on transmission-based precautions should remain in their rooms except for medically necessary care . Contact Precautions: Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for interactions that may involve contact with the residents or potentially contaminated areas in the resident's environment . Gloves: Whenever touching the patient's intact skin or surfaces and article in close proximity to the patient. [NAME] gloves upon entry into the room . Gowns: Whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environment surfaces or equipment in close proximity to the patient. [NAME] gown upon entry int the room . Review of the facility policy titled, Enhanced Barrier Precautions, with a review date on 3/26/2024, revealed the following: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and gloves use during high-contact resident care activities . High-contact care activities to consider include . dressing . device care or use: central lines . On 3/19/26 at 11:15 AM, an interview was conducted with Infection Preventionist (IP) N who verified responsibility for the Infection Prevention and Control Program (IPCP) and associated policies. IP N stated the following infection control policies had not been updated annually: Infection Prevention and Control Program: last revised/reviewed on 12/27/23. Infection Surveillance: last revised/reviewed 10/26/23. Antibiotic Stewardship Program: last revised/reviewed 12/13/23. Influenza Vaccination: last revised/reviewed 10/26/23. Pneumococcal Vaccine (Series): last revised/reviewed 10/30/23. On 3/19/26 at 12:02 PM, the Nursing Home Administrator (NHA) confirmed the IPCP policies were the most recently updated versions. The facility policy titled, Infection Prevention and Control Program, reviewed/revised 12/27/23 read, in part: .The facility shall conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures .

Based on observation, interview, and record review, the facility failed to ensure accurate and timely delivery of medications for four Residents (R13, R28, R29, and R80) of six residents reviewed for medication administration with 5 errors out of 26 opportunities resulting in a medication error rate of 19%. Findings include:Resident #28 (R28)During a medication administration observation for R28 on 3/18/26 at 1:04 PM. Registered Nurse (RN) B administered oxycodone 5 milligrams (mg) one tab by mouth and methocarbamol 500 mg one tab by mouth by to R28. R28's medication was delivered late and R28 only received one oxycodone and was to receive two tabs. (Error #1) Review of R28's medication administration record (MAR), dated March 2026, unveiled the following order:Oxycodone 5 mg give 2 tablets by mouth every 6 hours for moderate to severe pain with scheduled times at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. Resident #80 (R80)On 3/18/26 at 1:30 PM, an observation was made of RN B providing a medication pass for R80 who was administered peg tube feeding 237 milliliters (ml) via peg tube and a water flush of 240 ml. R80 received his tube feeding administration thirty minutes late. RN B was waiting to prepare water for R80 peg tube feed flush for over fifteen minutes before she just went to medication cart and took water from her pitcher with her personal protective gown on. (Error #2) Review of R80's MAR, dated March 2026, unveiled the following order:Enteral Feed Order five times a day Bolus 1 can of Jevity 1.5 (237 ml) 5x's/day via peg tube with scheduled time at 8:00 AM, 12:00 PM, 5:00 PM, 9:00 PM, and 1:00 AM. Resident #13 (R13)On 3/18/26 at 2:03 PM, an observation was made of RN B providing a medication pass for R13 who was administered peg tube feeding 237 ml via peg tube, glycopyrrolate 10 mg and a water flush of 240 ml. R13 received his tube feeding administration over an hour late. R13's micky tubing was noted to be on top of his bedside table lying on a piece of paper towel with a second paper towel over the top of it and not stored in a zip lock bag. (Error #3) Review of R13's MAR, dated March 2026, unveiled the following order:Enteral Feed Order five times a day Bolus 1 can of TwoCal HN 1.5 (237 ml) 5x's/day via peg tube with scheduled time at 7:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, and 4:00 AM. Resident #29 (R29)During a medication administration observation for R29 on 3/18/26 at 3:19 PM. RN B administered enoxaparin 30 mg subcutaneous injection and midodrine 10 mg by mouth to R29. R29's medication was delivered late as the enoxaparin was scheduled for 9:00 AM and the midodrine was scheduled for 1:00 PM. (Error #4 and #5) Review of R29's MAR, dated March 2026, unveiled the following order:Midodrine Oral Tablet 10 mg give 1 tablet by mouth three times a day for pots (sic) with scheduled time at 9:00 AM, 1:00 PM, and 5:00 PM.(brand name) Enoxaparin Solution 30mg/0.3ml inject 30 mg subcutaneously every 12 hours for blood thinner with scheduled time 9:00 AM and 9:00 PM. On 3/18/26 at 3:45 PM, an interview was conducted with RN B who was asked about the late administration of medications and the omission of R28's oxycodone and replied, I only gave him (R28) one. I guess I better double check the order. Oh, gosh. I should have given two. I better go ask him if he wants the second one. RN B proceeded to go ask R28 if he wanted the second oxycodone in which he did. RN B was asked when the last time she work on A-hall was and replied, It has been a couple of weeks. On 3/19/26 at 10:10 AM, an interview was conducted with the Director of Nursing (DON) who was asked what her expectations were of timely and accuracy medication administration and replied, Medications should be given no sooner than an hour before administration time and no longer than an hour after. Nurses should be double checking medications orders for accuracy. Review of policy titled, Medication Administration, dated 1/17/23, read in part Policy: 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.11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration. NOTE - If medication dispensed in a different dose/quantity per dose (example 1/2 pill or give 2 pills) a sticker will be placed on the medication packaging to denote to check the MAR for clarification.Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects.Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on observation, interview and record review, the facility failed to label opened multi-use medications, removed expired medications and ensure storage of medications according to professional standards of practice in two of two medication carts reviewed.Finding include:Review of the D-Hall medication cart with Registered Nurse (RN) R on 03/19/2026 at 8:40 AM, revealed the following: A multi-dose Humalog (rapid-acting insulin) U-100 vial stored inside a clear plastic bag. The vial was observed to be without a protective cap, indicating the medication was opened. The vial was noted to belong to Resident #57 and had a written open date of 2/14/2026 and expiration date of 3/14/2026. RN R confirmed the medication was expired and should have been removed from the active medication supply. An open multi-dose Symbicort 80 mcg (microgram)/4.5 mcg inhaler (medication used to treat asthma and chronic obstructive pulmonary disease). Upon inspection of the inhaler and box the inhaler was stored in, it was noted there was no written date of when the inhaler was opened and first used or when the medication would expire. When asked when the medication was opened and when it would expire, RN R confirmed the medication was an active supply and there was no dating on the inhaler or the storage box indicating when the inhaler was first used. RN R reported she was unsure if the medication had a shortened expiration date once opened. A clear plastic bag containing a multi-dose tube of erythromycin (antibiotic) ophthalmic ointment, a multi-dose bottle of moxifloxacin (antibiotic) ophthalmic solution, and a multi-dose bottle of polymyxin B sulfate/trimethoprim (antibiotic) ophthalmic solution. Resident #63's (R63) name was noted to be written on the outside of the clear plastic bag. RN R reported all the medications in the bag were currently prescribed and consistently being administered to R63. Further inspection of each medication with RN R revealed no written open date or expiration date listed on the medications. RN R reported she was unsure how long each medication could be used before expiring. On 3/19/2026 at 9:24 AM RN R reported she checked with the Director of Nursing (DON) regarding R63's ophthalmic medications and was instructed that no open or expiration date was needed to label the multi-dose medications because there's enough preservative in the solution to keep it good. Review of the facility's pharmacy reference guide provided by the DON revealed the following: Humalog Vial . Product expires 28 days after first use or removal from refrigerator, whichever comes first. Symbicort Discard when the counter reads 00 or 90 days after removal from the protective foil package, whichever comes first. It was noted that R63's ophthalmic medications were not listed on the facility's pharmacy reference guide. On 3/19/2026 at 10:15 AM, the DON reported the facility's pharmacy reference guide was not all inclusive. The DON was asked how staff determined what medications had shortened expiration dates upon opening if not included in the pharmacy guide to which she reported staff should refer to the manufacturer's inserts for each respective medication. On 3/19/2026 at 11:08 AM, the DON reported she reviewed the manufacturer's instructions for R63's moxifloxacin and polymyxin B sulfate/trimethoprim ophthalmic solutions and found both medications had shortened expiration periods of 28-30 days after opening. The DON reported she could not find a reference for R63's erythromycin ointment and therefore would defer to the manufacturer's printed expiration date on the medication tube. The DON reported she did not contact the facility consultant pharmacist to inquire about R63's erythromycin ointment. The DON confirmed all multi-dose medications should be labeled with the date the medication was initially opened and with expiration dates when indicated. On 3/18/26 at 2:30 PM, an observation was made of the A-hall medication cart for storage and compliance and was found to have two loose pills in the second draw identified as Baclofen 10 milligrams (mg) with marking IV/4936 and Carvedilol 3.125 mg with marking 1/Z both were white and round in color. The A-hall medication cart had several small pieces of paper and medication particles in the bottom of draw two. On 3/18/26 at 2:40 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was given the medication found loose in medication cart A-hall to dispose of. The NHA remarked we have a small vacuum to clean the medication carts out with. I am not sure why they are so dirty. On 3/19/26 at 10:10 AM, an interview was conducted with the Director of Nursing (DON) who was asked how often the nurses were to clean out the medication carts and replied, Weekly. The DON was asked if the facility had a small vacuum to clean the carts out why were they so dirty and replied, I did not know we had a vacuum to clean the medication carts out. I will have to see about that. Review of policy titled, Medication Administration, dated 1/17/23, read in part Policy: 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: Keep medication cart clean, organized, and stocked with adequate supplies.

Based on observation, interview, and record review the facility failed to provide an order, care plan interventions and goals for one Resident (Resident #58) of two residents reviewed for indwelling catheters.Findings include:Resident #58 (R58)On 3/17/26 at 12:50 PM, R58 was observed sitting in his wheelchair in the hallway. A urinary catheter drainage bag, attached to the wheelchair beneath the seat, was touching the floor beneath the wheelchair and dragging on the floor when the wheelchair was propelled. On 3/18/2026 at 8:40 AM, an observation was made of R58 sitting in his wheelchair in the lobby near the A-hall entrance. R58 proceeded to self-propel himself the wheelchair down A-hall with his catheter bag dragging on the floor in a privacy bag. R58's privacy bag had visible dust on the front, sides, and back of the privacy bag. On 3/18/26 at 8:42 AM, an interview was conducted with Certified Nurse Aide (CNA) F who was asked if R58's bag should be dragging on the floor collecting dust. CNA F replied, No, absolutely not. Review of R58's order summary, dated 9/17/26 through 3/18/26 unveiled no physician orders for an indwelling urinary catheter. R58's medical record was reviewed and lacked any order for an indwelling urinary catheter, care plan, interventions, goals, care, or monitoring. On 3/19/2026 at 10:10 AM, an interview was conducted with the DON who was asked what her expectations were for a resident with an indwelling urinary catheter and replied, To have an order indicating the size, care plan interventions, and monitoring. Review of policy titled, Appropriate Use of Indwelling Catheters, dated 12/28/2023, read in part Policy: It is the policy of this facility to ensure that a resident who is continent of bladder on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain.Policy Explanation and Compliance Guidelines.4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of changing (if applicable).6. Documentation to support decision making will be included in the medical record, including but not limited to.d. Services provided to restore normal bladder function to the extent possible.8. Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible.9. The care plan addresses the use of an indwelling urinary catheter, including strategies to prevent complications.

Based on observation, interview, and record review, the facility failed to ensure physician orders for the administration of supplemental oxygen, completion of respiratory assessments with respiratory treatments, appropriate cleaning and storage of respiratory equipment, and supervision during the administration of respiratory treatments for three Residents (R36, R80, R13) of five residents reviewed for respiratory care services. Findings include:Resident #80 (R80) On 3/17/26 at 3:05 PM, an observation was made of R80's nebulizer mask (a mask that goes over the nose/mouth/tracheostomy to direct vaporized medication into the airway) stored with tubing and mask connected in a bag with visible condensation in the medication cup. An interview was conducted on 3/17/26 at 3:10 PM, with Unit Manager/Registered Nurse (RN) C who was asked if the nebulizer mask was stored properly and replied, No, it should be taken apart rinsed out and left to dry and then stored in the bag apart. During an observation of R80 on 3/18/26 at 3:00 PM and at 3:20 PM. R80 was lying in bed receiving a nebulizer treatment with a mask and R80 was unattended during the treatment by RN B. On 3/18/26 at 3:30 PM, an interview was conducted with RN B who was asked about the nebulizer treatment procedure and storage and replied, I was unaware that I was required to stay in the room during the administration of the treatment. I did not rinse the nebulizer mask out and I should have. On 3/19/26 at 8:19 AM, an observation was made of R80 in his room lying in bed and receiving a nebulizer treatment with a mask and R80 was unattended by a RN M during the treatment. R80's nebulizer mask was not in the proper place of his tracheostomy (a surgical opening in the windpipe establishing an airway) and the mask was hanging down on his right shoulder. Certified Nurse Aide (CNA) F was present in the room with R80 and adjusted his mask. At 8:55 AM on 3/19/26, an observation was made of R80 in his room lying in bed who continued to receive the same nebulizer treatment with a mask and R80 was unattended by RN M. On 3/19/26 at 9:08 AM, an interview was conducted with RN M who was asked to walk this Surveyor through the process of delivering a nebulizer treatment to residents. RN M properly gave the steps on how to administer a nebulizer treatment. RN M admitted she failed to supervise the resident and rinse and store the equipment post treatment. Resident #13 (R13) On 3/17/26 at 3:05 PM, an observation was made of R13's nebulizer mask (a mask that goes over the nose/mouth/tracheostomy to direct vaporized medication into the airway) stored with tubing and mask connected in a bag with visible condensation in the medication cup. An interview was conducted on 3/17/26 at 3:10 PM, with Unit Manager/RN C who was asked if the nebulizer mask was stored properly and replied, No, it should be taken apart rinsed out and left to dry and then stored in the bag apart. On 3/19/26 at 8:19 AM, an observation was made of R13 in his room lying in bed and receiving a nebulizer treatment with a mask and R13 unattended by a RN M. R13's nebulizer mask became unattached from his tracheostomy. CNA F was present in the room with R13 and reattached the nebulizer mask to his tracheostomy. At 8:55 AM on 3/19/26, an observation was made of R13 in his room lying in bed who continued to receive the same nebulizer treatment with a mask and R13 was unattended by RN M. On 3/19/2026 at 10:10 AM, an interview was conducted with the Director of Nursing (DON) who was asked what her expectations were for a residents receiving nebulizer treatment and replied, To have pre and post assessment, for nursing to remain in the resident room until the treatment is completed and to rinse and let the respiratory equipment dry properly. Review of policy titled, Nebulizer Therapy, dated 5/15/24, read in part Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: 1. Care of the Resident.n. Observe resident during the procedure for any changes in condition. o. When medication delivery is complete, turn the machine off. Treatment may be considered complete with the onset of nebulizer sputtering. p. Disassemble and rinse the nebulizer water and allow to air dry. 2. Care of the Equipment. a. Clean after each use.c. Disassemble parts after every treatment. d. Rinse the nebulizer cup and mouthpiece with water. e. shake off excess water. f. Air dry on an absorbent towel. g. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. Resident #36 (R36) On 3/17/26 at 1:17 PM, R36 was observed lying in bed with a nasal cannula (flexible tubing that delivers supplemental oxygen into the nostrils) below her chin. R36 appeared agitated, moving her head side to side and continuously moving her extremities. An elastic band encircled R36's head in the forehead region. On 3/17/26 at 1:20 PM, Licensed Practical Nurse (LPN) J was queried regarding the oxygen requirements of R36 and the purpose of the elastic band on the head of R36. LPN J said R36 required the continuous use of supplemental oxygen but kept removing the nasal cannula. LPN J said the elastic band was intended to keep the nasal cannula in place. Review of the electronic medical record (EMR) disclosed R36 was hospitalized on [DATE] with acute respiratory failure with hypoxia (low levels of oxygen in body tissues) and pneumonia. R36 returned to the facility on 2/11/26. Further review of the EMR for 36 revealed a care plan dated as initiated 2/20/26 that read: Resident has an impaired pulmonary/respiratory status related to respiratory failure w/ [with] hypoxia. An intervention dated 2/20/26 read: Oxygen as ordered. The EMR of R36 did not contain a physician's order for supplemental oxygen. On 3/19/26 at 8:04 AM, R36 was observed lying in bed with the nasal cannula in only one nostril. R36 had audible crackles with inspiration and was coughing intermittently. The EMR of R36 included a physician's order for albuterol sulfate (a medication used to relax airway muscles and improve airflow in the lungs) by a nebulizer (an aerosol system that allows medication to be inhaled directly into the lungs) three times per day. LPN J was observed administering an albuterol sulfate nebulizer treatment for R36 on 3/19/26 at 8:04 AM. LPN J did not conduct a respiratory assessment before or after administering the nebulizer treatment. The Medication Administration Record (MAR), Treatment Administration Record (TAR) and Respiratory Administration Record (RAR) were reviewed on 3/19/26. Respiratory assessments were not documented before or after the three daily administrations of albuterol sulfate through the nebulizer in the month of March 2026. The Vitals portion of the EMR documented R36 had peripheral oxygen saturation (SPO2) levels obtained three times in the month of March 2026. The Director of Nursing (DON) was interviewed on 3/19/26 at 10:51 AM. When asked the frequency of supplemental oxygen for R36, the DON responded that R36 was to have continuous supplemental oxygen delivery. The DON confirmed that a physician's order was required to administer supplemental oxygen to a resident, and the order was to include the flow rate, delivery system, and parameters in which to administer supplemental oxygen. The DON reviewed the physician's orders for R36 and confirmed there was no physician's order for R36 to utilize supplemental oxygen. The DON said supplemental oxygen was usually used between 2-4 liters per minute (lpm) to keep SPO2 levels between 90-95%. When asked the expectation of the frequency of obtaining SPO2, the DON said SPO2 should be obtained at least once per day and as needed for respiratory distress. The DON was queried regarding the expectation for respiratory assessments with medication administration via nebulizer. The DON said respiratory assessments should be completed with each nebulizer treatment, including SPO2. The DON reviewed the EMR of R36 and confirmed respiratory assessments and SPO2 were not completed as expected. The policy Oxygen Administration dated as implement 6/23/25 read, in part: .Oxygen is administered under orders of a physician, except in the case of an emergency.The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system b. When to administer, such as continuous or intermittent and/or when to discontinue c. Equipment setting for the prescribed flow rates d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered e. Monitoring for complications associated with the use of oxygen. The policy Nebulizer Therapy dated as revised 5/15/24 read, in part: .Documentation. d. Resident vital signs and respiratory assessment e. Resident's response to treatment.

Based on interview, and record review, the facility failed to explain and obtain an acknowledgement of understanding for a binding arbitration agreement for one Resident (R10) of three Residents reviewed for proper execution of the facility's binding arbitration agreement.Findings include:After receiving a list of those residents who had signed the facility arbitration contract titled, ALTERNATIVE DISPUTE RESOLUTION AGREEMENT, three residents were interviewed regarding the arbitration agreement process.On 3/18/2026 at 1:05 PM, R10 was interviewed in his room. R10 stated he remembered nothing regarding an arbitration agreement.The electronic medical record revealed R10 was admitted on [DATE] as his own responsible party. The Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating R10 was cognitively intact.The ALTERNATIVE DISPUTE RESOLUTION AGREEMENT for R10 was reviewed and the final page had been E-signed (electronically signed) on 6/30/25. Twelve of the twenty points in the contract required an initial. Only one of the twelve blanks had been initialed. Point number 19 read, YOU ACKNOWLEDGE AND AGREE: (I) THAT YOU HAVE FULLY READ, UNDERSTAND AND ARE VOLUNTARILY ENTERING INTO THIS AGREEMENT; AND (II) THAT, YOU HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS BEFORE SIGNING THIS AGREEMENT. This point had not been initialed by R10.During an interview on 3/18/2026 at 2:04 PM, the acting admission Director (Staff) U stated, I was not here for this paperwork (R10's arbitration agreement). Staff U indicated she was presently orienting a new Admissions Coordinator.During an interview on 3/18/2026 at 2:15 PM, the Nursing Home Administrator (NHA) and the Business Office Manager (Staff) O reviewed R10's ALTERNATIVE DISPUTE RESOLUTION AGREEMENT and agreed the contract was not completed in full. The NHA said there were areas of improvement for those filling out the agreement in the future.On 3/18/2026 at 2:20 PM, R10 was approached again to discuss the binding arbitration agreement paperwork and the fact that it was not completely signed. R10 responded I probably did not understand it and so I did not sign it.

Based on interview and record review the facility failed to ensure communication/documentation occurred for coordination of care for hospice services provided for one Resident (R47) of one Resident reviewed for hospice services.Findings include:A review of the medical record for R47 revealed an admission to the facility with hospice services dated [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] indicated R47 was receiving hospice services. The Resident Roster printed on [DATE] indicated R47 was on hospice. The care plan printed on [DATE] for R47 included a focus of Hospice - Resident has a terminal prognosis with (Name of Hospice) related to end of life diagnosis . Date Initiated: [DATE]During an interview on [DATE] at 3:51 PM, the Registered Nurse (RN) L caring for R47 stated, I have no idea how hospice communicates with the facility. RN L said there were no charting or hospice folders that they were aware of. RN L stated, I get report when they (hospice personnel) have been here. That is all.During an interview on [DATE] at 4:11 PM, the Director of Nursing (DON) showed me the hospice binders containing hospice paperwork and stated, There are 4 or 5 hospices that come here. The hospice binder with records for R47 was reviewed and only contained one care plan. The DON could not find documentation from hospice personnel visits. There was no record of visits, progress, care performed, or future planned visits. Signature sheets were present in the binders, but no resident names were listed to determine who had been visited. The DON remarked the only signature sheet present in the binder with a resident's name recorded on it had died. The DON said she would look further for hospice documentation.During an interview on [DATE] at 4:39 PM, the DON described the hospice procedure but could not find documentation of hospice visits for R47. The DON had reviewed the medical record for R47 but could not determine the hospice service frequency, when hospice personnel (nurses, aides, social workers or chaplains) were here last, what services had been provided, or when the next planned visits were scheduled. The DON stated the hospice RN did often touch base but there was no documentation.During an interview on [DATE] at 4:50 PM, the Nursing Home Administrator (NHA) stated the hospice documentation might not yet be scanned into the medical record. She went to the medical records office but could not find documentation. The NHA agreed hospice collaboration was missing. During an interview on [DATE] at 10:02 AM, the DON said, some of the hospices did talk to her and filled out logs but others did not and no further hospice documentation was provided.The facility provided a policy titled Hospice dated as reviewed/revised [DATE] which read in part, .1. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the residents' care. 4. The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility. 6. The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities.

Based on interview and record review, the facility failed to ensure eligible residents were offered influenza and pneumococcal vaccines as recommended by the Centers for Disease Control and Prevention (CDC) for 2 residents (#12 and #87) of 5 residents reviewed for vaccination status.Findings Include:Resident #12 (R12)Review of R12's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/22/26 with diagnoses including cerebral infarction (stroke), moderate persistent asthma, dementia, and dysphagia (difficulty swallowing).Review of R12's Michigan Care Improvement Registry (MCIR [a database that documents immunizations administered to individuals in Michigan]) revealed the pneumococcal vaccination was, DUE NOW.Further review of R12's EMR revealed she was not offered a pneumococcal immunization.Resident #87 (R87)Review of R87's EMR revealed initial admission to the facility on 7/19/22 with diagnoses including congestive heart failure (CHF), vascular dementia, and peripheral vascular disease.Review of R87's MCIR revealed the following, Immunization Status and Shots Needed: Vaccine: PCV15 (Pneumococcal 15-valent conjugate vaccine)/PCV20/PCV21. Next Dose Due: Overdue. Overdue Date: 10/28/2020. Vaccine: Seasonal Influenza. Next Dose Due: Overdue. Overdue Date: 10/1/25.Further review of R87's EMR revealed he was not offered a pneumococcal or influenza immunization.On 3/19/26 at 11:15 AM, an interview was conducted with Infection Preventionist (IP) N who verified responsibility for the Infection Prevention and Control Program (IPCP) including the vaccination program. IP N verified R12 and R87 had not yet been offered their eligible immunizations per facility policy but was working to get caught up.Review of the facility policy titled, Pneumococcal Vaccine (Series), reviewed/revised 10/20/23, read, in part: It is our policy to offer our residents, staff, and volunteer workers immunizations against pneumococcal disease in accordance with current CDC guidelines and recommendations. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated.Review of the facility policy titled, Influenza Vaccination, reviewed/revised 10/26/23, read, in part: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunizations against influenza. Influenza vaccinations will be routinely offered from October 1st through March 31st unless such immunization is medically contraindicated.

Based on interview and record review, the facility failed to ensure eligible residents were offered a COVID-19 immunization as recommended by the Centers for Disease Control and Prevention (CDC) for 2 residents (#12 and #87) of 5 residents reviewed for vaccination status.Findings Include:Resident #12 (R12)Review of R12's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/22/26 with diagnoses including cerebral infarction (stroke), moderate persistent asthma, dementia, and dysphagia (difficulty swallowing).Review of R12's Michigan Care Improvement Registry (MCIR [a database that documents immunizations administered to individuals in Michigan]) revealed COVID-19 2025-26 was, DUE NOW.Further review of R12's EMR revealed she was not offered a COVID-19 immunization.Resident #87 (R87)Review of R87's EMR revealed initial admission to the facility on 7/19/22 with diagnoses including congestive heart failure (CHF), vascular dementia, and peripheral vascular disease.Review of R87's MCIR revealed the following, Immunization Status and Shots Needed: Vaccine: COVID-19 2025-26. Next Dose Due: Overdue. Overdue Date: 8/27/2025.Further review of R87's EMR revealed he was not offered a COVID-19 immunization.On 3/19/26 at 11:15 AM, an interview was conducted with Infection Preventionist (IP) N who verified responsibility for the Infection Prevention and Control Program (IPCP) including the vaccination program. IP N verified R12 and R87 had not yet been offered their eligible immunizations per facility policy but was working to get caught up.Review of the facility policy titled, COVID-19 Vaccination, reviewed/revised 12/31/25, read, in part: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC and/or FDA [Food and Drug Administration] guidelines unless such immunizations is medically contraindicated.

This citation pertains to Intake 2727226.Based on observation, interview, and record review, the facility failed to act upon a physician's order for one Resident (#2) out of three residents reviewed for quality of care. This deficient practice caused delayed medical treatment for Resident #2 resulting in the need for transfer to an emergency department (ED) due to septic shock (a life-threatening condition which occurs when blood pressure drops to a dangerously low level after an infection).Findings include:Resident #2 (R2)Review of a complaint sent to the State Agency (SA) on 1/29/26, read, in part: .Since June/July of 2025, [R2] has been experiencing an issue with her eye. Staff at the facility were unable to coordinate [R2's] care and this has caused a delay in her service provision. [R2] was not seen for her eye until 9/25/25 [sic] when she was transported via EMS [emergency medical services] to a optometrist. At that time, it was determined that [R2] required emergency services due [to] the infection in her eye progressing. The facility failed to properly service [R2], advocate for her, and meet her needs.Review of a document from a local ophthalmology clinic, dated 9/29/25, read, in part: Chief Complaint/Reason for Visit: [R2] brought into clinic by ambulance on a stretcher due to eye infection. Context/Onset: Months ago. Severity: Worsening. Care facility employees report hx [history of] red and irritated eye with purulent discharge for months worsening to boring pain [a deep, intense, and constant aching or gnawing sensation] and increase in redness in discharge in the last few weeks. [R2] presented to clinic without transfer of care of any care documents today. Upon clinical findings immediate concern for bacterial cellulitis and concern for sepsis given hx of MRSA (Methicillin Resistant Staphylococcus Aureus [antibiotic resistant strain of bacteria]) . recommend refer to [specialty hospital] ER [emergency room] for management and eval [evaluation] with inpatient ophthalmology. Spoke to.care facility manager who reported unable to determine when could be sent to [specialty hospital] for care, who recommend transfer to local ER to quicker facilitate transfer to [specialty clinic].Review of a Emergency Care/UC [Urgent Care] Document from a local ER, dated 9/29/25, read, in part: Presents per EMS, [R2] from [facility name] being tx [treated] for months for MRSA L [left] eye. She had appt [appointment] with [local ophthalmology clinic] and concern for sepsis so sent her. BP [blood pressure] in soft 70's [systolic pressure], pt [patient] pale, lethargic, skin cool to touch . Exam is concerning for endophthalmitis [purulent inflammation of the inner eye fluids] versus scleritis [inflammation of the eye's white outer layer] versus periorbital cellulitis [infection of the soft tissue in front of the eyelid] versus orbital cellulitis [infection of the skin, fat and muscles around the eye] . ocular exam is certainly limited due to patient's purulence, injection, chemosis [swelling or edema of the conjunctiva]. Patient was given sepsis bolus [a rapid infusion of intravenous fluids] as she was hypotensive on arrival, leukocytosis, she has 4/4 SIRS criteria [Systemic Inflammatory Response Syndrome, 4/4 suggests critical, often septic, illness] with hypotension, hypothermia. I discussed this with [physician name]. who felt that the patient would require higher level of care. Transfer center is arranging for transfer. Assessment/Plan: 1. Septic Shock, 2. Periorbital cellulitis, 3. Dacrocystitis [an infection of the tear drainage sac].Review of an Inpatient Discharge Summary from a Specialty Hospital, dated 10/2/25, read, in part: [R2].admitted .for preseptal (periorbital) cellulitis of left eye. active problems: keratitis (inflammation or infection of the cornea often causing severe pain, redness, blurred vision, and light sensitivity) of left eye due to bacteria. Sepsis - Present on Admission? Yes.Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/4/23 with diagnoses including schizoaffective disorder, morbid obesity, and cerebral infarction (stroke). Review of Section C: Cognitive Patterns in R2's most recent Minimum Data Set (MDS) assessment, dated 1/21/26, revealed their cognitive skills for daily decision making as, moderately impaired-decision poor; cues/supervision required.Review of R2's EMR revealed the following:Physician Progress Note on 4/7/2025 at 15:12 [3:12 PM]: [R2] is noted to have irritation and redness to bilateral eyes consistent with conjunctivitis (commonly known as pink eye).NP/PA [Nurse Practitioner/Physician Assistant] Progress Note: 5/13/2025 at 10:57 AM .Patient is seen for chronic conjunctivitis, new orders given. before starting antibiotic please culture left eye drainage.Review of a physician order, dated 5/17/25, read, Obtain left eye drainage culture TODAY .Review of a bacteriology report, dated 5/22/25, read, Procedure: eye culture. final report: 3+ (a moderate to high amount, 3+ on a scale of 1-4) Methicillin-Resistant Staphylococcus aureus (MRSA).Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/4/23 with diagnoses including schizoaffective disorder, morbid obesity, and cerebral infarction (stroke). Review of Section C: Cognitive Patterns in R2's most recent Minimum Data Set (MDS) assessment, dated 1/21/26, revealed their cognitive skills for daily decision making as, moderately impaired-decision poor; cues/supervision required.Review of a Physician Progress Note dated 6/26/25 at 11:23 AM, read, in part: [R2] is seen for continued management of conjunctivitis, again recent treatment with no to minimal effect. Provider gives new orders.and ophthalmology [a branch of medicine that deals with the diagnosis, treatment, and surgery of eye diseases and disorders] referral.Further review of R2's EMR revealed no physician order for an ophthalmology referral.Review of the following progress notes outlined the progression of R2's left eye infection over the course of the next three months:Pertinent Charting - Infection/Signs Symptoms Note on 7/1/25 at 00:39 [12:39 AM]: .green mucus drainage observed on ocular sinister inner canthus [inner corner of left eye]. Dried flaky drainage cleaned up on the lateral side [outside] of both eyes.Pertinent Charting - Infection/Signs Symptoms Note on 7/5/25 at 23:33 [11:33 PM]: .left eye MRSA.still crusted over throughout the day despite cleansing and inserting eye drops.Pertinent Charting - Infection/Signs Symptoms Note on 7/18/25 at 14:47 [2:47 PM]: .Bil [bilateral] eyes are red with drainage noted.Pertinent Charting - Infection/Signs Symptoms Note on 7/30/25 at 14:35 [2:35 PM] .MRSA left eye, eye remains red with some drainage.Transcribed Physician Progress Note on 8/13/25 at 17:29 [5:29 PM]: .repeated scleral injection [redness, inflammation, or dilation of blood vessels in the white outer layer of the eye].Pertinent Charting - Infection/Signs Symptoms Note on 8/26/25 at 13:49 [1:49 PM]: Site of Infection: Left Eye. Reason on antibiotics new signs & symptoms: increased redness, tenderness, and purulent (containing pus) drainage.Pertinent Charting - Infection/Signs Symptoms Note on 8/31/25 at 20:23 [8:23 PM]: .Residents eye is closed shut upon initial encounter; Resident assisted with cleansing eye from debris and crust. Resident stated that it was painful. yellow thick drainage coming from eye.Pertinent Charting - Infection/Signs Symptoms Note on 9/2/26 at 1440 [2:40 PM]: Continues on eye drops for MRSA for yellow puss [sic] drainage coming out of left eye.Pertinent Charting - Infection/Signs Symptoms Note 9/3/25 at 02:37 [2:27 AM]: MRSA in left eye. Resident had thick yellow/brown drainage to eyelashes that was keeping eye closed shut on first assessment. some swelling to area.Pertinent Charting - Infection/Signs Symptoms Note on 9/14/25 at 15:50 [3:50 PM]: Left eye still has some yellowish, crusty discharge.Review of a physician's order, dated 9/15/25, read, Ophthalmology appt [appointment] ASAP [as soon as possible] r/t [related to] chronic eye infections.On 2/23/26 at 1:51 PM, an interview was conducted with Receptionist D at the local ophthalmology clinic. Receptionist D confirmed the first contact the eye clinic received from the facility regarding R2 was on 9/25/25. Receptionist D stated the office usually can schedule patients with acute concerns like eye pain within three days.On 2/23/26 at 4:01 PM, R2 was observed sitting in a wheelchair near the front entrance of the facility. R2's left eye appeared swollen, blocking approximately half of her vision.On 2/24/26 at 12:58 PM, an interview was conducted with the Director of Nursing regarding the reason for two separate ophthalmology referrals, one on 6/26/25 and one of 9/15/25. The DON indicated she was unsure as this was before the time she accepted the position as Director of Nursing.On 2/24/26 at 11:42 AM, a telephone interview was conducted with Former Scheduler/Former Staff J regarding the scheduling process. Former Staff J indicated he attempted to schedule all appointments and referrals within a week of receiving them. When asked about the lapse in R2's June ophthalmology referral, Former Staff J stated he was likely not informed of the referral as there was an ongoing issue regarding missed orders around that time.On 2/24/26 at 3:10 PM, an interview was conducted with Unit Manager/RN [Registered Nurse] C regarding the facility process after receiving a physician referral. RN C stated after a referral is received from a provider, whether verbal, written, or in a progress note, it is transcribed in the EMR as an order so the transport driver can then schedule the appointment. When asked the reason for two separate ophthalmology referrals for R2, RN C could not find the 6/26/25 order in the EMR. RN C stated she was unsure where in the process it broke down, but somehow, it [the 6/26/25 referral] was missed and an ophthalmology appointment was not attempted to be scheduled until September.On 2/24/26 at 10:03 AM, R2 was observed lying in bed. Her left eye appeared swollen, and approximately one third of her eye could be visualized due to the inflammation. R2 was unable to recall the events leading up to her hospitalization but stated the vision in her left eye was still, a little blurry.

