Every finding on record at Medilodge of Holland

This citation pertains to intake #2994162 & 2999360.Based on interview and record review, the facility failed to maintain comfortable sound levels, ensure resident personal property was kept safe from loss, and provide person-centered care for 3 residents (Resident #87, #19, and Confidential Resident C) and residents involved in Resident Council, reviewed for homelike environment. This deficient practice has the potential to affect all 75 residents residing in the facility.Findings:Resident #87 (R87)Review of a Face Sheet revealed R87 was an [AGE] year-old female, admitted to the facility on [DATE], for short term rehab. R87 was her own decision maker.Review of R87's Nursing admission Evaluation dated 7/3/26 revealed R87 was alert and oriented and had no short-term or long-term memory problems. Review of R87's Nurses' Note dated 7/6/26 revealed, Nurse removed icy hot muscle rub from resident's room and explained why it could not be kept in her room. Informed resident that the medication would be locked in the medication cart with her name on it. Resident replied, this is ridiculous.During an interview on 7/7/26 at 9:55 AM, R87 reported that on the previous day, a facility staff member took my icy hot out of my bag without discussing it with me. Right in front of me. R87 verbalized that she did not appreciate the way the facility staff member treated her stating, don't take my sh*t unless you ask and the facility staff member could have talked it out and explained it to me before getting into her belongings and removing her personal item.R87 stated that she was extremely unhappy with staff stating, they lost their class. R87 was asked to elaborate on that statement and reported that 3rd shift staff were so loud in the hallway she was forced to keep her door shut but even with the door shut she could still hear staff loudly talking and interacting in the hallway which caused her to lose sleep. R87 went on to report that some of the facility staff were rough with care, specifically with turning her but did not report it as abuse but instead as rushed and thoughtless care and expressed that the staff were, b*tchy, crabby women.Resident #19 (R19)Review of a Face Sheet revealed R19 was a [AGE] year-old female, admitted to the facility on [DATE].Review of a Minimum Data Set (MDS) assessment for R19, with a reference date of 4/24/26 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated R19 had moderate cognitive impairment. During an interview on 7/6/26 at 10:40 AM, R19 stated, the aide (Certified Nursing Assistant [CNA]) (name omitted) is mean and rude to me. R19 reported she did not want that aide providing care for her and stated the aide made her feel bad.Review of R19's Quality Assistance Form dated 7/6/26 revealed a statement from R19 (name omitted) makes me feel like sh*t.Confidential Resident (CR) C Review of a Minimum Data Set (MDS) assessment for CR C, completed within the last 30 days revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated CR C was cognitively intact.During an interview on 7/6/26 at approximately 12:35 PM, CR C reported he wished to remain anonymous and stated that 3rd shift was not so nice.Review of the Resident Council Minutes revealed the following concerns:Handwritten notes for the meeting on 5/6/26 revealed, 8. Alarms for front door going and no one there to shut it off.9. Clothes missing.Minutes dated 6/3/26 revealed, Old Business.Door alarms going off for long periods of time.New Business Door alarms still going off-need signs that are more visible with clear instructions. Laundry still going missing.CNAs on 3rd shift are very loud and walk into rooms without knocking first. Handwritten notes for the meeting revealed, .Aides 3rd shift not using indoor voices. Also entering without knocking. Residents deserve privacy and respect for sleep.Resident #42 (R42)Review of a Face Sheet revealed R42 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis.Review of a Minimum Data Set (MDS) assessment for R42, with a reference date of 5/1/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R42 was cognitively intact. During an interview on 7/7/26 at 10:23 AM, R42 revealed he was the resident council president.R42 reported that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were proactive with addressing and quick to respond to the concerns identified during the resident council meetings, however, the noise levels and the missing laundry were consistently brought up during the monthly resident council meetings. R42 reported that the laundry tags (attached to resident clothing with their name) needed a resolution. During an interview on 7/8/26 at 2:19 PM, R42 confirmed that the complaints of the staff being too loud on 3rd shift as well as the excessive door alarms had also been ongoing unresolved concerns.During an interview on 7/7/26 at approximately 9:50 AM, Housekeeping Director (HD) H reported that they were having issues with the resident identifier tag staying on the clothing through the wash cycle which resulted in the inability to determine which clothing items belonged to the residents and the subsequent reports of missing items/clothing.Per the State Operations Manual, Of particular concern to comfortable sound levels is the resident's control over unwanted noise and a homelike environment is not achieved simply through enhancements to the physical environment. It concerns striving for person-centered care that emphasizes individualization, relationships and a psychosocial environment that welcomes each resident and makes her/him comfortable.

This citation pertains to intake #2994162 & 2999360.Based on observation, interview, and record review, the facility: 1.) failed to ensure medications were administered and laboratory testing was completed in accordance with physician orders for 3 residents (Resident #4, #17, and #54), and 2.) failed to observe the consumption of medication for 1 resident (Resident #70), out of 18 residents reviewed for nursing professional standards of practice.Findings: Resident #4 (R4) Review of a Face Sheet revealed R4 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Diabetes type 2. Review of R4's Order Summary dated 8/28/25 revealed, Hemoglobin A1C (laboratory testing for blood glucose levels over a period of time) every three months.starting on the 4th for Diabetic Monitoring. Review of R4's Treatment Administration Record revealed the Hemoglobin A1C was documented as completed (a checkmark with nursing initials). Review of R4's Electronic Medical Record revealed no laboratory results for the Hemoglobin A1C documented as completed on 6/4/26. There was no documentation that the laboratory testing had NOT been completed or that the provider had been notified of the incomplete laboratory testing. Review of R4's Practitioner Progress Note dated 6/8/26 revealed, .General health maintenance-A1c and TSH (thyroid laboratory test) ordered for next lab day (6/11/26). Review of R4's Practitioner Progress Note dated 6/22/26 revealed, .A1c and TSH ordered for 6/11/26, not yet resulted. During an interview on 7/726 at 3:28 PM, the Director of Nursing (DON) confirmed that there had been no A1C or TSH laboratory testing on 6/4/26 or 6/11/26 and she placed a new order for both to be drawn on the next lab day. Review of R4's Order Summary dated 7/7/26 at 3:24 PM revealed, Labs: A1C and TSH next lab day. Resident #17 (R17) Review of a Face Sheet revealed R17 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: syncope (fainting) and heart failure. Review of R17's Order Summary dated 06/26/26 revealed, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth three times a day related to HYPOTENSION, UNSPECIFIED (I95. 9) Hold for SBP (systolic blood pressure [top number]) > (greater than) 120. To be administered at 8:00 AM,. 