Every finding on record at Medilodge of Hillman

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse in review of two Residents (#26 & #19) of three residents reviewed for abuse. This deficient practice resulted in Resident #19 experiencing ongoing emotional distress, including fear of a sense of safety within the facility when in proximity of Resident #26 who was the one involved in the altercation.Findings include:Resident #19 (R19)A review of R19's Electronic Medical Record (EMR) revealed admission to the facility on 1/17/24, with diagnoses including major depressive disorder, and Post-Traumatic Stress Disorder (PTSD) (a mental health condition that develops after experiencing or witnessing a traumatic event). R19 was noted to have a Brief Interview for Mental Status (BIMS) score of 14/15, indicating cognition was intact.On 9/9/25 during an initial interview at 11:15 AM, R19 stated they were hit on the head and choked by another resident, just the other day. R19 stated the resident who had hit and choked him was Resident #26(R26). A facility volunteer who was visiting R19 at the time of the interview corroborated the description of the event provided by R19, stated they were laughing and talking when R26 came over and grabbed R19 by the neck and hit R19. R19 stated that if it hadn't been for the volunteer pulling R26 off, he didn't know what would have happened.On 9/9/25 at approximately 2:35 PM, the Nursing Home Administrator (NHA) stated they had personally done several follow-up visits with R19 post resident-to-resident incident. The NHA stated R19 only randomly brought up the incident in these conversations. When the NHA was asked what psychosocial behaviors the facility should observe related to R19's PTSD, regarding this incident, the NHA did not provide a response. Review of R19's EMR indicated the NHA had done two visits post incident.A review of the form entitled Physical Aggression Received indicated that on 8/26/25 an incident involving R19 had happened. The form provided a Nursing Description: Residents were in the dining room having lunch. Resident from room [ROOM NUMBER] approached resident from room [ROOM NUMBER] (wrong patient room) and grabbed R19 near R19's neck. A facility volunteer who was present in the dining room intervened immediately and separated the residents. This resident (R19) sustained a minor scratch on R19's chest; R19 has no other complaints. The portion titled Resident description stated .The volunteer and I were talking and laughing and (R26) grabbed me. I was not talking to R26 or about R26. The Immediate Action Taken portion stated Volunteer immediately separated the residents. Both residents involved were taken back to their perspective rooms by staff. Care plan updated for safety interventions. There are no noted updates to R19's care plan for safety interventions following the 8/26/25 incident.A review of R26's EMR, indicated R26 was admitted to the facility on [DATE], with diagnosis including Wernicke's Encephalopathy (an acute neurological disorder caused by severe thiamine (vitamin B1) deficiency), adjustment disorder with anxiety, alcohol use, alcohol induced psychotic disorder with delusions, and induced psychotic disorder with delusions. R26 was noted to have a BIMS score of 6/15 indicating severe cognitive impairment. R26's EMR revealed a court appointed guardian was in place to make medical and financial decisions.While conducting a phone interview with R26's guardian on 9/9/25 at 12:34 PM, the guardian stated she had not been informed of the resident-to-resident incident between R26 and another resident. The guardian stated she remembered that she requested to have R26's medication increased after a gradual dose reduction, that she felt were never a benefit for R26's mental health. A review of the form titled Physical Aggression Initiated dated 8/26/25 indicated At lunch time today resident (R26) became very upset with resident from room [ROOM NUMBER] (R19) and grabbed him. Volunteer.immediately separated residents. Administration and DON (Director of Nursing) notified, and investigation was initiated. Guardian was notified and requested that resident resume previous dose of Buspar (anti-anxiety medication used to treat generalized anxiety disorder), which was recently lowered. R26's description of the invent stated R19 was swearing at me when I walked in. R19 was being a smart ass. The Immediate Action taken stated Residents immediately separated and taken back to their own rooms.Care plan updated to reflect that residents from room [ROOM NUMBER] and room [ROOM NUMBER] will be separated at all dining times. There has been no update to R26's care plan to keep R26 separated from R19 at all dining times. A review of R26's progress notes indicated an increase in agitation as follows: on 8/15/25 at 3:08 PM, Resident came into this writer office asking when he can go home. He wants a nurse to come into his home and help with medication. This writer explained to him that he is currently here to make sure he's safe. He got upset and said I am safe you guys are f***keeping me here against my will. This writer explained to him that we are just here to keep him safe. He got upset and walked out of this writer's office.8/15/25 at 5:21 PM, Went to administer medications to pt (patient), he was speaking with social worker. Resident seemed very agitated, and said, we locked him out and he wants to get the F out of here. Res continued to be agitated stating that his house was taken away and all of his money.R26's care plan review indicated R26 Resident has a focus for impaired mood/psychiatric/ behaviors status related to alcohol induced psychosis, Wernicke's encephalopathy, poor impulse control, anxiety as evidenced by: Resident can be verbally aggressive towards other residents when he is agitated, has hallucinations of seeing people on the floor, sees rats, monkeys Delusions of thinking this is his house, thinks various things about [NAME] that cause him distress ie; thinks others are her, thinks he hears her, thinks she put him in a psych unit, spending all his money etc. Can make sexual statements to staff ie, come in bed with me as well as more aggressive statements Calls 911 - usually regarding issues with his house (here) His behaviors are unpredictable, and he can go from calm to agitated quickly without precipitating factors. Loud noises can be a trigger to behaviors. With interventions including Offer telephone to call family (daughter) which helps him to calm down. The resident's triggers for verbal aggression are other resident's yelling. The resident's behaviors are de-escalated by: distraction, food and fluid, conversation, by calling daughter. Behavioral health consults as needed. If resident presents/vocalizes self-harm, ensure resident's safety and notify Physician/NP/PA. Observe for and report to Physician/NP/PA any signs/symptoms for change in mood/acute psychosis from resident's baseline (hallucinations, delusions, inability to concentrate, depression, sleeping too much or too less, feelings of worthlessness or guilt, loss of pleasure or interest in activities, change in psychomotor skills, anxiety.There is no progress noted to indicate that the provider was notified of R26's recent change in behaviors prior to the resident-to-resident incident.Both R26 and R19 remain housed on the East wing down the hall called Jeff's Way approximately 22 feet from room [ROOM NUMBER] on the right and room [ROOM NUMBER] on the left going down that hall.On 9/10/25 at 2:58 PM, R26 was observed walking by R19's room. R26 was observed staring into room [ROOM NUMBER] as they walked by the room down the hallway. During a follow-up interview with R19 on 9/10/25 at 3:00 PM, R19 stated that they had left the facility and gone home because they were upset over some discarded food in R19's refrigerator, and R19 felt a lack of autonomy. R19 stated if they were home, they would not have to worry about what R26 might do. R19 stated that since the incident, the facility has told R19 they have made changes to R26 medications, which may be true, as R19 does not know what issues R26 has. However, R19 stated that they just don't feel safe, with R26 being so close to R19's room. R19 stated, just after the incident, any time they were in the dining room, laughing and having a good conversation with a friend, R26 would give him a mean look. R19 stated that anytime R26 is in the vicinity of R19, R26 looks at R19. R19 stated that R26 passes his room R26 peers into R19's room with each pass. This makes R19 very uncomfortable, and R19 just does not feel safe. The facility failed to implement timely measures to ensure R19's safety and emotional well-being. A review of the facility's Abuse Policy last reviewed/revised on 1/10/24, indicated 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, neglect, exploitation, and misappropriation of resident property. III Prevention of Abuse, Neglect and Exploitation.D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on observation, interview and record review, the facility failed to maintain a safe, comfortable and homelike environment by failing to ensure proper exhaust ventilation in the facility allowing the build-up of foul odors with the potential to affect all residents in the facility.Findings include: On 09/10/2025 at 10:30 AM, observed that the ventilation fan was not working in room [ROOM NUMBER]. A tissue test at the exhaust grille over the toilet noted that it was not pulling air in. During a facility tour with MD I, it was noted that the vent fans were not working in the 100 wing and were also not working in the two hundred wing, rooms 211-217, and rooms 216 through 228.On 09/10/2025 at 11:32 AM, a strong odor of urine was observed in hall 210-217 Eagle Lane.On 09/10/2025 at 12:00 PM, MD I printed a copy of the work history report for the last 12 months, documented weekly, showing that the Exhaust Fans Task had been completed and the task signed off on 9/5/2025.On 09/11/2025 at 11:05 AM, during interview with MD I, he stated he had gone up on the roof yesterday afternoon and discovered the ventilation units located on the roof of the facility were not functioning.

Based on observation and interview, the facility failed to maintain safe water temperatures at two hand washing sinks which could result in the potential for scalding risk to all residents that use these sinks.Findings include: On 09/09/25 at 11:20 AM, the water temperature at the handwashing sink in the dining room was measured with a rapid read thermometer to be 149 degrees Fahrenheit. The dining room was further observed to be accessible to all residents.On 09/09/2025 at 12:30 PM, the water temperature at the hand sink in the activities room called the Cowboy Lounge was measured with a rapid read thermometer to be 150 degrees Fahrenheit. On 09/10/2025 at 10:18 AM, interview with Head of Maintenance, Staff J noted that the sinks noted were on the same loop as the Laundry and they do not have individual mixing valves installed at the sink fixture.

Based on observation, interview, and record review, the facility failed to provide an adaptive call light to accommodate a physical impairment for one Resident (#14) of one Resident reviewed for accommodations of needs and preferences.Findings include: Resident #14 (R14)Review of R14's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including bipolar disorder, stiffness of the left hand, stiffness of the right hand, cognitive communication deficit, repeated falls, and need for assistance with personal care. Review of R14's most recent Minimum Data Set (MDS) assessment, dated 8/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment.On 9/9/25 at 11:22 AM, R14 was observed lying in bed. R14's left hand was observed to be contracted into a tight fist. R14's right hand was observed contracted into a tight fist with both the middle and ring fingers extended. A bedside table was positioned to the right of R14 with what appeared to be a video monitor with surgical tape covering the camera lens. When R14 was questioned about the purpose of the camera, she replied, That's how I alert the front desk. R14 explained she couldn't operate a standard call light due to the condition of her hands.Review of R14's EMR revealed the following progress notes:10/11/24 at 20:57 [8:57 PM]: .She [R14] is physically unable to to [sic] put enough pressure for her call light to go off. Three different styles were tried using her hands, head, shoulders and feet all unsuccessful.10/12/24 at 13:36 [1:36 PM]: .Res [resident] is unable to use a call light due to her crippling hands but does yell out when something is needed.10/13/24 at 13:48 [1:48 PM]: .Res is unable to use a call light due to her crippling hands but does yell out when something is needed.Review of R14's plan of care revealed a Focus, initiated 10/10/24, that read, Resident has an ADL [activities of daily living] self-care performance deficit related to muscle weakness and stiffness to left and right hand.The following intervention was initiated on 10/18/24: .Baby Monitor in place of call light, camera to be place [sic] away from resident for privacy, receiver to be with staff. Review of R14's EMR revealed the following physician order, initiated 3/25/25: Baby monitor with camera facing awat [sic] from resident to be used in place of call light due to resident physical inability to use standard call light.On 9/10/2025 at 9:22 AM, an interview was conducted with Certified Nursing Assistant (CNA) C who confirmed R14 had a baby monitor in her room in lieu of a call light. The baby monitor receiver was observed sitting at the nurse's station. CNA C explained the baby monitor transmitted continuous audio enabling R14 to speak into the camera when she required help. CNA C was unable to explain how privacy was provided while staff was performing cares or if R14 had a visitor as by-passers could overhear the receiver audio.On 9/10/25 at 12:06 PM, a follow-up interview was conducted with CNA C regarding the reliability of the baby monitor as a means of a call light. When asked if nursing staff could always hear R14 through the receiver if they were not at the nurses' station, CNA C stated staff tried to carry it around with them during rounds. CNA C acknowledged the reception range was limited depending on location in the building.On 9/10/2025 at 4:07 PM, the receiver was observed at the nurses' station with no staff in the vicinity.On 9/11/2025 at 8:22 AM, the receiver was observed at the nurses' station with no staff in the vicinity.On 9/11/2025 at 9:43 AM, the receiver was observed at the nurses' station with no staff in the vicinity.On 9/10/2025 at 4:05 PM, a follow-up interview was conducted with R14 regarding staff responsiveness to the baby monitor. R14 stated if staff doesn't respond to the baby monitor, her room is located close to the nurses' station so she could, Try to yell.Review of R2's MDS Assessment, dated 8/4/25, revealed she was dependent for all aspects of functional mobility and self-care activities.On 9/11/2025 at 9:58 AM, an interview was conducted with the Director of Nursing (DON), the Nursing Home Administrator (NHA), and Regional Director of Clinical Services (RDCS) F regarding the privacy and reliability concerns of the baby monitor. All parties agreed with the concerns and stated they would investigate a more appropriate adaptive call light system.Review of the facility policy titled, Resident Rights, reviewed 10/30/23, read, in part: .Upon admission, the resident and/or the resident's representative will be informed of the resident's rights and responsibilities.Review of the Hospitality Guide found in the admission Packet, read, in part: .The resident has a right to be treated with respect and dignity, including: .the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.Review of the facility policy titled, Call Lights: Accessibility and Timely Response, reviewed, 12/28/23, read, in part: .Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.