This citation pertains to Intake 2741948.Based on interview and record review, the facility failed to ensure a medication was administered in the prescribed form for one Resident (#1) of three residents reviewed for quality of care.Findings include:Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on 9/19/25 with diagnoses including malignant neoplasm of the lung (cancer), fracture of T7-78 vertebra, post-laminectomy syndrome (chronic back, neck, or limb pain which remains after spinal surgery), chronic obstructive pulmonary disease (COPD), and retention of urine.On 2/23/26 at 2:49 PM, a telephone interview was conducted with Complainant A regarding R1's care at the facility. Complainant A stated toward the end of R2's life, he was unable to swallow. Complainant A recalled one nurse tried to administer a medication tablet with water which caused R1 to choke. After that point, Complainant A stated the nurse staff would dissolve R1's pills in other medication liquids to form a solution.Review of R1's EMR revealed the following physician's orders: Lorazepam Oral Tablet 1 MG (milligram). Give 1 tablet by mouth every 1 hour as needed for anxiety. initiated 10/14/25. Atropine Sulfate Ophthalmic Solution. Give 1 drop sublingually [under the tongue] every 1 hours as needed for end of life, 1-2 drops as needed for secretions. initiated 10/15/25.Further review of R1's EMR revealed the following entries by Registered Nurse (RN) G:Orders - Administration Note on 10/15/25 at 16:38 [4:38 PM]: .Patient not drinking, on hospice.Orders - Administration Note on 10/15/25 at 16:38 [4:38 PM]: .Patient not eating, on hospice.10/16/25 at 11:42 AM: .[patient] can no longer swallow.Review of R1's Medication Administration Record (MAR) revealed he was administered Lorazepam tablets 25 times after the initial note indicating he was no longer eating or drinking.On 2/24/26 at 9:45 AM, an interview was conducted with RN G regarding R1's end-of-life care. When asked how R1was able to swallow Lorazepam tablets if he could no longer drink, eat, or swallow, RN G stated she dissolved the tablets in the Atropine to make a solution. When asked if a physician's order was needed to change the form of the medication, RN G indicated, No, we've [the facility] always done it that way for residents who are end-of-life care.On 2/24/26 at 10:21 AM, a telephone interview was conducted with facility Pharmacy Consultant/Pharmacist H regarding R1's medication orders. Pharmacist H indicated it is not standard of practice to dissolve a tablet into the solution of another medication. Pharmacist H stated there is a liquid form of Lorazepam available, and the order could have been optimized by writing it in the liquid formalization.On 2/24/26 at 12:58 PM, an interview was conducted with the Director of Nursing (DON) regarding the expectations with the administration of medications in the prescribed form. The DON stated according to the facility's standing orders, a medication can be crushed and dissolved into another medication unless contraindicated. This Surveyor asked for the facility's standing order policy.On 2/24/26 at 1:36 PM, the DON and Nursing Home Administration (NHA) stated the facility did not have a standing orders policy.

This citation pertains to Intake 2741948.Based on interview and record review, the facility failed to ensure prescribed medications were readily available for one Resident (#1) of three residents reviewed for pharmacy services.Findings include:Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on 9/19/25 at 1:47 PM with diagnoses including malignant neoplasm of the lung (cancer), fracture of T7-78 vertebra, post-laminectomy syndrome (chronic back, neck, or limb pain which remains after spinal surgery), chronic obstructive pulmonary disease (COPD), and retention of urine.On 2/23/26 at 2:49 PM, a telephone interview was conducted with Complainant A regarding R1's care at the facility. Complainant A stated R1 went a waited a significant amount of time for physician orders and missed the first dose of several medications as a result.Review of R1's EMR revealed the following physician's orders with a start date of 9/19/25: Morphine Sulfate ER [extended release] Tablet ER 30 MG [milligram]. Give 2 tablets by mouth every 12 hours for pain related to malignant neoplasm of.lung. Flomax Capsule 0.4 MG. Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia related to retention of urine. Prochlorperazine Maleate Table 10 MG. Give 1 tablet by mouth every 8 hours for Nausea; vomiting related to malignant neoplasm of.lung.Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT [micrograms per actuation]. 2 puff inhale orally every 12 hours for airway patency related to chronic obstructive pulmonary disease.Review of R1's Medication Administration Record (MAR) revealed the following missing doses of medications with the reason listed as, on order:Morphine Sulfate ER Tablet ER 30 MG: 9/19/25 evening dose.Flomax Capsule 0.4 MG: 9/19/25 dose.Prochlorperazine Maleate Table 10 MG: 9/19/25 evening dose and 9/20/25 morning dose.Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT: 9/19/25 evening dose.On 2/24/26 at 12:58 PM, an interview was conducted with the Director of Nursing (DON) regarding pharmacy orders for new admissions. The DON stated that depending on the medication, it's not uncommon to have a delay in the prescription arriving at the facility resulting in a missed dose for a resident. The DON explained that the facility kept a limited number of medications in their back-up supply and controlled substances can be delayed if there's an issue getting the physician's order to the pharmacy. When asked if the facility reviews the resident's medications prior to their arrival, the DON stated, We don't always have their discharge orders until they get here.Review of the facility policy titled, Orders - Admission, reviewed 1/30/24, read, in part: .A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide orders for the residents' immediate care and needs.The written orders should include at a minimum: .Medication orders if indicated.Review of the facility policy titled, Provider Pharmacy Requirements, revised 8/2020, read, in part: .The provider pharmacy agrees to perform all of, but not only, the following pharmaceutical services: .Providing routine and timely pharmacy service as contracted, as well as emergency pharmacy service 24 hours per day, seven days per week.

This citation pertains to intake 1234972Based on interview and record review, the facility failed to protect two Residents (#1 and #2) of four resident reviewed for right to be free from sexual abuse. This deficient practice resulted in psychosocial harm including feelings of embarrassment, devastation, anxiety, feelings of being violated, and trauma based on a reasonable person standard.Findings include:Review of a facility five-day investigation summary, submitted to the State Agency (SA) on 7/8/25 at 6:45 p.m., revealed the following: The Director of Nursing (DON) was notified by the Certified Nurses Assistant (CNA) that R1 was found in R2's bed.R2 was wearing her t-shirt and had her brief off.R1 was disrobed from the waist down and kneeling in another resident's bed.Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 6/14/25, revealed R1 was admitted to the facility on [DATE] with active diagnoses that included: Alzheimer's disease and depression. R1 scored a 2 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment.Resident #2 (R2)Review of the MDS assessment, dated 7/4/25, revealed R2 was admitted to the facility on [DATE], with active diagnoses that included dementia and Parkinson's disease. R2 scored a 99 on the BIMS assessment reflective of severe cognitive impairment.During an interview on 8/6/25 at 8:48 a.m., CNA A reported that R1 has tried to grab other residents breasts.we have to keep him away from the ladies.he does not prefer any particular resident, he will try with any of them.He has been sexually inappropriate and this behavior has increased over the last several months leading up to the incident with R2.During an interview on 8/6/25 at 8:55 a.m., CNA B reported R1 asks if he can touch woman's boobs and he has talked that way for a long time. I have worked here for 5 years, and he has been that way the whole time.During an interview on 8/6/25 at 9:02 a.m., Licensed Practical Nurse (LPN) C reported, I worked that night of the incident. When I walked into R2's room I couldn't believe what I was seeing, he was on her bed straddling her.R2 had no incontinence brief on.he (R1) was on his knees hovering over her. R2's legs were spread, if there was any abuse it was brief.she seemed embarrassed, and her face was flushed. R1 will make comments to the other residents and reach out to them, and we have had to watch him with other residents prior to this incident with R2.During an interview on 8/6/25 at 9:49 a.m., the DON reported, R1 was on the end of the bed on his knees and leaning over her.both R1 and R2's incontinence briefs were off, and they were naked from the waist down.During a phone interview CNA D reported, I was the one that found them that morning. When I went into her room he was on top of her and her legs were spread apart. Neither one of them had incontinence briefs on.I don't think R2 understood what was going on and R1 told me that they were making love.He has tried to touch other female resident's thighs and has been touchy with other residents in the past.During a phone interview on 8/6/25 at 10:47 a.m., Family Member E stated, My mom would be devastated and upset if she knew what had happened to her.she would have been in shock.she would have never done this with anyone, only my dad who was the only man she had ever been with.Review of the Electronic Medical Record (EMR) revealed R1 had sexually inappropriate behaviors on the following dates 1/3/25, 1/9/25, 2/13/25, 3/3/25, 4/9/25, 5/5/25, 5/7/25, 5/12/25, 6/2/25, 6/16/25 and 6/26/25.Review of Nurses notes dated 5/21/25 revealed R1 had been Touching and feeling the woman residents this shift. Resident (R1) asked another woman resident how many times she could do it tonight? The woman resident stated she doesn't know because she is old now, [R1] said so am I but I could do it three times tonight one at 9pm one at midnight and one at 3 am.During an interview on 8/6/25 at 10:59 a.m., Social Services worker F reported that she was unaware of the event on 5/21/25 and she was aware that R1 had sexual behaviors in the past, but the facility had not offered behavioral health services to the resident since 2019. Social Service worker F reviewed the EMR and reported there was not a care plan in place to keep the residents safe from R1's sexual inappropriate behaviors.During an interview on 8/6/25 at 12:00 p.m., the DON reported there was no trauma assessment completed on R2 following the incident. The DON acknowledged there was no care plan or interventions to monitor R2 for any catastrophic reactions (emotional or behavioral reactions) from R2.During an interview on 8/6/25 at 12:30 p.m., the Nursing Home Administrator (NHA) reported that she was aware R1 had sexual inappropriate behaviors with staff prior to the incident and was not aware of the event on 5/21/25. The NHA acknowledged there were no care plan interventions following the event for R2, the facility did not offer behavioral health services for R1, there were no care plan interventions prior to the incident for R1 regarding sexual inappropriate behaviors in order to keep other residents safe.Review of policy titled Abuse, Neglect, and Exploitation date reviewed/revised 1/10/24 read in part, .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Abuse means the willful infliction of injury.willful means the individual must have acted deliberately .sexual abuse is nonconsensual sexual contact of any type with a resident.the facility will develop and implement .policies and procedures that prohibit and prevent abuse.

Based on observation and interview, the facility failed to properly store and dispose of expired medications, and log refrigerator temperatures for immunization and insulin medications for one of one medication room and three of three medication carts reviewed for medication storage. Findings include: On 12/15/24 at 12:21 PM, Registered Nurse (RN) L was asked to open the medication room on D-hall. RN L was asked about refrigerator temperature logs and replied, I am not sure. I have never checked the temperature in the refrigerator. I was not aware we needed to do that. Inside the medication room an observation was made of one expired box of eight therapeutic nutrition powder supplement packages with a brand name, lot number 528092S00, and a use by date of 01NOV2024. No temperature log tracking sheet was placed/observed on the vaccination/medication refrigerator at the time of the observation. Review of the D-hall refrigerator temperature binder log, dated February 2024 through December 2024, revealed that temperatures for the medication refrigerator were not being completed twice daily as indicated on the tracking sheet findings include: a.) February temperature tracking sheet revealed 36 of 58 opportunities to record refrigerator temperature were not completed. b.) March temperature tracking sheet revealed 44 of 62 opportunities to record refrigerator temperature were not completed. c.) April temperature tracking sheet revealed 58 of 60 opportunities to record refrigerator temperature were not completed. (Last completed temperature check was on 4/14/24 no further temperatures recorded after this date). d.) May temperature tracking sheet revealed 62 of 62 opportunities to record refrigerator temperature were not completed. e.) June through December lacked any start of a tracking month/daily sheet to record refrigerator temperatures. On 12/15/24 at 12:25 PM, RN L unlocked the medication room on D-hall's refrigerator and inside the refrigerator an observation was made of one multi-use vial of influenza vaccine with an opened date of 11/9/24. RN L was asked how long the multi-use vial of influenza vaccine was good to use after it had been opened and replied, I am not sure. I would have to ask. Further inspection on the A-hall medication refrigerator revealed a second multi-use vial of tuberculosis testing solution with an opened date of 10/9/24 that was faded and worn. On the outside of the medication vial holder was a sticker for a date opened and expired that was not filled out. RN L again was not sure how long either vial was ok to use after it had been opened. On 12/15/24 at 12:34 PM, an observation was made of the medication cart on A-hall and revealed the following: a.) One name brand insulin pen with an opened date of 11/4/24 and an expiration date of 12/2/24. b.) One loose white oblong pill in the second drawer and identified as buspirone 15 milligrams (mg). c.) One inhaler (Umeclidinium/Vilanterol) opened with a count of 11 and undated. (Per pharmacy formulary only good for 42 days after opened). d.) One inhaler (Fluticasone/Umeclidinium/Vilanterol) opened with a count of 8 and undated. e.) One inhaler (Umeclidinium/Vilanterol) opened with a count of 7 and undated. On 12/15/24 at 1:00 PM, an observation was made of the medication cart on D-hall and revealed the following: a.) Three name brand insulin pens opened without an expiration date. b.) Two loose white pills with only one being identified as metoprolol 100 mg. c.) One nasal spray (Ipratropium Bromide) opened and undated. d.) Two empty boxes of name brand inhalers. e.) Three name brand inhalers opened and undated. On 12/15/24 at 1:08 PM, an interview was conducted with Licensed Practical Nurse (LPN) G who was asked where the inhalers were and replied, I am not sure. They should be in the boxes. LPN G was asked if medications needed an opened date and replied, I guess. I just started a few months ago. On 12/15/24 at 1:44 PM, an observation was made of the medication cart on B-hall and revealed the following: a.) An unlocked and unattended medication cart. No staff or nurse in sight. One resident in the hallway in a wheelchair with a family member visiting them. b.) Two loose pills in the second draw, one red capsule with imprint of [NAME] 330 unable to be identified, and one round yellow tablet identified as carbidopa-levodopa 25/100 mg. c.) One pill container with four compartments for morning, noon, evening, and bedtime. Pill container had six pills unidentified in the morning compartment, no pills in the noon compartment, two pills in the evening compartment, and three pills in the bedtime compartment. The pill container was not labeled with any resident name. On 12/15/24 at 1:50 PM, an interview was conducted with RN J who was responsible for the B-hall medication cart and was asked why the medication cart was unlocked and replied, I just forgot to lock it. I happen to do that from time to time. I know it should have been locked. I was just on a break. RN J was asked about the loose pills and pill container and replied, Yeah, the medication cart needs to be cleaned out. I am not sure who's pill container that is and it should have a name on it. On 12/15/24 at 2:05 PM, an interview was conducted with the Director of Nursing (DON), who was asked about the refrigerator in the medication room, dating medications, loose pills in the medication carts, and expired medications and replied, When medications are opened, they should be dated. Medication carts should be cleaned regularly. The medication refrigerator temperature needs to be checked twice daily. I was not aware that it was not being completed. The DON was asked how long multi-use vials were good to use after they had been opened and replied, I would have to check with pharmacy, but usually a month. Review of facility document titled, Vaccine Storage Temperature Log, dated March (2024) days 16-31, read in part, .Instructions: Place a (check mark) in the box that corresponds with the temperature (rows), day of the month, and am or pm (columns) for your temperature check. Then enter your initials and the time you monitored the temperature in the boxes at the top of the chart . Review of facility document titled, Did You Know, undated, read in part, .Open containers - Rule of thumb - Once drug products are opened and in use., they must be used within a specific time frame to avoid reduced stability, sterility and potentially reduced efficacy .A drug product's Beyond Use Date (BUD) is the manufacturers supplied expiration date OR the shortened date after opening, whichever comes first .TB (tuberculosis) solution: 30 days, refrigerated. Flu vaccine MDV (multi-dose vial): 28 days, refrigerated . Review of policy titled, Medication Storage, dated 1/30/24, read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts .) .5. Refrigerated Products .b. Temperatures are maintained within 36 - 46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee .7. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drug Policy. Review of policy titled, Medication-Destruction of Unused Drugs, dated 1/18/24, read in part, Policy: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations .

Based on interview and record review, the facility failed to implement an infection prevention and control program (IPCP) to prevent, recognize, and control infections, and failed to update infection control policies annually. This deficient practice resulted in the potential spread of infectious organisms and disease to all 82 residents residing in the facility. Findings include: On 12/15/24 at 12:43 p.m., the Director of Nursing (DON) was asked the name of the facility's Infection Preventionist (IP). The DON said the facility did not have an IP. The DON explained that someone from another building who was not employed at the facility was keeping up with infection control information at the facility. The DON said Registered Nurse (RN) D was the MDS nurse in the facility and had training in infection prevention and control, and any questions regarding the IPCP should be directed to RN D. The IPCP was reviewed with RN D on 12/17/24 at 9:09 a.m. RN D presented an IPCP binder divided by each month. The divider for December 2024 was empty. RN D was asked where December 2024 information was maintained. RN D said she did not know and said she would email the person who worked in a different building to obtain the December infection control monitoring and tracking. RN D explained that someone at another facility maintained their infection control program because they did not have an IP in the building. RN D was asked how the facility tracked residents who experienced signs and symptoms of infections. RN D said antibiotics are monitored on the dashboard in the electronic health records each day during morning meeting, but she did not know if or how they were documented for monitoring and tracking. RN D said the facility utilized McGeer Criteria (a minimum set of signs and symptoms which, when met, indicate a resident likely has an infection and may require an antibiotic). RN D was asked if nurses who work the floor had been educated on McGeer Criteria or if they had access to the McGeer Criteria. RN D said the nurses who work the floor were not provided education on McGeer Criteria nor did they have access to the McGeer Criteria to evaluate the likelihood of infections. Resident #60 (R60) R60 was prescribed the antibiotic Doxycycline in December 2024 for a respiratory infection. The respiratory symptoms persisted after the antibiotic course was completed and the Doxycycline was re-implemented as a second course of antibiotic therapy. During an interview with RN D on 12/17/24 at 9:09 a.m., RN D was asked about the Doxycycline for R60. RN D said, I think it's prescribed for osteomyelitis in his collar bone .or was that the amoxicillin? RN D was told the Doxycycline was documented as being for a respiratory infection. When asked why the same antibiotic was resumed if it was ineffective in resolving the infection after the first course of antibiotic therapy, RN D said, I do MDS. I've never been trained on the infection control policies. I don't really know anything about the infection control program . Resident #42 (R42)/Resident #329 (R329) RN D was asked about symptoms, monitoring, tracking, dates of positive testing, and mapping for two residents R42 and R329 who tested positive for COVID-19 in December 2024. RN D confirmed there was no information in the IPCP binder for R42 and R329. RN D reviewed the medical records of R42 and R329 and said nurses were documenting signs and symptoms. RN D was asked if testing of other residents had been completed when R42 and R329 tested positive. RN D said, I don't know. There was some talk in the morning meeting about doing testing on other residents, but I don't have a list if other residents who were tested , and I didn't take part in any testing. RN D was asked if a prevalent organism had been identified as the cause of infection for several residents with urinary tract infections. RN D admitted she did not know. RN D said nurse managers talked about urinary catheter care, pericare, and hand washing in the morning meeting, but said she didn't know if any documented education had been provided to the Certified Nursing Aides (CNA) who were responsible for providing direct care to residents. RN D admitted she did not know what was to be monitored, surveilled, tracked, evaluated, investigated, or documented for the IPCP. RN D said she is unfamiliar with the IPCP policies. RN D confirmed the IPCP policies that were provided were the most updated policies. The following infection control policies were not updated annually: 1. Pneumococcal Vaccine (Series) policy was dated as last reviewed/revised 10/30/23 2. Infection Preventionist policy was dated as last reviewed/revised 10/26/23 3. Influenza Vaccination policy was dated as last reviewed/revised 10/26/23 4. COVID-19 Vaccination policy was dated as last reviewed/revised 10/20/23. On 12/17/24 at 11:57 a.m., the DON was interviewed regarding the IPCP and said, we know infection control is a problem. The policy Infection Prevention and Control Program dated as reviewed/revised 12/27/23 read, in part: .The designated Infection Preventionist is responsible for the oversight of the program and serves as a consultant to our staff .The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings .The facility shall conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures .

Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist was employed at least part-time in the facility and was present to properly assess, implement, and manage the Infection Prevention and Control Program (IPCP). This deficient practice resulted in the potential for the spread of infection and communicable diseases to all 82 residents in the facility. Findings include: On 12/15/24 at 12:43 p.m., the Director of Nursing (DON) was asked the name of the facility's Infection Preventionist (IP). The DON said the facility did not have an IP. The DON explained that someone from another building who was not employed at the facility was keeping up with infection control information at the facility. The DON said Registered Nurse (RN) D was the MDS nurse in the facility and had training in infection prevention and control, and any questions regarding the IPCP should be directed to RN D. During an interview with RN D on 12/17/24 at 9:09 a.m., RN D was unable to answer questions regarding processes for identifying, monitoring, tracking, correlating, reporting, documenting, and controlling infections and communicable diseases for residents, staff, and other individuals in the facility. RN D said, I do MDS. I've never been trained on the infection control policies. I don't really know anything about the infection control program. An IP from another facility does our infection control. The Policy Infection Preventionist dated as reviewed/revised on 10/26/23 read, in part: .The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program . The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program to include the antibiotic stewardship program The IP will have the knowledge to perform the role .the IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees .The IP will physically work onsite in the facility .

Based on interview and record review, the facility failed to provide written transfer notifications to the resident/resident's representative and the Office of the State Long-Term care Ombudsman including reason, effective dates, and the location to which the resident was being transferred for four Residents (#5, #16, #33, #43) of seven residents reviewed for transfers out of the facility. Findings include: Resident #5 (R5) The medical record for R5 revealed a transfer to the hospital on 10/10/24 with readmission on 10/15/24. The medical record did not indicate a written notification of transfer in October was given to R5 or sent to the resident's representative. The Resident was on the Office of the State Long-Term care Ombudsman log as transferred but there was no indication on the log if the return was expected and no primary reason for the transfer. (This data was missing for all 16 residents on the October ombudsman log.) On 12/17/24 at 10:41 AM, Administrative Staff F stated the written transfer notice for R5 was not in the transfer binder and had not been sent. Staff F stated no written transfer notices were sent for the 9 residents on the ombudsman log for November and none were sent in December as she had not received an information from nursing. 45123 Resident #16 (R16) The medical record for R16 revealed a transfer to the hospital on 3/7/24 with readmission on 3/10/24. The medical record did not indicate a written notification of transfer was given to R16. The Resident was on the ombudsman log as transferred but there was no indication on the log if the return was expected or the primary reason for the transfer. Resident #33 (R33) The medical record for R33 revealed a transfer to the hospital on 6/22/24 with readmission on 7/2/24. The medical record did not indicate a written notification of transfer was given to R33 or the Resident's representative. The Resident was on the ombudsman log as transferred but there was no indication on the log if the return was expected or the primary reason for the transfer. 49310 Resident #43 (R43) The medical record for R43 revealed a transfer to the hospital on 12/10/24. The medical record did not document issuance of written notification for the reason for the transfer to R43 or R43's resident representative. On 12/17/24 at 2:45 p.m., Staff F confirmed she maintained the written notifications of bed holds and transfers in a binder. The binder contained dividers labeled by month with the written notifications filed by the month in which each resident was transferred to the hospital. The months of November 2024 and December 2024 were empty. Staff F said, It's a hit or miss if I receive them from nurses. I didn't receive any for November and December. Staff F said the expectations is for nurses to complete the written notifications and provide them to her the next business day to file in the binder. Staff F confirmed the notifications would be in the binder if they had been issued. The Transfer Discharge Policy dated as revised 10/30/23, read in part: .Provide transfer notice as soon as practicable to resident and representative . Social Services Director, or designee, shall provide notice of transfer to a representative of the Office of the State Long-Term care Ombudsman via monthly list .

Based on interview and record review, the facility failed to ensure four Residents (#5, #16, #33, and #43) of eight residents reviewed for hospitalization were provided written notice of bed hold when the residents were transferred to the hospital. Findings include: Resident #43 (R43) The medical record for R43 revealed a transfer to the hospital on 12/10/24. The medical record did not document issuance of the bed hold policy to R43 or R43's resident representative. 45123 Resident #16 (R16) The medical record for R16 revealed a transfer to the hospital on 3/7/24 with readmission on 3/10/24. The medical record did not indicate a notice of the resident's bed hold policy had been given to R16 or the resident's representative. Resident #33 (R33) The medical record for R33 revealed a transfer to the hospital on 6/22/24 with readmission on 7/2/24. The medical record did not indicate a notice of the resident's bed hold policy had been given to R33 or the resident's representative. 40383 Resident #5 (R5) The medical record for R5 revealed a transfer to the hospital on 10/10/24 with readmission on 10/15/24. The medical record did not indicate a notice of the resident's bed hold policy had been given to R5 or the resident's representative. On 12/17/24 at 10:41 AM, Administrative Staff F stated the bed hold notice for R5 was not in the transfer binder and had not been given. On 12/17/24 at 2:45 p.m., Staff F confirmed she maintained the written notifications of bed holds and transfers in a binder. The binder contained dividers labeled by month with the written notifications filed by the month in which each resident was transferred to the hospital. The months of November 2024 and December 2024 were empty. Staff F said, It's a hit or miss if I receive them from nurses. I didn't receive any for November and December. Staff F said the expectations is for nurses to complete the written notifications and provide them to her the next business day to file in the binder. Staff F confirmed the notifications would be in the binder if they had been issued. The Transfer Discharge Policy dated as revised 10/30/23, read in part: . Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer .

Based on observation, interview and record review, the facility failed to maintain personal privacy of medical information for one hallway of four hallways reviewed. This deficient practice resulted in Residents privacy being breached. Findings include: On 12/17/24 at 9:38 a.m., an observation was made of the D-hall medical cart computer. The D-hall medical cart computer was left with an open display for Resident 179 (R179), and visible on the computer screen were Physician Orders from the Electronic Medical Record program. The D-hall medical cart also had a clearly visible 'Controlled Substance Log' for R179 used to keep accurate count of controlled substances. Review of the facility's Federal Rights of Nursing Center Residents Requirements for Nursing Facilities given to each resident in the Hospitality Guide upon admission, read, in part, .(3) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records . An interview was conducted with the Director of Nursing (DON) on 12/17/24 at 12:45 p.m. The DON confirmed that the D-Hall medical cart computer display and other documentation should have been securely locked and closed.