12:00 PM, and 4:00 PM.Review of R17's Blood Pressure Summary and June Medication Administration Record revealed: On 6/26/26 R17's blood pressure was 126/77 and the 4:00 PM dose of midodrine was administered. On 6/27/26 R17's blood pressure was 122/66 and the 8:00 AM dose of midodrine was administered. On 6/27/26 R17's blood pressure was not assessed prior to the 4:00 PM dose of midodrine. The blood pressure assessment from 12:00 PM (118/60) was documented and the 4:00 PM dose of midodrine was administered. On 6/28/26 R17's blood pressure was 127/71 and the 4:00 PM dose of midodrine was administered. Review of R17's Blood Pressure Summary and July Medication Administration Record revealed: On 7/1/26 R17's blood pressure was not assessed prior to the 12:00 PM dose of midodrine. The morning blood pressure assessment (130/80) was documented and the midodrine was administered. On 7/3/26 R17's blood pressure was not assessed prior to the 8:00 AM dose of midodrine. The blood pressure assessment from the 7/2/26 4:00 PM dose (108/62) was documented and the midodrine was administered. On 7/3/26 R17's blood pressure was 139/71 and the 4:00 PM dose of midodrine was administered. On 7/5/26 R17's blood pressure was 128/81 and the 8:00 AM dose of midodrine was administered. On 7/6/26 R17's blood pressure was 134/70 and the 4:00 PM dose of midodrine was administered. Review of R17's Electronic Medical Record revealed no documentation related to the administration of the midodrine outside of the ordered parameters. Resident #54 (R54) Review of a Face Sheet revealed R54 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: heart failure and hypertension (high blood pressure. Review of R54's Order Summary dated 5/8/26 revealed, Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 MG (Isosorbide Mononitrate) Give 1 tablet by mouth in the morning related to CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE (I50.22) Hold for SBP less than 110 and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth in the morning related to CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE (I50.22) hold for SBP less than 110 or HR less than 60. Review of R54's Blood Pressure Summary and Pulse Summary revealed R54 had not had his blood pressure or heart rate assessed since 6/19/26. Review of R54's June and July Medication Administration Record revealed that from 6/19/26 to 7/7/26 all doses of Isosorbide and Metoprolol were administered. Review of R54's Electronic Medical Record revealed no documentation for the lack of blood pressure and heart rate assessments prior to the administration of R54's isosorbide and metoprolol. During an interview on 7/7/26 at 8:08 AM, Registered Nurse (RN) A reported that if the provider ordered parameters, the relevant vital signs are to be obtained prior to the administration of the medication. The nurse is responsible for reviewing the order prior to medication administration to ensure all necessary vital signs are obtained. During an interview on 7/7/26 at 8:13 AM, Licensed Practical Nurse (LPN) E reported that for medications ordered with parameters, the Electronic Medication Administration Record provides an area to input the supplementary documentation (vital signs, blood sugar, pain level, etc) and rationales for withholding the medication (if applicable). LPN E reported that a progress note should be completed if the medication was not administered. During an interview on 7/8/26 at 10:40 AM, the Director of Nursing (DON) confirmed R17 and R54's medication errors: not obtaining vital signs prior to the administration of medications, reusing vital sign assessments, and administering medications outside of parameters. Resident #70 (R70) During an observation on 07/06/26 at 9:56 AM, R70 sat on the edge of the bed and a plastic cup that contained pills sat on the overbed table in front of her. During an interview at the same time, R70 indicated that staff often leave her medications for her to take later, including her eye drops. Review of the Electronic Health Record (EHR) revealed R70 had not been assessed and approved to administer her own medications independently. Review of the facility policy Medication Administration, last reviewed1/17/23, revealed .medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards . (step 15) observe the resident consumption of the medications. Resident #75 (R75) During an interview on 7/7/26 at 8:32 AM, LPN E reported that R75 preferred to take medications slowly, at her own pace, and would often ask the nurse to leave the medications at her bedside so R75 could take her medications at her own leisure. LPN E reported that leaving medications at the bedside was against the facility policy, however, other people (nurses) leave them for her and leave the room. Review of the facility policy, Medication Administration last reviewed and revised 1/17/23 revealed, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Professional standards such as Nursing: Scope and Standards of Practice (American Nurses Association [ANA], 2021) apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications .1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication.Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses, administering medications using the seven rights, monitoring and evaluating medication effects, and assessing a patient's ability to self-administer medications. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of facility. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for residents. Findings Include: On 07/07/2026 at 9:30AM, observed in the 300-hallway shower room, black mildew-like growth, on the caulk (six to eight inches in length) on either side of the corner of the shower at the bottom juncture of the floor and wall. The wall covering directly beneath the shower head was bulging out from the wall, the wall surface below the covering felt solid. Housekeeping Director (HD) H stated that housekeeping had submitted a work order for the caulk to be replaced. Senior Maintenance Director (SMD) J stated they were aware of work order for the caulking in the shower room. On 07/07/2026 at 9:36AM, observed in the 100-hallway shower room, black mildew-like growth, on the caulk, in the shower area and the wall covering in shower area was bulging out from the wall. SMD J confirmed there was a work order for the caulking in the shower room.

Based on interview and record review, the facility failed to ensure that the resident's current advance directive was accurately reflected in the medical record for 1 of 3 residents (Resident #88) reviewed for the implementation of advance directives.Findings:Resident #88 (R88)Review of a Face Sheet revealed R88 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke) affecting the right dominant side and vascular dementia. Further review of the Face Sheet revealed R88 had a legal guardian.Review of R88's Advanced Directives Acknowledgements/CPR (Cardiopulmonary resuscitation) Consent signed and dated by R88's legal guardian on [DATE] revealed, No Resuscitation; In the event of a cardiac arrest, I am requesting a DNR (Do Not Resuscitate) order be issued.Review of R88's Do-Not-Resuscitate Order/Guardian Consent signed and dated by R88's legal guardian on [DATE] revealed the guardian consent to authorize no resuscitation in the event R88's heart should stop.Review of R88's Order Summary dated [DATE] revealed, Full Resuscitation.Review of R88's Electronic Medical Record (EMAR) revealed a banner with pertinent resident information which included reflected Code Status (Advance Directives) Full Resuscitate.During an interview on [DATE] at 9:24 AM, the Director of Nursing (DON) reported that the Unit Manager was responsible for ensuring the advance directive forms were completed as well as ensuring the EMAR accurately reflected the resident's/guardians wishes. The DON confirmed that R88's EMAR was inaccurate.During an interview on [DATE] at 2:44 PM, the DON reported she updated R88's code status order and ensured all applicable documentation had been scanned into R88's EMAR.Review of the facility policy, Residents' Rights Regarding Treatment and Advance Directives last reviewed/revised [DATE] revealed, .9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

Based on observation, interview, and record review, the facility failed to 1.) implement the facility policy for the prevention and treatment of pressure injuries, and 2.) ensure skin integrity/pressure injury assessments were comprehensive and complete for 1 of 3 residents (Resident #88), reviewed for pressure injury prevention and treatment. Findings:Resident #88 (R88)Review of a Face Sheet revealed R88 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke) affecting the right dominant side and vascular dementia.Review of R88's Hospice Note dated 6/24/26 and faxed to the facility on 6/26/26 revealed, (R88) is an [AGE] year old female admitted to hospice 7/10/25 with cerebrovascular disease .Ability to speak is declining .She is dependent for all ADLs (Activities of Daily Living): feeding, dressing, transfers, continence, bathing.Hoyer lift for transfers.Requires total assist for feeding, dressing, and hygiene.Incontinent of bladder and bowel .Poor appetite, she is eating less at meals and is more often refusing meals. Worsening dysphagia.Skin changes: left heel pressure injury has resolved .Summary of declines noted this certification period .decreased verbalization .speech limited to a few intelligible words such as what.Review of the Initial Social Service History dated 7/7/26 revealed R88 had severe cognitive impairment and was rarely/never understood due to a cerebral infarct affects residents ability to respond, vascular dementia, and dysphagia (difficulty swallowing).Review of R88's Nursing admission Evaluation dated 6/29/26 redness to buttocks .type-Pressure . There was no specific location of the pressure injury (left, center, or right buttock), no measurements, or descriptions of the wound.Review of R88's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 7/4/26 revealed a score of 17 indicating R88 was at a mild/low risk for pressure injuries. R88 was not identified as high risk (score of 12 or less). The following was documented for R88's Braden Scale:Sensory Perception: no