Based on interview and record review, the facility failed to act upon pharmacist recommendations for one Resident (#2) of five residents reviewed for medication regimen review.Findings include:Resident #2 (R2)Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 3/15/24 with diagnoses including major depressive disorder and bipolar disorder. Review of R2's most recent Minimum Data Set (MDS) assessment, dated 3/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 1, indicative of severe cognitive impairment.Review of R2's EMR revealed the following physician orders:Risperidone Intramuscular Suspension Reconstituted ER [extended release] 50 MG [milligram](Risperidone Microspheres). Inject 50 mg intramuscularly one time a day every 14 day(s), initiated 5/11/24.Ziprasidone HCl Oral Capsule 40 MG (Ziprasidone HCl). Give 1 capsule by mouth two times a day, initiated 5/3/24.Review of a pharmacy recommendation, dated 5/5/25, read, This resident is currently being treated with Risperidone and ziprasidone, both atypical antipsychotics, that may cause adverse metabolic or endocrine effects. Consider an EKG [electrocardiogram (a medical test that records the electrical activity of the heart)] at this time and every 6-12 months.On 5/7/25, Medical Director (MD) H responded, Will discuss with [Mental Health Service] - they manage her [R2's] antipsychotics.Review of R2's EMR revealed no communication or follow-up with mental health services.Review of a pharmacy recommendation, dated 8/25/25, read, In many cases, the combined use of two or more antipsychotic medications has not been demonstrated to be more effective than a single agent and has the potential for increased side effects. Please review the duplicate antipsychotic therapy. This combination will increase the risk of QT prolongation [a heart rhythm that causes fast, chaotic heartbeats]. Check an ECG [electrocardiogram] at this time.On 8/25/25, Medical Director (MD) H selected Other under the heading Physician/Prescriber Response without including clinical rationale.On 9/11/25 at 9:15 AM, an interview was conducted with Regional Director of Clinical Services (RDCS) H who verified R2 had not underwent an ECG and no follow-up documentation could be located in the EMR.Review of the facility policy titled, Addressing Medication Regimen Review Irregularities, reviewed 12/28/23, read, in part: .the pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and the reports must be acted upon. The attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

This citation pertains to intake MI00150640. Based on interview and record review the facility failed to provide safe and adequate assistance with bed mobility for one Resident (#2) of three residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in a fall with major injury, hospitalization , and death. Findings include: Resident #2 (R2) Review of a complaint submitted to the State Agency (SA) on [DATE], revealed, on [DATE], [Registered Nurse (RN) H] called the complainant and told them [R2] was having a routine brief exchange done by one staff member [Certified Nurse Assistant (CNA) D]. Complainant R stated that they were informed [CNA D] had rolled [R2] on her side. Complainant R stated that they were told that during this incident, [R2] fell out of bed, broke her shoulder and hip, and hit her head. Complainant R stated that [R2] passed away at the hospital on [DATE]. Complainant R stated that prior to this incident, there had always been two people present to change [R2]. Review of R2's hospital course, dated [DATE] through [DATE], revealed the following: a.) admitted to emergency department (ED) at 2:09 PM. b.) Results of x-rays suspected right proximal humeral fracture (broken bone in the upper arm that connects the shoulder and the elbow) and suspected impacted right subcapital femoral neck fracture (broken bone in the upper leg that connects the hip/pelvic area of the ball and socket joint that connects to the hip) at 3:50 PM. c.) Transferred to intensive care unit (ICU) and appeared toxic at 8:33 PM. d.) Went into rapid ventricular rate (RVR - irregular fast heartbeat), code blue (cardiac arrest), attempted arterial line (a thin, flexible tube inserted into an artery to monitor blood pressure and obtain blood samples), lifesaving emergency protocol was initiated including cardiopulmonary resuscitation (CPR) and advanced cardiovascular life support (ACLS), and emergently intubated (breathing tube inserted to assist with breathing) at 11:49 PM. e.) Death on [DATE] at 12:10 AM with death diagnosis of principle problem PEA (pulseless electrical activity) suspected embolic event. Some causes of a PEA are sepsis and trauma. Review of R2's death certificate, dated [DATE], read in part, .contributing cause of death: Complications of mechanical fall with fractures with approximate interval between onset and (death) .Hours . On [DATE] at 5:44 PM, Complainant R was called to review the allegations of the complaint intake. Complainant R stated, [R2] was undergoing a brief change with only one staff even though R2 was care planned to receive assistance from two. There were always two staff when we came to visit. The facility said [CNA D] was performing a brief change, [R2] was rolled onto her side. The facility claimed [R2] kicked her leg out, which contributed to the fall. Complainant R was asked if R2 was able to kick her leg out. Complainant R replied, No, [R2] could only stretch, and the facility staff had raised the bed. Emergency Medical Technician (EMT) said that they were not sure how [R2] got into the position she did. It made no sense to them. The facility said [R2] slid out of the bed and there is no way that she could do that. On [DATE] at 6:12 PM, an interview was conducted with Family Member (FM) Q regarding R2's fall at the facility. FM Q replied, The facility Nursing Home Administrator (NHA) and the Director of Nursing (DON) said that the report from the ED stated that a staff member was trying to stand [R2] up, but she hasn't stood her up in years. The NHA and the DON told them that there was a nurse in there and they were changing [R2], and she picked up her leg and slid off the bed and slid down to the floor as they were cleaning her. There was a bruise on [R2's] face. There was only one person in the room with her apparently. When I came to the facility to visit there was always two staff providing care to do a brief change. Review of R2's Emergency Medical Services (EMS) run report, dated [DATE] at 1:13 PM, read in part, .Dispatch priority: Critical (Priority 1) .Patient complaints: Right shoulder pain .Other symptoms: Pain: Hip .Cause: Fall from bed. Trauma criteria: Anticoagulants and bleeding disorders. Narrative: Dispatched via 911 to above address (local skilled nursing facility [SNF]) for a [AGE] year-old female who has fallen out of bed and has right arm pain. EMS arrive on scene to find patient lying supine [face up and on the back] on the floor next to her bed (at an approximate 45-degree angle from bed with head closer to bed and feet further from bed) .Staff x 3 at patient's side stating one staff was present and changing patients [brand name incontinence brief] when patient slid out of her bed. This staff states patient hit her head on the head of the bed rail as she was falling. Patient is on a blood thinner: Apixaban. No other details of fall were given .Patient states she has 9-,d+[DATE] pain in right shoulder. Patient says, Ow. Several times when there is a bump in the road .Approximately halfway through transport, patient states her hip hurts; this is a new onset per patient .Weight: 149.7 kg (kilograms) [329.34 pounds] . On [DATE] at 5:36 PM, an interview was conducted with Paramedic P who was asked if they had recalled R2 and her transfer out of the nursing facility. Paramedic P replied, Yes, it was very odd, and our team questioned what happened because [R2] was in an odd position from sliding out of bed and it did not add up. [R2] was at an angle to the bed, and she had hit her right arm on the left side of the bed. It was a weird situation. The CNA changed [R2] by herself. [R2] was three hundred pounds, and our team [EMS crew of three] could not move her by ourselves. The facility staff and our team had used the Hoyer lift to put [R2] on the gurney. I recall the CNA having a small body frame size. Review of R2's transfer form, dated [DATE] at 1:31 PM, revealed an unplanned transfer to a local hospital from a fall, hitting head, and complained of pain ,d+[DATE] in right shoulder and shoulder blade. Code status - full code. Usual functional status - Not ambulatory. Review of R2's initial fall report, dated [DATE] at 2:14 PM, read in part, .Description other intervention(s): Education to staff that 2 people assists (sic) need to be done with two people . Review of R2's progress note, dated [DATE] at 2:13 PM, read in part, This nurse [RN H] was heading down the hallway with medication cart to pass medications and [CNA D] come out of this resident's [R2] room and said [R2] fell out of bed! This nurse [RN H] instructed housekeeping to grab me the vitals cart and then grab the clinical management out of another residents room .This nurse [RN H] walked into [R2's] room at 1:10 PM to see her lying on the floor naked next to her bed with a pillow under her head .Once vitals obtained .called [on-call providers name] at 1:12 PM and he ordered to ship resident .EMS arrived .two CNAs and two people from EMS helped get this resident up with the Hoyer lift. [R2] was then taken out of the facility by EMS . Review of R2's progress note, dated [DATE] at 6:25 PM, read in part, .called [local ED] on a update .resident will be admitted up to ICU, residents blood pressures were very low and a central line had to be inserted, and [name brand medication - a vasoconstrictor] started. Resident also has a right femoral neck fracture. Review of facility investigation report, date [DATE], read in part, Resident: [R2] is a [AGE] year-old female resident, admitted on [DATE]. Primary diagnoses include .hemiplegia [muscle weakness or partial paralysis on one side of the body], morbid obesity and heart failure. Resident has a BIMS [brief interview for mental status] of 13 [indicative of intact cognition] and requires 2-person assistance for transfers and ambulates independently in her wheelchair .Reported Incident .had a witnessed fall on [DATE] .x-ray's showed right femur fracture and humeral fracture .Investigation .At 1:15 PM, Aide [CNA D], had checked on [R2]. [R2's] brief was soiled so the aide [CNA D] gathered up supplies she needed to change the resident [R2]. The aide [CNA D] was cleaning up the resident and had the resident roll to her [R2's] side and grab the side rails for assistance. The resident [R2] rolled to her side, then the resident crossed one leg over the other and as she did that she continued to roll and fell on to the floor. The aide [CNA D] attempted to prevent the resident from falling but was unable to stop the fall .Investigation Conclusion: [R2] is a 2-person assist for bed mobility. Review of R2's fall root cause analysis investigation tool, dated [DATE] at 1:10 PM, read in part, .Fall Huddle (What was different THIS time?): Resident being assisted with one-person assist instead of two-person like care planned. Root Cause of This Fall: Care plan not followed . On [DATE] at 10:00 AM, an interview was conducted with RN H who was asked if she recalled the fall in December for R2. RN H replied, Yes, I was heading down the East Hall with my medication cart to pass medication and [CNA D] came out of [R2's] room stating that she [R2] fell out of bed. I immediately went to assess [R2], who was lying on the floor next to her bed with her feet further away from the bed and her head closer to the bed and asked for clinical management to come. [R2] is not mobile, and she does not walk. [R2] was complaining of pain in her right shoulder. I asked [CNA D] what happened and [CNA D] told me she did not know. After EMS left [CNA D] said she rolled [R2] up on her side away from her to wipe her and [R2] rolled off the bed and [CNA D] told me she was by herself. On [DATE] at 10:35 AM, an interview was conducted with CNA D who was asked if she recalled the fall in December for R2. CNA D replied, Yes, I went in to [R2's] room because she had her call light on. [R2] was soiled so I went to get stuff to clean her up and, in the process, [R2] lifted her leg over her other leg, and she rolled off the bed onto the floor. CNA D was asked if there was another CNA working at the time she was providing care for R2 and replied, Yes, but she was with another resident. CNA D was asked if R2 was a one or two-person assistance for incontinence care and replied, I could have sworn she was a one-person assist, but I guess she was a two-person assist. [R2] had paralysis on her left side both upper and lower. On [DATE] at 10:55 AM, an interview was conducted with RN O / East Unit Manager who was asked if she recalled R2's fall in December. RN O replied, Yes, I was in the area. Staff came and got me and told me [R2] had fallen out of bed onto the floor. [R2] said her arm hurt. RN O was asked who was in the room at the time of the fall. RN O replied, [CNA D] was cleaning her up. RN O was asked how many staff should have been assisting with a brief change. RN O replied, [R2] required two staff assistance for a brief change. On [DATE] at 1:45 PM, an interview was conducted with the DON regarding R2's fall in December. The DON stated I was in the next room with the NHA doing a 72-hour care conference with another resident when staff came and got me. [CNA D] was not sure how [R2] fell exactly, but she put her leg over her other leg and lost her balance. [CNA D] tried to catch [R2] but could not. I interviewed [CNA D] and asked her why there was only one aide in the room and [CNA D] stated, I could do it by myself. The DON went on to further explain that [CNA D] was able to state what [R2's] Kardex and care plan was and repeated it to me. [CNA D] rolled [R2] away from her while she was providing care and did not follow policy. Review of R2's care plan, dated [DATE], read in part, .Goal: Resident has an ADL (Activities of Daily Living) self-care performance deficit related to fluctuating ADLs, generalized weakness, hemiplegia .Interventions .Bed mobility: 2 person assist .Toileting: 2 person assist .Goal: Resident is at risk for falls/injury related to decreased strength and endurance, history of falls .hemiplegia and hemiparesis . Review of R2's ADL report, dated [DATE] through [DATE], revealed R2 was dependent for toileting and was assisted by one staff. Review of policy titled, Activities of Daily Living (ADLs), dated [DATE], read in part, Policy: The facility takes measures to minimize the loss of residents' functional abilities, including activities of daily living (ADLs) Policy Explanation and Compliance Guidelines .2. The facility provides maintenance and restorative programs to assist residents in achieving and maintaining the highest practicable outcome based on their comprehensive assessment. 3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .5. The facility maintains individualized objectives of the care plan through periodic review and evaluation. Review of policy titled, Accidents and Supervision, dated [DATE], read in part, Policy: Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. Each resident will receive adequate supervision and assistive devices to prevent accidents .3. Implementing interventions to reduce hazard(s) and risk(s). 3. Implementation of Interventions - using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes .e. ensuring that the interventions are put into action .5. Supervision - Supervision is an intervention and means of mitigating accident risk. The facility provides adequate supervision to prevent accidents. Adequate supervision is .b. Based on the individual resident's assessed needs and identified hazards in their environment . Review of policy titled, Fall Prevention Program, dated [DATE], read in part, Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Policy Explanation and Compliance Guidelines .5. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care . Review of policy titled, Falls - Clinical Protocol, dated [DATE], read in part, Policy Explanation and Compliance Guidelines .2. Based on the assessment an initial plan of care will be developed and implemented to address identified risks .5. Interventions should be developed and implemented per the assessed needs .6. In addition, interventions for direct care givers should be placed on the CNA care card or similar format .