Based on interview and record review, the facility failed to failed to appropriately monitor and recognize the signs of over-sedation for one Resident (#11) out of six residents reviewed for quality of care. This deficient practice resulted in harm when Resident #11 continued to receive medication with sedating effects, required the emergency administration of medication to reverse the sedation, and sustained a fall resulting in a head injury. Findings include: This citation pertains to Intake # 9. Resident #11 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #11's minimum data set (MDS) assessment, dated 12/3/20, revealed Resident #11 required limited, one-person physical assistance with transfers and walking. Resident #11 was cognitively intact and had not had a fall in the six months prior to this assessment. A review of an Incident Report for Resident #11 provided by the Director of Nursing (DON), dated 12/13/20 at 1:00 p.m., revealed the following, in part: Res (Resident #11) in bed (after) receiving [MEDICATION(S)] (a narcotic reversing medication) r/t (related to) lethargy. In bed laying (with) feet on bed. Staff offered (Resident #11) to use BR (bathroom), (Resident #11) stated no. About two minutes later, staff heard a noise (and) entered room to find (Resident #11) on floor. A review of the Fall RCA (root cause analysis) Investigation Tool, attached to the incident report, revealed the following, in part: 8. Describe resident's mental status prior to fall: Lethargic - was given [MEDICATION(S)] per order. 9. Describe resident's psychological status prior to fall: Lethargic, calm . (Resident #11) had been lethargic (with) suspected med (medication) change started day before. NP (Nurse Practitioner) ordered [MEDICATION(S)] IM (intramuscular injection) given. Asked if (Resident #11) needed to use the bathroom, (Resident #11) said no. Asked if (Resident #11) wanted to lay down, (Resident #11) said yes. Helped her lay down (and) left the room. Minutes later heard her fall. Ran to room (and) observed (Resident #11) face down on floor. Started (first) aid (and) called 911 . Root Cause of This Fall: Medication. The forms were signed by Licensed Practical Nurse (LPN) G on 12/13/20 and the Unit Manager, Registered Nurse (RN) C on 12/14/20. A review of Resident #11's, ED (emergency department) Provider Documentation, dated and signed 12/13/20 at 6:08 p.m., revealed the following, in part: (Resident #11) allegedly switched from 1 pain medicine to another pain medicine. Was felt by staff that (Resident #11) was too sedated . given [MEDICATION(S)], and the patient ended up rolling out of bed falling and striking her head on the floor. Unknown loss of consciousness . (Resident #11) complains of some head pain where (they had) enlarged lacerations . Procedure: Laceration of the left side of the face was repaired using a running suture . The right side was repaired using a running suture and 2 simple uninterrupted sutures. A review of Resident #11's CT (Computed Tomography) Head (imaging of skull), signed and dated 12/12/20 at 4:30 p.m., revealed the following, in part: Impression: 2. Subcutaneous (under the skin) hematoma (severe bruise) and soft tissue swelling without convincing underlying calvarial (skull) fracture. A review of a progress note, dated 12/13/20 at 11:53 a.m. and signed by LPN G, revealed the following, in part: Sent to on-call NP (Nurse Practitioner). (Resident #11) has been hard to arouse today. (Resident #11) was falling asleep on her breakfast and morning breathing treatment. When I (LPN G) went to give (Resident #11) her 11 AM breathing treatment, I (LPN G) could not get (Resident #11) to hardly wake up . (Resident #11) had med changes that started yesterday . she started oxycodone (long-acting narcotic pain medication) 30 mg (milligram) and [MEDICATION(S)] (intermediate acting narcotic pain medication) 10-325 (mg). I'm (LPN G) wondering if she needs [MEDICATION(S)]? A review of the NP Progress Note, dated 12/13/20 at 12:57 a.m., revealed the following, in part: Notified by nursing staff that (Resident #11) is difficult to arouse today. She was falling asleep on her breakfast and morning breathing treatment. When nursing attempted to give (Resident #11) 11 AM breathing treatment, (Resident #11) could hardly wake up. (Resident #11) had med changes that started yesterday . started oxycodone . 30 mg. [MEDICATION(S)] 1 mg to be given IM stat (now). Nursing to continue to monitor closely. May hold meds if drowsy. During an interview on 1/3/21 at 1:37 p.m., LPN G reported they recalled the incident that occurred on 12/13/20 involving Resident #11. LPN G reported Resident #11 had been lethargic during medication pass on 12/13/20 at 7:00 a.m. LPN G reported when breakfast arrived a little later, Resident #11 was unable to sit at the bedside as they usually did and continued to sleep. LPN G reported Resident #11's vital signs were within normal range and therefore, was not overly concerned at that time. When asked if they were concerned that Resident #11 may have been over-medicated, LPN G reported they were not concerned until they could not arouse Resident #11 for their 11:00 a.m., scheduled breathing treatment, at which time she sent a message to the on-call NP. LPN G reported the NP ordered [MEDICATION(S)] 1 mg IM to be administered to Resident #11. LPN G reported the [MEDICATION(S)] was administered at approximately 1:00 p.m. LPN G reported they had never administered [MEDICATION(S)] prior to Resident #11 and had referred to the facility's drug reference guide for instructions on administration. When asked how Resident #11 responded after the administration of [MEDICATION(S)] 1 mg, LPN G reported the resident seemed more alert but did not want to get up to use the bathroom. LPN G reported the resident was repositioned in bed and went back to sleep. LPN G reported she and Certified Nurse Aide (CNA) F then left the room, stating, we would go back and check on her later. LPN G reported after they had left Resident #11's room, they heard Resident #11 fall. LPN G reported Resident #11 was found lying on the floor next to their bed and was bleeding from a wound on their head. LPN G stated the resident was more alert after the fall than when they had previously left the room. LPN G reported they administered first aid to the resident after the fall and called 911 for transport to the emergency department. During an interview, on 12/14/20 at 1:38 p.m., CNA F reported they recalled the incident that occurred on 12/13/20 involving Resident #11. CNA F reported the resident had been very tired that morning and could not stay awake for breakfast. CNA F reported Resident #11 was usually independent and that morning was, not like her usual self. CNA F reported they were present at the time LPN G administered [MEDICATION(S)] to Resident #11. When asked how the resident responded to the medication, CNA F reported Resident #11 did not wake up, all the way. CNA F did not remember how long they and LPN G stayed with Resident #11 after the administration of the [MEDICATION(S)] but that Resident #11's legs were, half off the bed, and they repositioned the resident's legs in bed before leaving the room. CNA F reported after they and LPN G then left the room and, not long after, they heard Resident #11 calling out for help. CNA F reported they found Resident #11 sitting on the floor next to their bed. When asked the condition of Resident #11 at that time, CNA F reported the resident was awake and complaining of trouble breathing. CNA F reported they had cared for Resident #11 on many occasions prior to and after the incident on 12/13/20 and that after 's fall on 12/13/20, the resident was, never the same, and required more assistance than needed prior to the fall. When asked if they were aware if Resident #11 had falls prior to the fall on 12/13/20, CNA F reported Resident #11 had not fallen prior to 12/13/20. A review of Resident #11's December 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #11's December 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN G documented administration of the 12/13/20 8:00 scheduled dose; and 2. Oxycodone 30 mg, give 1 tablet by mouth 2 times a day related to chronic pain syndrome. Hold if drowsy or asleep. Start date: 12/11/20. LPN G documented administration of the 12/13/20 9:00 a.m. scheduled dose on the MAR. A review of Resident #11's, Controlled Drug Administration Record(s), revealed the following, in part: 1) Lorazepam (a controlled anti-anxiety medication) 1 mg, take 1 tab by mouth three times a day as directed . may cause drowsiness . 12/13/20 0700 (7:00 a.m.), Dose/Amount Used: 1, Admin (administered) by (LPN G), and 2) [MEDICATION(S)] (oxycodone) CR 30 mg, take 1 tablet by mouth twice a day, hold if drowsy or asleep . may cause drowsiness or dizziness . 12/13/20 0700 (7:00 a.m.), Dose/Amount Used: 1, Admin by (LPN G). Both medications had been administered at the time of the morning breathing treatments and LPN G's identification of Resident #11's drowsiness and lethargy. During an interview, on 1/14/21 at 3:07 p.m., the DON reported an investigation had been conducted to determine why Resident #11 required the administration of [MEDICATION(S)] on 12/13/20. When asked for the investigative report, the DON reported the investigation had not been formally documented but they had reviewed Resident #11's medication logs and interviewed staff to determine the condition of the resident in the days prior to the incident, and found no indication as to why the resident became overly sedated. When asked what the procedure was for holding administration of medication, the DON reported medications were held according to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #11 had been awake and alert prior to administration of the medications. The DON reported they were unsure if administration of [MEDICATION(S)] was considered an emergency. When asked about the appropriate administration and effects of [MEDICATION(S)], the DON reported they would have to check the pharmacy reference for guidelines as [MEDICATION(S)] was not administered often at the facility. A review of the policy titled, Medication Administration, reviewed and revised 10/30/20, revealed the following, in part: Policy: 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. A review of the facility drug reference, provided by the DON on 1/14/21, revealed the following, in part: [MEDICATION(S)] hydrocholoride ([MEDICATION(S)]) . Indications & Dosages: Known or suspected opioid-induced respiratory depression . Adults: 0.4 to 2 mg . Repeat dose every 2-3 minutes, p.r.n. (as needed) . after reversal, additional dose(s) may be needed . Emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the policy titled, [MEDICATION(S)] ([MEDICATION(S)]) Administration, dated 8/2016, revealed the following, in part: Purpose: to provide safe administration of ([MEDICATION(S)]) in the event of narcotic toxicity . 4. Narcotic toxicity must be established before the administration of [MEDICATION(S)] . Considerations: The exact dose of [MEDICATION(S)] cannot be determined in advance for an individual . Discontinue [MEDICATION(S)] ([MEDICATION(S)]) when desired effect is achieved . refer to appropriate drug reference text for complete administration guidelines.

This citation pertains to intake number MI 434. Based on observation, interview, and record review, the facility failed to ensure the prevention of falls for 2 of 3 residents (#2 and #3) sampled for fall risk issues, when they failed to 1) use a gait belt during the transfer (movement from surface to surface) of Resident #2 from her wheelchair to her bed, and 2) failed to prevent the potential for falls in 1 of 3 residents (Resident #3) when the Resident was observed by the State Surveyor crab-walking in the hallway while seated in his wheelchair, without use of non-slip footwear, and in accordance with his care plan. This deficient practice resulted in Resident #2 experiencing a fall, sustaining a comminuted spiral fracture, with displacement, of her left femur requiring surgical intervention (ORIF; surgical procedure in which the Resident received placement of a plate and screws to stabilize the broken bone), and also in the potential for falls for Resident #3. Findings include: Resident #2 The medical facesheet revealed that Resident #2 is an [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets assessment dated [DATE] revealed Resident #2 was assessed as severely cognitively impaired (BIMS of 3/15), and required extensive assist for activities of daily living (ADL's) from a facility staff member, including transfers. The Fall Risk assessment dated [DATE] (untimed) identified Resident #2 at risk for falls due to medication use (diuretics, hypoglycemic agents, antihypertensives, narcotics and psychotropics), highly impaired visual acuity, incontinence of bowel and bladder, use of short discontinuous steps, use of an assistive device, and a decrease in her muscle coordination. According to the ADL care plan revised on 8/3/2017, Resident #2 was to be transferred with use of a gait belt, CGA (contact guard assist; a staff member holding onto the gait belt) of one staff member, and use of a front wheeled roller walker (FWW). Review of the Occurrence Report dated dated 8/10/2017 at 17:23 p.m., revealed that Resident #2 was being transferred from her wheelchair to her bed by CNA E on 8/7/2017 at 19:30 p.m., when the Resident's footing slipped causing her to lose her balance and fall to the floor. The CNA was not using a gait belt, per facility policy/procedure, at the time of the fall. The Resident was reported to have been sent to a local hospital for evaluation. She was diagnosed with [REDACTED]. According to the facility's Gait (ambulation) Belt Policy & Procedure (undated) facility staff are to provide increased security and prevention of injury for the Resident and staff, gait belts will be used during ambulation and transfer of all residents unless specifically contraindicated . (entry #1) Apply the belt around the resident's waist snugly enough to eliminate the possibility of sliding up on the ribs. (entry #2) To transfer the resident, grasp the belt on the back sides of the resident's waist and have the resident hold around your shoulders. On the count of three, raise the resident to a standing . (entry #4) If a resident begins to fall, use the ambulation belt to draw the resident close to your body, then gently and slowly lower the resident to the floor by allowing him/her to slide down your leg. During an interview on 8/22/2017 at 3:20 p.m., CNA E acknowledged that he had not utilized a gait belt during the transfer of Resident #2 during the transfer on 8/7/2017 at 19:30 p.m. I was moving to get in front of her. She didn't have a gait belt on. I held onto her shoulder and her brief. she was standing already. No time to get a gait belt on. Her right foot slid under the bed. She went to the floor pretty hard. She held onto the mobility bar as long as she could, but fell . Resident #3 During initial tour of the facility on 8/22/2017 at 8:00 a.m., sampled Resident #3 was observed in his wheelchair on the Denmark (D) hallway, crabwalking (using his feet to move him forward in his seated position), wearing a loose-fitting sock; he was not wearing non-slip footwear as had been care planned (initiated 2/15/2017). His right lower extremity had a splint device in place. CNA N told the State Surveyor, It's not a non-skid sock, but I'll get him one. She obtained a grippy sock which she placed on his left foot.

Based on observation, interview and record review, the facility failed to provide adequate supervision with hot liquids or assistance devices (cups with covered lids) as ordered to prevent accidents for one (Resident #100) of four residents reviewed for accidents, from 104 total facility residents. This deficient practice caused injury from spilled hot coffee, resulting in multiple (five) second-degree burns, pain, antibiotic treatment for [REDACTED]. Findings include: An abbreviated survey was conducted at the facility on 02/21/14 and 02/24/14 in response to a Facility Reported Incident (FRI) dated 02/19/14. The FRI report read in part: "On 2/18/14 at 5:26 p.m., (Resident #100) spilled coffee while repositioning himself in wheelchair. Immediate intervention initiated. Coffee tempted (sic) within normal limits. Investigation in progress." A review of Resident #100's "Admission Record", indicated he is a [AGE] year old man admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #100's annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #100 had 'moderately' impaired memory as assessed by a BIMS (Brief Interview for Mental Status) score of 10/15. Resident #100 needed 'set/up' help for eating, was non-ambulatory, used a wheelchair as his main mode of transportation and needed extensive assistance for dressing and hygiene needs. An interview took place on 2/21/14 at 2:40 p.m. with Certified Nurse Aide (CNA) "D", who was passing coffee and other hot drinks to residents in the dining room on 2/18/14, the date of the incident. CNA "D" stated, "I poured (Resident #100) a cup of coffee and went on down the table pouring drinks....All of a sudden I heard another resident yell, 'He spilt his coffee!'....I looked up to see (CNA "A") wheel (Resident #100) to the nurse....I thought we were supposed to use 'sippy lids' on the days he goes to dialysis...(Resident #100) is usually tired and doesn't seem to be as alert (on dialysis days)....This wasn't a dialysis day....I'd given him his shower earlier in the day, and he was his feisty self then." When CNA "D" was asked if she knew of any other residents given assessments and requiring cups with lids, CNA "D" replied "....Well, we just know who the residents are....we don't have a list posted anywhere, lids and such are listed on the 'tray cards', but those are in the kitchen till the meals come out." A telephone interview was conducted at 9:40 a.m. on 02/24/14 with CNA "A", who was asked about the events on 02/18/14. CNA "A" stated, "I was passing the cold drinks (juices, ice water etc.) in the dining room. I looked towards (Resident #100) because another gentleman was yelling. (Resident #100) was moving up and down in his wheelchair and I could see coffee on the floor... I immediately took him out of the dining room and took him to his room. I got help to lay him down in the bed and get his pants off and applied a cold wash cloth." CNA "A" was asked how she knew which residents needed 'sippy cups' with lids for beverages. CNA "A" stated "Well, we just know....with him (Resident #100) on good days we didn't always use a lid, bad days we did (use a cup and lid)." CNA "A" stated, "The 'pink sheets' (Care Delivery Guides located in each resident's closet) is where we find information like..sling sizes, cushions, special eating utensils etc." An interview was held with Resident #100 on 02/21/14 at 1:15 p.m., Resident #100 was asked to recall the events of 02/18/14. He stated, "I pulled the coffee off the table and that's what happened." Resident #100 was asked if he required 'lids' on his drinks. He replied, "Yes and no." When asked which beverages had a lid, Resident #100 stated, "The hot ones..." When asked if there was lid on his coffee the night he got burned, Resident #100 stated, "No, but I have them (lids) now." A current order for resident #100 was written on 01/02/13, with recommendations by the Occupational Therapist and signed by the physician, reading "Pt (patient) to have all liquids hot/cold served in cups with lids to decrease spillage." Observation was made of a dressing change to Resident #100's left posterior thigh on 02/21/14 at 2:35 p.m. with Licensed Practical Nurse (LPN) "G". Resident #100's dressings were removed, there were 5 different areas extending from the mid-thigh towards the knee, having the characteristics of second-degree burns involving the first two layers of skin with reddening, blisters and glossy appearance from leaking fluids. There was a heart shaped burn measuring 5.5 centimeters (cm) at the longest by 4 cm wide, below this burn was another area measuring 4 cm long by 2 cm wide. To the left of this burn was a very thin linear burn measuring 6 cm long by 0.5 cm wide. The last two areas were closer to the knee crease of the leg. One area was a fluid filled blister measuring 1.5 cm by 1.5 cm (round) and another linear burn measuring 3 cm long by 0.2 cm wide. The burns were covered with two- 8 inch by 3 inch non-stick pads and then wrapped with a gauze type dressing. Resident #100 winced and pulled his leg away while LPN "G" was cleaning these areas. LPN "G" stated, "(Resident #100) was never sent to the emergency room (on 2/18/14) for treatment, orders were obtained directly from the physician and began immediately." The Administrator was asked to provide any documentation regarding the facility's investigation into the events that transpired on 02/18/14. At 1:40 p.m. on 2/21/14, the Administrator provided documents that included witness statements, care plans, and physician orders. In reviewing the care plan titled "Nutrition Risk Care Plan" initiated 12/2013, 'Adaptive Equipment' is checked and written in: 'sip cups 2/19/14.' The Administrator stated, "The adaptive equipment (cups with lids) was not on the resident's (#100) care plan, but it is now." The Administrator confirmed the resident 'Care Delivery Guides' for CNA use were updated after Resident #100 sustained his injury. An interview was conducted with the Director of Nursing (DON) on 02/21/14 at 3:00 p.m. The DON stated, "(Resident #100) was here (at facility) and left on 1/13/13 to have his left leg amputated, he returned a few days later. The original order for 'sippy cups' wasn't placed back on the orders for him, and never made it to the care plans....but we (staff) were still following it (original order). The shower techs pass drinks before the meals, while the CNAs are getting residents ready for the dining room. Staff didn't know who needed 'sippy cups' while passing drinks, that information was on the care plans or should have been." A review of Resident #100's medical record revealed an order written [REDACTED].hold prosthesis (for Left BKA) until blisters are resolved to left inner thigh". Another order was written on 02/22/14 for "Rocephin (antibiotic) 1 gram injectable IM for two days (2/22/14-2/23/14)...." On 2/23/14 an order was written for "Augmentin (antibiotic) 250 mg (milligrams) orally every day for three days to start after dialysis on 02/24/14, 'possible cellulitis'." An interview was conducted with Registered Nurse (RN) "C" on 02/24/14 at 10: 45 a.m. RN "C" stated, "(Resident #100) spiked a temperature over the weekend and was started on antibiotics for suspected cellulitis (skin infection) of his left leg (location of the burns)." ( )