impairment-Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. (Slightly limited was not selected despite the known decline in speech/communication and her advanced dementia).Moisture: occasionally moistActivity: chair fastMobility: slightly limited-Makes frequent though slight changes in body or extremity position independently. (Very limited was not selected despite her dependence on 2 staff for bed mobility, transferring, and personal hygiene).Nutrition: adequate-Eats over half of most meals. Eats a total of 4 servings of protein each day. (Very poor was not selected despite that advancement of her dysphagia, weight loss, and poor intake noted in the hospice assessment dated [DATE]).Friction and Shear: potential problem-Moves feebly or requires minimum assistance. (Problem was not selected despite her dependence on 2 staff for bed mobility and transferring).During an observation and interview on 7/6/26 at 11:33 AM, R88's Legal Guardian (LG D) and Certified Nursing Assistant (CNA) B were in the room discussing R88's skin breakdown. R88 was sitting up in a wheelchair with a throw pillow behind her back and did not have a pressure reducing device in place. There were no pillows, wedges, or other offloading devices observed in R88's room to assist with repositioning/offloading pressure while R88 was in bed (to offload pressure to R88's buttocks, hips, or other bony prominences excluding her heels/feet). CNA B stated that R88's bottom is getting worse and she was now getting the pink cream applied which was used for residents with the open ones (pressure injuries). Previously, the white cream was applied as a barrier. CNA B reported that hospice staff would be at the facility for R88 that day (7/6/26) and she would be requesting a pressure mattress. Following that interaction, CNA B exited the room.LG D also reported that she had concerns with R88's care over the weekend and reported that she was unable to visit with R88 Saturday (7/4/26) but when she arrived to the facility on Sunday (7/5/26) at approximately 4:30-4:45 PM she observed R88 in bed crying and was informed by facility staff that R88 had not been out of bed that day. LG D stated, she likes to sleep in but not like that. LG D reported that while visiting with R88 on 7/5/26 it was identified that R88's skin breakdown on her bottom had worsened, further stating, that sore was not there on Friday (when she had last visited and observed R88's skin.) LG D reported that R88 was at high risk for skin breakdown due to her history of wounds, her reliance on 2 staff members to assist with bed mobility and transferring, her incontinence of bowel and bladder, her inability to make her needs known (repositioning and/or pain), and the ongoing decline of her health. LG D reported she was upset that not only had R88 been left in bed all day but also because of the lack of interventions implemented which resulted in the worsening of R88's skin breakdown. LG D reported that CNA B wrote down directions for R88's preferences and needs which was then posted in R88's clothes closet for staff to reference the morning of 7/6/26. Review of the care tips hung in R88's closet included the following handwritten directions .Please turn (R88) completely on her side (every 2 hours). New/old sore is getting worst (sic). Apply pink cream to open sores-white cream to red spots.During an observation and interview on 7/8/26 at 8:42 AM, CNA B reported that she had worked with R88 on Saturday (7/4/26), was off on Sunday (7/5/26), and had identified that R88's skin breakdown had progressively worsened on Monday (7/6/26) when she returned to work. CNA B confirmed R88 did not have a pressure reducing cushion for her wheelchair and obtained one on Monday to prevent additional deterioration of the breakdown as LG D required R88 to be up in her wheelchair for a set amount of time each day. CNA B began performing incontinence care for R88 and rolled her on her side to expose the area of breakdown for observation. CNA B pointed to the area of R88's coccyx/sacrum and stated, now she has an open area further stating that prior to her return to work on 7/6/26 the skin breakdown wasn't pink (referring to the wound bed) and wasn't open. CNA B reiterated that the skin breakdown wasn't like this when she got here (admitted ). CNA B was asked to describe R88's skin breakdown prior to Sunday (7/5/26) and she reported that R88 had areas of dark pigmentation and fragile skin (scar tissue from previous pressure injuries) and then pointed to the current area of breakdown and stated, it was a small little poke and confirmed the area had increased in size. CNA B was asked to provide a size comparison and established that prior to 7/5/26 the open area was the size of a #2 pencil poke (like the dot it would leave on a piece of paper) and it was now the size of the #2 eraser.CNA B reported that the white cream was applied to pink areas (areas of redness) and the pink cream was applied when it opens for pressure injuries/skin breakdown. CNA B reported that she had immediately notified Registered Nurse (RN) A on Monday 7/5/26 of R88's breakdown and had him put in for (order) pink cream.Review of R88's Order Summary dated 7/6/26 at 12:30 PM revealed, Cleanse MASD (Moisture Associated Skin Damage) to bilateral buttock and coccyx with soap and water, pat dry, apply antifungal powder and zinc oxide every morning and bedtime and as needed. Confirming R88's skin breakdown had worsened which required ordered treatment.Review of R88's Wound Assessments revealed no wound assessment/measurements were completed on 7/5/26 following the identification of the worsening of the skin breakdown or on 7/6/26 following the treatment order change (as of 7/8/26 at 9:00 AM).Review of R88's Electronic Medical Record revealed no documentation of the worsening of R88's skin breakdown or that the provider was notified of the worsening of R88's skin breakdown or the need for a change in treatment.Review of the Physician Communication Book (not part of the legal medical record but utilized to communicate non-emergent concerns with the provider) revealed no entries related to the worsening of R88's skin breakdown.Review of R88's Weekly Skin Assessments revealed no assessment was completed on 7/6/26 as required (as of 7/8/26 at 9:00 AM).Review of R88's risk for and actual impaired skin integrity Care Plans revealed no new or modified interventions following the identification of the worsening of R88's skin breakdown and had not been revised since 6/30/26.Review of R88's Skin Issue assessment dated [DATE] at 1:43 PM revealed, New skin Issue. Location: Buttocks - generalized. Issue type: Moisture associated skin damage (MASD). Progress: Monitoring: Wound healed or closed with continued monitoring. MASD: IAD Incontinence Associated Dermatitis. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 5.59 Width (cm): 6.8 Depth (cm): 0.Surrounding tissue: Blanching.Erythema.Fragile.Scarring.Additional care: Pressure reducing device for chair.Turning/repositioning program.Positioning wedge.Pressure reducing device for bed.Skin issue notification: Guardian.Provider.Wound nurse.Dietitian .hospice. The extent of the worsening of the skin breakdown cannot objectively be determined due to the lack of the initial measurements upon admission.During an interview on 7/8/26 at 9:24 AM, the Director of Nursing (DON) reported she was aware that R88's treatment order changed on 7/6/26 but was only notified that the skin breakdown had the appearance of yeast and therefore antifungal treatment was included. The DON confirmed R88's skin assessment was not completed on 7/6/26. During an interview on 7/8/26 at 10:45 AM, the DON reported that measurements of the areas of skin breakdown should have been obtained on admission as well as on 7/6/26. She confirmed that R88 was at a high risk for pressure injuries/skin breakdown and a risk assessment for an unavoidable pressure injury should have been completed and her care plan should have reflected that risk with high-risk interventions implemented at that time.During an interview on 7/7/26 at 8:28 AM, LPN E reported that if a new skin injury or the worsening of a previous injury was identified, the nurse caring for the resident would immediately notify the unit manager. The unit manager and Infection Control Preventionist would then assess and document on the skin injury, implement an appropriate order, notify the family and provider, and implement and/or update interventions on the resident's care plan.Review of the facility policy, Pressure Ulcer/Skin Breakdown-Clinical Protocol last reviewed/revised 3/20/24 revealed, .5. Initial screen.All PU/PI (pressure ulcer/pressure injury) or other skin related issues are measured and documented (electronic medical record).7.Weekly skin evaluation/assessment by the licensed nurse on residents who have no current PU/PI.8. Change of condition/New Skin Alteration: Notify physician and Resident Representative of all new and/or non-healing/worsening PU/PIs.18. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.