Based on observation, interview and record review, the facility failed to ensure appropriate labeling of inhaled medications in one (East Hall) of two medication carts reviewed for medication storage, resulting in the potential for unrecognized expiration of medications, decreased medication efficacy and adverse side effects of expired medications with the potential to affect all 18 residents residing on the East Hall. Findings include: On 10/08/2024 at 8:33 a.m., the East Hall medication cart was reviewed with Registered Nurse (RN) E. Observation of stored inhaled medications revealed an open box containing a Proair HFA inhaler (inhaled medication used to treat wheezing and shortness of breath). Further observation revealed the inhaler had 27 of 200 doses remaining. The inhaler or the box the inhaler was housed in was not labeled with a resident name, open date or expiration date. Upon inspection, RN E reported she could not determine who the inhaler belonged to, if the medication was expired, or when the medication would expire. Further review of the East Hall medication cart with RN E revealed an open Breztri Aerosphere inhaler (inhaled medication used to decrease swelling in the lungs) with 50 of 120 doses remaining. Further review revealed writing in red ink on the outside of the inhaler. The writing was smudged and ineligible. The resident's name, open or expiration date could not be determined. RN E confirmed she could read the smudged writing on the inhaler. Review of the facility policy titled, Medications and Biologicals - Labeling of, last reviewed 6/220/2024, revealed the following, in part: All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. Medication labels must be legible at all times . Labels for medication designed for multiple administrations (such as inhaler, eye drops), the label with identify the specific resident for whom it was prescribed .

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the identification and reporting of potential abuse or neglect for one Resident (#93) of two residents reviewed for abuse, resulting in the potential for unidentified abuse or neglect and further exposure to abusive situations. Findings include: Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed R93 was admitted to the facility on [DATE] and had diagnoses including dementia, stroke, right side hemiplegia (paralysis of right side of the body), and right hip fracture. Further review of the MDS data revealed R93 was dependent on staff for transfers and required partial/moderate assistance for rolling left and right in bed. The MDS data indicated R93 had short-term memory impairment and moderately impaired cognitive skills for daily decision making. Review of R93's MDS assessment, dated [DATE], revealed R93 expired in the facility on [DATE]. Review of R93's electronic medical record (EMR) revealed an assessment titled, Fall Follow Up, dated [DATE] at 1:24 p.m., for follow-up on R93's fall which occurred [DATE]. Further review of the assessment revealed the following: Additional Comments . order initiated . yesterday [DATE] for hematoma [right] upper arm . [R93] continues with linear scratch with tear to site. Cleansing provided and left open to air as ordered with discoloration/bruising now present by site and some bruising presented also to left forearm since additional fall documented in prior [follow-up] note to be [DATE] . Review of R93's assessments revealed no documentation or assessment related to a fall on [DATE] prior to the additional comments added to the follow-up dated [DATE] for R93's fall on [DATE]. Review of R93's Wound Evaluation, dated [DATE] at 8:22 a.m., revealed the following: Hematoma . Upper Right Arm (Inner), New - Minutes old . In-house Acquired . Area 3.26 cm2 [centimeters squared]. Length 5.56 cm. Width 3.38 cm . Review of photograph attached to the Wound Evaluation, revealed R93's right upper arm with noted dark purple bruising at the distal portion of the wound located on R93's inner arm, and reddened areas at the superior and lateral portions of the wound. The center portion of the wound was noted to have linear scratches with a round open area located at the lateral portion of the wound. During an interview on [DATE] at 9:25 a.m., the Director of Nursing (DON) was asked if a report or investigation was completed for R93's injuries noted on [DATE]. The DON presented a Statement of Witness, written, signed and dated by Certified Nursing Assistant (CNA) G on [DATE]. Review of the document revealed the following: I was in a resident's room getting them ready for breakfast. As I came out of the room . I was told that my [assistance] was needed as [R93] was found on the floor. We were able to get him back into bed . took [vitals] and two nurses were doing the skin assessment. At this time I had left the room. On [DATE] at 10:03 a.m., the Nursing Home Administrator (NHA) reported there was not an investigation initiated related to R93's injuries to his right upper arm and left forearm. The NHA confirmed the injuries were not reported to her or the State Agency (SA). On [DATE] at 2:00 p.m., the NHA presented an Incident Check off List for Nurses, as the summary of the incident related to R93's right upper arm injury. When asked when the form was completed, the NHA reported the DON had just completed the form as of that day, [DATE]. Review of the Incident Check Off List for Nurses, revealed the date of the incident as [DATE]. The time of the incident only listed the time as am [a.m.] The section of the form titled What Happened, was blank. It was noted the form did not include any information of where the resident was found, who found the resident or who, aside from CNA G, was present when the injury or fall was first identified. Further review of the document revealed R93's injuries included injuries to his right foot, a skin tear to his right knee and caught [right] arm, [no] bruises [at] time. Continued review revealed the following: Unwitnessed, [no] abuse verbalized. It was noted the form included no witness statements, including any statement or interview with R93. The form did not list a fall or any mechanism of injury. Review of the facility policy titled, Abuse, Neglect and Exploitation, last reviewed [DATE], revealed the following, in part: Possible indicators of abuse include . Physical injury of a resident, of unknown source . The facility will have written procedures that include: Reporting of alleged violations to the Administrator, state agency . No later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Based on interview and record review, the facility failed to ensure accurate advanced directive information was in place for one Resident (R16) of 13 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time). Findings include: The medical record revealed R16 was admitted to the facility on [DATE] with diagnoses of dementia, stroke (cerebrovascular accident), and traumatic brain injury. The Minimum Data Set (MDS) assessment, dated 9/8/2024, indicated R16 was classified with a primary diagnosis of Medically Complex Conditions including taking all nourishment via a tube feeding and had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severe cognitive impairment. The medical record contained: - An ADVANCE DIRECTIVES / MEDICAL TREATMENT DECISIONS form which indicated a Medical Durable Power of Attorney and full resuscitation (full code) dated 9/1/2021. - A DO-NOT-RESUSCITATE ORDER PATIENT ADVOCATED CONSENT form which indicated do not resuscitate (DNR) dated 4/26/2022. - A DECISION MAKING DETERMINATION FORM which indicated R16 was Incapable of making decisions regarding medical treatment. This determination was based upon: Resident's mental status (explain): Dementia, cerebral hemorrhage, confusion. Resident's diagnosis of: Dementia. This form was signed by the attending physician on 9/28/2024 but no Second Physician Signature, Second Physician Name and Date was present. During an interview on 10/08/24 at 9:15 AM, the Social Service Designee (Staff A) was asked about the advance directive change from full code to DNR for R16. Staff A reviewed the medical record and could not find documentation explaining the change and stated, I see it changed in 2022 and I will look for the notes on the decision. During an interview on 10/08/24 at 9:42 AM, Staff A said, The original declaration of incompetency is determined by two physicians but annually this is reassessed by one. The original declaration of incompetency was not found in the medical record and was requested. During an interview on 10/09/24 at 9:58 AM, the Nursing Home Administrator (NHA) stated, We do not have two doctors evaluating competency (for R16). The NHA explained there was nothing found in the hospital transfer records and no documentation was in the facility records to indicate why the code status had been changed. During an interview on 10/09/24 at 10:06 AM, the Director of Nursing (DON) stated, The code status looks like it was changed in 2021 but there is no documentation. Our general practice is to review the code status but there is no documentation of this review. During an interview on 10/09/24 at 10:30 AM, the Regional Registered Nurse (RN) B said, There was not a policy on resident competency, but presented the facility policy titled 'Residents' Rights Regarding Treatment and Advanced Directives', dated as last reviewed/revised on 1/1/2022. This policy read in part, .Any decision making regarding the resident's choices will be documented in the resident's medical record .

Based on observation, interview, and record review, the facility failed to implement fall prevention precautions for one Resident (Resident 20) of three residents reviewed for falls. Findings include: Resident 20 (R20) Review of R20's Electronic Medical Record (EMR), revealed a nursing quarterly/significant change evaluation, dated 9/17/24, indicated R20 had one to two falls in the last 90 days. R20 had fallen on 8/28/24. R20 had a risk fall score of 21, indicating a high risk for falls. Review of R20's care plan, dated 8/7/23, read in part, .Focus .has an ADL (activities of daily living) self-care performance deficit related to dementia, generalized weakness .Interventions: High back wheelchair to promote independence and comfort when up in wheelchair. Ambulation: 1 person assistance with a gait belt .uses a wheelchair for ambulation/transfer .Focus .is at risk for falls/injury related to generalized weakness, high risk of falls, history of falls, impaired cognition with decreased safety awareness .Interventions .Floor alarm mat to right side of bed when resident is in bed, so that staff know when resident is attempting to get self out of bed and staff can intervene to provide appropriate assistance for transfers . On 10/7/24 at 10:30 AM, an observation was made of the Assistant Director of Nursing (ADON) pushing R20 in their wheelchair from the east end nurses' station to their room without foot pedals. R20 was observed holding their feet up out in front of their wheelchair barely off the ground and nearly touching the floor. On 10/7/24 at 10:35 AM, an interview was conducted with the ADON, who was asked when they were with R20 in their room if R20 had foot pedals and replied, Yes. The ADON confirmed that R20's foot pedals were in a bag on the back of R20's wheelchair. The ADON was then asked if they should have put them on and replied, Yes. On 10/8/24 at 10:05 AM, an observation was made of R20 in his room. R20 was sitting on the side of their bed with both feet planted on their fall alarm mat. R20 was observed attempting to get up by pushing their arms on the bed mattress. R20 was unsuccessful and began to attempt to get up a second time. R20's floor alarm mat failed to alarm during R20's attempts to get up out of bed both times. On 10/8/24 at 10:07 AM, Registered Nurse (RN) E was alerted by this Surveyor that R20 was attempting to get out of bed and their floor alarm mat was failing to alarm. RN E walked down the east end hall towards R20's room and stopped at another resident's room to briefly talk with them, and then proceeded to R20's room. RN E asked R20 if they needed anything and R20 replied, 'Need to use the bathroom.' On 10/8/24 at 10:20 AM, an interview was conducted with RN E, who was asked why R20's floor alarm mat failed to alarm and replied, I am not sure. It should have alarmed when R20 was trying to stand up. RN E was asked if they knew how the floor alarm mats worked and replied, I am not exactly sure. I will get maintenance to look at the alarm. On 10/8/24 at 10:25 AM, an interview was conducted with Certified Nurse Aide (CNA) F, who was asked if they knew how the floor alarm mats worked and replied, No. On 10/8/24 at 10:27 AM, an interview was conducted with CNA D, who was asked if they knew how the floor alarm mats worked and replied, I think so. CNA D went into R20's room with this Surveyor to inspect R20's floor alarm mat. CNA D stated that, The floor mat alarm was acting like it was a hit or a miss when the floor alarm mat alarmed. I think they have a delay after they alarm for a few seconds. On 10/9/24 at 12:27 PM, an interview was conducted with the Director of Nursing (DON), who was asked if the cordless alarm mat was the best intervention for R20 and replied, Well, I am not too sure about them yet. They are new. I am not sure exactly how they work or how they reset. I need to get one in my office to look at it closer. I do not know why (R20's) did not go off if (R20) had both feet on the mat and was attempting to get up. The DON was asked if residents needed foot pedals applied to their wheelchairs during transport to a different location and replied, Yes. Staff should be applying foot pedals to prevent accident or injury. Review of policy titled, Fall Prevention Program, dated 10/26/23, read in part, Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Policy Explanation and Compliance Guidelines .5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a.) Interventions will be monitored for effectiveness .

Based on interview and record review, the facility failed to administer a blood pressure altering medication within ordered parameters for one Resident (#19) or five residents reviewed for unnecessary medications, resulting in the unwarranted administration of the medication and the potential for adverse side effects. Findings include: Resident #19 (R19) Review of R19's Medication Administration Records (MARs) for September 2024 through October 9, 2024, revealed the following physician order: Midodrine HCL [medication used to treat symptomatic low blood pressure] 10 MG [milligram]. Give 0.5 tablet by mouth three times a day for low blood pressure . hold SBP > 100 [when the top number of the blood pressure is greater than 100] . adjusted per [attending physician] . Start Date: 7/29/2024 . Further revealed the medication was administered outside of the ordered parameters on nine occasions per documentation on the MARs: 9/05/2024, 8:00 a.m., blood pressure 131/81. 9/05/2024, 5:00 p.m., blood pressure 103/67. 9/07/2024, 5:00 p.m., blood pressure 100/64. 9/08/2024, 5:00 p.m., blood pressure 101/62. 9/09/2024, 8:00 a.m., blood pressure 101/62. 9/26/2024, 8:00 a.m., blood pressure 121/63. 9/27/2024, 8:00 a.m., blood pressure 109/56. 9/28/2024, 5:00 p.m., blood pressure 116/71. 10/05/2024, 8:00 a.m., blood pressure 102/60. Further review of R19's electronic medical record (EMR) revealed no corresponding physician notification or order to administer the Midodrine10mg outside of the ordered parameters. During an interview on 10/09/24 at 9:39 a.m., the Director of Nursing (DON) reviewed R19's September 2024 and October 2024 MARs and confirmed the medication was administered outside of the ordered parameters. The DON stated the physician should be notified and a new order obtained if the resident's condition warrants administration outside of ordered parameters. Review of the facility policy titled, Medication Administration, last reviewed 1/17/2023, revealed the following, in part: Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for a psychotropic medication for one Resident (R27) of five residents reviewed for unnecessary medications. Findings include: Review of R27's medical record, revealed an admitted on 5/6/2020 with diagnoses which included major depressive disorder and anxiety disorder. A review of R27's Minimum Data Set (MDS) assessment dated [DATE], revealed a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating fully intact cognition. The medical record noted active Physician's Orders, dated 3/1/22 included: Fluoxetine HCl Capsule 40 mg (milligrams), one tablet a day for depression and busPIRone HCl tablet 10 mg one tablet three times a day for anxiety. During an interview on 10/08/24 at 9:42 AM, the Social Service Designee (Staff A) was asked about the process for GDRs and specifically for the documentation for R27. Staff A stated, The last GDR for busPIRone was on 2/2/2023 and they would look for further documentation on GDRs for R27. During an interview on 10/09/24 at 11:56 AM, the Director of Nursing (DON) stated, There was no GDR documentation for R27. During an interview on 10/09/24 at 12:30 PM, the Nursing Home Administrator (NHA) and Regional Clinical Consultant Registered Nurse (RN) B confirmed there was no GDR information for R27 that was found. The care plan for R27 included, Resident takes psychotropic/mood stabilizer medication as evidenced by antianxiety use, antipsychotic use. Date Initiated: 08/17/2023 Revision on: 08/17/2023. During an interview on 10/09/24 at 2:04 PM, the DON and NHA confirmed there was no GDR tracking that was taking place. The facility policy titled Use of Psychotropic Drugs and Gradual Dose Reductions, dated as reviewed/revised on 10/24/2022, read in part: .Gradual Dose Reduction (GDR) is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued . Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use psychotropic drugs. Therefore, dose reductions and behavioral interventions are part of medication management. This policy pertains to gradual dose reductions . [NAME] the first year, a GDR will be attempted annually .