BASED ON INTERVIEW, OBSERVATION, AND RECORD REVIEW, THE FACILITY FAILED TO TIMELY CONDUCT GASTROINTESTINAL (GI) ASSESSMENTS, FAILED TO IMPLEMENT THE BOWEL ELIMINATION CARE PLANS, FAILED TO FOLLOW PHYSICIAN ORDERED BOWEL PROTOCOLS AND FAILED TO MONITOR THE EFFECTIVENESS OF ADMINISTERED LAXATIVE MEDICATIONS FOR FIVE RESIDENTS (#4, #7, #9, #10, #11) OF 12 RESIDENTS REVIEWED FOR NEEDING A BOWEL PROTOCOL, IN TOTAL SAMPLE OF 25 RESIDENTS OUT OF A FACILITY POPULATION OF 96 RESIDENTS. RESIDENT #7 WAS KNOWN TO BE AT HIGH RISK FOR DEVELOPING CONSTIPATION DUE TO HER INABILITY TO AMBULATE SECONDARY TO [DIAGNOSES REDACTED]. RESIDENT #7 EXPERIENCED 11 DAYS WITHOUT A BOWEL MOVEMENT. DURING THESE 11 DAYS, RESIDENT #7 EXPERIENCED ABDOMINAL PAIN AND DISTENTION, NAUSEA, VOMITING AND DECREASED BOWEL SOUNDS. RESIDENT #7 REQUIRED THE EMERGENCY SERVICES OF A HOSPITAL FOR MEDICAL EVALUATION AND REMOVAL OF A FECAL IMPACTION. A FECAL IMPACTION IS AN ACCUMULATED MASS OF HARDENED STOOL THAT CAN'T BE ELIMINATED BY A NORMAL BOWEL MOVEMENT. A FECAL IMPACTION CAN RESULT IN INTESTINAL OBSTRUCTION AND/OR ULCERATION OR NECROSIS OF THE COLON POSSIBLY REQUIRING SURGICAL INTERVENTION. AFTER RESIDENT #7 RETURNED TO THE FACILITY FROM THE HOSPITAL, THE FACILITY FAILED TO RECOGNIZE THE EXTENT OF SERVICES RENDERED AT THE HOSPITAL, FAILED TO MONITOR RESIDENT #7'S GASTROINTESTINAL STATUS, AND FAILED TO IMPLEMENT AN EFFECTIVE PLAN OF CARE WHICH RESULTED IN RESIDENT #7 EXPERIENCING THREE ADDITIONAL EXTENDED TIME PERIODS WITHOUT HAVING A BOWEL MOVEMENT. THIS DEFICIENT PRACTICE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY OF RESIDENT #7. ON 5/1/13 AT 1:56 P.M., THE FACILITY WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON 4/29/13 AND BEGAN ON 3/12/13 WHEN THE FACILITY FAILED TO CONDUCT TIMELY GASTROINTESTINAL (GI) ASSESSMENTS, FAILED TO IMPLEMENT PHYSICIAN ORDERED BOWEL PROTOCOL AND THE BOWEL ELIMINATION CARE PLAN, AND FAILED TO MONITOR THE EFFECTIVENESS OF ADMINISTERED LAXATIVE MEDICATIONS FOR RESIDENT #7. DURING THE COMPLETION OF THE EXTENDED SURVEY 5/1/13 THROUGH 5/2/13, THE IMMEDIATE JEOPARDY WAS REMOVED BY THE FOLLOWING ACTIONS: -THE FACILITY PERFORMED AN INVESTIGATION INTO THE INCIDENT OF 3/19/13 RELATED TO RESIDENT #7 BEING TRANSFERRED TO THE emergency room FOR LACK OF A BOWEL MOVEMENT. -PHYSICIAN ORDERS [REDACTED].#7'S NEEDS. -VERIFICATION PER RECORD REVIEW, THAT AN INSERVICE WAS PROVIDED TO LICENSED STAFF MEMBERS ON THE FACILITY'S BOWEL PROTOCOL. REMAINING STAFF NOT INSERVICED WILL RECEIVE EDUCATION ON THE BOWEL PROTOCOL PRIOR TO THEIR SCHEDULED WORK SHIFT. -VERIFICATION BY RECORD REVIEW AND INTERVIEW, THE REGIONAL DIRECTOR OF CLINICAL OPERATIONS (RDCO) - NURSE CONSULTANT "B", EDUCATED THE DIRECTOR OF NURSING (DON) AND ALL FACILITY UNIT MANAGERS ON THE FACILITY'S BOWEL PROTOCOL. -VERIFICATION PER RECORD REVIEW, THE CARE PLANS FOR SAMPLED RESIDENTS WERE REVIEWED AND UPDATED TO REFLECT CURRENT BOWEL MOVEMENT RECORDS WITH APPROPRIATE INTERVENTION IMPLEMENTED, IF INDICATED. -INTERVIEWS WITH LICENSED NURSING STAFF, REPRESENTING MIDNIGHT, DAY AND AFTERNOON SHIFTS, VERIFIED KNOWLEDGE OF THE FACILITY'S BOWEL PROTOCOL AND THEIR RESPONSIBILITIES RELATED TO THE IMPLEMENTATION OF THE PROTOCOL. -INTERVIEWS WITH DON, UNIT MANAGERS AND CHARGE NURSES VERIFIED THE BOWEL PROTOCOL PROCESS AND THEIR RESPONSIBILITIES RELATED TO MONITORING, ASSESSMENT AND NOTIFICATION OF PHYSICIAN. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AT A PATTERN LEVEL WITH POTENTIAL FOR MORE THAN MINIMAL HARM, POTENTIALLY AFFECTING RESIDENTS (#4, #7, #9, #10, #11) PENDING: -VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH ENSURING RESIDENTS' INDIVIDUALIZED GASTROINTESTINAL NEEDS RELATED TO BOWEL ELIMINATION ARE MET BY PROVIDING APPROPRIATE CARE AND SERVICE TO ENSURE THEIR SAFETY AND WELL-BEING. FINDINGS INCLUDE: THE ADMISSION FACE SHEET (NOT DATED) REVEALED RESIDENT #7 IS A [AGE] year OLD WOMAN WHO RE-admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #7 WAS COGNITIVELY INTACT WITH A BRIEF INTERVIEW OF MENTAL STATUS (BIMS) OF 15/15, WAS ALWAYS INCONTINENT OF STOOL AND NEEDED EXTENSIVE ASSIST OF 2 STAFF FOR TOILETING. RESIDENT #7 WAS INTERVIEWED ON 4/30/13 AT 11:30 A.M. THE INCIDENT OF HER RECENT hospitalization RELATED TO NOT HAVING A BOWEL MOVEMENT FOR 11 DAYS WAS DISCUSSED. RESIDENT #7 WAS IN HER ROOM SITTING IN HER ELECTRIC WHEELCHAIR. AN OBSERVATION WAS MADE AT THIS TIME OF RESIDENT #7'S ABDOMEN. IT APPEARED ABNORMALLY LARGE AND ROUND. RESIDENT #7 STATED THIS WAS HER NORMAL APPEARANCE. RESIDENT #7 STATED DURING THE INCIDENT OF 3/19/13, WHICH RESULTED IN HER hospitalization FOR A FECAL IMPACTION, SHE FELT VERY UNCOMFORTABLE. RESIDENT #7 STATED THAT SHE REFUSED THE [MEDICATION NAME] SUPPOSITORY SEVERAL TIMES BECAUSE SHE DID NOT WANT TO BE DEALING WITH HER BOWELS IN THE MIDDLE OF THE NIGHT. RESIDENT #7 CONTINUED TO EXPLAIN THAT SHE NORMALLY HAS PROBLEMS HAVING A BOWEL MOVEMENT BECAUSE OF HER IMMOBILITY ISSUES. RESIDENT #7 STATED THAT STAFF HAVE TO LITERALLY PUSH ON HER ABDOMEN AND ASSIST HER TO EXPEL THE STOOL BECAUSE OF THE LACK OF BOWEL MUSCLE MOBILITY DUE TO HER [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #7'S CARE PLAN TITLED, "ALTERATION IN BOWEL ELIMINATION PLAN OF CARE" DATED 1/2013, WITH A GOAL TO HAVE A BOWEL MOVEMENT EVERY 3 DAYS, READ: "INTERVENTIONS: ...MONITOR BOWEL ELIMINATION USING CARE TRACKER (AND) BOWEL PROTOCOL AS NEEDED". THE PHYSICIAN ORDERS [REDACTED]. -IF NO BM (BOWEL MOVEMENT) X 3 DAYS, GIVE 30 CC (CUBIC CENTIMETERS) MOM (MILK OF MAGNESIA - A LAXATIVE) -ON DAY 4 IF NO BM BY 2100 (9:00 P.M.) AFTER MOM, ADMINISTER [MEDICATION NAME] SUPPOSITORY -IF NO BM 2 HOURS AFTER [MEDICATION NAME] SUPPOSITORY, GIVE FLEETS ENEMA. RESIDENT #7'S PHYSICIAN ORDER [REDACTED]. THE FACILITY'S "BOWEL AND BLADDER DETAIL REPORT" REVIEWED FOR DATES 3/8/13 THROUGH 3/20/13, REVEALED RESIDENT #7 HAD A MEDIUM BOWEL MOVEMENT ON 3/8/13 AT 1:03 A.M. THE ABOVE REPORT ALSO SHOWED NO FURTHER BOWEL MOVEMENT UNTIL 3/20/13 (11 DAYS LATER) AT 7:46 P.M. THE MEDICATION ADMINISTRATION RECORDS (MAR) DATED 3/1/13 THROUGH 3/31/13, REFLECTS RESIDENT #7 RECEIVED 30 CC OF MOM ON 3/11/13 AT 9:00 P.M. (PER RESIDENT #7'S REQUEST) WITH NO EFFECTS, POSITIVE OR NEGATIVE RECORDED. THE MAR REVEALED MOM 30 CC WAS GIVEN ON 3/13/13 AT 8:30 A.M. (NO EFFECTS -POSITIVE OR NEGATIVE RECORDED). ON 3/18/13 AT 9:00 A.M., AND ON 3/19/13 AT 9:00 A.M., RESIDENT #7 RECEIVED 30 CC OF MOM AND THE RECORD REFLECTS THE MEDICATION WAS INEFFECTIVE. ON 3/20/13 AT 8:40 A.M. ANOTHER 30 CC OF MOM WAS ADMINISTERED WITH NO RESULTS - POSITIVE OR NEGATIVE RECORDED. THE ONLY OTHER BOWEL MEDICATION INTERVENTION RECORDED ON THE MAR FOR RESIDENT #7 WAS A FLEETS ENEMA ADMINISTERED WITH NEGATIVE RESULTS ON 3/17/13 AT 0030 (12:30 P.M.). RESIDENT #7'S MEDICAL RECORD REVEALED "(NURSING) PROGRESS NOTES" DATED 3/15/13 AT 10:55 A.M., THAT READ, "RESIDENT (#7) C/O (COMPLAINED OF) ABD (ABDOMINAL) DISCOMFORT. BELLY DISTENDED AND FIRM. BS (BOWEL SOUNDS) NOTED IN RLQ (RIGHT LOWER QUADRANT). UNABLE TO PICK UP ANY OTHER BS. (NO) REPORTED BM SINCE 3/8/13. RESIDENT (#7) REPORTS RECEIVING MOM 'A BUNCH OF TIMES' AND 'A SUPPOSITORY AND AN ENEMA LAST NIGHT' ALL INEFFECTIVE..." RESIDENT #7'S MEDICAL RECORD REVEALED DURING THE DAYS OF 3/15/13 & 3/16/13, SHE WAS ADMINISTERED MAGNESIUM [MEDICATION NAME] (A LAXATIVE) AND A SOAP SUDS ENEMA, BOTH INEFFECTIVE FOR PRODUCING A BOWEL MOVEMENT. RESIDENT #7'S MEDICAL RECORD REVEALED AN "INTERIM (PHYSICIAN) ORDERS" DATED 3/16/13 AT 2:00 P.M., READ, "MAG [MEDICATION NAME] 150 CC NOW CALL (ATTENDING PHYSICIAN) IN A.M. 3/17/13 IF (NO) RESULTS." THERE WAS NO DOCUMENTATION THE PHYSICIAN WAS CALLED RELATED TO NEGATIVE RESULTS OF THIS INTERVENTION IN THE A.M. OF 3/17/13. RESIDENT #7'S MEDICAL RECORD REVEALED "(NURSING) PROGRESS NOTES" DATED 3/18/13 A.M. (NO SPECIFIC TIME DOCUMENTED) READ, "RES (RESIDENT #7) HAS HAD (NO) BM'S X 10 DAYS. RES HAS [MEDICATION NAME] SCHEDULED EOD (EVERY OTHER DAY) HAS RECEIVED MOM, SUPPOSITORIES, AND ENEMAS WITH (NO) RESULTS. (NURSE PRACTITIONER) PAGED... ABD VERY DISTENDED....". RESIDENT #7'S MEDICAL RECORD REVEALED "(NURSING) PROGRESS NOTES" DATED 3/19/13 A.M. (NO SPECIFIC TIME DOCUMENTED) READ, "RES (RESIDENT #7) HAD ABD FLAT PLATE (AN ABDOMINAL X-RAY) TODAY, (ATTENDING PHYSICIAN) AWARE OF RESULTS ILEUS (AN OBSTRUCTION OF THE INTESTINES, CAUSED BY IMMOBILITY OF THE BOWEL) NOTED... RES CONT (CONTINUES) TO BE DISTENDED...". A FOLLOW UP NURSING PROGRESS NOTE ON 3/19/13 AT 1630 (4:30 P.M.) READ, "RES (RESIDENT #7) C/O NAUSEA EMESIS X 1; RES SENT TO (HOSPITAL) ER (emergency room ) FOR EVAL (EVALUATION)." THE emergency room REPORT (UNTITLED) DATED 3/19/13 FOR RESIDENT #7, WHICH WAS NOT PRESENT IN RESIDENT #7'S MEDICAL RECORD AT THE TIME OF THE SURVEY AND WAS REQUESTED BY THIS SURVEYOR, READ, "INITIAL COMMENTS: PT (PATIENT) WITH NO BM UP TO 11 DAYS... C/O ABD PAINS, NON-FOCAL ABD CRAMPING AND PERSISTENT RUQ PAINS... ASSOCIATED SYMPTOMS: NAUSEA/VOMITING (EMESIS X 1)... X-RAY: COPIOUS STOOL... PROGRESS NOTES: ...WE'LL DISIMPACT... OPINION... SEVERE CONSTIPATION WITH SIGNIFICANT COLONIC STOOL PRESENT. THERE ALSO ARE MULTIPLE FLUID-FILLED SMALL BOWEL LOOPS, WHICH MAY BE THE RESULT OF DOWNSTREAM INHIBITION. ILEUS MAY BE CONSIDERED AS WELL. BOWEL OBSTRUCTION IS FELT TO BE LESS LIKELY." RESIDENT #7 RETURNED TO THE FACILITY FROM THE ACUTE CARE hospital on [DATE]. THE "(NURSING) PROGRESS NOTES" DATED P.M./NOC (NIGHT) (NO SPECIFIC TIME DOCUMENTED) READ, "NEW BM (BOWEL MOVEMENT) PROTOCOL ORDERS - ORDERS IN PLACE". RESIDENT #7'S MEDICAL RECORD REVEALED "(NURSING) PROGRESS NOTES" DATED 3/20/13 AT PM/NOC (NO SPECIFIC TIME RECORDED) READ, "RES CONTINUED BM PROTOCOL AND STARTED [MEDICATION NAME] AT 1400 (2:00 P.M.)... ABOUT 2000 (8:00 P.M.) RES HAD AN X-LARGE FORMED STOOL." THE STANDING BOWEL PROTOCOL ORDERS, SPECIFICALLY RELATED TO RESIDENT #7, AS WELL AS, THE PLAN OF CARE (RELATED TO THE BOWEL ELIMINATION) WAS NOT UPDATED AT THIS TIME. IN ADDITION, THE FACILITY FAILED TO IMPLEMENT ROUTINE GASTROINTESTINAL ASSESSMENT TO ENSURE ADEQUATE BOWEL ELIMINATION WAS ACHIEVED. THE FACILITY'S "BOWEL AND BLADDER DETAIL REPORT" REVIEWED FOR 3/20/13 THROUGH 4/29/13, REVEALED RESIDENT #7 HAD PERIODS OF NO BOWEL MOVEMENTS FOR 5 DAYS (4/3/13 THROUGH 4/8/13), 6 DAYS (4/8/13 THROUGH 4/14/13) AND 7 DAYS (4/22/13 THROUGH 4/29/13) WITHOUT THE BOWEL PROTOCOL ORDERS BEING IMPLEMENTED AND NO EVIDENCE OF A GASTROINTESTINAL ASSESSMENT PERFORMED ON RESIDENT #7. RESIDENT #7'S MEDICATION ADMINISTRATION RECORD DATED 4/1/13 THRU 4/30/13 REVEALED MOM 30 CC WAS ADMINISTERED ON 4/14/13 AT 7:00 A.M. WITH NEGATIVE RESULTS AND ON 4/28/13 AT 9:00 A.M. WITH NO INDICATION OF POSITIVE OR NEGATIVE RESULTS DOCUMENTED. NO OTHER MEDICATION INTERVENTIONS ARE DOCUMENTED AS BEING ADMINISTERED. DURING AN INTERVIEW WITH RDCO NURSE CONSULTANT "B" AND THE DON ON 4/30/13 AT 3:35 P.M., IT WAS STATED THEY REALIZED THE BOWEL PROTOCOL WAS NOT FOLLOWED FOR RESIDENT #7 AS THE PHYSICIAN ORDERED FROM 3/12/13 THRU 3/20/13. THE DON ACKNOWLEDGED RESIDENT #7 WAS SENT TO THE emergency roiagnom on [DATE] AND HE WAS UNAWARE RESIDENT #7 WAS diagnosed with [REDACTED]. THIS SURVEYOR REVIEWED THE BOWEL RECORD AND SHOWED THE BOWEL RECORD WHICH REVEALED THREE ADDITIONAL TIMES THE BOWEL PROTOCOL WAS NOT IMPLEMENTED SINCE THE hospitalization FOR THE BOWEL IMPACTION DATED 3/19/13. RDCO NURSE CONSULTANT "B" AND THE DON OFFERED NO RESPONSE. RDCO NURSE CONSULTANT "B" AND THE DON STATED THERE WERE UNOFFICIAL INTERVENTION SHEETS REFERRED TO AS THE "BOWEL PROTOCOL" ON WHICH THE NURSES WILL RECORD, WITH REGARDS TO BOWEL INTERVENTIONS IMPLEMENTED BUT, ADDED THAT THEY DID NOT FEEL THESE SHEETS WOULD SHOW COMPLIANCE WITH THE BOWEL PROTOCOL. ( ) ACCORDING TO THE MINIMUM DATA SET (MDS) assessment dated [DATE], RESIDENT #11 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A CARE PLAN FOR RESIDENT #11 DATED 11/7/12, IDENTIFIED A PROBLEM TITLED "ALTERATION IN BOWEL ELIMINATION WITH A RISK FOR CONSTIPATION" WITH A GOAL TO HAVE A BOWEL MOVEMENT EVERY 3 DAYS. THE CARE PLAN INTERVENTIONS INCLUDED TO MONITOR BOWEL ELIMINATION USING THE ELECTRONIC CARE TRACKER, AND "PROVIDE MEDICATION, AS ORDERED, TO AID IN THE ELIMINATION, AS ORDERED." A REVIEW OF "THE BOWEL AND BLADDER DETAIL REPORT" PRINTED FROM CARE TRACKER IDENTIFIED RESIDENT #11 AS HAVING AN EXTRA LARGE BOWEL MOVEMENT ON 4/14/13 AT 9:51 P.M. THE BOWEL RECORD IDENTIFIED THE NEXT BOWEL MOVEMENT FOR RESIDENT #11 DID NOT OCCUR UNTIL TEN DAYS LATER, ON 4/24/13 AT 3:32 A.M. THE BOWEL MOVEMENT WAS DESCRIBED AS "EXTRA LARGE". A REVIEW OF RESIDENT #11'S MEDICATION ADMINISTRATION RECORD (MAR) FOR THE MONTH OF 4/13, INDICATED RESIDENT #11 RECEIVED 30 CC OF MOM ON 4/19/13 (THE FIFTH DAY), ON 4/20/13 (THE SIXTH DAY), AND ON 4/24/13 (THE TENTH DAY). ON THE NINTH DAY, 4/23/13 AT 9:40 P.M., [MEDICATION NAME] SUPPOSITORY RECTAL WAS ADMINISTERED. ON 4/24/13, THE TENTH DAY, A FLEETS ENEMA WAS ADMINISTERED AT 2:30 A.M. RESIDENT #11 FINALLY HAD RESULTS OF A EXTRA LARGE BOWEL MOVEMENT AT 3:32 A.M. ON 4/24/13, AFTER THE ADMINISTRATION OF THE FLEETS ENEMA. UPON INTERVIEW ON 5/1/13 AT APPROXIMATELY 1:30 P.M., WITH LICENSED PRACTICAL NURSE (LPN) "N", HE CONFIRMED THE MAR DATA WRITTEN IN REGARD TO THE BOWEL PROTOCOL FOR RESIDENT #11. BASED ON RESIDENT #11'S STANDING PHYSICIAN ORDERS, CURRENT MONTHLY ORDERS (4/13) AND CARE PLAN, RESIDENT #11 SHOULD HAVE RECEIVED A DOSE OF MOM, FOLLOWED BY A SUPPOSITORY AND FLEETS ENEMA ON THE FOURTH DAY (4/18/13). ( ) ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #9 WAS admitted to the facility on [DATE] WITH PRIMARY [DIAGNOSES REDACTED]. THE CARE PLAN FOR RESIDENT #9, DATED 4/13/13, TITLED "ALTERATION IN BOWEL ELIMINATION PLAN OF CARE" INDICATED RESIDENT #9 had a history of [REDACTED]. THE GOAL FOR RESIDENT #9 WAS TO HAVE A BOWEL MOVEMENT EVERY 3 DAYS. THE CARE PLAN INTERVENTIONS INCLUDED TO MONITOR BOWEL ELIMINATION USING CARE TRACKER, AND "PROVIDE MEDICATION, AS ORDERED, TO AID IN THE ELIMINATION, AS ORDERED." A REVIEW OF "THE BOWEL AND BLADDER DETAIL REPORT" PRINTED FROM CARE TRACKER IDENTIFIED RESIDENT #9 AS HAVING A MEDIUM BOWEL MOVEMENT ON 2/2/13 AT 1:47 P.M. THE BOWEL RECORD IDENTIFIED THE NEXT BOWEL MOVEMENT FOR RESIDENT #9, ON 2/9/13, AS LARGE. THIS WAS 6 FULL DAYS LATER. A REVIEW OF RESIDENT #9'S MEDICATION ADMINISTRATION RECORD (MAR) FOR THE MONTH OF 2/13 INDICATED RESIDENT #9 RECEIVED NO MEDICATION FOR BOWEL CONSTIPATION. RESIDENT #9 HAD A SECOND EPISODE OF CONSTIPATION IN FEBRUARY 2013: THE "BOWEL AND BLADDER DETAIL REPORT" SHOWED ON 2/14/13 RESIDENT #9 HAD A LARGE BOWEL MOVEMENT AT 10:25 A.M. THE NEXT RECORDED BOWEL MOVEMENT OCCURRED ON 2/20/13 AT 12:44 P.M., 6 DAYS LATER. AGAIN, A REVIEW OF THE MAR SHOWED NO MEDICATION WAS GIVEN PER THE physician's orders [REDACTED]. ON 3/30/13 RESIDENT #9, ACCORDING TO THE BOWEL AND BLADDER DETAIL REPORT, HAD A BOWEL MOVEMENT AT 9:47 A.M. SIX DAYS LATER, ON 4/5/13 AT 12:01 P.M., RESIDENT #6 HAD A MEDIUM BOWEL MOVEMENT. THE MARCH 2013 MAR SHOWED NO MEDICATION WAS GIVEN RESIDENT #9 PER THE physician's orders [REDACTED]. ACCORDING TO THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 2/15/13, RESIDENT #10 WAS admitted to the facility on [DATE] WITH A PRIMARY [DIAGNOSES REDACTED]. THE CARE PLAN FOR RESIDENT #10, UPDATED 2/15/13, TITLED "ALTERATION IN BOWEL ELIMINATION PLAN OF CARE" INDICATED THE GOAL FOR RESIDENT #10 WAS TO HAVE A BOWEL MOVEMENT EVERY 3 DAYS. THE CARE PLAN INTERVENTIONS INCLUDED TO MONITOR BOWEL ELIMINATION USING CARE TRACKER, AND "PROVIDE MEDICATION, AS ORDERED, TO AID IN THE ELIMINATION, AS ORDERED." A REVIEW OF THE "BOWEL AND BLADDER DETAIL REPORT" PRINTED FROM CARE TRACKER IDENTIFIED RESIDENT #10 HAD A BOWEL MOVEMENT ON 2/12/13 AT 12:12 P.M. THE NEXT BOWEL MOVEMENT RECORDED WAS 6 DAYS LATER ON 2/18/13 AT 5:52 A.M. IT WAS NOTED TO BE A SMALL BOWEL MOVEMENT. A REVIEW OF THE MAR SHOWED NO MEDICATION WAS GIVEN DURING THE SIX DAYS, PER THE physician's orders [REDACTED]. PER THE CARE TRACKER DOCUMENTATION, RESIDENT #10 WENT 5 DAYS FROM 3/14/13 AT 10:33 A.M. UNTIL 3/19/13 AT 5:31 A.M. BETWEEN BOWEL MOVEMENTS. RESIDENT #10 HAD 7 DAYS BETWEEN BOWEL MOVEMENTS FROM 3/23/13 AT 8:06 A.M. UNTIL 3/30/13 AT 4:17 P.M. HE WENT 6 DAYS BETWEEN BOWEL MOVEMENTS FROM 4/2/13 AT 12:15 P.M. UNTIL 4/8/13 AT 6:13 A.M. AND HAD ANOTHER 5 DAY STRETCH WITH NO BOWEL MOVEMENT FROM 4/22/13 AT 7:56 A.M. UNTIL 4/27/13 AT 3:29 A.M. A REVIEW OF RESIDENT #10'S MAR SHOWED NO MEDICATION WAS GIVEN TO RESIDENT #10 DURING THESE 4 EPISODES OF CONSTIPATION PER THE physician's orders [REDACTED]. RESIDENT #4'S 2/12/13 MINIMUM DATA SET (MDS) ASSESSMENT SHOWED HE IS [AGE] years OLD AND ENTERED THE FACILITY ON 2/4/13. RESIDENT #4'S [DIAGNOSES REDACTED]. THE MDS SHOWED RESIDENT #4'S COGNITION WAS INTACT, BUT HE DID HAVE TIMES WHEN HE WAS CONFUSED OR FORGOT THINGS. HIS 2/11/13 CARE PLAN DOCUMENTED HIS RISK FOR CONSTIPATION AND INTERVENTIONS THAT INCLUDED, "MONITOR BOWEL ELIMINATION USING CARE TRACKER" AND "PROVIDE MEDICATION, AS ORDERED, TO AID IN ELIMINATION. AS ORDERED". THE BOWEL MANAGEMENT DOCUMENTATION WAS REVIEWED FOR RESIDENT #4. THE CARE TRACKER "BOWEL AND BLADDER DETAIL REPORT" (PRINT DATE 4/30/13) SHOWED RESIDENT #4 HAD A BM ON 2/21/13 WITH THE NEXT BM DOCUMENTED ON 2/27/13, 6 DAYS LATER. RESIDENT #4'S NAME SHOWED ON THE FACILITY'S DAILY BOWEL PROTOCOL SHEET DATED 2/26/13 BUT NO INFORMATION WAS GIVEN REGARDING HIS BM ACTIVITY OR WHAT MEDICATIONS WERE GIVEN. THE 2/13 MEDICATION "PRN (AS NEEDED) ADMINISTRATION RECORD" DID NOT DOCUMENT ANY BM MEDICATIONS BEING OFFERED OR GIVEN TO RESIDENT #4 DURING THE MONTH. THE CARE TRACKER "BOWEL AND BLADDER DETAIL REPORT" SHOWED RESIDENT #4 HAD A BM ON 2/28/13 WITH THE NEXT BM BEING DOCUMENTED AS OCCURRING ON 3/12/13, 11 DAYS LATER. THE REVIEW OF THE NURSES NOTES FROM 3/1/13 TO 3/12/13 SHOWED RESIDENT #4 COMPLAINED OF CONSTIPATION ON 3/12/13 AND "...SUPPOSITORY GIVEN @ (AT) 6:30 A.M. WITH NO RESULTS" AND "ENEMA GIVEN AT 9 A.M. X LG (WITH LARGE) RESULTS..." THE 3/13 "PRN ADMINISTRATION RECORD" ONLY DOCUMENTED THE "FLEETS ENEMA" BEING GIVEN ON 3/12/13. AN INTERVIEW WAS CONDUCTED WITH RESIDENT #4 ON 5/2/13 AT 7:15 A.M. RESIDENT #4 STATED HE REMEMBERED HE HAD RECEIVED "SOME SORT OF" ENEMA "QUITE A WHILE AGO" BUT COULD NOT REMEMBER ANY OTHER BM MEDICATIONS BEING OFFERED. HE SAID, "...I CAN'T SAY THEY WEREN'T I JUST DON'T REMEMBER... I REMEMBER FEELING CONSTIPATED MORE THAN ONCE..." ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP AND PROVIDE SAFETY INTERVENTIONS TO ENSURE EFFECTIVE SUPERVISION, THEN FAILED TO RECOGNIZE THE SAFETY FACTORS THAT CONTRIBUTED TO A FALL AND FAILED TO REVISE THE PLAN OF CARE INCLUDING PREVENTIVE MEASURES TO REDUCE THE LIKELIHOOD OF ANOTHER FALL FOR THREE AMBULATORY RESIDENTS (#101, #102 AND #103) FROM FOUR SAMPLED RESIDENTS IDENTIFIED AS HAVING RISK FACTORS FOR FALLING, FROM A TOTAL OF 103 RESIDENTS IN THE FACILITY. THIS FAILURE RESULTED IN RESIDENT #101 BEING PLACED IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY DUE TO REPEATED FALLS. IN ADDITION, RESIDENTS #102 AND #103 CONTINUED TO HAVE UNIDENTIFIED SAFETY RISKS RELATED TO THE ROOT CAUSE OF THE FALLS NOT BEING IDENTIFIED, THEREFORE, INCREASING THE POTENTIAL FOR FURTHER FALLS AND POTENTIAL INJURIES. FINDINGS INCLUDE. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON [DATE] AT 10:25 A.M. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] 12:36 P.M., WHEN RESIDENT #101 ATTEMPTED TO TRANSFER, WITHOUT ADEQUATE SUPERVISION, FROM HER BED TO HER CHAIR AND SLID TO THE FLOOR. THIS WAS AFTER HAVING HAD A SLIP AND FALL ON [DATE] AT 1:26 P.M., WHEN ATTEMPTING TO TRANSFER SELF FROM HER WHEELCHAIR TO BED WITH NO PREVENTIVE INTERVENTIONS IMPLEMENTED TO ENSURE ADEQUATE SUPERVISION AND SAFETY. IN ADDITION, RESIDENT #101 HAD A THIRD FALL ON [DATE] AT 1:02 P.M., WHEN SHE SLIPPED OUT OF HER WHEELCHAIR IN HER BEDROOM. THE FAILURE TO IMPLEMENT IMMEDIATE ACTION AT THIS TIME, RESULTED IN RESIDENT #101 FALLING ON [DATE] AT 3:00 P.M. THE "RESIDENT INCIDENT" REPORT READ, "RES (RESIDENT #101) STATED... 'MY LEGS SLIPPED AND I (RESIDENT #101) LANDED ON MY HIP AND BOUNCED'." RESIDENT #101 WAS SENT TO THE HOSPITAL WHERE SHE WAS diagnosed with [REDACTED]. RESIDENT #101 WAS admitted TO THE HOSPITAL FOR EVALUATION OF TREATMENT OPTIONS, AND WAS readmitted BACK to the facility on [DATE] WITH A SIGNIFICANT DECLINE IN PHYSICAL FUNCTION, SPECIFICALLY, NO LONGER ABLE TO INDEPENDENTLY AMBULATE OR TRANSFER, IMPAIRMENT IN RANGE OF MOTION AND SIGNIFICANT INCREASE IN PAIN. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 10:25 A.M. AND A WRITTEN PLAN FOR REMOVAL OF THE IMMEDIATE JEOPARDY WAS REQUESTED. ON [DATE] AT 3:30 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: -ON [DATE], A REVIEW OF THE "FALL ASSESSMENT AUDIT" TOOL DOCUMENT VERIFIED THE REVIEW PROCESS OF THE INCIDENT/ACCIDENT REPORTS, SPECIFICALLY RELATED TO FALLS, TO IDENTIFY ANY TRENDS/PATTERNS AND ROOT CAUSE OF FALL WAS INITIATED. -ON [DATE] AT 2:00 P.M., PER INTERVIEW WITH THE ADMINISTRATOR AND THE REGIONAL DIRECTOR OF CLINICAL OPERATIONS, IT WAS STATED THIS PROCESS WILL CONTINUE UNTIL THE REVIEW OF ALL INCIDENT/ACCIDENT REPORTS ARE COMPLETED FOR THE LAST 3 MONTHS, TO IDENTIFY PATTERNS/TRENDS IN ORDER TO IDENTIFY A ROOT CAUSE OF EACH FALL. -ON [DATE] AT 2:52 P.M., CONFIRMATION OF THE INITIATION OF THE CENTER'S QUALITY ASSURANCE PROCESS (QPI) PER INTERVIEW WITH THE ADMINISTRATOR AND A REVIEW OF "ACTION PLAN - FALLS" DATED ,[DATE]. -ON [DATE], A REVIEW OF THE "INSERVICE TRAINING RECORD" CONFIRMED THE INTERDISCIPLINARY TEAM WAS EDUCATED ON [DATE], TO THE PROCESS OF THE "DAILY CLINICAL REVIEW" MEETING AS WELL AS UTILIZATION OF ROOT CAUSE ANALYSIS. EDUCATION ALSO INCLUDED INITIATION, REVIEW AND UPDATING OF CARE PLANS, CARE DELIVERY GUIDES UPON ADMISSION, QUARTERLY, SIGNIFICANT CHANGE IN CONDITION AND (AS NEEDED) PER FACILITY POLICY. -ON [DATE], VERIFIED THE "INSERVICE TRAINING RECORD" DATED [DATE], SHOWED THE REGIONAL DIRECTOR OF REHAB PROVIDED EDUCATION TO FACILITY THERAPY STAFF ON COMMUNICATION AND COMPLETION OF THE NURSING TO THERAPY COMMUNICATION TOOL AS WELL AS COMPLETION OF DOCUMENTATION PERTINENT TO THE FALL. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL WITH HARM, DUE TO: -RESIDENT #101 HAD AN AVOIDABLE FALL ON [DATE], WHICH RESULTED IN A PELVIC FRACTURE INVOLVING THE RIGHT SIDE OF THE ACETABULUM WHICH RESULTED IN A HOSPITAL STAY. RESIDENT #101 WAS REadmitted to the facility on [DATE], WITH A SIGNIFICANT DECLINE IN PHYSICAL FUNCTIONAL STATUS IN THE AREAS OF TRANSFER, AMBULATION, RANGE OF MOTION AND SIGNIFICANT INCREASE IN PAIN. THE "physician's orders [REDACTED]. OBSERVATIONS ON [DATE] AT 1:30 P.M. AND [DATE] AT 1:20 P.M., SHOWED RESIDENT #101 WAS LYING IN HER BED. A SENSOR ALARM WAS IN USE AND A SMALL FLOOR MAT (MEASURING 36 BY 24 INCHES) WAS LOCATED ON THE WINDOW SIDE OF THE BED, WHICH ONLY PARTIALLY COVERED THE LENGTH OF THE BED ON ONE SIDE. THE DOOR SIDE OF THE BED HAD OPEN ACCESS, WITH NO MAT ON FLOOR. RESIDENT #101 HAD YELLOW SOCKS ON HER FEET (NOT GRIPPY SOCKS). DURING THE OBSERVATION ON [DATE] AT 1:30 P.M., RESIDENT #101 WAS ASKED IF SHE WAS HAVING ANY PAIN AND SHE RESPONDED STATING, "IT'S TERRIBLE!" DURING THE OBSERVATION ON [DATE] AT 1:20 P.M., RESIDENT #101 WAS ASKED AGAIN HOW HER PAIN LEVEL WAS AND SHE STATED: "THE LEG HURTS... STILL BAD... IT HURTS A LOT!" THE "INTERIM ORDERS" DATED [DATE] READ, "BED MOBILITY BAR ON (RIGHT) SIDE OF BED TO (DECREASE) PAIN DURING T/F (TRANSFER)... TRIAL OF HEAT PAD TO (DECREASE) PAIN AND (INCREASE) FUNCTIONAL T/F ON (RIGHT) HIP". -VALIDATION BY STATE AGENCY OF FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH PROVIDING ADEQUATE SUPERVISION AND SAFE ENVIRONMENT TO PREVENT ACCIDENTS. FINDINGS INCLUDE: THE MINIMUM DATA SET ((MDS) dated [DATE], REVEALED RESIDENT #101 IS A [AGE] year OLD WOMAN, WITH [DIAGNOSES REDACTED]. THIS MDS INDICATED SHE HAD MODERATELY IMPAIRED COGNITION WHICH WAS REFLECTED IN A BRIEF INTERVIEW OF MENTAL STATUS (BIMS) SCORE OF ,[DATE]. THIS MDS ALSO SHOWED RESIDENT #101 WAS INDEPENDENT WITH BED MOBILITY, TRANSFERS AND AMBULATION. IN ADDITION, THIS MDS SHOWED RESIDENT #101 HAD NO IMPAIRMENTS RELATED TO RANGE OF MOTION (ROM) TO UPPER OR LOWER EXTREMITIES AND WAS RECORDED TO HAVE HAD "0" FALLS IN THIS REVIEW PERIOD. THE MEDICAL RECORD REVEALED RESIDENT #101 HAD A COURT APPOINTED LEGAL GUARDIAN, DATED [DATE]. A REVIEW OF "RESIDENT INCIDENT" REPORTS REVEALED RESIDENT #101 HAD A FALL ON [DATE] AT 1:26 P.M. THE "RESIDENT INCIDENT DESCRIPTION" READ, "I WAS TRYING TO GET UP OUT OF MY WHEELCHAIR AND I SLIPPED AND fell ." RESIDENT #101 RECEIVED A SKIN TEAR WHICH WAS TREATED AND MONITORED FOR HEALING. THE "INVESTIGATIVE SUMMARIES" READ, "SUMMARY OF CORRECTIVE ACTION TAKEN: THERAPY COMMUNICATION FORM COMPLETED AND SUBMITTED TO THERAPY." THERE WAS NO INDICATION THE ROOT CAUSE OF THE SLIP AND FALL WAS INVESTIGATED AND/OR IDENTIFIED, AND THAT APPROPRIATE SUPERVISION AND SAFETY MEASURES WERE IMPLEMENTED. THE "NURSING THERAPY COMMUNICATION" FORM DATED [DATE], REVEALED THAT RESIDENT #101 WAS "NOT APPROPRIATE FOR REHAB SERVICES AT THIS TIME DUE TO RESIDENT VERBALIZES/DEMONSTRATES UNDERSTANDING OF IMPORTANCE OF USING BRAKES ON W/C (WHEELCHAIR) CONSISTENTLY. (NO) CHANGE IN FUNCTIONAL STATUS." THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" DATED [DATE], REVEALED RESIDENT #101 NEEDED "GENERAL SUPERVISION". THERE WERE NO REVISIONS OR UPDATES TO THE CARE PLAN TO ADDRESS THE NEED TO HAVE INCREASED SUPERVISION TO PREVENT FUTURE FALLS OR REVISIONS TO ADDRESS INTERVENTIONS TO ENSURE THE WHEELCHAIR BRAKES WERE LOCKED PRIOR TO TRANSFERS. THE "SAFETY DEVICE PLAN OF CARE" DATED [DATE], SHOWED NO REVISIONS OR UPDATES AFTER THE FALL ON [DATE], TO ADDRESS THE BRAKES ON THE WHEELCHAIR AND THE NEED TO ENSURE THAT THEY WERE KEPT LOCKED. FURTHER REVIEW OF THE "RESIDENT INCIDENT" REPORTS SHOWED RESIDENT #101 HAD A FALL ON [DATE] AT 12:36 P.M. THE "RESIDENT DESCRIPTION OF THE INCIDENT" READ, "I WAS TRYING TO GET IN MY CHAIR FROM THE BED AND SLID RIGHT ONTO THE FLOOR." IN THE AREA WHICH IDENTIFIED "CAUSE", THE REPORT READ, "MY SHOES SLIPPED." THE AREA ADDRESSING "EQUIPMENT CIRCUMSTANCES" DID NOT REVEAL THE USE OR NON-USE OF WHEELCHAIR BRAKES. THE SECTION UNDER "SUMMARY OF CORRECTIVE ACTION TAKEN" READ, "CARE PLAN REVISED, THERAPY REFERRAL SUBMITTED, ALL PREVIOUS INTERVENTIONS REMAIN APPROPRIATE AND IN PLACE." THERE WAS NO EVIDENCE IN THE MEDICAL RECORD THAT THE THERAPY REFERRAL WAS INITIATED OR FOLLOWED UP ON BY THE FACILITY. A REVIEW OF THE "FALL/INJURY..." AND "SAFETY DEVICE" CARE PLANS REVEALED THESE CARE PLANS WERE NOT UPDATED OR REVISED AFTER THIS FALL. THERE WAS NO INDICATION THE FALL WAS INVESTIGATED TO DETERMINE ROOT CAUSE OR THAT ADDITIONAL SUPERVISION AND SAFETY MEASURES WERE IMPLEMENTED TO PREVENT FUTURE FALLS. A CONTINUED REVIEW OF THE "RESIDENT INCIDENT" REPORTS REVEALED RESIDENT #101 HAD ANOTHER FALL ON [DATE] AT 1:32 P.M. THE "INCIDENT DESCRIPTION" READ, "RESIDENT SLIPPED OUT OF CHAIR." THERE WAS NO INDICATION IN THE REPORT IF THE WHEELCHAIR BRAKES WERE IN USE AT THE TIME OF THE FALL. THE REPORT READ, "IDENTIFY ACTIONS TAKEN: CARE PLAN REVISIONS, OTHER: THERAPY REFERRAL". THERE WAS NO EVIDENCE A THERAPY REFERRAL WAS COMPLETED; NOR, THAT THE "FALL/INJURY..." AND "SAFETY DEVICE" CARE PLANS WERE REVISED AS A RESULT OF ANOTHER SLIP AND FALL FOR THIS RESIDENT. THERE WAS NO INDICATION A ROOT CAUSE OF THE FALL WAS INVESTIGATED OR APPROPRIATE SUPERVISION AND SAFETY DEVICES/INTERVENTIONS WERE IMPLEMENTED TO PREVENT FUTURE FALLS AND INJURIES. THE "RESIDENT INCIDENT" REPORT DATED [DATE], SHOWED RESIDENT #101 HAD ANOTHER FALL ON [DATE] AT 3:00 P.M. THE "RESIDENT INCIDENT DESCRIPTION" READ, "(RESIDENT #101) STATED: 'I WAS TRYING TO MOVE THE TABLE AND MY LEGS SLIPPED AND I LANDED ON MY HIP AND BOUNCED.'" THE SECTION ADDRESSING "CORRECTIVE ACTION TAKEN" READ, "PATIENT SENT TO ER (emergency room ) FOR EVAL (EVALUATION) AND WAS admitted . UPON RETURN TO FACILITY, CARE PLANS WERE REVIEWED AND UPDATED. PATIENT'S ROOM ALSO CHANGED TO MOVE PATIENT CLOSER TO NURSES STATION." THE AREA REFERRING TO "..FINAL OUTCOME" READ, "...PATIENT CONTINUES TO HAVE PAIN FROM FRACTURE AND IS BEING TREATED." THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" DATED REVISED [DATE], REVEALED SPECIFIC INTERVENTIONS WHICH INCLUDED: "GENERAL SUPERVISION (DATED [DATE])... BED NEXT TO WALL - MAT NEXT TO BED (DATED [DATE])... PRESSURE ALARM - BED & CHAIR (DATED [DATE]), NON-SKID SOCKS (DATED [DATE])". THE "SAFETY DEVICE" CARE PLAN DATED [DATE], DID NOT SHOW ANY TYPE OF UPDATES OR REVISIONS. DURING AN INTERVIEW ON [DATE] AT 4:00 P.M. WITH THE REHAB DIRECTOR/REGISTERED OCCUPATIONAL THERAPIST (OTR) "C", SHE STATED SHE HAD NO OTHER DOCUMENTATION THAT A THERAPY REFERRAL WAS DONE FOR THE FALLS OCCURRING ON [DATE] AND [DATE] FOR RESIDENT #101. OTR "C" STATED THEY WOULD NORMALLY EVALUATE THE RESIDENT AFTER A FALL BUT, SHE HAD NO DOCUMENTATION THAT AN EVALUATION WAS DONE EXCEPT FOR THE FALL ON [DATE]. OTR "C" STATED RESIDENT #101 IS CURRENTLY RECEIVING THERAPY RELATED TO THE DECLINE IN MOBILITY DUE TO THE FALL ON [DATE], RESULTING IN A FRACTURED PELVIS. DURING AN INTERVIEW WITH REGISTERED NURSE (RN) "H" ON [DATE] AT 9:10 A.M., SHE STATED SHE WAS ONE OF THE NURSES RESPONSIBLE FOR THE MDS REPORTS. RN "H" STATED THEY (FACILITY) ARE IN THE PROCESS OF PERFORMING A MDS SIGNIFICANT CHANGE ASSESSMENT ON RESIDENT #101 RELATED TO A SIGNIFICANT DECLINE IN HER PHYSICAL FUNCTION IN ALL AREAS OF ADLS (ACTIVITY OF DAILY LIVING). RN "H" ALSO STATED RESIDENT #101 HAS HAD SIGNIFICANT INCREASE IN PAIN RELATED TO THE FRACTURED PELVIS WHICH IS BEING TREATED BY INCREASED PAIN MEDICATIONS. WHEN THE MDS dated [DATE] WAS REVIEWED WITH RN "H", SPECIFICALLY RELATED TO THE "FALLS" ASSESSMENT, WHICH WAS MARKED AS "0", RN "H" STATED THIS WAS A CODING ERROR. RN "H" STATED RESIDENT #101 HAD TWO FALLS DURING THAT REVIEW PERIOD, NAMELY, A FALL ON [DATE] AND A FALL ON [DATE]. RN "H" STATED THESE FALLS SHOULD HAVE BEEN ADDRESSED IN THE MDS dated [DATE] AND WERE NOT. HOWEVER, RN "H" STATED THE IDT (INTERDISCIPLINARY TEAM) EVALUATES EACH FALL AFTER IT OCCURS. THE CLINICAL RECORD REVIEW REVEALED "PROGRESS NOTES" ENTRY TITLED "IDT" NOTES FOR [DATE], WHICH REVIEWED RESIDENT #101'S FALL ON [DATE]. THERE WAS NO ANALYSIS OF THE FALL TO DETERMINE ROOT CAUSE OR PREVENTIVE MEASURES TO PREVENT FUTURE FALLS. THERE WERE NO OTHER ENTRIES FOR IDT NOTES UNTIL [DATE], WHICH ADDRESSED A CHANGE IN STATUS FOR RESIDENT #101, UNRELATED TO THE HISTORY OF FALLS. DURING AN INTERVIEW WITH THE NURSING HOME ADMINISTRATOR (NHA) ON [DATE] AT 8:55 A.M., SHE STATED: "I HAVE SEARCHED AND SEARCHED. WE DON'T HAVE ANY IDT NOTES FOR THAT TIME (TO ADDRESS THE MULTIPLE FALLS RESIDENT #101 EXPERIENCED)." THE NHA STATED THAT THE FACILITY HAD A CHANGE IN MANAGEMENT WHEN THE PREVIOUS DIRECTOR OF NURSING (DON) LEFT AND THE NEW DON STARTED. ACCORDING TO THE NHA, IT WAS DURING THAT TIME PERIOD THESE IDT MEETINGS WERE MISSED. IN AN INTERVIEW WITH THE NHA AND DON ON [DATE] AT 2:55 P.M., THE LACK OF ANALYSIS OF THE INCIDENT REPORTS TO DISCOVER ROOT CAUSE OF THE FALLS FOR RESIDENT #101 WAS DISCUSSED. NEITHER THE PATTERN OF 'TIME OF DAY' NOR HAVING ALL FALLS RELATED TO RESIDENT #101 'SLIPPING', HAD BEEN RECOGNIZED OR CONSIDERED BY STAFF. A REVIEW OF THE INCIDENT REPORTS ([DATE], [DATE] AND [DATE]) NOTED THE CARE PLANS WERE 'REVISED'; HOWEVER, NO DOCUMENTATION OF 'REVISIONS' ON THE CARE PLANS TITLED "FALLS/INJURY" AND "SAFETY DEVICES" WERE FOUND UNTIL THE FALL ON [DATE], RESULTING IN THE FRACTURED PELVIS. THE NHA STATED: "WE THOUGHT THEY (THE CARE PLANS) WERE APPROPRIATE." DURING THE INTERVIEW WITH THE NHA AND DON ON [DATE] AT 2:55 P.M., THE FOLLOWING WERE REVIEWED: THE FACT THERE WERE NO IDT NOTES ADDRESSING THE FALLS OF [DATE] AND [DATE]. THE NHA STATED IT WAS DURING THE TIME OF MANAGEMENT TRANSITION AND THE IDT WERE JUST MISSED. REVIEWED THE FACT THERE WAS NO THERAPY EVALUATIONS FOR THE FALLS OF [DATE] AND [DATE]. THE NHA ASKED IF THERAPY WAS ASKED FOR THEIR NOTES AND THIS SURVEYOR STATED THEY DID NOT HAVE ANY ADDITIONAL NOTES. THERE WAS NO RESPONSE FROM THE NHA OR DON. WHEN ASKED IF THE GUARDIAN WAS CONSULTED TO ADDRESS THESE SAFETY CONCERNS WHICH RESULTED IN MULTIPLE FALLS, THE NHA STATED SHE DID NOT KNOW. WHEN ASKED IF SAFETY DEVICES, SUCH AS ALARMS WERE CONSIDERED PRIOR TO THE FALL ON [DATE], RESULTING IN THE FRACTURED PELVIS. THE NHA STATED: "WE ARE ATTEMPTING TO KEEP HER INDEPENDENT... WE ARE ATTEMPTING TO REDUCE ALARMS (IN THE FACILITY). THEY TEND TO ANNOY RESIDENTS SO WE ARE TRYING NOT TO USE THEM." THE NHA STATED THAT ALARMS DO NOT PREVENT A FALL; HOWEVER, STATED IT WOULD ALERT STAFF WHEN RESIDENTS WERE PLACING THEMSELVES IN AN UNSAFE SITUATION, IN WHICH STAFF NEED TO IMMEDIATELY RESPOND TO. WHEN ASKED WHAT OTHER SAFETY INTERVENTIONS WERE PUT IN PLACE, INSTEAD OF ALARM DEVICES, TO MAINTAIN RESIDENT #101'S DEMONSTRATED NEED FOR INCREASED SUPERVISION, THERE WAS NO RESPONSE. DURING AN INTERVIEW ON [DATE] AT 11:10 A.M., WITH RESIDENT #101'S GUARDIAN "A", SHE WAS ASKED IF SHE WAS OPPOSED TO THE USE OF ALARMS. SHE STATED: "....MANY OF MY OTHER CLIENTS HAVE THEM... I ALWAYS WONDERED WHY THEY HAVE NEVER SUGGESTED ONE... WITH HER MANY FALLS." GUARDIAN "A" STATED SHE HAS SEEN RESIDENT #101 'SLIP' WHILE VISITING, WHEN RESIDENT #101 ATTEMPTED TO GET UP FROM HER WHEELCHAIR TO GO TO HER BEDSIDE STAND. GUARDIAN "A" STATED, "...I NEVER THOUGHT ABOUT IT AS A SAFETY ISSUE." SHE WAS UNAWARE THAT RESIDENT #101'S 'SLIPPING' RESULTED IN HER FALLS. GUARDIAN "A" STATED THE FACILITY NEVER ADDRESSED SAFETY CONCERNS WITH HER DURING THEIR CARE CONFERENCES. GUARDIAN "A" EMPHASIZED, "THEY (SAFETY ISSUES) WERE NOT ADDRESSED - NEVER." DURING OBSERVATIONS ON [DATE] AT 1:30 P.M. AND [DATE] AT 1:20 P.M., RESIDENT #101 WAS SEEN RESTING IN HER ROOM LYING IN HER BED. THE BED WAS OPENED ON BOTH SIDES (NOT POSITIONED BY THE WALL). THERE WAS A SMALL FLOOR MAT ON THE WINDOW SIDE OF THE BED WHICH MEASURED 36 INCHES BY 24 INCHES. THE DOOR SIDE OF THE BED WAS ACCESSIBLE, WITH NO FLOOR MAT ON THAT SIDE OF THE BED. THERE WAS A SENSOR ALARM IN USE. RESIDENT #101 HAD YELLOW SOCKS ON HER FEET, WITH NO GRIP DEVICE ON THE BOTTOM OF THE SOCKS. DURING BOTH OBSERVATIONS WHEN ASKED IF SHE WAS HAVING PAIN, RESIDENT #101 STATED RESPECTIVELY, "IT'S TERRIBLE!" AND "THE LEG HURTS... STILL BAD... IT HURTS A LOT!" THE "PHYSICIAN ORDERS" DATED [DATE] THROUGH [DATE], REVEALED an order for [REDACTED]. TWICE A DAY (9:00 A.M. AND 11:00 P.M.). IN ADDITION, THE "PHYSICIAN ORDERS" REVEALED an order for [REDACTED]. THE MEDICATION ADMINISTRATION RECORD (MAR) SHOWED RESIDENT #101 RECEIVED THE "AS NEEDED" MORPHINE SULFATE SEVERAL TIMES THROUGHOUT THE DAY IN ADDITION TO SCHEDULED MORPHINE SULFATE AS ORDERED TWICE A DAY. THERE WAS NO DOCUMENTATION OF THE EFFECTIVENESS OF THE "AS NEEDED" PAIN MEDICATION RECORDED ON THE MAR. THE MDS dated [DATE], REVEALED RESIDENT #102 IS A [AGE] year OLD WOMAN, WITH [DIAGNOSES REDACTED]. THIS MDS REVEALED RESIDENT #102 HAD A BIMS SCORE OF ,[DATE] INDICATIVE OF MODERATE COGNITIVE IMPAIRMENT. THIS MDS ALSO DOCUMENTED RESIDENT #102 WAS INDEPENDENT WITH TRANSFERS/AMBULATION AND HAD NO IMPAIRMENTS WITH RANGE OF MOTION (ROM) OF THE UPPER OR LOWER EXTREMITIES; FURTHERMORE, RESIDENT #102 HAD ONE FALL WITH MINOR INJURY DURING THE MDS REVIEW PERIOD. A REVIEW OF CARE PLAN TITLED "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" WITH A REVISION DATE OF [DATE], SHOWED UNDER "INTERVENTIONS": "GENERAL SUPERVISION AND INDEPENDENT WITH AMBULATION AND TRANSFER AND TO USE NON-SKID SOCKS." IN ADDITION, A CURRENT "FALL/INJURY..." CARE PLAN DATED [DATE], REVEALED INTERVENTIONS TO INCLUDE, "GENERAL SUPERVISION AND INDEPENDENT WITH AMBULATION AND TRANSFERS IN THE FACILITY... (TO WEAR) SHOES OR NON-SKID SOCKS." A REVIEW OF "RESIDENT INCIDENTS" REVEALED RESIDENT #102 HAD FALLS ON [DATE], [DATE], [DATE] AND [DATE]. THE INCIDENT REPORT DATED [DATE], SHOWED RESIDENT #102 WAS DEMONSTRATING OBSESSIVE-COMPULSIVE BEHAVIORS OF PUTTING ON AND OFF HER SHOES OVER AND OVER AGAIN. WHILE DOING SO, RESIDENT #102 LEANED TOO FAR FORWARD WHEN REACHING FOR HER SHOES, LOST HER BALANCE AND fell . RESIDENT #102 RECEIVED A CONTUSION (AN INJURY THAT DOES NOT DISRUPT THE INTEGRITY OF THE SKIN, BUT IS CHARACTERIZED BY SWELLING) AND A BRUISE TO THE HEAD FROM THE FALL. THERE WAS NO INDICATION AN INVESTIGATION INTO THE ROOT CAUSE OF THE FALL WAS PERFORMED NOR WERE APPROPRIATE CORRECTIVE INTERVENTIONS IMPLEMENTED. THE CORRECTIVE ACTION GIVEN WAS... 'REVISE THE CARE PLAN' AND 'THERAPY REFERRAL'. THE "FALL/INJURY..." CARE PLANS FOR RESIDENT #102 WERE REVIEWED TO DETERMINE THE REVISIONS MADE. THERE WAS NO DOCUMENTATION THE "FALL/INJURY..." CARE PLAN WAS REVISED WITH ANY NEW OR REVISED INTERVENTION. IN ADDITION, THERE WAS NO THERAPY REFERRAL FOR RESIDENT #102 DOCUMENTED IN THE MEDICAL RECORD RELATED TO THIS FALL. THE IDT (INTERDISCIPLINARY TEAM) NOTE DATED [DATE] READ, "RESIDENT (#102) fell IN ROOM AND SUSTAINED A BRUISE ON (TOP) (RIGHT) FOREHEAD. RESIDENT CONTINUES TO AMBULATE (WITHOUT) DISTRESS OR DIFFICULTY. RESIDENT WAS admitted TO HOSPICE...". THERE WAS NO ANALYSIS OF THE FALL TO DETERMINE CAUSATIVE FACTORS CONTRIBUTING TO THE FALL. FURTHERMORE, THERE WAS NO CORRECTIVE MEASURES ADDRESSED TO PREVENT FUTURE FALLS. THE "RESIDENT INCIDENT" REPORT DATED [DATE], REVEALED RESIDENT #102 REPORTED TO STAFF AFTER THE FALL, "I DON'T KNOW WHAT HAPPENED". ACCORDING TO THE REPORT, (RESIDENT #102) ALSO STATED SHE "JUST COULDN'T MOVE". THE INCIDENT REPORT DOCUMENTED SLIPPERS WERE ON HER FEET AND RESIDENT WAS INCONTINENT OF BOWEL AND BLADDER. THE INCIDENT REPORT READ, "PATIENT SUFFERED NO INJURY...". CORRECTIVE ACTION WAS "SLIPPERS HAVE BEEN REMOVED FROM THE ROOM AND STAFF EDUCATED ON TOILETING TIMES." IN ADDITION, THE CORRECTIVE ACTION READ THAT CARE PLANS WERE REVISED AND THERAPY REFERRAL WAS MADE. THERE WAS NO EVIDENCE THE ROOT CAUSE OF THE FALL WAS INVESTIGATED TO DETERMINE ALL CAUSATIVE FACTORS, NOR WERE APPROPRIATE INTERVENTIONS IDENTIFIED TO PREVENT FUTURE FALLS FOR RESIDENT #102. THE IDT NOTES DATED [DATE], DESCRIBING THE RESIDENT'S FALL ON [DATE] READ, "PT (PATIENT) OBSERVED LOSING BALANCE WHILE AMBULATING IN HALLWAY." THE RECOMMENDED INTERVENTIONS FOR RESIDENT #102 WERE "CARE PLAN REVIEWED AND UPDATED, THERAPY REFERRAL SUBMITTED...". THE "NURSING-THERAPY COMMUNICATION" FORM DATED [DATE] READ, "NOT APPROPRIATE FOR REHAB SERVICES AT THIS TIME, DUE TO DECLINE IN PHYSICAL/COGNITIVE/FUNCTIONAL STATUS... STAFF AWARE OF AND PROVIDING INCREASED ADL ASSISTANCE/SUPERVISION." A REVIEW OF THE CARE PLANS FOR RESIDENT #102 TITLED "FALL/INJURY ASSESSMENT..." AND "ALTERATION IN URINARY CONTINENCE PLAN OF CARE", REVEALED THESE CARE PLANS WERE NOT REVISED WITH ANY NEW INTERVENTIONS TO ADDRESS TOILETING FREQUENCY OR ADDITIONAL INTERVENTIONS TO INCREASE SUPERVISION OR SAFETY TO PREVENT FUTURE FALLS/INJURIES FOR THIS RESIDENT. THE "RESIDENT INCIDENT" REPORT DATED [DATE] READ, "RESIDENT (#102) WAS SITTING IN THE DINING ROOM, RESIDENT OBSERVED TO STAND AND BEGIN WALKING, LOST HER BALANCE FALLING INTO THE HALF WALL AND SLIDING TO FLOOR." THE REPORT CONCLUDED THERE WAS NO INJURY TO RESIDENT #102 WITH THIS FALL. NO EVIDENCE OF AN ANALYSIS OF THE FALL WAS PROVIDED TO DETERMINE THE CAUSATIVE FACTORS; NOR WERE APPROPRIATE INTERVENTIONS IDENTIFIED AND IMPLEMENTED TO PREVENT FUTURE FALLS. THERE WAS NO CORRECTIVE ACTIONS OF ANY KIND ADDRESSED IN THE INCIDENT REPORT FOR THIS FALL. THE IDT NOTES DATED [DATE], RECOUNTED THE FALL INCIDENT FOR RESIDENT #102 ON [DATE]; HOWEVER, NO ANALYSIS OF CAUSATIVE FACTORS WHICH MAY HAVE CONTRIBUTED TO THE FALL WERE NOTED AND THE IDT NOTES DID NOT ADDRESS CORRECTIVE MEASURES,SUCH AS INCREASED SUPERVISION OR SAFETY INTERVENTIONS TO PREVENT FURTHER FALLS. A "NURSING-THERAPY COMMUNICATION" FORM DATED [DATE] WAS FOUND IN RESIDENT #102'S CLINICAL RECORD. THE THERAPY ENTRY READ "PT (PATIENT) MAY BENEFIT FROM SKILLED THERAPY, YET PT IS CURRENTLY ON HOSPICE." FURTHERMORE, THERE WERE NO ACTIONS OR SAFETY INTERVENTIONS ADDRESSED TO MAINTAIN A SAFE ENVIRONMENT FOR RESIDENT #102. THE INCIDENT REPORT DATED [DATE], REVEALED "STAFF RESPONDED TO A "...LOUD SMACK... BLOOD WAS ON FLOOR UNDER RESIDENT'S FACE AND DENTURES WERE LAYING ON FLOOR." THE INCIDENT REPORT READ "RESIDENT (#102) STATED THAT SHE RAN INTO A W/C." RESIDENT #102 WAS SENT TO THE ER FOR EVALUATION AND TREATMENT. NO CORRECTIVE ACTION WAS DOCUMENTED OR ADDRESSED ON THE INCIDENT REPORT RELATED TO THIS FALL. THERE WAS NO EVIDENCE THE FALL WAS INVESTIGATED TO DETERMINE FACTORS THAT CONTRIBUTED TO THE FALL NOR WERE APPROPRIATE INTERVENTIONS RECOMMENDED TO PREVENT FALLS IN THE FUTURE FOR RESIDENT #102. THE HOSPITAL "RESIDENT TRANSFER FORM" FOR RESIDENT #102 DATED [DATE], READ UNDER "SPECIAL INSTRUCTIONS, "LACERATION - SOFT DIET X 1 WEEK. RINSE MOUTH AFTER EATING. FOLLOW UP IF SIGNS OF INFECTION. PENICILLIN V (AN ANTIBIOTIC) 500 MG (MILLIGRAMS) 3X A DAY X5 DAYS." A "NURSING-THERAPY COMMUNICATION" FORM WAS FOUND IN THE MEDICAL RECORD FOR RESIDENT #102 DATED [DATE] AND READ, "PT MAY BENEFIT FROM SKILLED THERAPY, YET PT CURRENTLY IS IN HOSPICE." THERE WERE NO RECOMMENDED SAFETY INTERVENTIONS OR SUGGESTIONS FOR INCREASED SUPERVISION NOTED BY THE THERAPY DEPARTMENT. THE "PROGRESS NOTES" TITLED "IDT" NOTES DATED [DATE], READ "RES (#102) REVIEWED @ IDT FOR FALL ON [DATE] RES RECEIVED A WOUND TO HER UPPER LIP. RES WAS TAKEN TO HOSP (HOSPITAL) AND RETURNED & WAS STARTED ON ABX (ANTIBIOTIC PROPHYLACTICALLY) FOR 5 DAYS. ALARMS WERE STARTED CP (CARE PLANS) IN PROGRESS. WILL CONTINUE TO MONITOR." THERE WAS NO DOCUMENTATION INDICATING AN EFFORT TO IDENTIFY FACTORS CONTRIBUTING TO THIS FALL HAD BEEN MADE, NOR EVIDENCE AN EVALUATION FOR PATTERNS OR TRENDS OF ALL RESIDENT #102'S RECENT FALLS TOOK PLACE. THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" FOR RESIDENT #102 DATED [DATE], DID NOT REVEAL ANY NEW OR REVISED INTERVENTIONS. THE IMPLEMENTATION OF AN ALARM DEVICE (MENTIONED IN THE IDT MEETING OF [DATE]) WAS NOT ADDRESSED ON THE CARE PLAN. A REVIEW OF THE "COMPREHENSIVE CARE PLAN REVIEW SUMMARY" DATED [DATE], WAS NOT UPDATED RELATED TO THE FALL ON [DATE] OR THE FALL ON [DATE]. THE AREA TITLED "SAFETY DEVICE" WAS MARKED WITH AN "X" IN THE AREA TO INDICATE RESIDENT #102 "DOES NOT HAVE (A) SAFETY DEVICE". DURING AN INTERVIEW WITH THE NHA ON [DATE] AT 4:25 P.M., SHE STATED: "YES, (RESIDENT #102'S) LAST TWO FALLS... THERAPY REFERRAL INDICATED SHE WOULD BENEFIT FROM SKILLED THERAPY AND THERE HAS BEEN NO ACTION BUT... WE HAVE TALKED WITH HOSPICE ...AND I THINK THERAPY WILL BE GIVEN. YES, I UNDERSTAND THERE WERE NO INTERVENTIONS PUT INTO PLACE TO ADDRESS SAFETY, BALANCE OR SUPERVISION ISSUES. LOOKING AT THE INCIDENT REPORTS... THE ROOT CAUSE WAS NOT ANALYZED... THAT IS CORRECT... I UNDERSTAND WE HAVE A PROBLEM...". DURING AN OBSERVATION ON [DATE] AT 2:35 P.M., RESIDENT #102 WAS IN HER ROOM SITTING IN HER RECLINER. RESIDENT #102 WAS DRESSED IN STREET CLOTHES WITH SHOES AND SOCKS ON HER FEET. THE CALL LIGHT WAS WITHIN HER REACH. THERE WAS NO SENSOR ALARM (PRESSURE ALARM) OR PERSONAL TABS ALARM IN USE, TO ALERT STAFF OF THE RESIDENT'S MOVEMENT. THE MDS dated [DATE], REVEALED RESIDENT #103 IS A [AGE] year OLD MAN WITH [DIAGNOSES REDACTED]. THE "PHYSICIAN ORDERS" DATED [DATE], REVEALED A [DIAGNOSES REDACTED].#103 DID NOT HAVE ANY IMPAIRMENT IN ROM OF THE UPPER OR LOWER EXTREMITIES. THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" FOR RESIDENT #103 DATED [DATE], REVEALED AN INTERVENTION FOR "INCREASED SUPERVISION" DATED [DATE], WITH NO DESCRIPTION OF HOW THIS WOULD BE ACCOMPLISHED. IN ADDITION, THIS CARE PLAN INDICATED AS OF [DATE], A PRESSURE ALARM WAS TO BE IN USE FOR RESIDENT #103. A REVIEW OF "RESIDENT INCIDENT" REPORTS SHOW RESIDENT #103 HAD A FALL ON [DATE]. THE REPORT "DESCRIPTION" READ "RESIDENT (#103) STATED HE ATTEMPTED TO GET UP OUT OF WHEELCHAIR AND THEN TRIED TO SIT BACK DOWN, BUT THE WHEELCHAIR MOVED FROM BEHIND HIM....RESIDENT IS NOT SURE WHY IT HAPPENED." THERE WAS NO DOCUMENTATION A PRESSURE ALARM WAS IN USE AT THE TIME OF THIS INCIDENT, AS INDICATED BY THE CARE PLAN. THE REPORT'S "FINAL OUTCOME" ADDRESSED "REASON" WHICH READ, "PATIENT HAS MULTIPLE INTERVENTIONS IN PLACE DUE TO RESTLESS/AGITATED BEHAVIORS. DESPITE INTERVENTIONS BEHAVIORS CONTINUE AND RESULTING FALLS ARE A POSSIBILITY." "IDENTIFIED ACTIONS TAKEN: CARE PLAN REVISION, OTHER: THERAPY REFERRAL". THERE WAS NO DOCUMENTATION THE FALL FOR RESIDENT #103 ON [DATE], WAS ANALYZED BY FACILITY STAFF TO DETERMINE THE CONTRIBUTING FACTORS FOR THE FALL; FURTHERMORE, NO EVIDENCE WAS PROVIDED TO SHOW THE RESIDENT'S CARE PLANS (WHICH INCLUDED MOOD AND BEHAVIORS, COGNITION, FALL/INJURY ASSESSMENT OR SAFETY DEVICES) WERE REVIEWED/REVISED TO ADDRESS APPROPRIATE MEASURES TO PREVENT FUTURE FALLS. A "NURSING - THERAPY COMMUNICATION" FORM DATED [DATE], READ "MAY BENEFIT FROM SKILLED THERAPY INTERVENTION DUE TO THE DEFICITS LISTED ABOVE AND WILL PURSUE EVALUATION AND TREATMENT ORDERS FOR : PT (PHYSICAL THERAPY) R/T (RELATED TO) DECREASED SAFETY AWARENESS / FUNCTIONAL STATUS AND OT (OCCUPATIONAL THERAPY) R/T INCREASED BEHAVIORS, INCREASED FALL RISK." THE THERAPY EVALUATIONS WERE COMPLETED FOR RESIDENT #103, BUT NOT UNTIL SIX DAYS LATER ON [DATE] FOR BOTH PT AND OT. THE "RESIDENT INCIDENT" REPORT DATED [DATE], INDICATED RESIDENT #103 HAD A FALL AT 1:20 A.M. THE "INCIDENT DESCRIPTION" READ, "RESIDENT NOTED TO BE AMBULATING THROUGH RESIDENT BEDROOM DOORWAY, AS STAFF WAS APPROACHING RESIDENT ...(HE) SIDE STEPPED LOST BALANCE AND fell TO FLOOR. PRESSURE ALARM WAS ON BUT DID NOT SOUND. INSPECTION OF PRESSURE ALARM BOX NOTED ... PRESSURE PAD PLUG ...NOTED WITH BROKEN CLASP ALLOWING FOR LOOSE CONNECTION." THE IMMEDIATE ACTION WAS TO EDUCATE STAFF TO "CLOSELY INSPECT ALL ASPECTS OF PRESSURE SAFETY DEVICES, CORDS, BOX, AND WIRING...". THE "FINAL OUTCOME" ADDRESSED TRENDS AND ACTIONS TAKEN WHICH READ, "PATIENT HAS HISTORY OF FALLS SIMILAR TO THIS....CARE PLAN REVISION, OTHER: THERAPY REFERRAL." THERE WAS NO INDICATION THIS FALL WAS EVALUATED TO DETERMINE CAUSATIVE FACTORS OR APPROPRIATE INTERVENTIONS TO DECREASE THE RISK OF FURTHER FALLS FOR RESIDENT #103. THE MEDICAL RECORD REVEALED THE PT AND OT EVALUATIONS RECOMMENDED FOR RESIDENT #103 ON [DATE], TO ADDRESS POOR SAFETY AWARENESS AFTER HE HAD FALLEN ON [DATE], WERE NOT COMPLETED UNTIL [DATE], AFTER AN ADDITIONAL FALL HAD OCCURRED ON [DATE]. THE "SAFETY DEVICE" CARE PLAN FOR RESIDENT #103 WAS NOT UPDATED TO INCLUDE THE USE OF THE SAFETY ALARM DEVICE OR THE INSPECTION REQUIREMENTS TO ENSURE PROPER FUNCTIONING OF THE DEVICE. THERE WAS NO DOCUMENTATION OF STAFF EDUCATION RELATED TO THE MALFUNCTIONING DEVICE OR THE ADDITIONAL REQUIREMENTS FOR STAFF INSPECTING THE DEVICE. THE "FALL/INJURY..." CARE PLAN FOR RESIDENT #103 WAS NOT UPDATED TO INCLUDE ADDITIONAL SUPERVISION, SUCH AS "CLOSE VISUAL SUPERVISION" OR "RESIDENT SPECIFIC SUPERVISION", BASED ON RESIDENT #103'S MOST RECENT FALLS ON [DATE] AND [DATE]. DURING AN INTERVIEW WITH THE DON ON [DATE] AT 4:30 P.M., HE STATED THERE WAS NO DOCUMENTATION THAT EDUCATION WAS PROVIDED TO STAFF RELATED TO THE ALARM DEVICE AND THE REQUIRED INSPECTION OF THE DEVICE. IN ADDITION, THE DON CONFIRMED (AFTER REVIEWING THE CARE PLANS) THERE WERE NO REVISIONS TO THE CARE PLANS TO ADDRESS THE INSPECTIONS REQUIREMENTS OR THE NEED FOR INCREASED SUPERVISION TO ATTEMPT TO PREVENT FURTHER FALLS FOR THIS RESIDENT. A REVIEW OF THE PROCEDURE TITLED "FALL AND INJURY" DATED [DATE] READ, "THE INTERDISCIPLINARY TEAM (IDT) WORKS WITH THE RESIDENT AND FAMILY TO IDENTIFY AND IMPLEMENT APPROPRIATE INTERVENTIONS THAT REDUCE THE RISK OF FALLS OR INJURIES WHILE MAXIMIZING DIGNITY AND INDEPENDENCE. 1. ASSESS AND REVIEW RISK FACTORS AND HAZARDS FOR FALLS AND INJURIES USING THE FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE. 2. REVIEW / EVALUATE OTHER INTERDISCIPLINARY TEAM (IDT) ASSESSMENTS. 3. DISCUSS GOALS AND INTERVENTIONS WITH RESIDENT / FAMILY FOR INCLUSION IN THE PLAN OF CARE. 4. SCHEDULE A COMPREHENSIVE CARE PLAN REVIEW MEETING (CCPR)... ....(FACILITY) REVISES THE RESIDENTS PLAN OF CARE AND/OR CENTER PRACTICES TO REDUCE THE LIKELIHOOD OF ANOTHER FALL. DETERMINING CAUSAL FACTORS LEADING TO A RESIDENT FALL IS NECESSARY TO PROVIDE CONSISTENT INTERVENTION TO PREVENT FUTURE OCCURRENCES." A REVIEW OF THE FACILITY'S POLICY TITLED "FALL/INJURY MANAGEMENT-POST FALL OR INJURY" DATED [DATE] READ, "-DETERMINING WHAT MAY HAVE CAUSED OR CONTRIBUTED TO THE FALL -ADDRESSING THE CONTRIBUTING FACTORS FOR THE FALL -REVISING THE RESIDENTS PLAN OF CARE AND / OR CENTER PRACTICES TO REDUCE