Based on interview and record review, the facility failed to accurately document the administration of narcotics for 3 of 3 residents (Resident #29, Resident #39, and Resident #65) reviewed for narcotic reconciliation. Findings:Resident #29 (R29)During an interview on 07/06/26 at 11:00 AM employee 0 stated that R29 had left the building that morning (7/6/26) at 8:40 AM and was transported to the hospital. Review of an Individual Patient's Narcotic Record reflected documentation that R29 received one tab of oxycodone 15 milligrams (MG) at 9:30 AM on 07/06/26 (when R29 was not in the building). During an interview on 07/06/26 at 11:25 AM, Registered Nurse (RN) Q reviewed the above mentioned document for R29 and stated that the incorrect time was documented. Resident #39 (R39)Review of an Individual Patient's Narcotic Record on 07/06/26 at 11:07 AM reflected documentation that R39 received one dose of morphine sulfate 20 MG at 12:00 PM on 07/06/26. During an interview on 07/06/26 at 11:25 AM, RN Q reviewed the above documentation for R39 and indicated that documentation reflected when the medication was scheduled to be given, not when it was actually administered to R39. During an observation on 07/06/26 at 11:32 AM, the bottle of liquid morphine sulfate ordered for R39 was checked (in the presence of the Director of Nursing (DON)) to ensure the remaining medication in the bottle matched the remaining amount documented on the Individual Patient's Narcotic Record. The documented amount of morphine sulfate remaining was 14.5 milliliters (ML's) and the visualization of the remaining amount in the bottle was approximately 16.5 ML's. The DON stated that the discrepancy should have been reported and corrected. Resident #65 (R65) Review of an Individual Patient's Narcotic Record on 07/06/26 at 11:09 AM reflected documentation that R65 had received one dose of Norco 10-325 MG's at noon on 07/06/26. During an interview on 07/06/26 at 11:25 AM, RN Q reviewed the above documentation for R65 and indicated that documentation reflected when the medication was scheduled to be given, not when it was actually administered to R65. RN Q acknowledged that the documentation should match the time given. During an interview on 07/06/26 at 11:27 AM, the Director of Nursing indicated that the expectation for documentation of all administered controlled substances was to document the precise time the medication was administered to the resident.

This citation pertains to intake #2664534Based on interview and record review, the facility failed to ensure medications were available and given within physician ordered parameters for two of three resident's (Resident 100 and Resident 109) reviewed for professional standards. Findings:Resident #100 (R100)Review of an admission Record revealed R100 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnosis of Parkinson's Disease and Dementia. Review of an Electronic Medication Administration Record (Emar) dated August 2025 revealed a medication order for R100 to take Namenda one 10 milligram (mg) tablet twice daily for Dementia. Documentation for administration of this medication to R100 reflected that the medication was not available starting the evening of August 12th and continued to be unavailable until the morning of August 22nd. Further review of the documentation revealed that a physician was not notified that the medication was unavailable for R100 and that the resident subsequently did not receive 19 doses of the Namenda. Resident #109 (R109)Review of an admission Record revealed R109 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of hypertensive (related to high blood pressure) heart disease with heart failure, chronic kidney disease stage 3, and aortic valve stenosis (blockage). Review of an Emar dated December 2025 for R109 revealed the following physician order: Hydralazine 25 mg one tab by mouth every 12 hours for high blood pressure-HOLD for blood pressure less than 140/90, start date 12/02/25. Further review of the December 2025 Emar for R100 revealed that despite that nursing had documented blood pressures just prior to administration of the Hydralazine, the medication was given outside physician ordered parameters 16 times.During an interview on 12/26/25 at 11:30 AM, the Director of Nursing could not explain the unavailable Namenda and the Hydralazine being administered outside physician ordered parameters and indicated that this was not the professional standard for nurses.

This citation pertains to intake # 2664534Based on observation, interview, and record review, the facility failed to secure prescription medications in two of four treatment carts and one of four medication carts, and for three of four residents (Resident R100, Resident R109, Resident 108) reviewed for medication storage. Findings:During an observation on 12/26/2025 at 12:43 PM, the treatment cart on the 400 hall was not locked. Upon review, the drawers contained prescription ointments, bandages and scissors. During an observation on 12/30/25 at 7:15 AM, the 200-hall treatment cart was not locked and contained prescription medications and treatments. During an observation on 12/30/25 at 9:02 AM, the 100-hall medication cart was unlocked and unattended by a nurse. During an observation on 12/26/25 at 3:30 PM a small plastic cup of prescription medications sat on top of the 100-hall medication cart and was not attended by a nurse. Resident #100 (R100)Review of an admission Record revealed R100 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of Parkinson's and dementia. During a telephone interview on 12/26/25 at 11:20 AM, family member L stated while visiting in the past, R100's medications have been observed on the bedside table without a nurse present in the room. During an interview on 12/26/25 at 12:40 AM, R100 stated yes when asked if his medications are left on the table for him to take at a later time. Resident #109 (R109)Review of an admission Record revealed R109 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's disease.During an observation on 12/30/25 at 6:58 AM R109 laid in bed resting with his eyes closed. A small plastic cup containing pills sat on top of the over bed table. A nurse was not present in the room. Resident #108 (R108)Review of an admission Record reflected R108 admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis of the left side following a stroke), a history of brain cancer and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R108 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15.During an interview on 12/26/2025 at 3:50 PM, R108 and their partner reported that nurses will leave R108's medication at the bedside from time to time. R108's partner reported that when this happens, I make sure she gets all the pills down. Review of the facility Policy and Procedure-Medication Storage revealed the following: All drugs and biologicals will be stored in locked compartments and .during a medication pass medications will be under the direct observation of the person administering medications.