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the thorough investigation of potential abuse or neglect for one Resident (#93) of two residents reviewed for abuse, resulting in the potential for unidentified abuse or neglect and further exposure to abusive situations. Findings include: Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed R93 was admitted to the facility on [DATE] and had diagnoses including dementia, stroke, right side hemiplegia (paralysis of right side of the body), and right hip fracture. Further review of the MDS data revealed R93 was dependent on staff for transfers and required partial/moderate assistance for rolling left and right in bed. The MDS data indicated R93 had short-term memory impairment and moderately impaired cognitive skills for daily decision making. Review of R93's MDS assessment, dated [DATE], revealed R93 expired in the facility on [DATE]. Review of R93's electronic medical record (EMR) revealed an assessment titled, Fall Follow Up, dated [DATE] at 1:24 p.m., for follow-up on R93's fall which occurred [DATE]. Further review of the assessment revealed the following: Additional Comments . order initiated . yesterday [DATE] for hematoma [right] upper arm . [R93] continues with linear scratch with tear to site. Cleansing provided and left open to air as ordered with discoloration/bruising now present by site and some bruising presented also to left forearm since additional fall documented in prior [follow-up] note to be [DATE] . Review of R93's assessments revealed no documentation or assessment related to a fall on [DATE] prior to the additional comments added to the follow-up dated [DATE] for R93's fall on [DATE]. Review of R93's Wound Evaluation, dated [DATE] at 8:22 a.m., revealed the following: Hematoma . Upper Right Arm (Inner), New - Minutes old . In-house Acquired . Area 3.26 cm2 [centimeters squared]. Length 5.56 cm. Width 3.38 cm . Review of photograph attached to the Wound Evaluation, revealed R93's right upper arm with noted dark purple bruising at the distal portion of the wound located on R93's inner arm, and reddened areas at the superior and lateral portions of the wound. The center portion of the wound was noted to have linear scratches with a round open area located at the lateral portion of the wound. On [DATE] at 9:58 a.m., the Director of Nursing (DON) was asked to present all of R93's incident and fall investigations from [DATE] through [DATE]. Review of the reports provided by the DON revealed no investigation related to a fall or injury on [DATE], as referred to in the Wound Evaluation, dated [DATE] at 8:22 a.m. and the Fall Follow Up assessment dated [DATE] at 1:24 p.m. The DON reviewed R93's record and confirmed she could not fully determine the cause of R93's injury based on the information from CNA G's statement or the EMR. During an interview on [DATE] at 9:25 a.m., the DON was asked if a report or investigation was completed for R93's injuries noted on [DATE]. The DON presented a Statement of Witness, written, signed and dated by Certified Nursing Assistant (CNA) G on [DATE]. Review of the document revealed the following: I was in a resident's room getting them ready for breakfast. As I came out of the room . I was told that my [assistance] was needed as [R93] was found on the floor. We were able to get him back into bed . took [vitals] and two nurses were doing the skin assessment. At this time I had left the room. The DON reported she could not find any other investigative documents at that time but would look for more documentation related to the R93's right upper arm injury and to R93 being found on the floor in his room on [DATE] as referenced in the Fall Follow Up, dated [DATE]. On [DATE] at 10:03 a.m., the Nursing Home Administrator (NHA) reported there was not an investigation initiated related to R93's injury to his right upper arm or of the presumed fall on [DATE]. The NHA presented a hospice service progress note, dated [DATE]. Further review of the document revealed the following, in part: Safety: [R93] fell again this [morning], fell out of bed, caught [right] arm in part of bed, skinned first [and] second toes of [right] root and [right] knee. Bed in low position [and] fall mat next to bed. On [DATE] at 2:00 p.m., the NHA presented an Incident Check off List for Nurses, as the summary of the incident related to R93's right upper arm injury. When asked when the form was completed, the NHA reported the DON had just completed the form as of that day, [DATE]. Review of the Incident Check Off List for Nurses, revealed the date of the incident as [DATE]. The time of the incident only listed the time as am [a.m.] The section of the form titled What Happened, was blank. It was noted the form did not include any information of where the resident was found, who found the resident or who, aside from CNA G, was present when the injury or fall was first identified. Further review of the document revealed R93's injuries included injuries to his right foot, a skin tear to his right knee and caught [right] arm, [no] bruises [at] time. Continued review revealed the following: Unwitnessed, [no] abuse verbalized. It was noted the form included no witness statements, including any statement or interview with R93. The form did not list a fall or any mechanism of injury. Review of R93's care plan revealed the following: Resident has . self-care performance deficit related to CVA/TIA [stroke], dementia, generalized weakness, hemiplegia, impaired ability to make self understood, Date Initiated: [DATE] . Bed Mobility: 2 person assist, Date Initiated: [DATE] .Resident has impaired communication related to history of CVA/TIA with dysarthria [difficulty speaking], anarthria [complete loss of speech], dysphonia and aphasia [difficulty understanding and expressing written and spoken language] . Review of the facility policy titled, Abuse, Neglect and Exploitation, last reviewed [DATE], revealed the following, in part: Possible indicators of abuse include . Physical injury of a resident, of unknown source . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include . Identifying and interviewing all involved persons, included the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations . Providing complete and thorough documentation of the investigation.

This citation is linked to intake MI00141867. Based on observation, interview, and record review, the facility failed to provide pressure ulcer care per professional standards of practice for one Resident (R10) of three reviewed for pressure ulcer care. This deficient practice resulted in the worsening of a facility aquired pressure injury to an unsgateable pressure injury requiring antibiotics. Findings include: R10 R10 developed an in house Moisture Associated Skin Damage area on 11/24/23 which subsequently worsened to stage II, and ultimately progressed to an unstageable pressure injury on 2/5/24 with worsening measurements through 2/26/24. R10 also developed a wound infection, requring treatment with antibiotics. The facility failed to ensure the approriate pressure reducing surface for the bed was in place, failed to provide aspetic (clean technique) wound care, failed to consitently measure and document wound care, and failed to appropriately turn/reposition R10 for pressure relief. On 2/29/24 at 8:30 AM, an observation was made of R10 in her room lying on her left side in bed. R10's bed mattress was a regular mattress. R10 lacked a pressure reduction mattress or an air mattress. On 2/29/24 at 8:45 AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked if the facility had an air mattress or a pressure reduction mattress for R10 and replied, We ordered one. The NHA was then asked when it was ordered and replied, I would have to check. On 2/29/24 at 9:20 AM, an observation was made of R10's incontinence care with Certified Nurse Aide (CNA) D. R10 had a very pungent odor when CNA D started to provide incontinence care. R10's wound dressing on her sacral area was observed to be a 4 x 4 cm (centimeter) foam boarder gauze which was completely saturated, and drainage was observed on her incontinence brief. CNA D replied to this Surveyor, Do you think I should let the nurse know so she can change the dressing? On 2/29/24 at 9:35 AM, an observation was made of Registered Nurse (RN) C providing a wound dressing change on R10. RN C failed to wash her hands prior to starting the wound dressing change and did not use wound cleaner to clean R10's wound prior to soaking up the wound drainage with gauze and applying medi honey, calcium alginate, and a new foam boarder gauze. RN C left the bottom of the foam boarder dressing unsealed just above the coccyx area which left the potential for stool incontinence to enter the open wound. RN C brought one 4 x 4 gauze to clean R10's wound that was saturated with drainage. On 2/29/24 at 9:45 AM, an interview was conducted with RN C who was asked how often she had to perform the dressing change for R10. RN C replied, Sometimes. The dressing change is ordered for evening shift to compete. RN C was asked how and if she documents that she completed the dressing change and replied, Um, I don't. On 2/29/24 at 10:15 AM, an observation was made of CNA D and CNA F repositioning R10 after her incontinence care and placed R10 on her left side. This surveyor asked CNA D which side R10 was lying on and replied, Oh yeah! I need to turn her on her other side she was just on her left side. On 2/29/24 at 10:45 AM, an interview was conducted with the Regional Clinical Nurse (RNC) N and asked what types of interventions were in place for R10 to help reduce and heal pressure ulcers and replied, We added an air mattress as an intervention. The RNC N was asked when the pressure reduction mattress was ordered for R10 and replied, I am not sure. I would have to ask the administrator. RNC N was asked if the frequency of dressing changes for R10 was sufficient for the amount of drainage R10 was having and replied, I will change the orders. On 2/29/24 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) regarding R10's pressure ulcer. The DON was asked why dietary was not consulted sooner about the wound not healing and replied, Dietician comes on Thursday or Friday each week. I talked with her on the first or second of February about another resident and I am not sure why we did not talk about [R10] that same day. We did discuss her on 2/8/24 The DON was asked about a pressure reduction or distribution mattress and replied, I am not sure when we ordered it. I would have to ask the administrator. The DON was asked why wound evaluations were not documented between 12/19/23 through 1/16/24 and replied, That was when the old wound nurse manager was here, and we let her go. I think she purposely removed the wound measurements from the task list. The DON was asked if wounds are discussed regularly and replied, We talk about them daily. The DON was asked if wounds were discussed so frequently then why did the measurements get missed for almost a month and replied, I am not sure why. During the above interview, the DON was made aware of CNA D not knowing which way that R10 had been positioned during care rounds and repositioning and that CNA D had placed her back on the same side. The DON responded, Maybe a visual chart would benefit them with knowing which position in the correct way to place the resident on a turning schedule. The DON was asked if wound measurements should be documented weekly and replied, Yes. Including all previously measured areas such as depth and or tunneling. The following measurements are for the same sacral/coccyx wound for R10 as follows: Review of R10's wound evaluation, dated 11/24/23, revealed moisture associated skin damage (MASD) measuring 0.6 x 0.5 cm (centimeters) and in house acquired. Review of R10's wound evaluation, dated 12/18/23, revealed a stage II pressure ulcer measuring 0.8 x 0.6 cm. *Note: No wound evaluations documented 12/19/23 through 1/16/24. Review of R10's wound evaluation, dated 2/5/24, revealed an unstageable pressure ulcer measuring 3.5 x 1.7 cm. Review of R10's wound evaluation, dated 2/12/24, revealed an unstageable pressure ulcer, with interventions as follows: Incontinence management, mattress with pump, moisture barrier/control, and turning/repositioning program. Review of R10's wound evaluation, dated 2/19/24, revealed an unstageable pressure ulcer measuring 3.2 x 1.9 cm with a depth of 1.0 cm and undermining 0.8 cm. Review of R10's wound evaluation, dated 2/26/24, revealed an unstageable pressure ulcer measuring 3.9 x 2.1 cm and lacked any measurements for depth and undermining. Review of R10's care plan, date 8/23/23, read in part, .Focus: Resident has episodes of (bladder / bowel) incontinence .Interventions: Uses disposable briefs .Assist resident with toileting needs every 2 hrs [hours] .Check at regular intervals and change as needed .Observe peri (skin surrounding genitals and rectal area)/rectal-area for redness, irritation, skin excoriation/breakdown .Provide peri-care after each incontinence episode .Focus: Resident is at risk for impaired skin integrity . Review of R10's care plan, date 1/19/24, read in part, . Focus: Resident has impaired skin integrity as evidence by: unstageable pressure ulcer to coccyx .Goal: Healing and/or improvement . Interventions: Resident is to be repositioned q2h [every two hours] .Administer treatment(s) per orders . Complete wound evaluation to observe the progress of the resident's skin condition . Review of R10's physician order, dated 2/29/24, revealed the following, Amoxicillin-Pot Clavulanate Tablet 875-125 mg [milligram], give 1 tablet by mouth every 12 hours for bacterial infection for 10 days will pull first dose out of backup. Review of R10's progress note, dated 2/28/24 at 7:35 PM, read in part, . Site of infections: coccyx wound. Reason on antibiotics/new signs & symptoms: She went to the wound clinic apt. [appointment] today for her first visit for the assessment of the coccyx wound. Per wound clinic she will be started on [brand name antibiotic] b.i.d. [twice daily] give one tablet p.o. [by mouth] for 10 days. x-ray the right pelvis 3 views for osteomyelitis. Labs to be obtained on 2/29/24 . Review of R10's progress note, dated 2/29/24 at 7:31, read in part, .Wound appears to be infected, thick purulent drainage noted. Resident started on antibiotics today for possible sepsis. Area is deep, very dark base, tunneling noted at all edges. Wound with very pungent odor, odor is noted at doorway . Review of R10's physician order, dated 2/28/24 at 4:09 PM, revealed the following, Ceftriaxone sodium solution reconstituted 1 gm [gram], inject 1 gm intramuscularly one time only for infection . Review of R10's progress note, dated 2/22/24 at 2:53 PM, read in part, .Wound clinic consult .consult out to wound clinic, awaiting to be seen . Review of R10's physician order, dated 2/7/24 through 2/9/24, revealed the following, Cleanse with wound cleanser. Pat dry. Apply Medi honey/honey gel to wound bed. Apply calcium alginate AG (Silver) to wound bed. Cut to size of open area. Apply skin prep to peri wound. Cover with border foam. Every evening shift for wound care. Review of R10's physician order, dated 2/5/24, revealed the following, Ensure Roho is in place to w/c [wheelchair] at all times for weight distribution. Every shift, and Resident is to be repositioned q2 [every two] and PRN [as needed]. Assist resident to reposition in chair frequently. Limit time upright in w/c. Every shift for wound care. Review of R10's physician order, dated 11/25/23 through 12/11/23, revealed the following, Cleanse coccyx and (R) [right] buttock wounds r/t (related to) MASD with wound cleanser, pat dry with gauze, apply skin prep to peri wound, cover wounds with hydrocolloid (moisture absorbing dressing type) dressing. Change dressing Every evening shift every 3 day(s) for MASD. Review of R10's physician order, dated 12/12/23 through 12/18/23, revealed the following, Cleanse coccyx wounds r/t [related to] MASD with wound cleanser, pat dry with gauze, apply skin prep to peri wound, cover wounds with hydrocolloid dressing. Change dressing every 3 days and PRN if soiled or dislodged. Check placement of dressing Q [every] shift. Discontinue when healed. Every evening shift every 3 day(s) for MASD. Review of R10's physician order, dated 12/19/23 through 1/29/24, revealed the following, Cleanse with wound cleanser. Pat dry. Apply collagen as directed to (coccyx). Skin barrier wipe to peri wound. Cover with (border foam). Every evening shift. Review of R10's physician order, dated 1/29/24 through 2/7/24, revealed the following, Cleanse with wound cleanser. Pat dry. Apply calcium alginate AG (silver) to wound bed. Cut to size of open area. Apply dermaseptin (skin protection ointment) to peri wound. Cover with border foam. Every evening shift for wound care. Review of R10's treatment administration record (TAR), dated February 2024, revealed wound care was not documented as provided on the 7th and the 27th of the month. Review of R10's treatment administration record (TAR), dated January 2024, revealed wound care was not documented as provided for 10 opportunities of 31 days. Review of R10's progress notes, dated January 2024, lacked any nursing notes to support the above wound dressing changes not documented as completed. Review of R10's treatment administration record (TAR), dated December 2023, revealed wound care was not documented as provided for 9 opportunities of 20 days. Review of R10's progress notes, dated December 2023, lacked 8 of 9 nursing notes to support the above wound dressing changes not completed. Review of R10's tasks, dated 10/27/23, revealed a turning per care plan. Review of R10's tasks, dated 2/5/24, revealed a turning and repositioning every 2 hours. Review of R10's interdisciplinary team notes (IDT), dated 11/24/23 through 2/29/24, revealed one note entered in the electronic medical record on 1/29/24 when R10's pressure ulcer was noted to be worsening. Review of R10's minimal data set (MDS), dated [DATE], revealed in section E no refusals of care and in section M marked no pressure ulcers and at risk for developing. Review of R10's wound clinic visit report, dated 2/28/24, revealed a care plan for nutrition, osteomyelitis, pressure ulcer, soft tissue infection, and wound/skin impairment. At the time of survey exit, R10 remained on a bed without an air mattress. Review of policy titled, Clean Dressing Change, dated 12/28/23, read in part, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: . 3. Set up clean field with needed supplies for wound cleansing and dressing application .5. Wash hands and put on gloves . 10. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound . 14. Secure dressing . Review of policy titled, Wound Treatment Management, dated 10/26/23, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . Review of policy titled, Pressure Injury Prevention and Management, dated 1/1/22, read in part, Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . Policy Explanation and Compliance Guidelines: . 3. Assessment of Pressure Injury Risk . c. Assessment of pressure injuries will be performed by a licensed nurse, and documented in the medical record . 4. Interventions for Prevention and to Promote Healing . c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions . include . i. Redistribute pressure (such as repositioning, protecting and /or offloading heels, etc.); . iii. Provide appropriate, pressure-redistributing, support surfaces . f. Interventions will be documented in the care plan and communicated to all relevant staff . Review of policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 1/1/22, read in part, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers . and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection . Policy Explanation and Compliance Guidelines: . 4. The interdisciplinary team will assess and document and individual's significant risk factors for developing PU/PI [pressure ulcer/pressure injury] . 7. Continued assessment and management . PUSH [pressure ulcer scale for healing] tool completed on PU/PI weekly during the weekly wound measurements . 15. The IDT team will review each pressure ulcer weekly for progress and changes . Review of NPIAP (National Pressure Injury Advisory Panel) standards of practice recommendations access on 3/14/24 located at: https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/647dc6c178b260694b5c9365/1685964483662/Quick_Reference_Guide-10Mar2019.pdf Revealed the following: 7.9 For individuals with a pressure injury, consider changing to a specialty support surface when the individual: Cannot be positioned off the existing pressure injury Has pressure injuries on two or more turning surfaces (e.g., the sacrum and trochanter) that limit repositioning options Has a pressure injury that fails to heal or the pressure injury deteriorates despite appropriate comprehensive care Is at high risk for additional pressure injuries Has undergone flap or graft surgery Is uncomfortable ' Bottoms out ' on the current support surface.