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO REVISE CARE PLANS TO ADDRESS ADEQUATE SUPERVISION AND PREVENTIVE MEASURES TO REDUCE THE LIKELIHOOD OF ANOTHER FALL FOR 3 OF 4 SAMPLED RESIDENTS (#101, #102 AND #103) WHO HAVE HAD MULTIPLE FALLS, FROM A TOTAL OF 103 RESIDENTS IN THE FACILITY. THIS FAILURE WAS EVIDENCED BY RESIDENT #101 CONTINUING TO SLIP AND FALL, AND ON 1/27/13, RESIDENT #101 SLIPPED TO THE FLOOR WHICH RESULTED IN A FRACTURED PELVIS AND INCREASED PAIN NEEDING ADDITIONAL PAIN MEDICATION WITH A SUBSEQUENT DECLINE IN HER PHYSICAL FUNCTION INCLUDING HER ABILITY TO TRANSFER AND AMBULATE INDEPENDENTLY. IN ADDITION, THIS FAILURE TO REVISE THE CARE PLANS FOR RESIDENTS #102 AND #103 CONTRIBUTED TO THEIR REPEATED FALLS, CAUSING MINOR INJURIES AND POTENTIAL FOR INJURY RESULTING IN HARM. FINDINGS INCLUDE: THE MINIMUM DATA SET ((MDS) dated [DATE], REVEALED RESIDENT #101 IS A [AGE] year OLD WOMAN, WITH [DIAGNOSES REDACTED]. THIS MDS INDICATED SHE HAD MODERATELY IMPAIRED COGNITION WHICH WAS REFLECTED IN A BRIEF INTERVIEW OF MENTAL STATUS (BIMS) SCORE OF 8/15. THIS MDS ALSO SHOWED RESIDENT #101 WAS INDEPENDENT WITH BED MOBILITY, TRANSFERS AND AMBULATION. IN ADDITION, THIS MDS SHOWED RESIDENT #101 HAD NO IMPAIRMENTS RELATED TO RANGE OF MOTION (ROM) TO UPPER OR LOWER EXTREMITIES AND HAD A CODING ERROR, WHICH INDICATED RESIDENT #101 HAD "0" FALLS IN THIS REVIEW PERIOD. THE MEDICAL RECORD REVEALED RESIDENT #101 HAD A COURT APPOINTED LEGAL GUARDIAN, DATED 9/21/11. A REVIEW OF "RESIDENT INCIDENT" REPORTS REVEALED RESIDENT #101 HAD A FALL ON 9/25/12 AT 1:26 P.M. THE "RESIDENT INCIDENT DESCRIPTION" READ, "I WAS TRYING TO GET UP OUT OF MY WHEELCHAIR AND I SLIPPED AND fell ." RESIDENT #101 RECEIVED A SKIN TEAR WHICH WAS TREATED AND MONITORED FOR HEALING. THE INCIDENT REPORT REVEALED THE WHEELCHAIR BRAKES WERE NOT IN USE AT THE TIME OF THE RESIDENT'S ATTEMPTED TRANSFER WHICH CONTRIBUTED TO THE FALL. THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" DATED 7/13/12, REVEALED RESIDENT #101 NEEDED "GENERAL SUPERVISION". THERE WERE NO REVISIONS OR UPDATES TO THE CARE PLAN TO ADDRESS THE NEED TO HAVE INCREASED SUPERVISION TO PREVENT FUTURE FALLS OR REVISIONS TO ADDRESS INTERVENTIONS TO ENSURE THE WHEELCHAIR BRAKES WERE LOCKED PRIOR TO TRANSFERS, FOLLOWING THE FALL ON 9/25/12. IN ADDITION, THE "SAFETY DEVICE PLAN OF CARE" DATED 7/13/12, SHOWED NO REVISIONS OR UPDATES AFTER THE FALL ON 9/25/12, TO ADDRESS THE BRAKES ON THE WHEELCHAIR AND THE NEED TO ENSURE THEY WERE KEPT LOCKED DURING RESIDENT TRANSFERS. FURTHER REVIEW OF THE "RESIDENT INCIDENT" REPORTS SHOWED RESIDENT #101 HAD A FALL ON 11/1/12 AT 12:36 P.M. THE "RESIDENT DESCRIPTION OF THE INCIDENT" READ, "I WAS TRYING TO GET IN MY (WHEEL)CHAIR FROM THE BED AND SLID RIGHT ONTO THE FLOOR." IN THE AREA WHICH IDENTIFIED "CAUSE", THE REPORT READ "MY SHOES SLIPPED." THE AREA ADDRESSING "EQUIPMENT CIRCUMSTANCES" DID NOT REVEAL THE USE OR NON-USE OF WHEELCHAIR BRAKES. THE SECTION UNDER "SUMMARY OF CORRECTIVE ACTION TAKEN" READ, "CARE PLAN REVISED...". A REVIEW OF THE "FALL/INJURY..." AND "SAFETY DEVICE" CARE PLANS FOR RESIDENT #101 REVEALED THESE CARE PLANS WERE NOT UPDATED OR REVISED AFTER THIS FALL. A CONTINUED REVIEW OF THE "RESIDENT INCIDENT" REPORTS SHOWED RESIDENT #101 HAD ANOTHER FALL ON 12/11/12 AT 1:32 P.M. THE "INCIDENT DESCRIPTION" READ, "RESIDENT SLIPPED OUT OF (WHEEL)CHAIR." THERE WAS NO INDICATION IN THE REPORT IF THE WHEELCHAIR BRAKES WERE IN USE AT THE TIME OF THE FALL. THE REPORT READ, "IDENTIFY ACTIONS TAKEN: CARE PLAN REVISIONS...". THERE WAS NO EVIDENCE THAT THE "FALL/INJURY..." AND "SAFETY DEVICE" CARE PLANS WERE REVISED AS A RESULT OF ANOTHER SLIP AND FALL FOR RESIDENT #101. THE "RESIDENT INCIDENT" REPORT DATED 1/28/13, SHOWED RESIDENT #101 HAD ANOTHER FALL ON 1/27/13 AT 3:00 P.M. THE "RESIDENT INCIDENT DESCRIPTION" READ, "(RESIDENT #101) STATED, 'I WAS TRYING TO MOVE THE TABLE AND MY LEGS SLIPPED AND I LANDED ON MY HIP AND BOUNCED.'" THE SECTION ADDRESSING "CORRECTIVE ACTION TAKEN" READ, "PATIENT SENT TO ER (emergency room ) FOR EVAL (EVALUATION) AND WAS admitted . UPON RETURN TO FACILITY, CARE PLANS WERE REVIEWED AND UPDATED. PATIENT'S ROOM ALSO CHANGED TO MOVE PATIENT CLOSER TO NURSES STATION." THE "physician's orders [REDACTED]. THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" FOR RESIDENT #101 DATED REVISED 1/30/13, REVEALED SPECIFIC INTERVENTIONS WHICH INCLUDED: "GENERAL SUPERVISION (DATED 7/13/12)... BED NEXT TO WALL - MAT NEXT TO BED (DATED 7/12/12)... PRESSURE ALARM - BED & CHAIR (DATED 1/30/13), NON-SKID SOCKS (DATED 2/4/13)". THE "SAFETY DEVICE" CARE PLAN DATED 7/13/12, DID NOT SHOW ANY TYPE OF UPDATES OR REVISIONS. IN AN INTERVIEW WITH THE ADMINISTRATOR (NHA) AND DIRECTOR OF NURSING (DON) ON 2/7/13 AT 2:55 P.M., A REVIEW OF THE INCIDENT REPORTS (9/25/12, 11/1/12 AND 12/11/12) NOTED THE CARE PLANS WERE 'REVISED'; HOWEVER, NO DOCUMENTATION OF 'REVISIONS' ON THE CARE PLANS TITLED "FALLS/INJURY" AND "SAFETY DEVICES" WERE FOUND UNTIL RESIDENT #101 fell on [DATE], RESULTING IN A FRACTURED PELVIS. THE NHA STATED, "WE THOUGHT THEY (THE CARE PLANS) WERE APPROPRIATE." DURING THE CONTINUED INTERVIEW WITH THE NHA AND DON ON 2/7/13 AT 2:55 P.M., THE NHA WAS ASKED IF THE GUARDIAN WAS CONSULTED TO ADDRESS THESE SAFETY CONCERNS FOLLOWING THE MULTIPLE FALLS EXPERIENCED BY RESIDENT #101. THE NHA STATED SHE DID NOT KNOW. THE NHA WAS ASKED BY THIS SURVEYOR IF SAFETY DEVICES, SUCH AS ALARMS, WERE CONSIDERED PRIOR TO THE FALL ON 1/27/13, RESULTING IN THE FRACTURED PELVIS. THE NHA STATED: "WE ARE ATTEMPTING TO KEEP HER INDEPENDENT... WE ARE ATTEMPTING TO REDUCE ALARMS (IN THE FACILITY). THEY TEND TO ANNOY RESIDENTS SO WE ARE TRYING NOT TO USE THEM." THE NHA SAID THAT ALARMS DO NOT PREVENT A FALL; HOWEVER, STATED IT WOULD ALERT STAFF THAT RESIDENTS WERE PLACING THEMSELVES IN AN UNSAFE SITUATION, IN WHICH STAFF NEED TO IMMEDIATELY RESPOND TO. WHEN ASKED WHAT OTHER SAFETY INTERVENTIONS WERE PUT IN PLACE, INSTEAD OF ALARM DEVICES, TO MAINTAIN RESIDENT #101'S DEMONSTRATED NEED FOR INCREASED SUPERVISION, THERE WAS NO RESPONSE. DURING AN INTERVIEW ON 2/7/13 AT 11:10 A.M. WITH RESIDENT #101'S GUARDIAN "A", SHE WAS ASKED IF SHE WAS OPPOSED TO THE USE OF ALARMS. SHE STATED: "...MANY OF MY OTHER CLIENTS HAVE THEM... I ALWAYS WONDERED WHY THEY HAVE NEVER SUGGESTED ONE... WITH HER MANY FALLS." GUARDIAN "A" STATED SHE HAS SEEN RESIDENT #101 "SLIP" WHILE VISITING, WHEN RESIDENT #101 ATTEMPTED TO GET UP FROM HER WHEELCHAIR TO GO TO HER BEDSIDE STAND. GUARDIAN "A" STATED: "...I NEVER THOUGHT ABOUT IT AS A SAFETY ISSUE." SHE WAS UNAWARE THAT RESIDENT #101'S 'SLIPPING' RESULTED IN HER FALLS. GUARDIAN "A" STATED THE FACILITY NEVER ADDRESSED SAFETY CONCERNS WITH HER DURING THEIR CARE CONFERENCES. GUARDIAN "A" EMPHASIZED, "THEY (SAFETY ISSUES) WERE NOT ADDRESSED - NEVER." DURING OBSERVATIONS ON 2/6/13 AT 1:30 P.M. AND 2/7/13 AT 1:20 P.M., RESIDENT #101 WAS SEEN RESTING IN HER ROOM, LYING IN HER BED. THE BED WAS OPENED ON BOTH SIDES (NOT POSITIONED BY THE WALL). THERE WAS A SMALL FLOOR MAT ON THE WINDOW SIDE OF THE BED WHICH MEASURED 36 INCHES BY 24 INCHES. THE DOOR SIDE OF THE BED WAS ACCESSIBLE, WITH NO FLOOR MAT ON THAT SIDE OF THE BED. THERE WAS A SENSOR ALARM IN USE. RESIDENT #101 HAD YELLOW SOCKS ON HER FEET, WITH NO GRIP DEVICE ON THE BOTTOM OF THE SOCKS. DURING BOTH OBSERVATIONS, WHEN ASKED IF SHE WAS HAVING PAIN, RESIDENT #101 STATED RESPECTIVELY, "IT'S TERRIBLE!" AND "THE LEG HURTS... STILL BAD... IT HURTS A LOT!" THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE "PHYSICIAN ORDERS" DATED 2/01/13-2/18/13 SHOWED AN INCREASE OF THE PRN (AS NEEDED) [MEDICATION NAME] SULFATE 10 MILLIGRAMS (MG) FROM EVERY 4 HOURS TO EVERY 2 HOURS. THIS MAR indicated [REDACTED]. RESIDENT #101'S FOURTH FALL RESULTED IN THE FRACTURED PELVIS AND CAUSED SIGNIFICANT INCREASED PAIN AND DECREASED FUNCTIONAL ABILITIES. THIS DECLINE WAS AVOIDABLE RELATED TO THE RESIDENT'S CARE PLANS NOT BEING REVISED WITH INDIVIDUALIZED INTERVENTIONS, INCLUDING ADEQUATE SUPERVISION AND PREVENTIVE MEASURES WHICH WOULD MAINTAIN A SAFE ENVIRONMENT FOR THE RESIDENT. THE MDS dated [DATE], REVEALED RESIDENT #102 IS A [AGE] year OLD WOMAN, WITH [DIAGNOSES REDACTED]. THIS MDS REVEALED RESIDENT #102 HAD A BIMS SCORE OF 9/15 INDICATIVE OF MODERATE COGNITIVE IMPAIRMENT. THIS MDS ALSO DOCUMENTED RESIDENT #102 WAS INDEPENDENT WITH TRANSFERS/AMBULATION AND HAD NO IMPAIRMENTS WITH RANGE OF MOTION (ROM) OF THE UPPER OR LOWER EXTREMITIES; FURTHERMORE, RESIDENT #102 HAD ONE FALL WITH MINOR INJURY DURING THE MDS REVIEW PERIOD. A REVIEW OF CARE PLAN TITLED "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" WITH A REVISION DATE OF 7/10/12, SHOWED UNDER "INTERVENTIONS": "GENERAL SUPERVISION AND INDEPENDENT WITH AMBULATION AND TRANSFER AND TO USE NON-SKID SOCKS". IN ADDITION, A CURRENT "FALL/INJURY..." CARE PLAN DATED 1/11/13, REVEALED INTERVENTIONS TO INCLUDE: "GENERAL SUPERVISION AND INDEPENDENT WITH AMBULATION AND TRANSFERS IN THE FACILITY... (TO WEAR) SHOES OR NON-SKID SOCKS." A REVIEW OF "RESIDENT INCIDENTS" REVEALED RESIDENT #102 HAD FALLS ON 11/3/12, 1/10/13, 1/29/13 AND 2/1/13. THE INCIDENT REPORT DATED 11/3/12, SHOWED RESIDENT #102 WAS DEMONSTRATING OBSESSIVE-COMPULSIVE BEHAVIORS OF PUTTING ON AND OFF HER SHOES, OVER AND OVER AGAIN. WHILE DOING SO, RESIDENT #102 LEANED TOO FAR FORWARD WHEN REACHING FOR HER SHOES, LOST HER BALANCE AND fell . RESIDENT #102 RECEIVED A CONTUSION (AN INJURY THAT DOES NOT DISRUPT THE INTEGRITY OF THE SKIN, BUT IS CHARACTERIZED BY SWELLING) AND A BRUISE TO THE HEAD FROM THE FALL. THE CORRECTIVE ACTION GIVEN WAS "REVISE THE CARE PLAN...". THE "FALL/INJURY..." CARE PLANS FOR RESIDENT #102 WERE REVIEWED TO DETERMINE THE REVISIONS MADE. THERE WAS NO DOCUMENTATION THE "FALL/INJURY..." CARE PLANS WERE REVISED WITH ANY NEW OR REVISED INTERVENTION. THE "RESIDENT INCIDENT" REPORT DATED 1/10/13, REVEALED RESIDENT #102 REPORTED TO STAFF AFTER THE FALL, "I DON'T KNOW WHAT HAPPENED". ACCORDING TO THE REPORT, (RESIDENT #102) ALSO STATED SHE "JUST COULDN'T MOVE". THE INCIDENT REPORT DOCUMENTED SLIPPERS WERE ON HER FEET AND RESIDENT WAS INCONTINENT OF BOWEL AND BLADDER. THE INCIDENT REPORT READ, "PATIENT SUFFERED NO INJURY...". CORRECTIVE ACTION WAS "SLIPPERS HAVE BEEN REMOVED FROM THE ROOM AND STAFF EDUCATED ON TOILETING TIMES." IN ADDITION, THE CORRECTIVE ACTION READ THAT CARE PLANS WERE 'REVISED'. THE "NURSING-THERAPY COMMUNICATION" FORM DATED 1/11/13 READ, "NOT APPROPRIATE FOR REHAB SERVICES AT THIS TIME, DUE TO DECLINE IN PHYSICAL/COGNITIVE/FUNCTIONAL STATUS... STAFF AWARE OF AND PROVIDING INCREASED ADL ASSISTANCE/SUPERVISION." A REVIEW OF THE CARE PLANS FOR RESIDENT #102 TITLED "FALL/INJURY ASSESSMENT..." AND "ALTERATION IN URINARY CONTINENCE PLAN OF CARE", REVEALED THESE CARE PLANS WERE NOT REVISED WITH ANY NEW INTERVENTIONS TO ADDRESS TOILETING FREQUENCY OR ADDITIONAL INTERVENTIONS TO INCREASE SUPERVISION OR SAFETY TO PREVENT FUTURE FALLS/INJURIES FOR THIS RESIDENT. THE "RESIDENT INCIDENT" REPORTED DATED 1/29/13 READ, "RESIDENT (#102) WAS SITTING IN THE DINING ROOM, RESIDENT OBSERVED TO STAND AND BEGIN WALKING, LOST HER BALANCE FALLING INTO THE HALF WALL AND SLIDING TO FLOOR." THERE WAS NO CORRECTIVE ACTIONS OF ANY KIND ADDRESSED IN THE INCIDENT REPORT FOR THIS FALL, NOR WAS THE CARE PLAN ADDRESSING 'FALL/INJURY' REVISED. THE INCIDENT REPORT DATED 2/1/13, REVEALED "STAFF RESPONDED TO A "...LOUD SMACK... BLOOD WAS ON FLOOR UNDER RESIDENT'S FACE AND DENTURES WERE LAYING ON FLOOR." THE INCIDENT REPORT READ, "RESIDENT (#102) STATED THAT SHE RAN INTO A W/C." RESIDENT #102 WAS SENT TO THE ER FOR EVALUATION AND TREATMENT. NO CORRECTIVE ACTION WAS DOCUMENTED OR ADDRESSED ON THE INCIDENT REPORT RELATED TO THIS FALL. THE "PROGRESS NOTES" TITLED "IDT" NOTES DATED 2/1/13, READ, "...ALARMS WERE STARTED CP (CARE PLANS) IN PROGRESS. WILL CONTINUE TO MONITOR." THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" FOR RESIDENT #102 DATED 1/11/13, DID NOT REVEAL ANY NEW OR REVISED INTERVENTIONS. THE IMPLEMENTATION OF AN ALARM DEVICE (MENTIONED IN THE IDT MEETING OF 2/1/13) WAS NOT ADDRESSED ON THE CARE PLAN. A REVIEW OF THE "COMPREHENSIVE CARE PLAN REVIEW SUMMARY" DATED 1/10/13, WAS NOT UPDATED RELATED TO THE FALL ON 1/29/13 OR THE FALL ON 2/1/13. THE AREA TITLED "SAFETY DEVICE" WAS MARKED WITH AN "X" IN THE AREA TO INDICATE RESIDENT #102 "DOES NOT HAVE (A) SAFETY DEVICE". DURING AN INTERVIEW WITH THE NHA ON 2/7/13 AT 4:25 P.M., SHE STATED: "YES, I UNDERSTAND THERE WERE NO INTERVENTIONS PUT INTO PLACE TO ADDRESS SAFETY, BALANCE OR SUPERVISION ISSUES. LOOKING AT THE INCIDENT REPORTS... I UNDERSTAND WE HAVE A PROBLEM...". DURING AN OBSERVATION ON 2/7/13 AT 2:35 P.M., RESIDENT #102 WAS IN HER ROOM SITTING IN HER RECLINER. RESIDENT #102 WAS DRESSED IN STREET CLOTHES WITH SHOES AND SOCKS ON HER FEET. THE CALL LIGHT WAS WITHIN HER REACH. THERE WAS NO SENSOR ALARM (PRESSURE ALARM) OR PERSONAL TABS ALARM IN USE, TO ALERT STAFF OF THE RESIDENT'S MOVEMENT. THE MDS dated [DATE], REVEALED RESIDENT #103 IS A [AGE] year OLD MAN WITH [DIAGNOSES REDACTED]. THE "PHYSICIAN ORDERS" DATED 2/1/13, REVEALED A [DIAGNOSES REDACTED].#103 DID NOT HAVE ANY IMPAIRMENT IN ROM OF THE UPPER OR LOWER EXTREMITIES. THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" FOR RESIDENT #103 DATED 8/30/12, REVEALED AN INTERVENTION FOR "INCREASED SUPERVISION" DATED 8/30/12, WITH NO DESCRIPTION OF HOW THIS WOULD BE ACCOMPLISHED. IN ADDITION, THIS CARE PLAN INDICATED, AS OF 1/8/13, A PRESSURE ALARM WAS TO BE IN USE FOR RESIDENT #103. A REVIEW OF "RESIDENT INCIDENT" REPORTS SHOW RESIDENT #103 HAD A FALL ON 1/14/13. THE REPORT "DESCRIPTION" READ, "RESIDENT (#103) STATED HE ATTEMPTED TO GET UP OUT OF WHEELCHAIR AND THEN TRIED TO SIT BACK DOWN, BUT THE WHEELCHAIR MOVED FROM BEHIND HIM... RESIDENT IS NOT SURE WHY IT HAPPENED." THERE WAS NO DOCUMENTATION A PRESSURE ALARM WAS IN USE AT THE TIME OF THIS INCIDENT, AS INDICATED BY THE CARE PLAN. THE INCIDENT REPORT READ, "IDENTIFIED ACTIONS TAKEN: CARE PLAN REVISION...". THERE WAS NO EVIDENCE PROVIDED TO SHOW THE RESIDENT'S CARE PLANS (WHICH INCLUDED MOOD AND BEHAVIORS, COGNITION, FALL/INJURY ASSESSMENT OR SAFETY DEVICES) WERE REVIEWED/REVISED TO ADDRESS APPROPRIATE MEASURES TO PREVENT FUTURE FALLS. THE "RESIDENT INCIDENT" REPORT DATED 1/20/13, INDICATED RESIDENT #103 HAD A FALL AT 1:20 A.M. THE "INCIDENT DESCRIPTION" READ, "RESIDENT NOTED TO BE AMBULATING THROUGH RESIDENT BEDROOM DOORWAY, AS STAFF WAS APPROACHING RESIDENT ...(HE) SIDE STEPPED LOST BALANCE AND fell TO FLOOR. PRESSURE ALARM WAS ON BUT DID NOT SOUND. INSPECTION OF PRESSURE ALARM BOX NOTED ...PRESSURE PAD PLUG ...NOTED WITH BROKEN CLASP ALLOWING FOR LOOSE CONNECTION." THE IMMEDIATE ACTION WAS TO EDUCATE STAFF TO CLOSELY INSPECT ALL ASPECTS OF PRESSURE SAFETY DEVICES, CORDS, BOX AND WIRING. THE "FINAL OUTCOME" ADDRESSED "...CARE PLAN REVISIONS". THE "SAFETY DEVICE" CARE PLAN FOR RESIDENT #103 WAS NOT UPDATED TO INCLUDE THE USE OF THE SAFETY ALARM DEVICE OR THE INSPECTION REQUIREMENTS TO ENSURE PROPER FUNCTIONING OF THE DEVICE. THERE WAS NO DOCUMENTATION OF STAFF EDUCATION RELATED TO THE MALFUNCTIONING DEVICE OR THE ADDITIONAL REQUIREMENTS FOR STAFF INSPECTING THE DEVICE. THE "FALL/INJURY..." CARE PLAN FOR RESIDENT #103 WAS NOT UPDATED TO INCLUDE ADDITIONAL SUPERVISION, SUCH AS "CLOSE VISUAL SUPERVISION" OR "RESIDENT SPECIFIC SUPERVISION" BASED ON RESIDENT #103'S MOST RECENT FALLS ON 1/14/13 AND 1/20/13. DURING AN INTERVIEW WITH THE DON ON 2/7/13 AT 4:30 P.M., SHE CONFIRMED (AFTER REVIEWING THE CARE PLANS) THERE WERE NO REVISIONS TO THE CARE PLANS TO ADDRESS THE INSPECTION REQUIREMENTS OR THE NEED FOR INCREASED SUPERVISION TO ATTEMPT TO PREVENT FURTHER FALLS. A REVIEW OF THE PROCEDURE TITLED "FALL AND INJURY" DATED APRIL 2012 READ, "THE INTERDISCIPLINARY TEAM (IDT) WORKS WITH THE RESIDENT AND FAMILY TO IDENTIFY AND IMPLEMENT APPROPRIATE INTERVENTIONS THAT REDUCE THE RISK OF FALLS OR INJURIES WHILE MAXIMIZING DIGNITY AND INDEPENDENCE. 1. ASSESS AND REVIEW RISK FACTORS AND HAZARDS FOR FALLS AND INJURIES USING THE FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE... 3. DISCUSS GOALS AND INTERVENTIONS WITH RESIDENT/FAMILY FOR INCLUSION IN THE PLAN OF CARE...". A REVIEW OF THE FACILITY'S POLICY TITLED, "FALL/INJURY MANAGEMENT-POST FALL OR INJURY" DATED JULY 2012 READ, "...-REVISING THE RESIDENT'S PLAN OF CARE AND/OR CENTER PRACTICES TO REDUCE THE LIKELIHOOD OF ANOTHER FALL. PROCEDURES: 1. ASSESS THE RESIDENT AND IMPLEMENT APPROPRIATE MEASURE TO PROVIDE IMMEDIATE CARE AFTER A FALL/INJURY... 4. DISCUSS RISK FACTORS, HAZARDS AND INTERVENTIONS WITH RESIDENT/FAMILY FOR INCLUSION IN THE PLAN OF CARE. -DETERMINE WHAT MAY HAVE CAUSED OR CONTRIBUTED TO THE FALL/INJURY. 5. REVISE INTERVENTIONS ON THE FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE...". ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE ONE RESIDENT (#21) WITH A KNOWN HISTORY OF FALLS OF EIGHT RESIDENTS REVIEWED FOR FALLS OF 21 SAMPLED RESIDENTS, FROM THE 101 FACILITY RESIDENTS, RESULTING IN HARM TO RESIDENT #21 WHO RECEIVED 6 FRACTURED RIBS AND A BROKEN FINGER FROM THE FALL. FINDINGS INCLUDE: REVIEW OF THE 2/17/12 FACILITY'S INVESTIGATION REPORT SHOWED ON 2/11/12 AT APPROXIMATELY 8:00 P.M., RESIDENT #21'S PRESSURE ALARM WAS SOUNDING. THE REPORT DOCUMENTED LICENSED PRACTICAL NURSE (LPN) "DD" ENTERED RESIDENT #21'S ROOM AND FOUND HER WALKING TOWARD THE TOILET AND ASSISTED HER ONTO THE TOILET. AS HE WAS WAITING FOR HER OUTSIDE THE BATHROOM DOOR, PER THE REPORT, LPN "DD" SAW RESIDENT #61 IN THE HALL TRYING TO SIT IN HIS WHEELCHAIR AND "LOOKED LIKE HE WAS GOING TO FALL". THE REPORT DOCUMENTED LPN "DD" LEFT RESIDENT #21'S ROOM AND ASSISTED RESIDENT #61 TO A SEATED POSITION IN HIS WHEELCHAIR. THE REPORT SHOWED, WHEN LPN "DD" RETURNED TO THE ROOM, HE FOUND RESIDENT #21 ON THE FLOOR NEAR HER BED WITH BLEEDING NOTED FROM HER FOREHEAD. THE REPORT DOCUMENTED AFTER THE FALL, RESIDENT #21 COMPLAINED OF PAIN IN HER RIGHT HAND AND RIGHT SIDE OF HER TORSO. THE 2/11/12 HOSPITAL X-RAY SHOWED RESIDENT #21 RECEIVED "FRACTURES OF THE LATERAL ASPECTS OF THE 5TH, 6TH, 7TH, 8TH AND 9TH RIBS ON THE RIGHT SIDE." THE HOSPITAL 2/11/12 X-RAY REPORT ALSO DOCUMENTED RESIDENT #21 HAD "...A FRACTURE OF THE DISTAL 5TH METACARPAL BONE..." THE REVIEW OF RESIDENT #21'S CLINICAL FACE SHEET SHOWED SHE HAD ENTERED THE FACILITY ON 5/11/11, AFTER FALLING AT HOME. HER [DIAGNOSES REDACTED]. THE 1/07/12 MINIMUM DATA SET (MDS) ASSESSMENT DOCUMENTED RESIDENT #21 NEEDED EXTENSIVE ASSISTANCE WHEN TRANSFERRING AND AMBULATING DUE TO MUSCLE WEAKNESS. THE MDS SHOWED HER COGNITION WAS IMPAIRED AND SHE HAD POOR SAFETY AWARENESS. THE 1/12 CARE PLAN DOCUMENTED HER POOR SAFETY AWARENESS AND WHILE SHE HAD RESIDED AT THE FACILITY, SHE HAD FALLEN ON 5 PREVIOUS OCCASIONS WITHOUT INJURY. DUE TO HER FALL RISK, PRESSURE ALARMS WERE USED IN HER WHEELCHAIR AND IN HER BED. THE PHYSICIan order for [REDACTED]. THE PHYSICIAN ORDERS SHOWED A FENTANYL PATCH WAS ADDED ON 2/13/12 TO ASSIST IN THE REDUCTION OF PAIN FROM THE FRACTURES. RESIDENT #21 WAS NOT AVAILABLE FOR INTERVIEW OR OBSERVATION. LPN "DD" WAS INTERVIEWED ON 2/22/12 AT 9 A.M. HE SAID THE REPORT WAS NOT COMPLETELY CORRECT. LPN "DD" EXPLAINED, AFTER HE ASSISTED RESIDENT #61 IN THE HALL, HE WENT BACK TO CHECK ON RESIDENT #21 AND SHE WAS STILL IN THE BATHROOM. LPN "DD" STATED RESIDENT #8 HAD WANTED A PAIN PILL EARLIER AND HE THOUGHT HE COULD GIVE IT TO HER BEFORE RESIDENT #21 WAS READY TO LEAVE THE BATHROOM. LPN "DD" SAID, "THAT WAS VERY POOR JUDGEMENT ON MY PART, WE CAN'T LEAVE (RESIDENT #21) ALONE IN THE BATHROOM... SHE DOESN'T USE HER CALL LIGHT, SHE'S VERY UNSTEADY ON HER FEET AND JUST STARTS WALKING AND THEN FALLS... I SHOULD'VE WAITED UNTIL AFTER I HAD ASSISTED (RESIDENT #21) FROM THE TOILET AND THEN GIVEN (RESIDENT #8) HER PAIN MEDICATION..." INTERVIEWS WERE CONDUCTED WITH REGISTERED NURSE (RN) "EE", LPN "GG ", CERTIFIED NURSE AIDE (CNA) "LL" AND CNA "MM" ON 2/23/12 AT 6:40 A.M., 6:50 A.M., 7 A.M. AND 7:30 A.M. RESPECTIVELY. THE 4 STAFF SAID, RESIDENT #21 DID NOT USE HER CALL LIGHT TO ASK FOR ASSISTANCE. THEY ALSO STATED ANY RESIDENT THAT DOES NOT USE THEIR CALL LIGHT "FOR ANY REASON" IS NEVER LEFT ALONE ON THE TOILET. CNA "LL" EXPLAINED, HE WAS RESIDENT #21'S PRIMARY CNA AND HAD WORKED WITH HER SINCE SHE HAD ENTERED THE FACILITY. HE SAID, RESIDENT #21 HAD FALLEN MULTIPLE TIMES AND STAFF WOULD TRY TO ANTICIPATE HER NEEDS. CNA "LL" EXPLAINED, "AFTER THIS FALL, (RESIDENT #21) WAS IN A LOT OF PAIN AND IT WAS DIFFICULT FOR HER TO MOVE." HE STATED, "...(RESIDENT #21) WAS NOT HERSELF AFTER THE FALL... IT WAS DIFFICULT AND PAINFUL FOR HER TO MOVE WITH THOSE BROKEN RIBS..." ON 2/24/12 AT 1 P.M., A PHONE INTERVIEW WAS CONDUCTED WITH RESIDENT #21'S FAMILY MEMBER "XX". HE STATED HE VISITED RESIDENT #21 "ON A REGULAR BASIS..." FAMILY MEMBER "XX" EXPLAINED HE WAS AWARE STAFF HAD TO ASSIST RESIDENT #21 TO THE TOILET. HE SAID, "SHE JUST WOULDN'T ASK FOR HELP..." FAMILY MEMBER "XX" STATED, "AFTER THE FALL, THEY (STAFF) GAVE HER PAIN MEDICINE FOR HER PAIN BUT THOSE RIBS REALLY HURT... SHE JUST COULDN'T MOVE ANYMORE..." THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 2/24/12 AT 10 A.M. SHE SAID THE INFORMATION LPN "DD" GAVE WAS CORRECT. THE DON SAID, "(LPN "DD") KNEW (RESIDENT #21) WAS NOT TO BE LEFT ALONE IN THE BATHROOM... HE USED BAD JUDGEMENT... STAFF KNEW NOT TO LEAVE HER ALONE WHILE SHE WAS IN THE BATHROOM..." WHEN THE DON WAS ASKED IF RESIDENT #21 USED HER CALL LIGHT, SHE SAID RESIDENT #21 DID NOT USE HER CALL LIGHT TO ASK FOR ASSISTANCE. THE DON STATED, "...THAT'S WHY YOU DIDN'T LEAVE HER ALONE IN THE BATHROOM..." ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE EACH RESIDENT WITH ASSISTANCE DEVICES (WHEELCHAIR FOOT PEDALS) TO PREVENT ACCIDENTS. THIS AFFECTED ONE RESIDENT (#1) OF FOUR SAMPLED RESIDENTS, FROM A TOTAL RESIDENT POPULATION OF 107. THIS FAILURE RESULTED IN RESIDENT #1 FALLING OUT OF THE WHEELCHAIR, STRIKING HER HEAD, LOSING CONSCIOUSNESS FOR APPROXIMATELY 60 SECONDS, AND REQUIRING MEDICAL EVALUATION FOR POTENTIAL FRACTURES AND 9 SUTURES TO CLOSE A LACERATION ON HER FOREHEAD. FINDINGS INCLUDE: AN INVESTIGATION TOOK PLACE AT THE FACILITY ON 9/14/11 IN RESPONSE TO A FACILITY REPORTED INCIDENT (FRI) SHOWING RESIDENT #1 fell AND SUSTAINED INJURY ON 7/30/11. THE RESIDENT "FACE SHEET" DOCUMENTS RESIDENT #1 IS A NINETY YEAR OLD FEMALE. HER ORIGINAL admitted WAS 9/12/2005. THE FACE SHEET ALSO DOCUMENTS [DIAGNOSES REDACTED]. RESIDENT #1'S MINIMUM DATA SET (MDS) QUARTERLY assessment dated ,[DATE], SECTION G, "FUNCTIONAL STATUS FOR TRANSFERS" SHOWED RESIDENT #1 AT LEVEL "2" FOR BALANCE DURING TRANSFERS, "NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE". A "RESIDENT LIFTING, TRANSFERRING AND REPOSITIONING DATA COLLECTION" assessment dated [DATE], CLASSIFIES RESIDENT #1 AS "TOTAL DEPENDENCE." A "FOOT PEDAL ASSESSMENT" DATED 12/30/10 AND UPDATED ON 7/05/11 WITH "NO CHANGES" CONCLUDES "FOOT PEDALS REQUIRED" FOR RESIDENT #1. THE "ADL/MOBILITY: PLAN OF CARE" DATED 12/30/10 AND UPDATED 7/05/11 DOCUMENTS THE FOLLOWING: "FOOT PEDALS REQUIRED WHEN STAFF PROPEL WHEELCHAIR." THE CERTIFIED NURSE AIDE (CNA) "A"/SHOWER AIDE WHO WAS PROVIDING CARE TO RESIDENT #1 AT THE TIME OF THE INCIDENT ON 7/30/11 AT 6:45 A.M., WAS INTERVIEWED BY THIS SURVEYOR AT 10:45 A.M. ON 9/14/11. CNA "A" STATED, "(RESIDENT #1) HAD NO FOOT PEDALS ON HER CHAIR AT THE TIME OF THE FALL. I BACKED HER ONTO THE WHEELCHAIR SCALE, NOTED HER WEIGHT AND PUSHED HER FORWARD OFF THE SCALE. HER FEET MADE CONTACT WITH THE GROUND AND SHE WAS PROPELLED FORWARD ONTO THE FLOOR." A NURSES NOTE DATED 7/30/11, DOCUMENTS THE FOLLOWING: "RESIDENT (#1) WAS IN WHEELCHAIR AND WAS BEING WEIGHED BY CNA WHEN RESIDENT fell on FLOOR WHILE CNA WAS PUSHING WHEELCHAIR OFF OF THE SCALE AND RESIDENT fell FORWARD HITTING FACE AND HEAD ON SHOWER ROOM FLOOR. THIS NURSE OBSERVED RESIDENT ON SHOWER ROOM FLOOR, LAYING ON HER RIGHT SIDE, BLOOD NOTED ON FLOOR UNDER HEAD. INITIAL NEURO ASSESSMENT RESULTED IN NO REACTION IN PUPILS (ABNORMAL FINDING) AND RESIDENT UNRESPONSIVE TO TOUCH, OR SOUND. WITHIN 60 SECONDS RESIDENT OPENED HER EYES WHILE VITAL SIGNS WERE BEING OBTAINED. DUE TO RESIDENT'S MENTAL STATUS, PAIN IS DIFFICULT TO JUDGE. THERE WAS NOTICEABLE GRIMACING IN FACE AS RESIDENT WAS LYING STILL ON THE FLOOR." THE emergency room (ER) REPORT DATED 7/30/11, DOCUMENTS RESIDENT #1 WAS EVALUATED FOR CERVICAL SPINE AND CRANIAL FRACTURES. THE COMPUTED TOMOGRAPHY (CT SCANS) OF THE RESIDENT'S HEAD AND NECK WERE NEGATIVE FOR FRACTURES. THE ER REPORT ALSO DOCUMENTED THE RESIDENT RECEIVED 9 SUTURES TO CLOSE A LACERATION AT THE HAIRLINE OF HER FOREHEAD. RESIDENT #1 RETURNED TO THE FACILITY LATER THE SAME DAY AT 11:00 A.M. LICENSED NURSING STAFF "C" WAS INTERVIEWED AT 11:20 AM ON 9/14/11. STAFF "C" STATED, "BEFORE THE INCIDENT IT WAS COMMON FOR ME TO SEE STAFF PUSHING (RESIDENT #1) IN HER WHEELCHAIR USING ONE FOOT PEDAL WITH ONE FOOT CROSSED OVER THE OTHER. IT MAY HAVE BEEN BECAUSE STAFF COULD NOT FIND ANOTHER FOOT PEDAL." AFTER THE INCIDENT WITH RESIDENT #1, AN "IN-SERVICE TRAINING RECORD" DATED 8/01/11, DOCUMENTED TRAINING FOR ALL NURSING STAFF REGARDING "FOOT PEDAL USE". THE OBJECTIVE FOR THE TRAINING INCLUDED: "ALL NURSING STAFF WILL UNDERSTAND FOOT PEDALS MUST BE ON EVERY WHEELCHAIR WHEN USED FOR TRANSFERRING RESIDENTS OR TRANSPORTING RESIDENTS. NO EXCEPTIONS." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY SERVICES RELATED TO THE PROVISION OF A HOT PACK TREATMENT, RESULTING IN HARMFUL NEGLECT OF ONE COGNITIVELY IMPAIRED RESIDENT (#1) WHO IS VERBALLY NON-COMMUNICATIVE, OUT OF TWO RESIDENTS WHO WERE REVIEWED FOR HOT PACK TREATMENTS RESULTING IN THE RESIDENT DEVELOPING A 2ND DEGREE THERMAL BURN TO HER LEFT UPPER ARM. THE FACILITY FAILED TO FOLLOW MANUFACTURER'S SAFE OPERATION RECOMMENDATIONS FOR USE OF A HYDROCULATOR AND A REGISTERED NURSE (RN) "A" FAILED TO ADHERE TO PROFESSIONAL STANDARDS OF PRACTICE. THESE FAILURES RESULTED IN IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY WAS IDENTIFIED ON 2/07/11 AT 2:30 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 2/03/11 AT APPROXIMATELY 3:05 A.M., WHEN RN "A" PROVIDED THE FOLLOWING INAPPROPRIATE CARE TO RESIDENT #1'S LEFT ARM: ? WRAPPED A HOT PACK WHICH WAS HEATED FROM A HYDROCULATOR (AN ELECTRIC HEATING MACHINE) AT A TEMPERATURE LAST RECORDED AT 180 DEGREES (?) FAHRENHEIT (F) WHICH IS 15? GREATER THAN THE MANUFACTURER'S SAFETY PRECAUTION RECOMMENDATION. ? USED TWO STANDARD BATH TOWELS TO COVER THE HOT PACK INSTEAD OF THE EIGHT TO TEN LAYERS OF HEAVY TOWELING/HOT PACK COVERS SUCH AS TERRY CLOTH AS DIRECTED BY THE FACILITY'S HYDROCULATOR PACK PROCEDURE. ? LEFT THE HOT PACK ON RESIDENT #1'S ARM FOR APPROXIMATELY FIFTEEN MINUTES WITHOUT ASSESSING THE CONDITION OF HER SKIN BENEATH THE HOT PACK, INSTEAD OF THE 3-5 MINUTES AS DIRECTED BY THE FACILITY'S PROCEDURE. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 02/07/11 AT 2:40 P.M. ON 2/7/11 AT 5:20 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE HYDROCULATOR WAS OBSERVED SECURED IN THE ADMINISTRATOR'S OFFICE, TO PREVENT FACILITY STAFF, WHO HAVE NOT BEEN EDUCATED ON THE HYDROCULATOR PROCEDURE, FROM USING IT. THE ADMINISTRATOR STATED ON 2/7/11 AT 5:20 P.M., "THE KEYS FOR THE HYDROCULATOR ROOM WILL BE SUPPLIED TO ONLY THE THERAPY MANAGER, DIRECTOR OF NURSING (DON), MAINTENANCE DIRECTOR AND MYSELF. THE FLOOR NURSES WILL NOT HAVE ACCESS TO THE HYDROCULATOR". ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT AN ISOLATED LEVEL, WITH THE POTENTIAL FOR MORE THAN MINIMUM HARM DUE TO: ? THE FACILITY'S HYDROCULATOR PACK PROCEDURE DOES NOT REFLECT THE MANUFACTURER'S RECOMMENDATION OF THE SAFE WATER TEMPERATURE. ? STAFF EDUCATION OF AN APPROPRIATE HYDROCULATOR PACK PROCEDURE AND VERIFICATION OF FACILITY STAFF'S ADHERENCE TO THE PROCEDURE HAS NOT BEEN COMPLETED. ? DEMONSTRATION THAT RESIDENT CARE POLICY/PROCEDURE/PROTOCOLS REFLECT CURRENT PROFESSIONAL STANDARDS OF PRACTICE/MANUFACTURER'S RECOMMENDATION FOR ANY RESIDENT CARE DEVICE USED IN THE FACILITY HAS NOT OCCURRED. ? REASSESSMENT OF STAFF EDUCATION NEEDS AND VALIDATION OF APPROPRIATE PROCESSES/SYSTEMS ARE IN PLACE TO PREVENT NEGLECT THROUGHOUT THE FACILITY HAS NOT OCCURRED. FINDINGS INCLUDE: ON 2/07/11 AT APPROXIMATELY 9:45 A.M., A FACILITY ACCIDENT/INCIDENT REPORT DATED 2/03/11 INVOLVING RESIDENT #1 WAS REVIEWED. THE REPORT READS, "WARM COMPRESS APPLIED APPROX. 3A & REMOVED 3:15A. NOTED ARM WARM, WAS PINK. NO BLISTERING. RECHECKED ARM COLOR AT 4:15. ARM NOTED RED. COOL CLOTH APPLIED." A REVIEW OF THE FACILITY'S INITIAL INVESTIGATION REPORT DATED 2/3/11, REFLECTS THAT A WARM COMPRESS TREATMENT WAS ORDERED BY RESIDENT #1'S PHYSICIAN. RESIDENT #1 DEVELOPED A 2ND DEGREE BURN TO HER UPPER LEFT ARM. THIS REPORT READS, "...A HYDROCULATOR PACK WAS TAKEN FROM THERAPY AND WRAPPED IN 2 TOWELS AND PLACED ON RESIDENT UPPER LEFT ARM OVER A DRESSING COVERED WITH [MEDICATION NAME] AT APPROX. 3:00AM...WAS CHECKED AT APPROX. 3:15 AND AREA NOTED TO BE PINK, HYDROCULATOR PACK REMOVED FROM ARM... ASSESSMENT OF RESIDENT (#1)'S ARM DONE AT 6:55 A.M. TO BE, 3 CENTIMETER (CM) BY 1 CM LINEAR BLISTER HAD DEVELOPED, THE MD (MEDICAL DOCTOR) NOTIFIED, NO NEW ORDERS AT THIS TIME. MD PHONED (NO TIME SPECIFIED) AND ORDERED [MEDICATION NAME] (BURN CREAM) TO BLISTER BID (2 TIMES A DAY) TREATMENT; FIRST TREATMENT WAS DONE AT 10:25 A.M. ON 2/03/11." AN INTERVIEW WITH THE FACILITY ADMINISTRATOR ON 2/07/11 AT 9:50 A.M., CONFIRMED THAT RESIDENT #1 SUSTAINED A 2ND DEGREE BURN TO HER LEFT UPPER/INNER ARM AFTER A HOT PACK WAS APPLIED BY FACILITY STAFF, REQUIRING MEDICAL TREATMENT. A REVIEW OF RESIDENT #1'S CLINICAL RECORD REVEALED SHE IS A [AGE] year OLD FEMALE WHO HAS RESIDED AT THE FACILITY SINCE 10/15/06. THE RECORD REVIEW REVEALS HER [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #1'S ANNUAL MINIMUM DATA SET ((MDS) dated [DATE], REVEALED HER COGNITION IS HIGHLY IMPAIRED. SHE HAS MEMORY LOSS, IS UNABLE TO MAKE DECISIONS AND IS UNABLE TO UNDERSTAND OR BE UNDERSTOOD. SHE ALSO HAS "NO SPEECH". FURTHER REVIEW OF HER ANNUAL MDS AND CARE PLAN DATED 8/04/10, REVEALED RESIDENT #1 IS TOTALLY DEPENDENT UPON STAFF FOR ALL HER ACTIVITIES OF DAILY LIVING (ADL) AND DIRECTS STAFF TO "ANTICIPATE RES. (RESIDENT) NEEDS AND MONITOR FOR NON-VERBAL S/S (SIGNS/SYMPTOMS) OF NEEDS." THE CLINICAL RECORD REVIEW OF RESIDENT #1 SHOWS A WRITTEN PHYSICIAN ORDER [REDACTED].M. THAT READS, "...WARM COMPRESS TO AREA TID (THREE TIMES DAILY), 20 MINUTES AT A TIME. USE PER PROTOCOL". THE RESIDENT'S WRITTEN PLAN OF CARE DOES NOT REFLECT THIS TREATMENT INTERVENTION, OR ANY OF THE PROCEDURAL INTERVENTIONS AS DIRECTED BY THE FACILITY'S HYDROCULATOR PACK PROCEDURE OR THE HYDROCULATOR MANUFACTURER'S RECOMMENDATIONS FOR SAFE OPERATION. AN OBSERVATION OF RESIDENT #1'S LEFT UPPER/INNER ARM WAS CONDUCTED BY THIS SURVEYOR WITH LICENSED PRACTICAL NURSE (LPN) "E" ON 2/07/11 AT 10:20 A.M. ON THE INSIDE OF RESIDENT #1'S LEFT UPPER ARM, A 2ND DEGREE BURN MEASURING 3 CM'S BY 1 CM AT THE WIDEST POINT IS SEEN. THE BURN IS LOCATED 8 CM'S ABOVE THE POINT OF THE ELBOW AND 15 CM'S BELOW THE "BOIL". THE "BOIL" MEASURING APPROXIMATELY 2 CM'S OPENING AND APPROXIMATELY 15 CM'S OF RUDDY COLORED SKIN SURROUNDING THE OPENING, WAS OBSERVED TO BE PACKED WITH STERILE GAUZE, AND COVERED WITH A NON-STICK DRESSING AND TAPE. LPN "E" STATED, "...THERAPY HAD MANIPULATED THE BOIL AND GOT THE CORE OUT, ANTIBIOTICS WERE ORDERED ALONG WITH THE HOT PACKS." THE BURNED SKIN IS OBSERVED BELOW THE EXISTING "BOIL" BEING TREATED. WHEN LPN "E" WAS ASKED WHY THE "BOIL" AREA DID NOT BURN, SHE STATED "THE SKIN MUST HAVE BEEN PROTECTED BY THE DRESSING COVERING THE 'BOIL'." RESIDENT #1 WAS SEATED IN A GERI CHAIR WITH HER EYES CLOSED DURING THIS SKIN OBSERVATION. SHE DID NOT RESPOND TO QUESTIONS ASKED OF HER BY THIS SURVEYOR. WHEN LPN "E" WAS ASKED IF RESIDENT #1 COMMUNICATES, LPN "E" RESPONDED, "NO, SHE DOESN'T TALK OR CRY OUT, WE WATCH FOR FACIAL GRIMACING." ON 2/07/11 AT APPROXIMATELY 12:15 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH RN "A". RN "A" VERIFIED SHE WAS THE NURSE WHO APPLIED A HOT PACK TO RESIDENT #1 ON 2/3/11 AT APPROXIMATELY 3:00 A.M. RN "A" WAS ASKED TO DESCRIBE THE INCIDENT DATED 2/3/11 INVOLVING RESIDENT #1. RN "A" STATED, "CERTIFIED NURSE AIDE (CNA "B") WENT TO THE THERAPY ROOM AND OBTAINED A HYDROCULATOR PACK...SHE BROUGHT IT TO ME IN A REGULAR BATH TOWEL, I THEN WRAPPED IT IN ANOTHER BATH TOWEL AND PLACED IT UNDER (RESIDENT #1'S) LEFT ARM AROUND 3:00 A.M. ...I WENT BACK AT APPROXIMATELY 3:15 A.M. TO CHECK ON IT.... (RESIDENT #1'S) ARM WAS PINK, SO I TOOK THE PACK OUT. I WENT BACK SOMEWHERE AROUND 4:00 A.M. AND HER ARM WAS RED, SO WE APPLIED A COOL WASH CLOTH... THE DON WAS IN THE BUILDING, SO I HAD HER COME LOOK AT IT WITH ME." THIS SURVEYOR ASKED RN "A" WHAT EDUCATION SHE RECEIVED REGARDING THE APPLICATION OF HOT PACKS AND SPECIFIC USE OF THE HYDROCULATOR. SHE REPLIED, "NONE." RN "A" WAS THEN ASKED IF SHE SOUGHT FACILITY REFERENCES OR POLICY AND PROCEDURE (P&P) FOR APPLICATION OF HOT PACKS AND SHE REPLIED, "NO." ON 2/07/11 AT 11:45 A.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH CNA "B". CNA "B" STATED SHE WAS ASSISTING THE NURSE WITH MORNING TREATMENTS. CNA "B" STATED, "I WENT TO THE THERAPY ROOM AND GOT A HOT PACK FROM THE MACHINE...". CNA "B" WAS ASKED IF SHE HAD RECEIVED EDUCATION ON THE SAFE USE OF HOT PACKS OR THE HYDROCULATOR. SHE REPLIED, "NO." ON 2/07/11 AT 11:15 A.M., AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON). THE DON STATED SHE WAS IN THE FACILITY ON 2/3/11 WHEN RESIDENT #1 RECEIVED THE HOT PACK TREATMENT PROVIDED BY RN "A" AND AT APPROXIMATELY 4:10 A.M., RN "A" NOTIFIED HER OF THE RED AREA ON RESIDENT #1'S ARM. THE DON STATED SHE ASSESSED RESIDENT #1'S INJURED ARM AND DESCRIBED THE AREA AS "CHERRY RED...TO BE ABOUT THE SIZE OF A MEDIUM APPLE". THE DON WAS ASKED IF THE NURSING STAFF HAVE BEEN INSERVICED ON HOT PACK APPLICATIONS AND USE OF THE HYDROCULATOR. HER RESPONSE WAS, "I'M NOT SURE; I WOULD NEED TO CHECK ON THAT." THE DON THEN STATED THERE IS ONE ADDITIONAL RESIDENT (#2), WHO CURRENTLY RESIDES IN THE FACILITY THAT HAS A PHYSICIan order for [REDACTED]. UPON INSPECTION OF A HYDROCULATOR HEATING MACHINE DONE AT 10:45 A.M. ON 2/07/11, A COPY OF THE HYDROCULATOR PACK PROCEDURE FROM THE REHABILITATION SERVICES PRACTICE MANUAL, PAGE 4.7.1, DATED DECEMBER 2000, WAS DISPLAYED ON THE THERAPY ROOM WALL ABOVE THE MACHINE. A HAND WRITTEN NOTE ON THE PROCEDURE COPY READS, "HYDROCULATOR PACKS (159.8?F TO 180 PER CLEANING LOG)". THERAPY STAFF "C" VERIFIED THE TEMPERATURE RANGE HAD CHANGED. THE ORIGINAL TEMPERATURE RANGE USED TO BE 159.8?F - 174?F. THERAPY STAFF "C" WAS ASKED "WHEN AND WHO CHANGED THE PROCEDURE?" HE REPLIED, "OUR REGIONAL SUPERVISOR FOR THERAPY DID." A REVIEW OF THE "HYDROCULATOR TEMPERATURE AND CLEANING RECORD" REVEALS TEMPERATURE READINGS RECORDED FROM 11/11/10 THROUGH 2/07/11, RANGED BETWEEN 164?F TO 180?F. A TELEPHONE INTERVIEW WAS CONDUCTED WITH THE REGIONAL SUPERVISOR FOR THE THERAPY DEPARTMENT ON 2/07/11 AT APPROXIMATELY 12:25 P.M. SHE CONFIRMED CHANGING THE "PROCEDURE" TEMPERATURE RANGE ON THE FORM. SHE STATED SHE "CHANGED IT TO MATCH THE TEMPERATURE RANGE ON THE CLEANING LOG". THE REGIONAL SUPERVISOR FOR THE THERAPY DEPARTMENT WENT ON TO SAY THAT SHE BELIEVES THE CLEANING LOG WAS AN "OLD FACILITY" FORM. SHE CONFIRMED THE HYDROCULATOR CURRENTLY USED IN THE FACILITY IS NEW TO THIS FACILITY, AND THE CORPORATION'S ACCEPTED TEMPERATURE NORM IS 176?F. WHEN ASKED IF 176?F IS THE MANUFACTURER'S RECOMMENDATION, SHE REPLIED "I DON'T KNOW, WE GO WITH THE POLICY WE HAVE." ON 2/07/11 AT 12:40 P.M., AN INTERVIEW WAS CONDUCTED WITH THE REGIONAL DIRECTOR OF CARE SERVICES (RDCS) AND THE FACILITY ADMINISTRATOR. THE RDCS STATED "THE NURSES DO NOT HAVE ACCESS TO THE HYDROCULATOR P&P; IT'S IN THE THERAPY MANUAL, LOCATED IN THE GYM." A REVIEW OF THE HYDROCULATOR PACK PROCEDURE, DATED "DECEMBER 2000" OBTAINED FROM THE "REHABILITATION SERVICES PRACTICE MANUAL" READS: ? "SUBJECT: HYDROCULATOR PACK ? EQUIPMENT/SUPPLIES: HYDROCULATOR PACKS (159.8?F - 174.2?F) ? PROCEDURE: #5. WRAP THE HYDROCULATOR PACK WITH 8-10 LAYERS OF HEAVY TOWELING/HOT PACK COVERS SUCH AS TERRY CLOTH... #8. CHECK THE AREA IN 3-5 MINUTES FOR REDNESS. IF REDNESS APPEARS, APPLY ADDITIONAL LAYERS OF TOWELING... #13. REVIEW AND REVISE PLAN OF CARE AS NEEDED... #15. PROVIDE STAFF EDUCATION AS APPLICABLE." THE FACILITY ADMINISTRATOR PROVIDED THIS SURVEYOR WITH A COPY OF THE MANUFACTURER'S (TROPIC HEATER HEATING UNITS) SAFETY PRECAUTION FOR THE HYDROCULATOR USED AT THE FACILITY. A REVIEW OF THESE SAFETY PRECAUTION RECOMMENDATIONS READS, "...THE THERMOSTAT IS EXTREMELY SENSITIVE AND THE SLIGHTEST ADJUSTMENT WILL ALTER THE TEMPERATURE SEVERAL DEGREES. THE RECOMMENDED OPERATING TEMPERATURE IS 160? TO 165? DEGREES F ...THE TEMPERATURE OF THE WATER SHOULD BE CHECKED WITH A THERMOMETER AFTER EVERY ADJUSTMENT, BEFORE USING THE TROPIC PAC... CONSTANTLY MONITOR TROPIC PAC APPLICATION TO ENSURE THAT THE SKIN IS NOT BECOMING TOO HOT... DO NOT APPLY OVER INSENSITIVE SKIN OR IN THE PRESENCE OF POOR CIRCULATION... DO NOT USE TROPIC PAC DIRECTLY OVER CUTS, ABRASIONS OR WOUNDS... EXERCISE EXTREME CAUTION WITH USING TROPIC PACS ON NON-COMMUNICATIVE INDIVIDUALS". THE FACILITY NEGLECTED TO ENSURE THE FACILITY HYDROCULATOR PACK PROCEDURE WAS CONSISTENT WITH THE MANUFACTURER'S RECOMMENDED OPERATING TEMPERATURE. THE FACILITY NEGLECTED TO ENSURE THE HYDROCULATOR PACK PROCEDURE WAS ACCESSIBLE FOR FACILITY STAFF USE. THE FACILITY NEGLECTED TO ENSURE THEIR STAFF, WHO UTILIZED THE HYDROCULATOR WHEN PROVIDING A HOT PACK TREATMENT TO THEIR RESIDENTS, WERE EDUCATED AND DEMONSTRATED COMPETENCY REGARDING THE HYDROCULATOR PACK PROCEDURE. THE FACILITY STAFF NEGLECTED TO IMPLEMENT THE FACILITY'S HYDROCULATOR PACK PROCEDURE. ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP AN INDIVIDUALIZED AND COMPREHENSIVE PLAN OF CARE FOR ONE (#1) OF TWO RESIDENTS REVIEWED FOR CARE PLANNING THE treatment of [REDACTED]. RESULTING IN A 2ND DEGREE THERMAL BURN TO THE RESIDENT. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S CLINICAL RECORD REVEALED SHE IS A [AGE] year OLD FEMALE WHO HAS RESIDED AT THE FACILITY SINCE 10/15/06. THE RECORD REVIEW REVEALS HER [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #1'S ANNUAL MINIMUM DATA SET ((MDS) dated [DATE], REVEALED HER COGNITION IS HIGHLY IMPAIRED. SHE HAS MEMORY LOSS, IS UNABLE TO MAKE DECISIONS AND IS UNABLE TO UNDERSTAND OR BE UNDERSTOOD. SHE ALSO HAS "NO SPEECH". FURTHER REVIEW OF HER ANNUAL MDS AND CARE PLAN DATED 8/04/10, REVEALED RESIDENT #1 IS TOTALLY DEPENDENT UPON STAFF FOR ALL HER ACTIVITIES OF DAILY LIVING (ADL) AND DIRECTS STAFF TO "ANTICIPATE RES. (RESIDENT) NEEDS AND MONITOR FOR NON-VERBAL S/S (SIGNS/SYMPTOMS) OF NEEDS." THE CLINICAL RECORD REVIEW OF RESIDENT #1 ALSO SHOWS A WRITTEN PHYSICIAN ORDER [REDACTED].M. THAT READS, "...WARM COMPRESS TO AREA TID (THREE TIMES DAILY), 20 MINUTES AT A TIME. USE PER PROTOCOL...". A REVIEW OF THE FACILITY'S INITIAL INVESTIGATION REPORT DATED 2/3/11. REFLECTS THAT A WARM COMPRESS TREATMENT WAS ORDERED BY RESIDENT #1'S PHYSICIAN. RESIDENT #1 DEVELOPED A 2ND DEGREE BURN TO HER UPPER LEFT ARM. THIS REPORT READS, "...A HYDROCULATOR PACK WAS TAKEN FROM THERAPY AND WRAPPED IN 2 TOWELS AND PLACED ON RESIDENT UPPER LEFT ARM OVER A DRESSING COVERED WITH [MEDICATION NAME] AT APPROX. 3:00AM...WAS CHECKED AT APPROX. 3:15 AND AREA NOTED TO BE PINK, HYDROCULATOR PACK REMOVED FROM ARM...." AN INTERVIEW WITH THE FACILITY ADMINISTRATOR ON 2/07/11 AT 9:50 A.M., CONFIRMED THAT RESIDENT (#1) SUSTAINED A 2ND DEGREE BURN REQUIRING MEDICAL TREATMENT, TO HER LEFT UPPER/INNER ARM AFTER A HOT PACK WAS APPLIED BY FACILITY STAFF. AN OBSERVATION OF RESIDENT #1'S LEFT UPPER/INNER ARM WAS CONDUCTED BY THIS SURVEYOR WITH LICENSED PRACTICAL NURSE (LPN) "E" ON 2/07/11 AT 10:20 A.M. ON THE INSIDE OF RESIDENT #1'S LEFT UPPER ARM, A 2ND DEGREE BURN MEASURING 3 CM'S BY 1 CM AT THE WIDEST POINT WAS SEEN. ON 2/07/11, A REVIEW OF THE HYDROCULATOR PACK PROCEDURE, DATED "DECEMBER 2000", OBTAINED FROM THE "REHABILITATION SERVICES PRACTICE MANUAL" WAS DONE. IT READS: ? "PROCEDURE: #5. WRAP THE HYDROCULATOR PACK WITH 8-10 LAYERS OF HEAVY TOWELING/HOT PACK COVERS SUCH AS TERRY CLOTH... #8. CHECK THE AREA IN 3-5 MINUTES FOR REDNESS. IF REDNESS APPEARS, APPLY ADDITIONAL LAYERS OF TOWELING... #13. REVIEW AND REVISE PLAN OF CARE AS NEEDED... #15. PROVIDE STAFF EDUCATION AS APPLICABLE." ON 2/7/11, THE FACILITY ADMINISTRATOR PROVIDED THIS SURVEYOR WITH A COPY OF THE MANUFACTURER'S (TROPIC HEATER HEATING UNITS) SAFETY PRECAUTION FOR THE HYDROCULATOR USED AT THE FACILITY. A REVIEW OF THESE SAFETY PRECAUTION RECOMMENDATIONS READS, "...THE TEMPERATURE OF THE WATER SHOULD BE CHECKED WITH A THERMOMETER AFTER EVERY ADJUSTMENT, BEFORE USING THE TROPIC PAC... CONSTANTLY MONITOR TROPIC PAC APPLICATION TO ENSURE THAT THE SKIN IS NOT BECOMING TOO HOT... DO NOT APPLY OVER INSENSITIVE SKIN OR IN THE PRESENCE OF POOR CIRCULATION... DO NOT USE TROPIC PAC DIRECTLY OVER CUTS, ABRASIONS OR WOUNDS... EXERCISE EXTREME CAUTION WITH USING TROPIC PACS ON NON-COMMUNICATIVE INDIVIDUALS". A REVIEW OF RESIDENT #1'S PLAN OF CARE DONE ON 2/7/11, DOES NOT REFLECT THE PHYSICIAN ORDERED TREATMENT INTERVENTION ("...WARM COMPRESS TO AREA TID (THREE TIMES DAILY), 20 MINUTES AT A TIME... USE PER PROTOCOL"), OR ANY OF THE PROCEDURAL INTERVENTIONS AS DIRECTED BY THE FACILITY'S HYDROCULATOR PACK PROCEDURE OR THE HYDROCULATOR MANUFACTURER'S RECOMMENDATIONS FOR SAFE OPERATION. ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADHERE TO PROFESSIONAL NURSING STANDARDS OF PRACTICE WHEN A WARM COMPRESS TREATMENT/HOT PACK WAS IMPLEMENTED FOR A COGNITIVELY IMPAIRED, NON-COMMUNICATIVE RESIDENT (#1) OF TWO RESIDENTS REVIEWED FOR HOT PACK TREATMENTS FROM A TOTAL OF 93 RESIDENTS. THIS FAILURE RESULTED IN RESIDENT #1 DEVELOPING A THERMAL 2ND DEGREE BURN. FINDINGS INCLUDE: MICHIGAN NURSES ASSOCIATION PUBLICATION TITLED "PROFESSIONAL AND LEGAL REGULATION OF NURSING PRACTICE IN MICHIGAN", 3RD EDITION, PAGES 9 AND 10, READS, "...THE REGISTERED NURSE COLLECTS COMPREHENSIVE DATA PERTINENT TO THE PATIENT'S HEALTH OR SITUATION... ANALYZES THE ASSESSMENT DATA TO DETERMINE THE [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #1'S CLINICAL RECORD REVEALED SHE IS A [AGE] year OLD FEMALE. THE RECORD REVIEW REVEALS HER [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #1'S ANNUAL MINIMUM DATA SET ((MDS) dated [DATE], REVEALED HER COGNITION IS HIGHLY IMPAIRED. SHE HAS MEMORY LOSS, IS UNABLE TO MAKE DECISIONS AND IS UNABLE TO UNDERSTAND OR BE UNDERSTOOD. SHE ALSO HAS "NO SPEECH". FURTHER REVIEW OF HER ANNUAL MDS AND CARE PLAN DATED 8/04/10, REVEALED RESIDENT #1 IS TOTALLY DEPENDENT UPON STAFF FOR ALL HER ACTIVITIES OF DAILY LIVING (ADL) AND DIRECTS STAFF TO "ANTICIPATE RES. (RESIDENT) NEEDS AND MONITOR FOR NON-VERBAL S/S (SIGNS/SYMPTOMS) OF NEEDS." A REVIEW OF THE FACILITY INVESTIGATION REPORT DATED 2/3/11, REFLECTS THAT A WARM COMPRESS TREATMENT WAS ORDERED BY RESIDENT #1'S PHYSICIAN AND SHE DEVELOPED A 2ND DEGREE BURN TO HER UPPER LEFT ARM. THIS REPORT READS, "...A HYDROCULATOR PACK WAS TAKEN FROM THERAPY AND WRAPPED IN 2 TOWELS AND PLACED ON RESIDENT'S UPPER LEFT ARM OVER A DRESSING COVERED WITH [MEDICATION NAME] AT APPROX. 3:00AM...WAS CHECKED AT APPROX. 3:15 AND AREA NOTED TO BE PINK, HYDROCULATOR PACK REMOVED FROM ARM... ". AN OBSERVATION OF RESIDENT #1'S LEFT UPPER/INNER ARM WAS CONDUCTED BY THIS SURVEYOR WITH LICENSED PRACTICAL NURSE (LPN) "E" ON 2/07/11 AT 10:20 A.M. ON THE INSIDE OF RESIDENT #1'S LEFT UPPER ARM, A 2ND DEGREE BURN MEASURING 3 CM'S BY 1 CM AT THE WIDEST POINT WAS SEEN. ON 2/07/11, A REVIEW OF THE FACILITY'S HYDROCULATOR PACK PROTOCOL, DATED "DECEMBER 2000", OBTAINED FROM THE "REHABILITATION SERVICES PRACTICE MANUAL" WAS DONE. IT READS: . "PROCEDURE: #5. WRAP THE HYDROCULATOR PACK WITH 8-10 LAYERS OF HEAVY TOWELING/HOT PACK COVERS SUCH AS TERRY CLOTH... #8. CHECK THE AREA IN 3-5 MINUTES FOR REDNESS. IF REDNESS APPEARS, APPLY ADDITIONAL LAYERS OF TOWELING... #13. REVIEW AND REVISE PLAN OF CARE AS NEEDED... #15. PROVIDE STAFF EDUCATION AS APPLICABLE." ON 2/7/11, THE FACILITY ADMINISTRATOR PROVIDED THIS SURVEYOR WITH A COPY OF THE MANUFACTURER'S (TROPIC HEATER HEATING UNITS) SAFETY PRECAUTION FOR THE HYDROCULATOR USED AT THE FACILITY. A REVIEW OF THESE SAFETY PRECAUTION RECOMMENDATIONS READS, "...THE TEMPERATURE OF THE WATER SHOULD BE CHECKED WITH A THERMOMETER AFTER EVERY ADJUSTMENT, BEFORE USING THE TROPIC PAC...CONSTANTLY MONITOR TROPIC PAC APPLICATION TO ENSURE THAT THE SKIN IS NOT BECOMING TOO HOT...DO NOT APPLY OVER INSENSITIVE SKIN OR IN THE PRESENCE OF POOR CIRCULATION... EXERCISE EXTREME CAUTION WITH USING TROPIC PACS ON NON-COMMUNICATIVE INDIVIDUALS". A REVIEW OF RESIDENT #1'S PLAN OF CARE DONE ON 2/7/11, DOES NOT REFLECT THE PHYSICIAN ORDERED TREATMENT INTERVENTION ("...WARM COMPRESS TO AREA TID (THREE TIMES DAILY), 20 MINUTES AT A TIME ...USE PER PROTOCOL"), OR ANY OF THE PROCEDURAL INTERVENTIONS AS DIRECTED BY THE FACILITY'S HYDROCULATOR PACK PROCEDURE OR THE HYDROCULATOR MANUFACTURER'S RECOMMENDATIONS FOR SAFE OPERATION. ON 2/07/11 AT APPROXIMATELY 12:15 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH RN "A". RN "A" VERIFIED SHE WAS THE NURSE WHO APPLIED A HOT PACK TO RESIDENT #1 ON 2/3/11 AT APPROXIMATELY 3:00 A.M. RN "A" WAS ASKED TO DESCRIBE THE INCIDENT DATED 2/3/11 INVOLVING RESIDENT #1. RN "A" STATED, "CERTIFIED NURSE AIDE (CNA "B") WENT TO THE THERAPY ROOM AND OBTAINED A HYDROCULATOR PACK... SHE BROUGHT IT TO ME IN A REGULAR BATH TOWEL, I THEN WRAPPED IT IN ANOTHER BATH TOWEL AND PLACED IT UNDER (RESIDENT #1'S) LEFT ARM AROUND 3:00 A.M... I WENT BACK AT APPROXIMATELY 3:15 A.M. TO CHECK ON IT... (RESIDENT #1'S) ARM WAS PINK, SO I TOOK THE PACK OUT. I WENT BACK SOMEWHERE AROUND 4:00 A.M. AND HER ARM WAS RED, SO WE APPLIED A COOL WASH CLOTH... THE DON WAS IN THE BUILDING, SO I HAD HER COME LOOK AT IT WITH ME." THIS SURVEYOR ASKED RN "A" WHAT EDUCATION SHE RECEIVED REGARDING THE APPLICATION OF HOT PACKS AND SPECIFIC USE OF THE HYDROCULATOR. SHE REPLIED, "NONE." RN "A" WAS THEN ASKED IF SHE SOUGHT FACILITY REFERENCES OR POLICY AND PROCEDURE (P&P) FOR APPLICATION OF HOT PACKS AND SHE REPLIED, "NO." THE FACILITY'S INITIAL INVESTIGATION OF THIS INCIDENT/ACCIDENT REFLECTS THE DON WAS IN THE FACILITY AT THE TIME WHEN RN "A" IMPLEMENTED THIS TREATMENT ORDER. THE AMERICAN NURSES ASSOCIATION PROVIDES A DOCUMENT TITLED, "CODE OF ETHICS FOR NURSES WITH INTREPRETIVE STATEMENTS" VIA THE INTERNET WEBSITE WWW.NURSINGWORLD.ORG THAT READS ON PAGE 9, "...NURSES ARE REQUIRED TO HAVE KNOWLEDGE RELEVANT TO THE CURRENT SCOPE AND STANDARDS OF NURSING PRACTICE... WHERE THE CARE REQUIRED IS OUTSIDE THE COMPETENCIES OF THE INDIVIDUAL NURSE, CONSULTATION SHOULD BE SOUGHT OR THE PATIENT SHOULD BE REFERRED TO OTHERS FOR APPROPRIATE CARE...". ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE SUPERVISION OF A HOT PACK TREATMENT TO ONE COGNITIVELY IMPAIRED RESIDENT (#1) WHO IS VERBALLY NON-COMMUNICATIVE, OUT OF TWO RESIDENTS WHO WERE REVIEWED FOR HOT PACK TREATMENTS RESULTING IN THE RESIDENT DEVELOPING A 2ND DEGREE THERMAL BURN TO HER LEFT UPPER ARM. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S CLINICAL RECORD REVEALED SHE IS A [AGE] year OLD FEMALE WHO HAS RESIDED AT THE FACILITY SINCE 10/15/06. THE RECORD REVIEW REVEALS HER [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #1'S ANNUAL MINIMUM DATA SET ((MDS) dated [DATE], REVEALED HER COGNITION IS HIGHLY IMPAIRED. SHE HAS MEMORY LOSS, IS UNABLE TO MAKE DECISIONS,AND IS UNABLE TO UNDERSTAND OR BE UNDERSTOOD. SHE ALSO HAS "NO SPEECH". FURTHER REVIEW OF HER ANNUAL MDS AND CARE PLAN DATED 8/04/10, REVEALED RESIDENT #1 IS TOTALLY DEPENDENT UPON STAFF FOR ALL HER ACTIVITIES OF DAILY LIVING (ADL) AND DIRECTS STAFF TO "ANTICIPATE RES. (RESIDENT) NEEDS AND MONITOR FOR NON-VERBAL S/S (SIGNS/SYMPTOMS) OF NEEDS." ON 2/07/11 AT APPROXIMATELY 9:45 A.M., AN ACCIDENT/INCIDENT REPORT DATED 2/03/11, INVOLVING RESIDENT #1 WAS REVIEWED. THE REPORT READS, "WARM COMPRESS APPLIED APPROX. 3A & REMOVED 3:15A. NOTED ARM WARM, WAS PINK. NO BLISTERING. RECHECKED ARM COLOR AT 4:15. ARM NOTED RED. COOL CLOTH APPLIED." THE FACILITY'S INITIAL INVESTIGATION REPORT REFLECTS ASSESSMENT OF RESIDENT #1'S ARM DONE AT 6:55 A.M., TO BE, "3 CENTIMETER (CM) BY 1 CM LINEAR BLISTER HAD DEVELOPED, THE MD (MEDICAL DOCTOR) NOTIFIED, NO NEW ORDERS AT THIS TIME. MD PHONED (NO TIME SPECIFIED) AND ORDERED SILVIDENE (BURN CREAM) TO BLISTER BID (2 TIMES A DAY) TREATMENT; FIRST TREATMENT WAS DONE AT 10:25 A.M. ON 2/03/11." ON 2/07/11 AT APPROXIMATELY 12:15 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH RN "A". RN "A" VERIFIED SHE WAS THE NURSE WHO APPLIED A HOT PACK TO RESIDENT #1 ON 2/3/11 AT APPROXIMATELY 3:00 A.M. RN "A" WAS ASKED TO DESCRIBE THE INCIDENT DATED 2/3/11 INVOLVING RESIDENT #1. RN "A" STATED, "CERTIFIED NURSE AIDE (CNA "B") WENT TO THE THERAPY ROOM AND OBTAINED A HYDROCULATOR PACK...SHE BROUGHT IT TO ME IN A REGULAR BATH TOWEL, I THEN WRAPPED IT IN ANOTHER BATH TOWEL AND PLACED IT UNDER (RESIDENT #1'S) LEFT ARM AROUND 3:00 A.M...I WENT BACK AT APPROXIMATELY 3:15 A.M. TO CHECK ON IT... (RESIDENT #1'S) ARM WAS PINK, SO I TOOK THE PACK OUT. I WENT BACK SOMEWHERE AROUND 4:00 A.M. AND HER ARM WAS RED, SO WE APPLIED A COOL WASH CLOTH... THE DON WAS IN THE BUILDING, SO I HAD HER COME LOOK AT IT WITH ME." A REVIEW OF THE HYDROCULATOR PACK PROCEDURE, DATED "DECEMBER 2000", OBTAINED FROM THE "REHABILITATION SERVICES PRACTICE MANUAL" READS: ? "SUBJECT: HYDROCULATOR PACK ? EQUIPMENT/SUPPLIES: HYDROCULATOR PACKS (159.8?F - 174.2?F) ? PROCEDURE: #5. WRAP THE HYDROCULATOR PACK WITH 8-10 LAYERS OF HEAVY TOWELING/HOT PACK COVERS SUCH AS TERRY CLOTH... #8. CHECK THE AREA IN 3-5 MINUTES FOR REDNESS. IF REDNESS APPEARS, APPLY ADDITIONAL LAYERS OF TOWELING... #13. REVIEW AND REVISE PLAN OF CARE AS NEEDED... #15. PROVIDE STAFF EDUCATION AS APPLICABLE." A REVIEW OF THE MANUFACTURER'S SAFETY PRECAUTIONS FOR THE HYDROCULATOR READS: ? "CONSTANTLY MONITOR TROPIC PAC APPLICATION TO ENSURE SKIN IS NOT BECOMING TOO HOT... ? DO NOT APPLY OVER INSENSITIVE SKIN OR IN THE PRESENCE OF POOR CIRCULATION... ? DO NOT USE TROPIC PAC DIRECTLY OVER CUTS, ABRASIONS OR WOUNDS... ? EXERCISE EXTREME CAUTION WHEN USING TROPIC PACS ON NON-COMMUNICATIVE INDIVIDUALS..." DURING THE INTERVIEW WITH RN "A" ON 02/07/11 AT 12:18 P.M., SHE STATED SHE LEFT THE WARM COMPRESS IN PLACE FOR 15 MINUTES BEFORE CHECKING RESIDENT #1'S SKIN. RN "A" FAILED TO FOLLOW THE THERAPY PROCEDURE, AND THE MANUFACTURER'S SAFETY PRECAUTIONS BY: 1) FAILED TO REASSESS THE SKIN AFTER 3-5 MINUTES AFTER APPLICATION. APPLY MORE TOWELING IF AREA IS RED. 2) FAILED TO WRAP THE HYDROCULATOR PACK WITH 8-10 LAYERS OF HEAVY TOWELING/HOT PACK COVERS SUCH AS TERRY CLOTH. 3) FAILED TO USE EXTREME CAUTION WITH A NON-COMMUNICATIVE INDIVIDUAL. ( ) --