Based on observation, interview, and record review, the facility failed to follow infection control practices for enhanced barrier precautions and medication administration for four of six residents (Resident #100, Resident #104, Resident #105, and Resident #106) reviewed for infection control. Findings:Resident #100 (R100)Review of an admission Record reflected R100 admitted to the facility 2/20/2025 with diagnoses that included neuromuscular dysfunction of the bladder. Review of a Care Plan initiated 2/20/2025, revised 10/14/2025 reflected that R100 required enhanced barrier precautions related to Foley catheter placement. During an observation on 12/26/25 at 12:40 PM, there was no signage on R100's room that indicated he required Enhanced Barrier Precautions (EBP) nor any Personal Protective Equipment (PPE) for staff to utilize when providing close contact care. Resident #104 (R104)Review of an admission Record reflected R104 admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder. Review of a Care Plan initiated on 11/28/24, revised 12/02/2024 reflected that R104 required enhanced barrier precautions related to an indwelling catheter. During an observation on 12/26/25 at 12:22 PM, there was no signage on R104's room that indicated that he required Enhanced Barrier Precautions (EBP) nor any Personal Protective Equipment (PPE) for staff to utilize when providing close contact care. Resident #105 (R105)Review of an admission Record reflected R105 admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder. Review of a Care Plan initiated on 1/02/2025, revised 5/01/2025 reflected R105 required enhanced barrier precautions related to indwelling catheter and a chronic wound. During an observation on 12/26/25 at 12:28 PM, there was no signage on R105's room that indicated he required Enhanced Barrier Precautions (EBP) nor any Personal Protective Equipment (PPE) for staff to utilize when providing close contact care. Resident #106 (R106)Review of an admission Record reflected R106 admitted to the facility on [DATE] with diagnoses that included cutaneous abscess of abdominal wall and encounter for attention to other artificial openings of digestive tract.Review of a Care Plan initiated on 11/15/2025, revised 11/17/2025 reflected R106 required enhanced barrier precautions related to a feeding tube. During an observation on 12/26/25 at 12:46 PM, there was no signage on R105's room that indicated she required Enhanced Barrier Precautions (EBP) nor any Personal Protective Equipment (PPE) for staff to utilize when providing close contact care. During an interview on 12/30/2025 at 9:54 AM, the Director of Nursing (DON) and Registered Nurse (RN) A reported they were both certified Infection Control Practitioners. The DON and RN A indicated that they were new to their roles and had conducted an audit of the building to identify all residents who required Enhanced Barrier Precautions (EBP). The DON and RN A confirmed that observations made on 12/26/2025 revealed that EBP had NOT been in place as required. When asked, RN A stated she had not reviewed physician orders or care plans as a part of the audit.Review of a policy Enhanced Barrier Precautions (EBP) revised 3/26/2024 reflected It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.During an observation on 12/26/25 at 3:36 PM, Registered Nurse (RN) K prepared medications for the resident residing in room [ROOM NUMBER] and popped a medication out of the card. The pill landed on top of the medication cart and RN K scooped the pill up using the medication card and placed the pill in the plastic medication cup that contained other medications. RN K then took the cup of medication to room [ROOM NUMBER] and administered them to the resident.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach of residents for one of three residents (Resident#107) reviewed for call light placement. Findings:Resident #107 (R107)Review of an admission Record reflected R107 originally admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side paralysis following a stroke). Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R107 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10/15. The assessment reflected R107 needed setup or clean-up assistance to eat and with oral hygiene and was dependent on staff for toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During an observation and interview on 12/26/2025 at 12:27 PM, R107 was observed in bed, the touch pad call light was out of reach. R107 reported that her call light is out of reach two to three times a day and that it is very frustrating.During an observation on 12/26/2025 at 12:30 PM, Medical Records (MR) staff member C came into R107's room at the surveyor's request and confirmed R107's call light was not within reach.Review of the facility Policy and Procedure Call Lights: Accessibility and Timely Response reflected .staff are educated in the proper use of the resident call system .and ensuring resident access to the call light.

This citation has two deficient practice statements. DPS A Based on observation, interview, and record review, the facility failed to follow standards of practice when caring for peripherally inserted central catheter (PICC) lines for two of two resident's (Resident #230 and Resident #224) reviewed. Findings: Resident #230 (R230) Review of an Admission Record revealed R230 was a [AGE] year old Spanish speaking male, admitted to the facility on [DATE], with pertinent diagnoses of recent surgical removal of the right great toe due to osteomyelitis and the need for IV (intravenous) antibiotics. During an observation on 05/06/25 at 11:42 AM, Registered Nurse (RN) D entered R230's room to hang antibiotics and administer them through the PICC line. The PICC line did not have an end cap on it. RN D correctly cleaned the end of the PICC line with an alcohol wipe and then laid the end of the PICC line on R230's blanket. RN D prepared the antibiotic and connected the tubing to the end of the PICC line without cleaning the end of the PICC line again. During an observation on 05/07/25 at 3:04 PM, R230's PICC line did not have an end cap on it. Resident #224 (R224) Review of an Admission Record revealed R224 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of peritoneal abscess (an infection in the digestive system) caused by methicillin resistant staphlococcus aureus (MRSA). During an observation on 05/06/25 at 09:30 AM, RN C prepared the PICC for administration of antibiotics and the line did not have an end cap on it. During an observation on 05/07/25 at 3:27 PM, R224's PICC line did not have an end cap on it. During an interview on 05/07/25 at 2:14 PM, Infection Control Nurse (ICN) A stated that PICC lines should be capped for infection control prevention. During an interview on 05/08/25 at 10:20 AM, the Director of Nursing (DON) stated that PICC lines should have end caps on them and they sometimes come to (the facility) without them placed at the hospital. The DON was not sure if they had a current supply of end caps for the PICC lines available in the facility. Proper care of central line insertion sites is critical for the prevention of central line- associated bloodstream infection (CLABSI) (Box 42.6) (CDC, 2017; INS, 2016a). Nurses and health care providers must have specialized education regarding care of CVCs and implanted infusion ports (TJC, 2018). Nursing responsibilities for central lines include careful monitoring, flushing to keep the line patent, and site care and dressing changes to prevent CLABSIs (INS, 2016a). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1001). Elsevier Health Sciences. Kindle Edition. 29073 DPS B Based on interview and record review the facility failed to implement its Water Management Program according to facility policy. Findings: During an interview on 5/7/2025 at 2:30 PM, the facility Water Management Program Plan and Policy were requested along with monthly water assessments from the Nursing Home Administrator (NHA). On Wednesday 5/7/25 the Water Management Program was received along with the facility policy and the January 2025 water monitoring log. During an interview on 5/8/2025 at 1:06 PM, the NHA reported that the facility had not been completing the monthly water assessments for chlorine as the policy required for the months of February, March and April 2025 as the policy required. According to the NHA, It just fell off the radar due to a transition in maintenance staff at the facility. At this time, the monthly water assessments for 2024 were requested. As of the time of exit, 5/8/2025 at 12:30 PM, no documentation was received. Review of the facility policy Water Management Program implemented 1/1/2021, last reviewed/revised 7/14/2020, indicated It is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous, mycobacteria, and fungi) in the facility's water systems. The policy specified 7. Testing protocols and control limits will be established for each control measure. A. individuals responsible for testing or visual inspections will document findings, b. When control limits are not maintained, corrective actions will be taken and documented accordingly.; c. Protocols and corrective actions will reflect current industry guidelines (i.e. ASHRAE, OSHA, CDC). 8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will verify the program activity for which they are responsible. 9. The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness.