This citation is linked to intake MI00141807. Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice for five Residents (R2, R3, R4, R7, and R8) of six residents reviewed for respiratory care. Findings include: On 2/28/24 at 11:30 AM, an observation was made of R8 in the East dining room. R8 was sitting in her wheelchair at a dining table with a portable oxygen tank on the back of her wheelchair and oxygen tubing draped over the back of her wheelchair. R8's oxygen tubing was two inches from touching the floor and was not stored in a plastic bag. On 2/28/24 at 11:32 AM, an observation was made of R8's room. R8 had an oxygen concentrator in her room, her oxygen tubing was connected to the concentrator and her tubing was draped over the arm of her recliner and the nasal cannula was tucked in between the armchair and the seat. On 2/28/24 at 11:33 AM, an observation was made of R7 in his room and lying in bed wearing a nasal cannula connected to an oxygen concentrator. R7's oxygen tubing was undated. Review of R7's treatment administration record (TAR), dated February 2024, lacked an order to change oxygen tubing weekly. On 2/28/24 at 11:40 AM, an observation was made of R2 in his room. R2 had a portable oxygen tank to the right of his door with oxygen tubing coiled up on top of the tank and not stored in a plastic bag. On 2/28/24 at 11:50 AM, an observation was made of R4's room. R4 lacked a 'oxygen in use' sign on the outside of her door. On 2/28/24 at 11:52 AM, an interview was conducted with Registered Nurse (RN) / unit manager B and asked about oxygen tubing storage and maintenance and replied, Tubing is changed weekly and dated and if not in use should be stored in a plastic bag. On 2/28/24 at 12:00 PM, an observation was made of R3 in the main dining room. R3 was observed sitting at a table in her wheelchair with a portable oxygen tank and wearing oxygen via nasal cannula. R3's oxygen tubing was observed to be dragging on the floor as she backed her wheelchair away from the table. An observation was made of a light brown colored liquid beneath the dining table where R3 was sitting. On 2/28/24 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked what her expectations for oxygen maintenance and storage and replied, Tubing is stored in a plastic bag if not in use and tubing is changed weekly. Review of policy titled, Oxygen Administration, dated 10/26/23, read in part, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences .Policy Explanation and Compliance Guidelines: .5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measure include: . b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .e. Keep delivery devices covered in plastic bag when not in use. 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use .

This citation is linked to intake MI00141807. Based on observation, interview, and record review the facility failed to ensure infection control practices were followed with respiratory equipment/storage and during a wound dressing change per standards of practice. Findings include: On 2/28/24 at 11:30 AM, an observation was made of R8 in the East dining room. R8 was sitting in her wheelchair at a dining table with a portable oxygen tank on the back of her wheelchair and oxygen tubing draped over the back of her wheelchair. R8's oxygen tubing was two inches from touching the floor and was not stored in a plastic bag. On 2/28/24 at 11:32 AM, an observation was made of R8's room. R8 had an oxygen concentrator in her room, her oxygen tubing was connected to the concentrator and her tubing was draped over the arm of her recliner and the nasal cannula was tucked in between the armchair and the seat. On 2/28/24 at 11:40 AM, an observation was made of R2 in his room. R2 had a portable oxygen tank to the right of his door with oxygen tubing coiled up on top of the tank and not stored in a plastic bag. On 2/28/24 at 11:50 AM, an observation was made of R4's room. R4 had an oxygen concentrator in her room and oxygen tubing that lacked a date. R4 lacked a 'oxygen in use' sign on the outside of her door. On 2/28/24 at 11:52 AM, an interview was conducted with Registered Nurse (RN) / unit manager B and asked about oxygen tubing storage and maintenance and replied, Tubing is changed weekly and dated and if not in use should be stored in a plastic bag. On 2/28/24 at 12:00 PM, an observation was made of R3 in the main dining room. R3 was observed sitting at a table in her wheelchair with a portable oxygen tank and wearing oxygen via nasal cannula. R3's oxygen tubing was observed to be dragging on the floor as she backed her wheelchair away from the table. An observation was made of a light brown colored liquid beneath the dining table where R3 was sitting. On 2/28/24 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked what her expectations for oxygen maintenance and storage and replied, Tubing is stored in a plastic bag if not in use and tubing is changed weekly. On 2/29/24 at 9:35 AM, an observation was made of Registered Nurse (RN) C providing a wound dressing change on R10. RN C failed to wash her hands prior to starting the wound dressing change and did not use wound cleaner to clean R10's wound prior to soaking up the wound drainage with gauze and applying Medi honey, calcium alginate, and a new foam boarder gauze. RN C left the bottom of the foam boarder dressing not sealed just above the coccyx area and the potential for stool incontinence to enter the open wound. RN C brought one 4 x 4 gauze to clean R10's wound that was saturated with drainage. Review of policy titled, Oxygen Administration, dated 10/26/23, read in part, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences . Policy Explanation and Compliance Guidelines: . 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measure include: . b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated . e. Keep delivery devices covered in plastic bag when not in use. 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use . Review of policy titled, Clean Dressing Change, dated 12/28/23, read in part, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: . 3. Set up clean field with needed supplies for wound cleansing and dressing application . 5. Wash hands and put on gloves . 10. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound . 14. Secure dressing .

Based on observation, interview, and record review, the facility failed to assess safe self-administration of medication for one Resident (R5) of three residents reviewed for medication administration. Findings include: On 2/28/24 at 12:10 PM, an observation was made of R5 in his room. R5 was lying in his bed holding a nebulizer treatment in his right hand and was asleep. R5's nebulizer machine was on, and the nebulizer medication cup had condensation inside. R5 was awakened and asked how long he had been asleep and if he completed his nebulizer treatment and replied, The nurse came in about ten or fifteen minutes ago and I was awake then. Review of R5's physician order, dated 2/22/24, revealed an order for albuterol sulfate inhalation nebulizer solution (2.5 mg [milligrams] / 3 ml [milliliters]) 0.083% (Albuterol Sulfate) . 2.5 mg inhale orally via nebulizer three times a day for pneumonia (scheduled at 8:00 AM, 12:00 PM, and 6:00 PM). Review of R5's nursing readmission evaluation, dated 2/7/24, section II. Medications, read in part, .Does the resident wish to self-administer medications - No . Review of R5's care plan, dated 2/6/24, showed it lacked a care plan for safe self-administration of medication. On 2/28/24 at 12:45 PM, an interview was conducted with the Director of Nursing (DON). When asked if residents should be left unattended during a nebulizer treatment and if residents should be assessed for safe self-administration of medications, the DON replied, Nurses are to stay with residents during a nebulizer treatment unless they are assessed to self-administer medications. When asked if R5 had an assessment to self-administer medications for nebulizer treatments, the DON replied, No. Review of policy titled, Nebulizer Therapy, dated 1/1/22, read in part, . 1. Care of the Resident . n. Observe resident during the procedure for any change in condition . Review of policy titled, Medication - Resident Self-Administration of, dated 1/30/24, read in part, Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: . 13. The care plan must reflect resident self-administration .

This citation is linked to intake MI00141867. Based on observation, interview, and record review, the facility to provide indwelling catheter care per standards of practice for two Residents (R5 and R7) of three residents reviewed for catheter care. Findings include: On 2/28/24 at 12:10 PM an observation was made of R5 in his room and lying in his bed. R5 was observed to have an indwelling urinary catheter with a drainage bag hanging off the right side of his bed. R5 was asked if he had a catheter securement device on his leg and pulled back his bed sheet and replied, No. See, I do not have one. On 2/28/24 at 12:30 PM an observation was made of R7 in his room with the Director of Nursing (DON). R7 was observed to have an indwelling urinary catheter with a drainage bag hanging of the right side of his bed. The DON was asked if R7 had a catheter securement device on his leg and the DON stated, He should. The DON then looked at R7's catheter which lacked a catheter securement device on his leg. On 2/28/24 at 12:45 PM an interview was conducted with the DON. When asked if residents with indwelling urinary catheters should be wearing a catheter securement device, the DON replied, Yes. Review of policy titled, Catheter Care Procedure - Urinary, dated 12/28/23, read in part, .5. Catheters should be secured to prevent pulling and damage to the urethral meatus (opening). This may be accomplished by: a. Utilizing the appropriate drainage device (leg bag or catheter bag); b. Leg strap; c. Velcro strap; d. Linen/clothing clamp; e. Adhesive securing device .