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE RESIDENT CARE PLANS AND PREVENTIVE MEASURES WERE FOLLOWED TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS FOR THREE OF SEVEN RESIDENTS (#7, #16, #20) REVIEWED WITH PRESSURE ULCERS, FROM A TOTAL SAMPLE OF 16 RESIDENTS. IN ADDITION, THE FACILITY FAILED TO FOLLOW THEIR OWN POLICY AND PROCEDURES TO ENSURE RESIDENTS WERE ASSESSED FOR SKIN BREAKDOWN ON A WEEKLY BASIS. THIS FAILURE RESULTED IN THREE RESIDENTS (#7, #16, #20) DEVELOPING AVOIDABLE PRESSURE ULCERS. FINDINGS INCLUDE: ACCORDING TO THE CLINICAL RECORD, RESIDENT #16'S [DIAGNOSES REDACTED]. RESIDENT #16'S MINIMUM DATA SET (MDS) ASSESSMENTS COMPLETED ON 5/25/10, 8/17/10, AND 11/3/10 INDICATE RESIDENT #16 HAD NO AREAS OF SKIN BREAKDOWN. RESIDENT #16'S "SKIN INTEGRITY ASSESSMENT: PREVENTION AND TREATMENT PLAN OF CARE" SHOWS RESIDENT #16 WAS DETERMINED ON 7/13/09 TO BE "AT RISK" FOR SKIN BREAKDOWN WITH A SCORE OF 17 ON THE BRADEN RISK ASSESSMENT. THE CARE PLAN ALSO IDENTIFIED AS A RISK FACTOR RESIDENT #16'S PERIPHERAL [MEDICAL CONDITION]. INTERVENTIONS ON THE CARE PLAN WERE GENERAL AND INCLUDED BASIC SKIN HYGIENE AND INSPECTION OF THE SKIN FOR SIGNS AND SYMPTOMS OF BREAKDOWN. DURING THE MONTH OF OCTOBER 2010 AND THE FIRST THREE WEEKS OF NOVEMBER 2010, RESIDENT #16 RECEIVED WEEKLY SKIN ASSESSMENTS. THESE ASSESSMENTS ARE COMPLETED BY THE FLOOR NURSES, WITH REFERRALS MADE TO THE WOUND CARE NURSE, AS NEEDED. RESIDENT #16'S TREATMENT RECORD SHOWS THE WEEKLY SKIN ASSESSMENT DUE ON NOVEMBER 23, 2010 WAS MISSED. ON 11/30/10, AN "ACCIDENT-INCIDENT REPORT" WAS COMPLETED BY THE WOUND CARE NURSE FOLLOWING A SKIN ASSESSMENT ON RESIDENT #16. DURING THE ASSESSMENT, THE WOUND CARE NURSE DISCOVERED TWO PRESSURE ULCERS: ONE ON THE RIGHT LATERAL FOOT AND ONE ON THE TOE OF THE LEFT FOOT. ACCORDING TO THE ACCIDENT-INCIDENT REPORT, THE WOUND CARE NURSE INSTRUCTED THE RESIDENT TO REMOVE HER SHOES AND NOT TO WEAR THEM FOR THE PRESENT TIME. A WEEK LATER, ON 12/6/10, ACCORDING TO THE PRESSURE ULCER HEALING (PUSH) CHART, RESIDENT #16'S PRESSURE ULCER WAS SLIGHTLY WORSE, WITH A PUSH SCORE OF 9, INSTEAD OF 8, THE PREVIOUS WEEK'S SCORE. THE PHYSICIAN SAW RESIDENT #16 ON 12/6/10 AND WROTE THE FOLLOWING PROGRESS NOTE: "2 PRESSURE SORES ON (RIGHT) FOOT FROM SHOE WAS CALLUS ON SIDE. (RIGHT) FOOT AND OVER DOWN OF 1 TOE. CONTINUE RECENT ORDERS. CONSULT THERAPY RE (REGARDING) PROBABLE CHANGE IN FOOTWEAR TO PREVENT (UNREADABLE WORD) PRESSURE SORES ON FEET." A WOUND CARE MEETING WAS HELD ON 12/6/10. THE PROGRESS NOTE OF THAT MEETING STATES: "(RIGHT) LATERAL FOOT HAS AN UNSTAGEABLE ULCER 1.5 X 1.5. NO S/S (SIGNS AND SYMPTOMS) OF INFECTION. (LEFT) FOOT 2ND TOE HAS AN UNSTAGEABLE ULCER WITH SOME YELLOW SLOUGH 0.2 X 0.4. NO C/O (COMPLAINTS OF) DISCOMFORT. SHOES DISCONTINUED, APPT. (APPOINTMENT) MADE FOR ORTHOPEDIC SHOES... CP (CARE PLAN) REVIEWED AND UPDATED." RESIDENT #16, WHO DID NOT HAVE A HISTORY OF PRESSURE ULCERS, BUT WAS CONSIDERED AT RISK FOR PRESSURES ULCERS, DEVELOPED PRESSURE ULCERS ON HER FEET ON 11/30/10. AN OBSERVATION ON 1/5/11 AT 10:30 A.M., REVEALED THE ULCER ON HER LEFT TOE WAS HEALED. THE PRESSURE ULCER ON HER RIGHT FOOT WAS STILL NOT HEALED. THE FACILITY CANNOT DEMONSTRATE THEY DID ALL THEY COULD TO PREVENT THE DEVELOPMENT OF RESIDENT #16'S PRESSURE ULCERS BECAUSE: 1) THE FACILITY FAILED TO DO A WEEKLY SKIN CHECK ON RESIDENT #16 ON 11/23/10. AFTER A TWO-WEEK GAP, WHEN RESIDENT #16 WAS CHECKED ON 11/30/10, RESIDENT #16 HAD DEVELOPED 2 UNSTAGEABLE PRESSURE ULCERS, AND; 2) THE FACILITY FAILED TO IDENTIFY THE INCREASED RISK TO RESIDENT #16 OF DEVELOPING PRESSURE ULCERS ON HER FEET, DUE TO RESIDENT #16 HAVING PERIPHERAL [MEDICAL CONDITION]. THUS, THE FACILITY DID NOT IMPLEMENT PREVENTION STRATEGIES, SUCH AS EVALUATING ON A PERIODIC BASIS THE RESIDENT'S FOOTWEAR, OR ADDRESSING OTHER FOOT ISSUES, SUCH AS CALLUSES OR CORNS. ( ) RESIDENT #20 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. IN ADDITION, THE RESIDENT WAS BEING treated for [REDACTED]. THIS [MEDICAL CONDITION] DEVICE CHANNELS AIRFLOW VIA A FULL FACE MASK. A REVIEW OF THE MEDICAL RECORD FOR RESIDENT #20'S SHOWED A "SKIN INTEGRITY ASSESSMENT: PREVENTION AND TREATMENT PLAN OF CARE," WITH AN ENTRY DATED 11/28/10 WHICH READ, "MONITOR AREA ON BRIDGE OF NOSE EVERY DAY FOR SIGNS AND SYMPTOMS OF INFECTION." THE "GOAL" OF THE TREATMENT PLAN INDICATED THE AREA WOULD BE HEALED WITHOUT AN INFECTION BY 12/8/10. NO INTERVENTIONS WERE WRITTEN OR IDENTIFIED ADDRESSING THIS AREA ON RESIDENT #20'S NOSE BRIDGE. THERE WERE NO FURTHER MEASUREMENTS OR DESCRIPTIONS OF THE PRESSURE SORE AREA RECORDED FROM 11/28/10 UNTIL 1/3/11. A NOTATION DATED 1/03/11 ON THE SKIN GRID SHOWED RESIDENT #20 HAD AN UNSTAGEABLE PRESSURE AREA ON THE BRIDGE OF THE NOSE, MEASURING 0.6 CENTIMETERS (CM) IN LENGTH BY 0.5CM IN WIDTH WITH AN UNKNOWN DEPTH. ON 1/3/11 AT APPROXIMATELY 2:30 P.M., RESIDENT #20 WAS OBSERVED TO HAVE AN UNSTAGEABLE PRESSURE ULCER PRESENTING ITSELF AS A BROWN SCABBED AREA MEASURING APPROXIMATELY 0.5CM IN DIAMETER, SURROUNDED WITH REDNESS ON THE BRIDGE OF HIS NOSE. ON 1/4/11 AT APPROXIMATELY 10:30 A.M., RESIDENT #20'S NOSE WAS AGAIN OBSERVED. THE NOSE BRIDGE OF RESIDENT #20 WAS SHOWN TO HAVE A PARTIAL THICKNESS LOSS OF THE DERMIS PRESENTING ITSELF AS A SHALLOW OPEN ULCER MEASURING APPROXIMATELY 0.5CM, SURROUNDED BY WHITISH TISSUE. THE RESPIRATORY THERAPIST WAS INTERVIEWED ON 1/4/11 AT APPROXIMATELY 10:30 A.M. IN RESIDENT #20'S ROOM. WHEN THE FULL FACE MASK WAS PLACED ON RESIDENT #20'S FACE, THE FACE MASK CAME INTO DIRECT CONTACT WITH THE BRIDGE OF RESIDENT #20'S NOSE. THE MASK HAS A TWIST DIAL USED TO ADJUST PRESSURE ON THE BRIDGE OF THE NOSE, AND ALLOW PROPER FITTING OF THE MASK. HOWEVER, NO DIRECTIONS OR CARE PLAN INTERVENTIONS WERE IN PLACE FOR ADJUSTING THE MASK FOR PROPER FIT. THIS FAILURE CAUSED THE MASK TO BE IN CONSTANT CONTACT WITH THE RESIDENT'S SKIN. OBSERVATION SHOWED THE MASK CUT INTO THE NOSE, CONTRIBUTING TO THE DEVELOPMENT OF A PRESSURE ULCER AND CONTINUING TO IRRITATE THE SKIN, NOT ALLOWING IT TO HEAL. THE INJURY WAS FIRST IDENTIFIED BY FACILITY STAFF ON 11/28/10. THE PRACTICE OF THE CONTINUED USE OF THE MASK WITHOUT PROPER ADJUSTMENT AND LACK OF MONITORING CONTRIBUTED TO THE ONGOING DEVELOPMENT OF THE PRESSURE AREA ON RESIDENT #20'S NOSE BRIDGE FOR 35 DAYS. ( ) RESIDENT #7'S CLINICAL RECORD WAS REVIEWED DURING THE SURVEY PERIOD OF 1/3/11 THROUGH 1/6/11. THE FACE SHEET REVEALED RESIDENT #7 IS A [AGE] year-old FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS admitted IN A "VEGETATIVE STATE" AND REMAINS IN THIS CONDITION. THE MINIMUM DATA SET ((MDS) dated [DATE], INDICATED RESIDENT #7 IS TOTALLY DEPENDENT ON STAFF FOR POSITIONING AND CARES. RESIDENT #7'S "TREATMENT SHEET" REVEALED THE "WEEKLY SKIN ASSESSMENTS" FOR 11/4/10 AND 11/11/10 WERE NOT PERFORMED. THE NURSING "PROGRESS NOTES" DATED 11/15/10 READ, "SM AREA TO (L) INNER THIGH-STAGE II 2.5 X 0.5 CM (CENTIMETER). (NO) DRAINAGE." THE PRESSURE ULCER WAS DOCUMENTED AS "HEALED" ON THE "SKIN GRID" SHEET DATED 11/22/10. THE CARE PLAN (NOT DATED) FOR THE CERTIFIED NURSE AIDE (CNA) TITLED, "CARE DELIVERY GUIDE" READ, "CATHETER-STRAP ON AT ALL TIMES". IN AN INTERVIEW ON 1/5/11 AT 9:00 A.M., WITH THE DIRECTOR OF NURSING (DON), SHE STATED, "YEAH, I'M NOT GOING TO LIE... YES, IT WAS PREVENTABLE. IT WAS AN EASY FIX... ALL WE HAD TO DO IS KEEP A CATHETER STRAP ON AT ALL TIMES... AND WE DIDN'T...". IN THE CLINICAL RECORD UNDER NURSING NOTES, AN "ACCIDENT/INCIDENT REPORT" DATED 12/8/10 READ, "CNA BROUGHT THIS NURSE TO SHOWER ROOM. OPEN AREA NOTED IN UPPER INNER (RIGHT) THIGH MEASURING 0.6 X 5 (CM)...". DURING AN INTERVIEW ON 1/5/11 AT 2:28 P.M. WITH WOUND CARE NURSE "D", HE STATED, "THE FIRST BREAKDOWN ON THE (LEFT) INNER THIGH... I BELIEVE IT WAS DETERMINED TO BE FROM THE FOLEY CATHETER TUBING... I DON'T KNOW OF ANY PREVENTIVE MEASURES THAT WERE PUT INTO PLACE AT THE TIME... AND YES, SHE (RESIDENT #7) DID HAVE ANOTHER BREAKDOWN ON THE RIGHT (INNER) THIGH... SAME ISSUE, THE FOLEY CATHETER TUBING." DURING AN INTERVIEW ON 1/5/11 AT 2:33 P.M. WITH THE DON, SHE STATED, "...ACTUALLY WE DID PUT A CATHETER STRAP ON THE FOLEY BUT, DIDN'T COMMUNICATE IT WELL, ALL STAFF DID NOT KNOW OF THE INTERVENTION... WE ALSO IMPLEMENTED POSITIONING TECHNIQUES OF THE CATHETER... IT WAS AN EASY FIX... BUT, IT WASN'T COMMUNICATED WELL AND THEREFORE, NOT DONE... AND IT RESULTED IN THE SECOND PRESSURE ULCER... SAME ISSUE." DURING AN OBSERVATION ON 1/4/11 AT 1:55 P.M., THE RESIDENT RECEIVED FOLEY CATHETER CARE. THERE WAS NO FOLEY CATHETER STRAP IN PLACE AT THIS TIME, AS INDICATED BY THE CNA CARE PLAN. ON 1/5/11 AT 8:30 A.M. AND AT 11:00 A.M., RESIDENT #7 WAS RESTING IN BED AND WAS WITNESSED TO HAVE NO FOLEY CATHETER STRAP IN PLACE AT EITHER OF THESE OBSERVATIONS . ON 1/5/11 AT 11:45 A.M., THIS SURVEYOR HAD CNA "E" AND REGISTERED NURSE "E" CONFIRM RESIDENT #7 DID NOT HAVE A FOLEY CATHETER STRAP IN PLACE. THE INNER THIGHS WERE OBSERVED DURING THIS TIME. NO OPEN AREAS WERE PRESENT; HOWEVER, THE UPPER RIGHT INNER THIGH HAD AN AREA APPROXIMATELY 5 X 2 CM WHICH WAS RED AND SHINY. RN "E" STATED, "(RESIDENT #7) IS TO HAVE A FOLEY STRAP IN PLACE AT ALL TIMES." THIS WAS A RE-OCCURRING PRESSURE ULCER THAT COULD HAVE BEEN AVOIDED IF THE FACILITY WOULD HAVE CONTINUOUSLY USED A FOLEY CATHETER STRAP AS INDICATED IN THE CNA CARE PLAN. ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY MONITOR THE BLOOD SUGAR LEVEL FOR ONE (#1) OF TWELVE RESIDENTS REVIEWED WHO RECEIVED INSULIN THERAPY, RESULTING IN THE RESIDENT BEING TRANSFERRED TO THE HOSPITAL DUE TO A HYPOGLYCEMIC REACTION RESULTING IN HARM. FINDINGS INCLUDE: RESIDENT #1 WAS AN [AGE] year-old FEMALE admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. RESIDENT #1 WAS RECEIVING 12 UNITS OF [MEDICATION NAME] (A LONG-ACTING INSULIN) EVERY MORNING SINCE [DATE]. A REVIEW OF RESIDENT #1'S PHYSICIAN ORDERS [REDACTED]. INSTEAD, BLOOD SUGAR MONITORING TWICE A DAY (6 AM AND 4 PM) WITH SLIDING SCALE INSULIN COVERAGE OF [MEDICATION NAME] REGULAR INSULIN (A SHORT-ACTING INSULIN) WAS ORDERED TO BE GIVEN BASED ON THE RESIDENT'S BLOOD SUGAR LEVELS. ON [DATE], AN ORDER WAS WRITTEN BY THE NURSE PRACTITIONER TO RE-START [MEDICATION NAME] AT 30 UNITS EVERY EVENING (9 PM), IN ADDITION TO THE REGULAR INSULIN COVERAGE PER THE SLIDING SCALE. NO ORDER WAS WRITTEN TO MONITOR THE BLOOD SUGAR PRIOR TO GIVING THE [MEDICATION NAME] THAT WAS STARTED ON [DATE] AT 9 PM. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. HOWEVER, ACCORDING TO THE [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. NO INSULIN WAS GIVEN AT THIS TIME AND NO EVIDENCE WAS SHOWN THAT RESIDENT #1 WAS treated for [REDACTED]. THAT EVENING AT 4 PM, THE RESIDENT'S BLOOD SUGAR WAS 139 MG/DL, AND INSULIN WAS NOT GIVEN. THE 30 UNITS OF [MEDICATION NAME] WERE AGAIN GIVEN AT 9 PM ON [DATE]. THE MAR indicated [REDACTED]. THE MAR indicated [REDACTED]. THAT EVENING AT 4 PM, THE RESIDENT'S BLOOD SUGAR WAS 235 MG/DL, AND 4 UNITS OF [MEDICATION NAME] REGULAR INSULIN WAS GIVEN. IN ADDITION, 30 UNITS OF [MEDICATION NAME] WAS GIVEN AT 9 PM ON [DATE]. THE SEPTEMBER MAR indicated [REDACTED]. THAT EVENING AT 4 PM, RESIDENT #1'S BLOOD SUGAR WAS 79 MG/DL, AND THE MAR indicated [REDACTED]. A NURSES NOTE DATED [DATE] AT 7 AM READS, "TOOK BLOOD SUGAR AT 5:20 AM, BLOOD SUGAR 33 MG/DL, RE-CHECKED 32 MG/DL. PATIENT UNRESPONSIVE TO STERNAL RUB, RADIAL PULSE STRONG 100, RESPIRATIONS 12, OXYGEN SATURATION BY PULSE OXIMETER 91 PERCENT AT 4 LITER OF OXYGEN. INTERMUSCULAR [MEDICATION NAME] (1 MG) GIVEN, BLOOD SUGAR 31 MG/DL AT 5:27. DOCTOR... NOTIFIED AND SHE SAID TO TRANSFER RESIDENT TO emergency room ." THE NURSES NOTE FURTHER INDICATED "EMS ARRIVED AT 5:32 AM AND RESIDENT LEFT 5:40 AM." AN INTERVIEW TOOK PLACE WITH RESIDENT #1'S PHYSICIAN ON [DATE], AT APPROXIMATELY 2 PM AND AGAIN AT 4:15 PM. THE INTERVIEWS REVEALED THAT THE PHYSICIAN DID NOT KNOW OF THE INCREASE IN THE RESIDENT'S [MEDICATION NAME] FROM 12 UNITS TO 30 UNITS UNTIL [DATE]. SHE EXPLAINED THAT IT WOULD HAVE BEEN HER INTENTION THAT THE RESIDENT BE RESTARTED ON THE PREVIOUS DOSAGE OF 12 UNITS OF [MEDICATION NAME] AND NOT 30 UNITS. SHE FURTHER EXPRESSED THAT SHE WOULD LIKED TO HAVE BEEN NOTIFIED OF THE DROPPING TREND OF BLOOD SUGARS FROM 160 MG/DL TO 65 MG/DL BY THE FACILITY STAFF. SHE FURTHER EXPLAINED THE MISSING BLOOD SUGAR CHECK OF [DATE] AT 6 AM, WOULD HAVE BEEN HELPFUL TO IDENTIFY THE TREND OF THE LOWERING OF THE RESIDENT'S BLOOD SUGAR. UPON INTERVIEW WITH THE NURSE PRACTITIONER (NP) ON [DATE] AT 1:30 PM BY PHONE, SHE HAD NO EXPLANATION OF WHY SHE HAD INCREASED RESIDENT'S (#1) [MEDICATION NAME] FROM 12 UNITS TO 30 UNITS. THE NP ALSO STATED SHE WOULD EXPECT TO BE NOTIFIED OF A BLOOD SUGAR OF 79 MG/DL AT 4:00 PM ON [DATE], BEFORE THE 30 UNITS OF [MEDICATION NAME] WERE GIVEN AT 9:00 PM THAT EVENING. THE FACILITY FAILED TO ADEQUATELY MONITOR THE BLOOD SUGAR FOR RESIDENT #1 OR NOTIFY THE PHYSICIAN OF THE LOWERING TREND IN BLOOD SUGARS AFTER A LARGE INCREASE OF THE ADMINISTRATION OF INSULIN, WITHOUT ADDITIONAL MONITORING. THIS FAILURE RESULTED IN RESIDENT #1 EXPERIENCING A SEVERE HYPOGLYCEMIC REACTION RESULTING IN HER hospitalization on [DATE]. RESIDENT #1 expired on [DATE]. ( )