Based on observation, interview, and record review, the facility failed to position two of two resident's (Resident #37 and Resident #49) in a manner to reduce the likelihood of choking or aspirating. Findings: Resident #37 (R37) Review of an Admission Record revealed R37 was a [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of dementia, epilepsy, cognitive communication deficit, generalized muscle weakness, and the need for assistance with personal care. R37 utilized a tube feed to assist with nutrition and hydration and required assistance from 1 staff person for bed mobility and eating. During an observation on 05/08/25 at 9:03 AM, R37 (a) laid in bed awake with the head of the bed at 14 degrees, (b) held an emesis basin with both hands and it sat on her chest touching her chin and bottom lip, (c) had a white cloth that sat under the basin and was saturated with emesis. R37 stated I'm sick a lot. R37 had 2 glasses of nectar thick fluids bedside and within reach. During an interview on 05/08/25 at 9:13 AM, Unit Manager-Licensed Practical Nurse (UM-LPN) E reported that R37 reported feeling sick most everyday and R37 held onto the emesis basis like a security blanket. It's a comfort thing for her, she doesn't get sick though. During an interview on 05/08/25 at 9:26 AM, certified nurse aide (CNA) K indicated that she had last observed R37 at approximately 7:30 that morning, provided morning cares, and R37 had asked CNA K for an emesis basin. CNA K was not aware that R37 had vomited. Resident #49 (R49) Review of an Admission Record revealed R49 was a [AGE] year-old female, last admitted the facility on 02/06/25, with pertinent diagnoses of a stroke, dementia, seizure disorder, and the need for a tube feed for nutrition and hydration. During an observation on 05/08/25 at 9:45 AM, R49 laid in bed, the tube feed was running, and the resident's upper body was positioned at 20 degrees. During an interview on 05/08/25 at 9:50 AM, the Director of Nursing (DON) came to R49's room and stated that she could not say for sure if the head of the bed was below 30 degrees. The DON stated that there had been a level attached to the side of the bed to assist staff with making sure the bed was at elevated to at least 30 degrees when the tube feed was running, but it was missing from the bed. The DON also indicated that a sign was supposed to hang on the wall at the head of the bed to show staff visually what the head of the bed would look like at 30 degrees, but it was missing from the wall. During the same interview, LPN F appeared at the doorway, the DON remained LPN F that the head of the bed should be at least 30 degrees when the tube feed was running. LPN F stated that she had tried to raise the head of the bed earlier that morning, but R49 seemed uncomfortable, and so LPN F left the head of the bed lowered with the tube feed running. Review of Care Plans for R49 revealed that for the focus areas at risk for altered nutrition, impaired gastrointestinal status, impaired communication, and impaired cognitive function, none of the care plans included safety interventions related to maintaining the head of the bed at 30 degrees or more when the tube feed ran and 30 minutes following. During an interview on 05/08/25 at 10:40 AM, the DON reported that the facility did not have a policy and procedure related to tube feedings that directed staff to maintain the head of the bed at 30 degrees or more when a tube feed ran. Review of the Fundamentals of Nursing revealed, Enteral Feedings .To reduce the risk for aspiration, nurses follow several practices, such as keeping the head of bed elevated at 30 to 45 degrees .[NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1121). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing. Findings include: During an interview with Maintenance Director (MD) C, at 1:02 PM on [DATE], it was found that he mostly takes care of the Water Management Plan (WMP). When asked if there was a team that he would meet with to go over the plan, MD C stated only if things go wrong. When asked what kind of tests are performed on the facilities water supply? MD C stated he tests for free chlorine monthly and a Legionella test every six months. When asked when the last Legionella sample had been done, MD C stated it had been over 6 months due to a staff leaving and the bottles not getting ordered. When asked what was used to test for free chlorine in the water supply, MD C handed the surveyor free chlorine test strips. MD C stated the test strips had expired and that he needed to get more. Observation found that the test strips used a color gradient and went from ,d+[DATE] parts per million (ppm) with no accurate way to get a concentration to the tenth of a ppm. Further observation found the test strips had expired on ,d+[DATE]. All logged chlorine test samples were found to be .25 ppm. When asked what the facility uses as a control limit, MD C, stated .25 ppm. A record review of the facilities Water Management Program policy, not dated, found that section one under Policy Explanation and Compliance Guidelines states I. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. The policy goes on to state 8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program activity for which they are responsible. 9. The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness.

Based on observation, interview, and record review, the facility failed to ensure proper accountability and storage of controlled substances and medications resulting in controlled substance verifying counts not conducted on the Lodge Hall, an unaccounted for controlled substance for one resident (R25), and an outdated and in use medication with a shortened shelf life after opening, and the potential for controlled substance diversion and administration of outdated medication with decreased efficacy. Findings: On 5/9/23 at approximately 11:12 AM an observation and interview were conducted with Licensed Practical Nurse (LPN) E at the Lodge Hall medication cart. It was also observed that the Electronic Medical Record (EMR) displayed a list of seven resident names in a bright pink color. LPN E reported that the resident names in the bright pink color displayed by the EMR system indicated the medications were late for administration. LPN E reported that although the system indicated the medications were late the facility had a liberalized med pass providing a widened administration time frame. LPN E reported that, because the nurse assigned the Lodge Hall did not report for work, the Lodge Hall residents were split up amongst the remaining three nurses assigned to other halls and shared in the medication administration on the Lodge Hall. In a follow up interview on 5/9/23 at 3:12 PM, LPN E reported that the four medication carts used on the four separate halls all have a universal key. That is, any one medication cart key can open any of the four medication carts. LPN E reported that while any nurse with any medication cart key can open any cart, the keys for the controlled substances drawer is specific to each cart. LPN E reported that when medication administration on a unit is split amongst three different nurses the controlled substance key is locked in the top drawer of the cart on the shared hall. LPN E reported this makes the controlled substance key for the shared hall available to any of the nurses from the other halls. LPN E indicated that after the nurse passes medications to their split of residents for the shared hall the controlled substance key is again locked in the top drawer for the next nurse. LPN E reported that there is not a count and verification of the controlled substances in the shared cart when the responsibility of this cart changes between the three different nurses. On 5/9/23 at 11:55 AM an interview was conducted with Registered Nurse (RN) F on the Great Lakes Hall. RN F reported that when three nurses share in a medication pass on another hall that she will pass medications on her hall first before going to the unstaffed nurse hall. RN F reported the nurses split the residents up and that the controlled substance key is locked in the top drawer, making it available for the next nurse. RN F did not indicate that the controlled substances count is verified between all the nurses sharing the medication cart. On 5/11/23 at 2:59 PM an interview was conducted with the Director of Nursing (DON). The DON reported that when three halls have nurse coverage but the fourth does not, the three nurses will split up the residents for the fourth hall medication pass. The DON reported it varies on what time each nurse will be able to medications to the residents on the hall not staffed with a nurse. The DON reported that all medication cart keys work to open any medication cart but indicated the controlled substance drawer key is specific to that cart. The DON reported that this key is locked in the unstaffed nurse hall medication cart. The DON reported that this gives each of the nurses access to the controlled substances. The DON reported that the controlled substances are not counted each time a different nurse assumes responsibility of the medication cart. Review of the facility document titled Narcotic Shift Count labeled for the Lodge Hall was reviewed. The document reflected on 5/9/23 at 6:00 AM the written initials of the Off Going Nurse were documented but the slot for the On Coming Nurse was blank. This indicated that the end and the beginning of shift narcotic count was not conducted with two nurses. The Narcotic Shift Count log did not display the initials of any of the three nurses that had divided the Lodge Hall residents for medication pass and had singular access to the locked controlled substance drawer. These included LPN E scheduled for the Windmill Island Hall, LPN F on the Great Lakes Hall, and LPN K scheduled on the White Pines Hall. The Narcotic Shift Count log reflected that the next narcotic count after the initials of the off-going nurse at 6:00 AM was conducted on 5/9/23 at 10:21 AM by LPN J and LPN L. In an interview conducted 5/11/23 at 4:08 PM the DON reported that LPN J counted narcotics with the off going nurse on the Lodge Hall as the oncoming nurse at 6:00 AM on 5/9/23 but failed to initial the Narcotic Shift Count log leaving that section blank. The DON did not provide any further information on verification of accuracy of narcotic counts between the three nurses that shared the medication cart on the morning of 5/9/23. The policy provided by the facility titled Controlled Substance Administration and Accountability, last revised 1/1/2022 was reviewed. The facility document reflected, 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. In this policy under the heading Policy Explanation and Compliance Guidelines included 8. The Charge Nurse on duty will maintain the keys to controlled substance containers. The keys to this container should not be shared with other staff, including licensed staff without first conducting a complete controlled substance count. R25 Review of the EMR reflected R25 was admitted to the facility 10/28/22 with diagnoses that included Dementia and Anxiety Disorder. The EMR reflected that R25 had a current order for the controlled substance Alprazolam, 1 milligram (mg) every six hours and this had been administered to her on 5/11/23 at 12:00 PM. On 5/11/23 at 12:37 PM a review was conducted of the Great Lakes Hall medication cart locked controlled substance drawer with LPN F. The review revealed that the medication blister card for Alprazolam 1 mg for R25 contained 7 tablets, but the Control Substance Record (aka controlled substance proof of use log) reflected 8 tablets remained after the dose administered by LPN F at 12:00 PM on 5/11/23. This indicated that one dose of the controlled substance Alprazolam was unaccounted for. LPN F acknowledged a discrepancy between the documented amount remaining and the actual amount remaining. On 5/11/23 at 2:59 PM an interview was conducted the Director of Nursing (DON). The DON was asked what actions were taken regarding the discrepancy noted on the Great Lakes Hall medication cart controlled substance drawer for the medication Alprazolam for R25. The DON reported the discrepancy was a medication error. The DON was asked if the rest of the controlled substances on the Great Lakes medication cart were counted to ensure no other discrepancies existed. The DON reported a count of the Great Lakes Hall controlled substances had not been conducted. On 5/11/23 at approximately 12:45 PM a review was conducted of the medication room refrigerator on the Great Lakes Hall with LPN F. The review revealed an opened and in use multidose vial of Purified Protein Derivative (PPD) solution dated 4/7/23. LPN F reported that the medication is only good for 30 days once it is open and indicated it should have been discarded. Review of the manufacturer's package insert for PPD solution reflected Storage: A vial of (PPD solution) which has been entered and in use for 30 days should be discarded. Do not use after expiration date. The manufacturer's recommendations reflected the vial of PPD solution dated 4/7/23 found in the refrigerator of the Great Lakes Hall should have been discarded 5/6/23 but had remained available for use at least until it's discovery on 5/11/23.