Based on observation, interview, and record review, the facility failed to consistently document narcotic drug disposition in two of two medication carts during review for medication storage. This deficient practice had the potential to affect the entire facility population and resulted in the potential for drug diversion, misappropriation, and the potential for untreated conditions related availability of medications. Findings include: On 10/18/23 at 8:00 AM, an observation was made of medication administration on the [NAME] Hall with Registered Nurse (RN) H. This surveyor observed the narcotic count book with RN H. The narcotic count book was noted to have several missing narcotic count verification signatures by nurses when a shift-to-shift count of narcotics for this medication cart were completed. RN H was asked why she did not sign off on the medication cart count this morning and if she counted narcotics with the off going nurse from the prior shift. RN H replied, I usually do not sign the book until I take my first narcotic out of the box. I did verify the count with the last nurse. RN H was asked if this was standard of practice or facility policy to wait and sign the narcotic count as RN H had described, or if her signature should have been completed at the time of verification of narcotic counts. RN H replied, Well I guess it should be done at the same time the count has been completed. That is just normally how I do the signing. I wait. I do not know why. Review of the [NAME] controlled medication shift change sign out sheet, dated 8/1/23 through 10/18/23, revealed the following sections to be filled in by nursing: a date, time, number of medication cards received from pharmacy, number of empty medication cards, total current medication cards in the narcotic lock box, signature of outgoing nurse, and signature of incoming nurse. The following narcotic counts were observed missing signatures: August 2023 a. 8/3/23 missing signature on afternoon shift, b. 8/4/23 missing signature on afternoon and evening shift, c. 8/8/23 missing signature on afternoon shift, d. 8/10/23 missing signature on day and afternoon shift, e. 8/12/23 missing signature on day shift, f. 8/14/23 missing signature on day, afternoons, and evening shifts, g. 8/15/23 missing signature on day and afternoon shifts, h. 8/19/23 missing signatures on day, both signatures on afternoon, and one on evening shifts, i. 8/20/23 missing signature on afternoon shift, j. 8/24/23 missing signatures on day, both signatures on afternoon, and one for evening shifts, and k. 15 missing total count of cards blank for the month of August, and no sheets provided for 8/26/23 through 9/4/23. September 2023 a. 9/11/23 missing signatures on day, both signatures on afternoon, and one on evening shifts, b. 9/12/23 missing signature on day and afternoon shifts, c. 9/16/23 missing signature on day and afternoon shifts, e. 9/17/23 missing signature on afternoon shift, d. 9/20/23 missing signature on afternoon shift, f. 9/25/23 missing signature on both day signatures and one from afternoon shift, g. 9/26/23 missing signature on day and afternoon shifts, h. 9/28/23 missing signature on day, both afternoon signatures, and one signature for evening shifts, i. 9/30/23 missing signature on both day signatures and one from afternoon shift, and j. 17 missing total count of cards blank for the month of September. October 2023 a. 10/1/23 missing signature on day and afternoon shifts, b. 10/7/23 missing signature on day shift, c. 10/8/23 missing signature on day and evening shifts, d. 10/9/23 missing signature on afternoon and both signatures for evening shifts, e. 10/10/23 missing signature on both day signatures and one from afternoon shift, f. 10/12/23 missing signature on day and afternoon shifts, g. 10/15/23 missing signature on day and afternoon shifts, h. 10/18/23 missing signature on day shift, and i. 9 missing total count of cards blank for the month of September. Review of the East controlled medication shift change sign out sheet, dated 8/1/23 through 10/18/23, revealed the following sections to be filled in by nursing: a date, time, number of medication cards received from pharmacy, number of empty medication cards, total current medication cards in the narcotic lock box, signature of outgoing nurse, and signature of incoming nurse. The following narcotic counts were observed missing signatures: September 2023 a. 9/21/23 missing signature on day and afternoon shifts, and b. 2 missing total count of cards blank for the month of September. October 2023 a. 10/7/23 missing signature on both day signatures and one from afternoon shift, b. 10/17/23 missing signature on day and afternoon shifts, and c. 2 missing total count of cards blank for the month of October. On 10/19/23 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the narcotic count sheets and if they should be filled out completely between shift to shift. The DON replied, Yes. Both nurses should be counting the cards, and the pills, and then signing that the counts were correct and verified. There should not be any blank spots in the totals and signature columns. Review of facility policy titled, Controlled Substances Administration & Accountability, dated 1/1/22, read in part, Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines: . 5. Each time a controlled substance and control count sheet is received, it should be added to the shift verification sheet column for number of control count sheets present . 11. Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services or His/her designee immediately. Documentation should be made on the shift verification sheet .

Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate less than 5% for two Residents (R33 & R21) of three residents reviewed for medication administration. This deficient practice resulted in the potential for medical complications in resident treatment and conditions. Findings include: On 10/18/23 at 8:00 AM, a medication administration was observed with Registered Nurse (RN) H. The following was observed: Resident #21 (R21) was given (name brand) liquid advanced wound care protein, 30 ml (milliliters), mixed in six ounces of water in a cup, and dispensed orally by mouth. Review of R21's physician order, dated 10/11/23, revealed, (name brand) liquid advanced wound care protein, two times a day for wound healing. R21's order lacked a dose amount or route for his liquid advanced wound care protein. On 10/18/23 at 9:20 AM, a medication administration was observed with RN J. The following was observed: Resident #33 (R33) was given lorazepam 0.5 mg (milligrams), one tab, crushed, mixed with 5 ml of water, and administered via enteral tube (a tube that had be placed within the digestive system or intestine to allow liquid nutrition, water, and medications to enter the stomach). R33 was given hyoscyamine 0.125 mg, one tab, crushed, mixed with 5 ml of water, and administered via enteral tube. R33 was given vitamin B6 50 mg, one tab, crushed, mixed with 5 ml of water, and administered via enteral tube. R33 was given famotidine 10 mg, two tabs, crushed, mixed with 5 ml of water, and administered via enteral tube. R33 was given apixaban 5 mg, one tab, crushed, mixed with 5 ml of water, and administered via enteral tube. Review of R33's physician order, dated 8/21/23, revealed, lorazepam 0.5 mg, give one tablet by mouth three times a day for seizures. Review of R33's physician order, dated 10/13/23, revealed, hyoscyamine 0.125 mg, give one tablet by mouth every 12 hours for for (sic) secretions. Review of R33's physician order, dated 7/30/23, revealed, Vitamin B6, oral tablet 50 mg, give one tablet by mouth every day shift for supplement. Review of R33's physician order, dated 9/21/23, revealed, Famotidine, oral tablet 10 mg, give two tablets by mouth every morning and at bedtime .give a total of 20 mg BID (twice a day). Review of R33's physician order, dated 9/21/23, revealed, Apixaban, oral tablet 5 mg, give one tablet by mouth every morning and at bedtime for previous clots. R33's medications lacked complete physician orders to consistently direct administration of medications by either oral or enteral route. On 10/18/23 at 9:45 AM, an interview was conducted with RN J, who was asked how she administered medications to residents and what steps she would take to ensure accuracy to medication administration. RN J replied, I follow all the medication rights. On 10/19/23 at 10:35 AM an interview was conducted with Unit Manager, RN A, who was asked how much liquid advanced wound care protein R21 was to be administered by RN H. RN A replied, I would need to check the order. RN A reviewed the physician order for R21 originally placed by RN B, and replied, I don't see an amount to administer. I will need to review the dietary notes and call the physician for clarification. Review of R21's progress note, dated 10/10/23 at 3:56 PM, read in part, . Starting 30 cc (cubic centimeters/milliliters) (name brand) liquid advanced wound care protein to aid in wound healing . On 10/19/23 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked what her expectations were for medication administration and physician orders, and replied, I would expect the nurses to be following the physician orders and following the rights of medication administration. The DON was asked if she expected physician orders to be complete with a dose amount, and replied, Yes, the orders should have a specified amount of medication to be administered. Review of facility policy titled, Medication Administration, dated 1/1/22, 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 (medication administration record) to verify resident name, medication name, form, dose, route, and time of administration . c. If other the PO (by mouth) route, administer in accordance with facility policy for the relevant route of administration . The medication error rate was calculated based on 6 of 26 opportunities for error and resulted in a 23.08% medication error rate.

Based on observation, interview, and record review, the facility failed to prevent falls and provide supervision, for 2 of 4 residents (Residents #1 and #3) sampled for safety issues, from a total sample of 4 residents. This deficient practice resulted in: 1) Resident #1 sustaining a fall with injury (a fracture of her right wrist), when facility staff failed to review the care plan prior to providing cares to the Resident, failed to supervise the Resident in the shower, and failed to ensure the Resident wore appropriate footwear in the shower, and 2) the potential for Resident #3 to experience a fall with the potential for injury when facility staff failed to place anti-roll backs on his wheelchair and utilize hipsters at all times. Findings include: Resident #1 The medical facesheet revealed Resident #1 is a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE], revealed Resident #1 was mildly, cognitively impaired (BIM score 12/15), and required minimal assistance of a facility staff member with activities of daily living (ADLs) including bathing. Review of the Fall Risk Evaluation dated 2/2/2018, revealed Resident #1 was assessed at risk for falls due to health conditions, including cognition (dementia) and circulatory/heart issues. Review of the Care Plan revealed facility staff were to ensure Resident #1 was to wear appropriate footwear when out of bed (initiated 2/12/2018), and to provide supervision for safety; do not leave alone in the shower (initiated 2/12/2018). Review of the facility accident and incident report dated 4/18/2018 (untimed), revealed that on 4/18/2018 at 3:00 p.m., Resident #1 experienced an unwitnessed fall in the east hallway shower room as she was attempting to put on flip flops post shower. The flip flops worn by Resident #1 during her fall, were described in the report to have no grippers. The report included that Resident #1's care plan had included the use of proper foot wear and supervision with showers. Acknowledged in the report was that planned interventions were not in place, and staff did not know (Resident #1) and did not check the care plan. Per the report Resident #1 was sent to a local hospital for evaluation. Review of the Operative Report dated 4/25/2018 (untimed), revealed Resident #1 sustained a displaced, comminuted [MEDICAL CONDITION] ulnar/radius shaft of her right arm. On 4/25/2018, Resident #1 underwent surgery for [REDACTED]. During an interview on 5/1/2018 at 8:40 a.m., Resident #1 said she had been taken to the shower room on the east hallway on 4/18/2018 by CNA E. Resident #1 said, I fell about four weeks ago. I broke two bones in my right arm. I was in the shower. I was by myself; I wasn't supposed to be. Somebody was supposed to be with me. She (CNA E) got another call. She went out. She didn't come back. I waited for about twenty minutes. I started to put on my pants. I put on my shirt. I didn't have a call light in the shower. I fell . I hit my arm. I yelled 'help, help, help' . They never left me alone, before. Resident #1 said she tried to put her flip flops on, but one slid away from her and she fell backward. Resident #1 pointed out, and the State Surveyor observed, the flip flops next to the Resident's bed, she had worn when she fell ; the soles were a compressed, hardened foam that were non-grip, and had slide potential when used on tile or a potentially wet surface. During an interview on 5/1/2018 at 1:45 p.m., CNA E acknowledged she had been assigned on 4/18/2018, to work with Resident #1, a resident she had not worked with before. She said she had taken Resident #1 to the east hallway shower, set her up, then left the shower room. I'll be honest; I didn't look at her care plan before I worked with her that day. I won't lie; I should've looked a her care plan before I worked with her. She should've been supervised at all times in the shower room. I found that out after I looked at her care plan after the fall . She had flip flops; they weren't appropriate for the shower. They don't grip and they can be slippery, even on dry tile. During an interview on 5/1/2018 at 4:10 p.m., the Nursing Home Administrator acknowledged CNA E had not reviewed, as expected, the care plan of a resident (Resident #1) she had not previously cared for, and that Resident #1 had not been supervised, nor worn appropriate foot wear in the shower room, resulting in a fall with injury ([MEDICAL CONDITION] arm) on 4/18/2018 at 3:00 p.m. Resident #3 Review of the medical facesheet revealed Resident #3 is a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#3 was severely cognitively impaired (no BIM score entry), and required minimal to extensive assistance of a facility staff member with activities of daily living (ADL's). Review of the Fall Risk Evaluation dated 3/18/2018, revealed Resident #3 was assessed at high risk for falls (score 22). Review of the Care Plan revealed facility staff were to ensure Resident #3 wore hipsters at all times (initiated 4/16/2018, revised 4/24/2018), and to utilize a wheelchair with anti rollbacks (initiated 3/19/2018). On 5/2/2018 at 11:15 a.m., Resident #3 was observed by this Surveyor to attempt self-transfer from his bed. A housekeeper was observed to stop the Resident, and put on the call light for assistance; she waited with the Resident for an additional 5 minutes. CNA I came in response to the call light, and proceeded to assist Resident #3 to the bathroom for toileting. Resident #3 had been incontinent of urine and CNA I removed his pajama bottom and brief for cleansing. Resident #3 was not wearing his hipsters, as care planned. CNA I completed cleansing the Resident, then put on his hipsters. CNA I admitted she had almost forgotten to apply the Resident's hipsters, commenting He wears them when he's up; they're new to the care plan, like just last week. Resident #3 was not wearing his hipsters at all times, as care planned. On 5/2/2018 at 11:45 a.m., Resident #3 was observed in his wheelchair in the east hallway. He was observed by this Surveyor without presence of anti-rollbacks on his wheelchair, as care planned. The Director of Nursing said, He's supposed to have anti-roll backs on his wheelchair. He has a different wheelchair now, and they should've put the anti-roll backs on it. I'll tell maintenance to put 'em on right away. According to the facility's Falls Clinical Protocol reviewed/revised (MONTH) (YEAR), it states (entries #4 & #5), Interventions should be developed and implemented per the assessed needs. In addition, interventions for direct care givers should be placed on the CNA care card or similar format. Entry (3) (a) states, Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life.