This citation refers to intake M100134981. Based on interview and record review, the facility failed to report and thoroughly investigate an allegation of valued ring missing for 1 (Resident #423), resulting in the State Agency not being notified of a potential misappropriation of property. Findings include: Resident #423 Review of a Face Sheet revealed R423 originally admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness), vascular dementia, and a right above the knee amputation. In an interview on 5/10/23 at 10:35 AM, R423's wife (Family Member) FM M reported the resident had a gold ring with a diamond on it that was tight on his finger that was missing since around September of last year. FM M reported she told the Nursing Home Administrator (NHA) and the Social Worker (SW). In an interview on 5/11/23 at 8:09 AM, the NHA reported he did not report the ring was missing for R423 because they were doing Caring Partner rounds and was not updated that the ring was still missing. His last communication with the resident's wife was that she was going to check with her sons and the van they transport him in to make sure they did not have it. Review of a Quality Assistance Form received 11/9/22 revealed a concern from R423's wife that a gold banded rings is not on the resident, and she last saw the ring 11/4/23. The findings revealed they searched the facility and sent a message to all staff. FM M is to ask her sons and search the van to see if they have it. Review of a policy titled Abuse, Neglect and Exploitation revised 10/24/22 revealed: It is the policy of this facility to provide protections for 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.

Based on observation, interview and record review, the facility failed to assess and implement care and services for 1 (Resident #53), reviewed for range of motion, resulting in a resident not receiving appropriate care for contractures and the potential for worsening. Findings include: Resident #53 (R53) Review of a Face Sheet revealed R53 originally admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness), epilepsy, and a left femur fracture. Review of the Minimum Data Set (MDS) dated [DATE] revealed R53 is cognitively intact and requires extensive assistance of one staff for bed mobility and transfers did not occur. She has limited range of motion on one side of her upper and lower extremities, and no behaviors of rejecting care. During an observation and an interview on 5/9/23 at 2:19 PM, R53 was in bed and reported she is weak on the left side of her body and complained she did get therapy off and on. Her left hand is contracted with her fingers folded at a 90-degree angle at her knuckles. She denied wearing or having any splints for her hands. Her left arm was not supported or elevated. During an observation and an interview on 5/11/23 at 9:00 AM, Occupational Therapist (OT) H reported R53 has severe contractures, and the facility was going to start contracture care on R53 starting the following week. R53s insurance would not allow therapy to have more treatments with them but did do some passive range of motion in the past. OT H is motivated to have therapy and needs some encouragement. R53 currently has a brace for her hand and should be care planned for a wearing schedule. R53 has had a brace that OT H knew of since she started at the facility last spring. OT H went to R53's room and asked the resident where her hand splints/braces were, and the resident did not know. After searching R53's room she found 2 different hand splints and said she could wear either one. OT H had a challenging time putting the splint on to fit the residents' hand and said R53's contractures are definitely worse than before. R53 was complaining her left shoulder was having some pain and OT H reported R53 was to wear a sling as well. R53 reported she asked staff to put on her braces a while ago, but the staff was not sure if they should, so they left to room to ask someone and never came back. R53 reported the staff did not want to take her word for it. OT H reported the nursing staff are notified of therapy recommendations/treatments by a Therapy Communication to Nursing form that is kept in a binder in the gym and is also told to the Director of Nursing (DON), Unit Managers (UM), and the floor nurse. Review of the Therapy Communication to Nursing document dated 7/14/21 for R53 revealed: Subluxation sling and resting hand splint to be worn as tolerated throughout the day. Review of an Occupational Therapy Encounter dated 7/13/22 for R53 revealed: Patient also placed (left) splint on (left) hand and encouraged to wear for 2 hours. Review of the Care Plan for R53 revealed a focus of Monitor/document/report to Nurse/MD (As needed/signs or symptoms) or complications related to arthritis: Joint pain; Joint stiffness, usually worse on wakening; Swelling; Decline in mobility; Decline in self-care ability; Contracture formation/joint shape changes; Crepitus (creaking or clicking with joint movement); pain after exercise or weight bearing, Initiated: 01/25/202. Interventions included: Position flaccid left upper and lower extremity so they are supported, as she tolerates, initiated: 06/28/2022. No interventions for braces, splints, or slings.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for 1 of 3 residents (R44) utilizing a CPAP (continuous positive airway pressure) machine, resulting in R44's CPAP equipment not being cleaned per facility policy and the potential for the spread of illness and disease. Findings include: Resident #44 A review of R44's Admission Record, dated 5/10/23, revealed R44 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 44's Admission Record revealed multiple diagnoses that included heart failure, atrial fibrillation (an irregular heart rhythm), insomnia, and sleep apnea. A review of R44's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/10/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R44 was cognitively intact. During an observation and interview on 5/10/23 at 10:20 AM in R44's room, R44's CPAP (continuous positive airway pressure) mask was observed hanging from the side of the machine. The mask was not bagged. R44 stated the staff do not clean his CPAP equipment. He stated no one has ever cleaned the removable humidifier chamber or facial pillow/ mask or headgear. R44 stated the only people who have touched his CPAP machine or equipment was the medical equipment company that comes in weekly to change his CPAP tubing and check his machine's functionality. A review of R44's Treatment Administration Record (TAR), dated 2/1/23 to 5/10/23, failed to reveal any entries that indicated R44's CPAP mask, tubing, removable humidifier chamber, and/or headgear and straps had been cleaned. A review of R44's care plans failed to reveal any interventions that included the cleaning of R44's CPAP equipment (i.e., mask, tubing, removable humidifier chamber, headgear, and straps). The only mention of R44's CPAP usage were two interventions (one in the alteration in sleep care plan and one in the altered respiratory status care plan) that revealed R44 used a CPAP machine with the settings listed and that he was independent with putting on/taking it off the headgear and mask. During an interview on 05/11/23 at 08:10 AM, Licensed Practical Nurse (LPN) E stated the nurses wash the residents' face masks and removable humidifier chamber daily on the Day shift for those on CPAP machines. She stated sometimes she has to do it twice a shift because some of the residents will take a nap during the day and use their machines. LPN E stated after the nurses wash/clean a resident's face mask and removable humidifier chamber, they document it in the TAR. During an interview on 05/11/23 at 09:07 AM, Registered Nurse (RN) F stated the nurses clean