Based on observation, interview and record review, the facility failed to prevent the development of three avoidable stage II pressure ulcers for 1 Resident (#3) of 4 Residents reviewed for pressure ulcers from a total sample of 15 residents. This deficient practice resulted in harm for Resident #3 after she was identified at risk for acquiring pressure ulcers and not provided interventions to prevent the ulcers from developing, causing unnecessary pain and discomfort with the potential for slow healing. Findings include: A review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3, a [AGE] year old, was admitted to the facility on [DATE] following bilateral arthroplasty of the hips due to pathologic fractures of the femurs. Resident #3's [DIAGNOSES REDACTED]. Resident #3 was her own person, fully alert and oriented. At the time of her admission, she had two hip surgical incisions and no signs or symptoms of pressure ulcers were noted. A review of Resident #3's Norton Plus Pressure Ulcer Scale Assessments dated 11/03/16, 11/10/16, and 11/18/16, revealed Resident #3 was at moderate risk for acquiring pressure ulcers. A review of Resident #3's Nursing Skin Assessment upon admitted d 11/03/16, revealed she had no pressure ulcer upon admission. A review was conducted of Resident #3's Wound History Screen, dated 11/05/16 through 11/30/16, and signed by Wound Nurse/Registered Nurse (RN) B. On 11/05/16, Wound Nurse/Registered Nurse (RN) B recorded observation of stage II pressure ulcers on Resident #3's right ischial trochanter, 0.2 centimeters (cm) x 0.2 cm and the left ischial trochanter, 2.5 cm x 0.2 cm. The right ischial trochanter resolved on 11/14/16 and the left resolved on 11/30/16. There was no wound documentation; including measurements and orders for treatment, written for the additional stage II pressure ulcer on the coccyx Resident #3 acquired on 11/25/16. A review of Resident #3's Medication Administration Record [REDACTED]. A review was conducted of Resident #3's At Risk for Skin Integrity Deficit Care Plan history dated 11/03/16 through 11/30/16. The Skin Integrity Care Plan, had no preventative skin ulcer measures put in place until 11/10/16, five days following their discovery. On 11/03/16, the original care plan read, with all cares .discreetly assess for any evidence of skin integrity deficits, excoriation, breakdown etc ., has multiple compounding medical comorbidities causing weakness and places her at risk for skin integrity deficits ., .if using a w/c (wheelchair) ensure reducing cushion is in place ., and .assist with repositioning and with bed mobility, as needed .is independent with bed mobility and positioning needs . On 11/29/16 at 7:30 p.m., an interview was conducted with Resident #3 regarding her pressure ulcer areas. Resident #3 said, .I have something (sore) on my bottom and it hurts .every time I move .I had a shower today, but no one put anything (dressing) on it .usually have it (coccyx pressure ulcer) covered . This Surveyor asked her if she had any sores, besides her bilateral hip incisions when she came from the hospital to the facility. Resident #3 said, .No .when I first got here it was hard to turn in bed .they (staff) never told me I needed to move around (turn often to different positions while in bed) . a trapeze (hanging grab-bar) would have been very helpful I got side rails (placed on the bed for repositioning) .it was hard to move around the first week and a half . On 12/01/16 at 2:10 p.m., an interview with Licensed Practical Nurse (LPN) H revealed she was Resident #3's nurse second shift on 11/29/16. LPN H said Resident #3 had her shower around 2:30 p.m./3:00 p.m. and .I didn't put a dressing on her bottom (open stage II pressure ulcer) because there wasn't an order written [REDACTED].#3, during the 11/30//16 interview at 8:05 a.m., Resident #3 said someone finally came in and covered her coccyx ulcer with a dressing that morning, going at least 10 hours without any protection from rubbing on the ulcer. On 12/01/16 at 8:00 a.m., this Surveyor conducted an interview with Resident #3. Resident #3 said, .I had the worst night of sleep .in the afternoon (11/30/16, day two of the survey) .they (facility) put a new mattress on my bed .makes so much noise .hard to sleep .it has air in it .never had one of these since I came in . Observation at that time showed an alternating air mattress on the resident's bed. A review of Resident #3's Skin Integrity Care Plan dated 11/10/16 read, .use an alternating air mattress on her bed . Resident #3 did not have a pressure relief air mattress until 11/30/16, 20 days after it was noted as required on her care plan. On 12/01/16 at 9:50 a.m., this Surveyor observed Wound Nurse/RN B change the coccyx stage II pressure ulcer dressing on Resident #3. There was no documentation provided pertaining to an order for [REDACTED]. RN B said, .I was in and out of the facility during the month of November .not able to monitor her (Resident #3's) care the whole time .not sure who took my place (as wound nurse) .it is up to the resident's nurse to take over if I am not here . On 12/01/16 at 12:40 p.m., Resident #3 told this Surveyor, .they (staff) never told me I needed to try to change positions so I wouldn't get sores .that was hard for me to do at the beginning, with two (bilateral) hip incisions .When asked if the nursing staff had instructed her on the importance of changing her position frequently, to prevent pressure ulcers, Resident #3 stated, No, I never was (educated by staff) On 12/01/16 at 2:30 p.m., an interview was conducted with Regional Clinical Care Coordinator for Corporate/RN C. CCC/RN C stated, .(I) looked for (specific)pressure relieving interventions (before the pressure ulcers) .didn't find any written .not even float heels .saw she just got her mattress yesterday . ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ADEQUATE SUPERVISION AND ASSISTANCE DEVICES WERE IMPLEMENTED FOR FIVE (#3, #5, #6, #7, #8) OF 11 RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL POPULATION OF 74 RESIDENTS IN THE FACILITY. THE FAILURE TO ENSURE SAFETY MEASURES WERE IN PLACE, RESULTED IN RESIDENT #8 FALLING AND SUSTAINING MAJOR HEAD INJURIES (A SUBARACHNOID HEMORRHAGE AND SUBDURAL HEMATOMA). IN ADDITION, THIS FAILURE ALSO RESULTED IN MULTIPLE FALLS AND MINOR INJURIES TO RESIDENTS #3, #5, #6 AND #7. FINDINGS INCLUDE: THE FACE SHEET REVEALED THAT RESIDENT #8 IS A [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #8 REQUIRED LIMITED ASSISTANCE OF ONE WITH TRANSFER, AMBULATION IN HER ROOM AS WELL AS IN THE CORRIDOR. THIS MDS ASSESSMENT SHOWED HER "BALANCE DURING TRANSITIONS AND WALKING" WAS NOT STEADY WITHOUT "HUMAN ASSISTANCE" WHEN MOVING FROM SEATED TO STANDING POSITION, WALKING, TURNING AROUND, MOVING ON AND OFF TOILET AND SURFACE TO SURFACE TRANSFERS. RESIDENT #8'S CARE PLAN TITLED "FALLS" DATED 11/14/11, READ, "ENSURE THAT HER CALL LIGHT IS WITHIN REACH AT ALL TIMES. SHE REQUIRES CONTACT GUARD OF STAFF R/T (RELATED TO) INSTABILITY...". THE FACILITY'S "INTERVENTION & DOCUMENTATION TICKLER FOR FALLS" (NOT DATED) READ: "THE MOST COMMONLY DOCUMENTED INTERVENTION TO PREVENT A RECURRENCE OF ANOTHER FALL IS, 'REMIND RESIDENT TO USE CALL LIGHT FOR ASSISTANCE.' USE THIS, LIST IDEAS THAT WOULD BE RESIDENT SPECIFIC... ASSURE CALL LIGHT IS WITHIN REACH". A REVIEW OF AN INCIDENT/ACCIDENT REPORT DATED 11/12/11 SHOWED RESIDENT #8 fell on THAT DAY AT 1:00 A.M. THE REPORT NOTED THAT THE RESIDENT'S PERSONAL ALARM WAS SOUNDING; HOWEVER, THERE WAS NO MENTION OF THE CALL LIGHT BEING ACTIVATED. THE FACILITY "INCIDENT/ACCIDENT REPORT INVESTIGATION", DATED 11/12/11, INDICATED "ASSISTIVE DEVICES: ...CALL LIGHT... ROUTINELY REQUIRED 'NO'"; AND IN THE COMMENT AREA WAS "NOT USED". DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 12/21/11 AT 1:35 P.M., SHE STATED RESIDENT #8 HAS AN EXTENSIVE HISTORY OF FALLS AND REQUIRES HER CALL LIGHT TO CALL FOR HELP FOR ACTIVITIES, INCLUDING TOILETING. THE DON STATED, "IT (THE CALL LIGHT) IS ROUTINELY REQUIRED, ALWAYS! SHE (RESIDENT #8) USES HER CALL LIGHT 8-9 TIMES OUT OF 10... ABSOLUTELY IT (THE CALL LIGHT) IS REQUIRED USE FOR ALL RESIDENTS." THE "PROGRESS NOTES" IN RESIDENT #8'S CLINICAL RECORD READ, "IDT (INTERDISCIPLINARY TEAM MEETING) MET AND DISCUSSED RESIDENT'S FALL FROM 11/12/11... (RESIDENT #8) ASSISTED TO BATHROOM AFTER SHE HAD FALLEN, AT WHICH TIME SHE DID HAVE SEIZURE ACTIVITY NOTED... NEURO CHECKS WERE INITIATED AND WERE WNL (WITHIN NORMAL LIMITS) UNTIL DURING THE DAY SHIFT WHEN BP (BLOOD PRESSURE) DECREASED AND PULSE INCREASED. SHE WAS SENT TO ER (emergency room ) FOR EVALUATION AND WAS admitted R/T (RELATED TO) A BRAIN BLEED... ADDITIONAL FINDINGS: HAS BEEN NOTED TO HAVE URINARY FREQUENCY AT TIMES." IN THE IDT NOTE THERE WAS NO MENTION OF CALL LIGHT ISSUES. THE ER REPORT TITLED "HISTORY & PHYSICAL" DATED 11/12/11, READ, "(RESIDENT #8) WAS BROUGHT INTO THE emergency room TODAY AFTER A FALL." THIS REPORT READ, UNDER THE SUBJECT TITLED, "ASSESSMENT AND PLAN": "1. TINY SUBDURAL HEMORRHAGE LEFT PARIETAL REGION. 2. FREQUENT FALLS. 3. MILD SUBARACHNOID HEMORRHAGE ON HEAD CT (COMPUTER TOMOGRAPHY)... 10. PROBABLE UTI (URINARY TRACT INFECTION)." DURING AN INTERVIEW ON 12/20/11 AT 1:30 P.M. WITH RESIDENT #8, WHEN ASKED HOW SHE WOULD CALL FOR HELP, SHE REACHED FOR THE CALL LIGHT ON THE SIDE OF HER BED AND STATED, "(I WOULD USE) THIS (TO ASK FOR HELP)." RESIDENT #8 WAS THEN ASKED IF SHE NEEDED TO TOILET WHAT WOULD SHE DO. RESIDENT #8 RAISED THE CALL LIGHT BUTTON UP AND STATED, "THIS". WHEN ASKED IF SHE RECALLED THE INCIDENT IN WHICH SHE fell on [DATE] AND HIT HER HEAD, SHE SHOOK HER HEAD "NO". THE FACE SHEET ON RESIDENT #7 REVEALED THAT HE IS A [AGE] year OLD MALE WITH [DIAGNOSES REDACTED]. THE MDS assessment dated [DATE], REVEALED RESIDENT #7 REQUIRES EXTENSIVE ASSIST OF ONE PERSON WITH ALL TRANSFERS, AMBULATION IN HIS ROOM AND IN THE CORRIDORS. THIS MDS SHOWED RESIDENT #7'S "BALANCE DURING TRANSITIONS AND WALKING" WAS NOT STEADY WITHOUT "HUMAN ASSISTANCE" WHEN MOVING FROM SEATED TO STANDING POSITION, WALKING, TURNING AROUND, MOVING ON AND OFF TOILET AND SURFACE TO SURFACE TRANSFERS. RESIDENT #7'S CARE PLAN DATED 10/19/11, RELATED TO "FALLS", READ, "HE (RESIDENT #7) IS TO HAVE A PRESSURE ALARM USED AT ALL TIMES WHEN IN BED AND WHEN IN W/C (WHEELCHAIR)... (AND) INITIATE 15 MINUTE CHECKS." THE FACILITY'S "INTERVENTION & DOCUMENTATION TICKLER FOR FALLS" FOR RESIDENT #7 (NOT DATED) READ AS FOLLOWS: "THE MOST COMMONLY DOCUMENTED INTERVENTION TO PREVENT A RECURRENCE OF ANOTHER FALL IS, 'REMIND RESIDENT TO USE CALL LIGHT FOR ASSISTANCE.' USE THIS, LIST IDEAS THAT WOULD BE RESIDENT SPECIFIC... ASSURE CALL LIGHT IS WITHIN REACH... CHECK ALARM FOR PROPER FUNCTIONING AND CHARGED BATTERY...". A REVIEW OF AN INCIDENT/ACCIDENT REPORT FOR RESIDENT #7 REVEALED HE fell on [DATE] AT 10:30 P.M. THE "PROGRESS NOTES", DATED 10/25/11 IN RESIDENT #7'S CLINICAL RECORD READ, "IDT MET TO DISCUSS FALL NOTED FROM 10/23/11. RESIDENT fell AFTER SELF TRANSFER FROM HIS WHEELCHAIR WHILE IN HIS ROOM. DURING (THE) INVESTIGATION IT IS NOTED THAT HIS ALARM SYSTEM WAS PRESENT, BUT NOT FUNCTIONING AT THE TIME OF THIS FALL." THERE WAS NO RECORD THAT THE CALL LIGHT WAS WITHIN REACH AT THE TIME OF HIS FALL. THE INCIDENT/ACCIDENT REPORT DOCUMENTED "NO BRUISES, INJURIES NOTED". ANOTHER INCIDENT/ACCIDENT REPORT DATED 10/27/11, REVEALED A FALL INVOLVING RESIDENT #7 ON 10/27/11 AT 8:30 P.M. IN THE "F-HALL(WAY)". THE INITIAL ASSESSMENT READ, "...ALARM WAS NOT GOING OFF.... IMMEDIATE (ACTION) TAKEN ALARM WAS TURNED ON." THE INCIDENT/ACCIDENT REPORT NOTED RESIDENT #7 WAS DISCOVERED TO HAVE A "BRUISE ON THE (RIGHT) HAND." DURING A TOUR OF THE FACILITY ON 12/20/11 AT 11:30 A.M., RESIDENT #7 WAS OBSERVED SLEEPING IN HIS BED. THE RESIDENT'S CALL LIGHT WAS HANGING OFF THE FOOT OF THE BED AND WAS UNREACHABLE BY RESIDENT #7. ANOTHER OBSERVATION ON 12/20/11 AT 1:18 P.M. SHOWED RESIDENT #7 RESTING IN HIS BED. HIS CALL LIGHT WAS HANGING OFF THE END OF THE BED AND WAS NOT WITHIN REACH OF RESIDENT #7. DURING AN OBSERVATION ON 12/21/11 AT 8:45 A.M., RESIDENT #7 WAS IN THE DINING ROOM IN HIS WHEELCHAIR. HIS PERSONAL ALARM WAS ATTACHED TO HIS CLOTHING; HOWEVER, THE ALARM SWITCH WAS IN THE "OFF" POSITION. DURING AN INTERVIEW WITH CERTIFIED NURSE AIDE (CNA) "F" ON 12/21/11 AT 8:46 A.M., SHE CONFIRMED THE RESIDENT'S ALARM WAS IN THE "OFF" POSITION. CNA "F" STATED, "YES, IT'S OFF. HIS ALARM SHOULD ALWAYS BE TURNED ON. I DON'T KNOW WHY IT IS NOT (TURNED ON)." ON 12/21/11 AT 12:55 P.M., AN INTERVIEW TOOK PLACE WITH THE DIRECTOR OF NURSING (DON) AND LICENSED PRACTICAL NURSE (LPN) "A". OBSERVATIONS OF RESIDENT CALL LIGHTS NOT WITHIN REACH AND PERSONAL ALARMS NOT BEING TURNED ON WERE RELAYED AT THIS TIME. THE DON STATED (IN RESPONSE TO THIS SURVEYOR'S OBSERVATION OF THE CALL LIGHT HANGING OFF THE FOOT OF RESIDENT #7'S BED), "IT SHOULD HAVE BEEN WITHIN REACH." LPN "A" ADDED, "ABSOLUTELY!" WHEN ASKED ABOUT THE FACILITY'S RESPONSIBLITY TO PROVIDE ASSISTANCE TO RESIDENTS, THE DON STATED, "YES, THE FACILITY WOULD BE REMISS (CARELESS OR NEGLIGENT)." ( ) ACCORDING TO HIS MEDICAL RECORD ADMISSION SHEET, RESIDENT #6 IS A [AGE] year OLD MAN. HIS PRIMARY [DIAGNOSES REDACTED]. A FACILITY INCIDENT/ACCIDENT REPORT, DATED 9/26/11, SHOWED ON THAT DATE RESIDENT #6 HAD BEEN SEATED IN HIS WHEELCHAIR NEAR THE NURSES' STATION. THE REPORT INDICATED HE WENT TO SLEEP AND fell OUT OF THE WHEELCHAIR ONTO THE FLOOR. THE FALL RESULTED IN A SKIN TEAR, WITH BLEEDING, TO HIS RIGHT ELBOW. THE INTERDISCIPLINARY TEAM (IDT) NOTES FROM 9/27/11 SHOW THE ADDITION OF THIS INTERVENTION TO RESIDENT #6'S SAFETY CARE PLAN: "WHEN HE IS NOTED TO BE SLEEPING IN HIS W/C (WHEELCHAIR) OFFER TO ASSIST HIM TO HIS ROOM TO LIE DOWN FOR A REST/NAP." AN INCIDENT/ACCIDENT REPORT, DATED 10/16/11 AT 1:50 P.M., SHOWED RESIDENT #6 WAS IN THE HALL PROPELLING HIMSELF IN HIS W/C WITH HIS EYES CLOSED, WHEN HE BUMPED HIS HEAD ON THE MEDICATION CART, CAUSING HIS RIGHT EYEBROW TO TURN RED. RESIDENT #6, ACCORDING TO THE REPORT, OPENED HIS EYES FOR A MOMENT, THEN RETURNED TO SLEEP. STAFF RESPONSE WAS TO LOCK THE W/C BRAKES WHILE RESIDENT #6 WAS SLEEPING. NEITHER BEFORE NOR AFTER THE ACCIDENT DID STAFF FOLLOW THE CARE PLAN AND TAKE RESIDENT #6 TO HIS ROOM TO REST IN HIS BED. ON 10/18/11, A SECOND INTERVENTION, NEARLY IDENTICAL TO THE 9/27/11 INTERVENTION, WAS PLACED ON RESIDENT #6'S SAFETY CARE PLAN: "WHEN TIRED OR DISPLAYS EVIDENCE OF LETHARGY OFFER (RESIDENT'S NAME) A NAP IN HIS BED." A THIRD INCIDENT/ACCIDENT REPORT FOR RESIDENT #6, DATED 11/28/11, SHOWED ON THAT DATE AT 2:30 A.M., RESIDENT #6 WAS OBSERVED FALLING ASLEEP IN HIS W/C IN THE HALLWAY. ACCORDING TO THE REPORT, STAFF APPROACHED RESIDENT #6 WHO LEANED FORWARD AND fell OUT OF HIS W/C AT THAT TIME. RESIDENT #6 WAS THEN PUT TO BED. THE INCIDENT/ ACCIDENT REPORT'S CORRECTIVE ACTIONS ONLY INDICATED THE RESIDENT WAS PUT TO BED TO PREVENT AN IMMEDIATE REPEAT OF THE FALL. MEASURES TO CORRECT THE REPETITIVE FALLS RESIDENT #6 WAS HAVING FROM HIS WHEELCHAIR WERE NOT IDENTIFIED OR ADDRESSED. ACCORDING TO A FACILITY INCIDENT/ ACCIDENT REPORT DATED 11/13/11, ON THAT DAY AT 6:55 P.M., RESIDENT #6 EXPERIENCED A FOURTH FALL FROM HIS W/C. RESIDENT #6'S FALL OCCURRED IN THE LOUNGE AND WAS UNOBSERVED. ACCORDING TO THE REPORT, THE PRESSURE ALARM IN RESIDENT #6'S W/C DID NOT SOUND. DURING A MEETING ON 12/21/11 AT 12:55 P.M., THE DON STATED THE FACILITY SUSPECTS RESIDENT #6 WENT TO SLEEP AND fell OUT OF HIS W/C. ACCORDING TO INCIDENT/ACCIDENT REPORTS, RESIDENT #6 HAD THE ADDITIONAL FOLLOWING FALLS WHEN HE ATTEMPTED TO STAND UP ON HIS OWN: 9/25/11 AT 8:00 P.M.; 10/12/11 AT 6:50 P.M.; 10/19/11 AT 6:50 P.M.; AND 10/19/11 AT 6:50 P.M. ON 12/21/11 AT 2:15 P.M., A MEETING WAS HELD WITH THE ADMINISTRATOR, THE DIRECTOR OF NURSING (DON), STAFF "A" (ASSISTANT DIRECTOR OF NURSING), STAFF "B" (SOCIAL SERVICES DESIGNEE), STAFF "C" (THE ENVIRONMENTAL SAFETY COORDINATOR), STAFF "D" (ACTIVITY DIRECTOR), AND STAFF "E" (RN AND REHABILITATION THERAPIST). DURING THIS MEETING, RESIDENT #6'S FALLS WERE DISCUSSED. THE STAFF WERE ASKED, GIVEN RESIDENT #6 HAD 8 FALLS FROM HIS WHEELCHAIR IN 3 MONTHS WHY THEY HAD NOT CONSIDERED USING A PHYSICAL RESTRAINT TO PREVENT HIS FALLING. THE ADMINISTRATOR, DON, AND STAFF "A" STATED THEY WERE A "RESTRAINT FREE FACILITY". AFTER MUCH DISCUSSION, STAFF ACKNOWLEDGED THEY NEEDED TO RE-EVALUATE THE POTENTIAL USE OF ALL SAFETY DEVICES THAT COULD BE USED TO PREVENT FALLS, ESPECIALLY FOR RESIDENTS EXPERIENCING MULTIPLE FALLS. ACCORDING TO FACILITY INCIDENT/ ACCIDENT REPORTS, RESIDENT #6 WAS DISCOVERED WITH 5 SKIN TEARS OF UNKNOWN ORIGIN IN THE PAST 3 MONTHS: ON 9/26/11, 10/19/11, 10/29/11, 10/31/11, AND 11/2/11. IN REVIEWING THE INCIDENT/ACCIDENT REPORTS, ABUSE WAS RULED OUT IN ALL INCIDENTS, HOWEVER, CORRECTIVE ACTIONS WERE NOT ALWAYS IDENTIFIED, OR FOLLOWED. FOR THE RESIDENT'S FIRST SKIN TEAR OF 9/26/11, THE ONLY CORRECTIVE ACTION IDENTIFIED ON THE INCIDENT/ACCIDENT REPORT WAS: "WRAP ARM IN GAUZE (?) GRIPS." NO LONG TERM PREVENTIVE ACTION WAS SUGGESTED. AFTER THE 10/29/11 SKIN TEAR, THE IDT TEAM NOTES OF 10/31/11 READ: "THE CARE PLAN REFLECTS THE NEED TO USE SKIN PROTECTORS AND HE SOMETIMES DOES NOT LIKE TO USE THEM. AT THE TIME THIS SKIN TEAR WAS NOTED, SKIN PROTECTORS WERE NOT BEING USED." THE IDT CONCLUDED THE NEED TO "WRITE an order for [REDACTED]." ON 10/31/11, THE FOLLOWING WAS ADDED TO RESIDENT #6'S CARE PLAN: " ...APPLY HOUSE LOTION DAILY... UTILIZE BUE (BELOW UPPER EXTREMITIES) PROTECTIVE ARM SLEEVES AS ORDERED." ON 10/31/11, ANOTHER SKIN TEAR WAS NOTICED BY AN UNIDENTIFIED CERTIFIED NURSE AIDE (CNA) ON RESIDENT #6'S RIGHT FOREARM. THE INCIDENT/ACCIDENT REPORT NOTES A BANDAID WAS PLACED ON THE SKIN TEAR. THE ONLY CORRECTIVE ACTION IDENTIFIED WAS "GAVE NEWSPAPER TO READ." THE IDT MEETING ON 11/1/11 DISCUSSED THIS SKIN TEAR, NOTING AGAIN THE NEED FOR PROTECTIVE SLEEVES AND USE OF LONG-SLEEVES FOR RESIDENT #6. THE 11/2/11 INCIDENT/ACCIDENT REPORT SHOWS RESIDENT #6 WAS DISCOVERED WITH A SKIN TEAR ON HIS LEFT ELBOW AT 9:35 P.M. THE CORRECTIVE ACTION READS: "RESIDENT'S PROTECTIVE SLEEVES WERE PLACED ON HIM," INDICATING THE STAFF HAD NOT FOLLOWED THE CARE PLAN AND HAD THE PROTECTIVE SLEEVES ON RESIDENT #6 DURING THE DAY. THE IDT TEAM NOTE, DATED 11/3/11, REVIEWED THE CARE PLAN AND RESIDENT #6'S "CHRONIC HISTORY OF MULTIPLE SKIN DEFICITS," BUT THEY DID NOT ADDRESS WHETHER THE CARE PLAN FOR THE USE OF PROTECTIVE SLEEVES WAS BEING FOLLOWED AT THE TIME OF THE ACCIDENT. ACCORDING TO HIS ADMISSION SHEET, RESIDENT #3 IS AN [AGE] year OLD MAN WHO WAS admitted to the facility on [DATE] FOR REHABILITATION AND AFTERCARE FOLLOWING A TRAUMATIC HIP FRACTURE. RESIDENT #3 ALSO HAS A [DIAGNOSES REDACTED].M., RESIDENT #3 WAS FOUND NAKED, SITTING ON THE FLOOR AT THE END OF HIS BED. THE RESIDENT'S SENSOR ALARM ON HIS BED WAS FOUND TO BE DISCONNECTED. THE FACILITY INCIDENT/ACCIDENT REPORT FOR RESIDENT #3, DATED 11/28/11, SHOWED ON THAT DATE AT 2:55 A.M., RESIDENT #3 WAS FOUND OUTSIDE HIS BATHROOM DOOR ON THE FLOOR. THE REPORT INDICATES THE RESIDENT'S PRESSURE ALARM MALFUNCTIONED AND DID NOT SOUND. ACCORDING TO HIS ADMISSION SHEET, RESIDENT #5 WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. AN INCIDENT/ACCIDENT REPORT, DATED 10/29/11, REVEALED AT 12:30 P.M. ON THAT DATE, RESIDENT #5 fell TRYING TO GET INTO BED BY HIMSELF. HE WAS FOUND ON THE FLOOR OF HIS ROOM BETWEEN HIS WHEELCHAIR AND BED. THE REPORT SHOWED THE RESIDENT'S PERSONAL TAB ALARM DID NOT ALARM AT THE TIME OF THE FALL. THE CORRECTIVE ACTION ON THE INCIDENT/ACCIDENT REPORT READ: "MADE SURE ALARMS ARE ATTACHED AND PLACED RES (RESIDENT) IN BED." A REVIEW OF FACILITY INCIDENT/ACCIDENT REPORTS FOR THE PAST 3 MONTHS FOR THE 11 RESIDENTS ON SAMPLE, REVEALED A TOTAL OF 45 FALLS. AS REPORTED ABOVE, IT WAS CALCULATED IN OVER 10% OF THESE FALLS, (RESIDENT #3 ON 11/6/11 AND 11/28/11; RESIDENT #5 ON 10/29/11; RESIDENT #6 ON 11/13/11; AND RESIDENT #7 ON 10/27/11) THE RESIDENTS' ALARMS DID NOT FUNCTION PROPERLY. ( ) --