residents' CPAP masks and tubing daily on the Day shift. She stated the cleaning is documented in the TAR. During an interview on 05/11/23 at 09:20 AM, LPN G stated residents' CPAP masks and tubing are cleaned daily on the Night shift. She stated it is then documented in the TAR. During an interview on 5/11/23 at 2:30 PM, the Director of Nursing (DON) stated the facility obtained a physician's order to clean R44's headgear and straps, tubing, and mask yesterday (5/10/23). This was confirmed with a review of R44's physician orders. A review of R44's physician orders, dated 6/29/22 to 5/11/23, failed to reveal any physician orders instructing the facility staff to clean R44's CPAP removable humidifier chamber. A second review of R44's May 2023 TAR revealed R44's mask was cleaned on 5/11/23 during the Day shift (probably after 9:20 AM since LPN G was R44's nurse on that shift and did not know she needed to clean his mask when interviewed). A review of the facility's CPAP/BiPAP (continuous positive airway pressure/bi-level positive airway pressure) Cleaning policy and procedure, reviewed/revised 1/1/22, revealed, 1. CPAP/BiPAP equipment may vary by manufacturer. Common equipment includes the machine, tubing, mask, headgear/strap, disposable/nondisposable filters, and humidifier chamber. 2. Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections . 5. Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclose in machine storage when not in use. 6. Weekly cleaning activities: a. Wash headgear/straps in warm, soapy water and air dry. b. Wash tubing with warm, soapy water and air dry . However, the facility's policy did not address the cleaning of the removable humidifier chamber that contains water to provide humidification while the CPAP is in use. The humidifier chamber may contain standing water when not in use that can harbor bacteria and other organisms which serve as a source of respiratory infections.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with Doctor's Orders and Manufacturer's recommendations for two Residents (R62 and R41) resulting in a medication error rate of greater than five percent, ineffective and reduced efficacy of the medications administered, and the potential for all facility residents to receive medication incorrectly. R62 Review of the Electronic Medical Record (EMR) reflected R62 originally admitted to the facility 1/22/2022 with pertinent diagnoses that included End Stage Renal Disease (ESRD) and Dependence on Renal Dialysis. On 5/11/2023 at 8:52 AM a medication administration observation was conducted with Licensed Practical Nurse (LPN) E and R62 in his room. LPN E was observed administering oral medication to R62. The medications included sevelamer carbonate 800 mg, three tabs with the direction for the medications to be administered with meals. In an interview conducted 5/11/2023 at 10:55 AM R62 reported that he ate breakfast approximately 8:00 AM. Review of the EMR Physicians Orders reflected an Order dated 4/25/2023 for the medication Sevelamer Carbonate Tablet 800 mg, Give 3 tablets by mouth with meals related to End Stage Renal Disease, and Give 1 tablet by mouth at bedtime related to End Stage Renal Disease Give with Food. Review of the manufacturer's package insert for the medication sevelamer carbonate revealed that the medication is a phosphate binder indicated for the control of serum (blood) phosphorus in patients with chronic kidney disease on dialysis. The manufacturer's directions on Dosage and Administration reflected the medication is to be taken with meals and is titrated (dosing adjustments) based on serum phosphorus levels. This revealed that changes in dosing with proper administration may be necessary to achieve desired phosphorus levels. Laboratory testing of blood is necessary to determine if dosing must be adjusted. Review of the laboratory test results of Phosphorus levels for R62 are as follows: -2/20/2023 - 7.8 High with a reference range (normal levels) 2.6 to 4.5. -3/08/2023 - 7.3 High -3/20/2023 - 7.6 High -4/17/2023 - 7.8 High Review of the EMR Doctor Order's history for R62 for the medication sevelamer carbonate reflected increasing dosing since 4/22/2022. On 4/22/2022 R62 received one tab with meals then later this was increased to two tabs with meals. On 8/19/2022 the dose of sevelamer carbonate was increased to three tabs with meals. The latest Doctors Order of 4/25/2023 reflected the dose increased to three tabs with meals and one tab with a nighttime snack. Documents provided by the facility titled Hemodialysis Communication Record are a record of communications from the dialysis center to the facility each time R62 had dialysis. The Hemodialysis Communication Record returned to the facility 2/8/23 was reviewed. The section with the heading To be completed by dialysis center reflected please give three tablets of (sevelamer carbonate) with each meal. (Patient) needs to take with first bite of food. On 5/12/2023 at 10:14 AM a telephone interview was conducted with Dialysis Clinical Manager (DCM) I at the dialysis center that performs renal dialysis for R62. DCM I reported that sevelamer carbonate should be taken literally with meals as the medication physically binds with the phosphorus in the food. DCM I reported that if the medication is not administered exactly as ordered it does not remove the phosphorus and that dialysis does not remove phosphorus from the body. DCM I reported that too much phosphorus in the system can cause calciphylaxis. DCM I explained that this condition is deposits of calcium where it shouldn't be, like under the skin or around blood vessels. DCM I was informed of the history of R62 of essentially unchanging serum phosphorus levels but multiple dose increases of sevelamer carbonate doses over time. DCM I reported that there is no benefit if sevelamer carbonate is not taken with the food which indicated prolonged incorrect medication administration to a compromised Resident. R41 Review of the medical record reflected that R41 initially admitted to the facility 3/11/22 with a pertinent diagnosis of Autoimmune Thyroiditis. This is an inflammatory condition that prevents the thyroid gland from producing enough hormones resulting in hypothyroidism (low thyroid hormone). Review of the Doctor's Orders for R41 reflected an order for Levoxyl tablet 50 micrograms (mcg), Give 1 tablet by mouth in the morning for low thyroid hormone. Give 30 minutes before food or other meds. On 5/11/23 at 8:05 AM a medication administration was observed with Registered Nurse (RN) F. RN F was observed to administer eight oral medications to R41 in her room. The medication Levoxyl 50 mcg was included with the other medications. On 5/11/23 at 10:01 AM an interview was conducted with R41 in her room. R41 reported she did eat breakfast prior to receiving the morning oral medications. Review of the manufacturer's package insert for the medication Levoxyl reflected, Administer once daily, on an empty stomach one-half to one hour before breakfast with a full glass of water. And Administer at least 4 hours before or after drugs that are known to interfere with absorption.

Based on interview and record review, the facility failed to track the vaccination status and provide the pneumococcal vaccine for 2 of 5 residents (R24 and R223) reviewed, resulting in a delay in R24 and R223 receiving their requested pneumococcal vaccines. Findings include: R24 A review of R24's Admission Record, dated 5/11/23, revealed R24 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 24's Admission Record revealed multiple diagnoses that included congestive heart failure, diabetes, and weakness. A review of R24's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/14/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R24 was cognitively intact. A review of R24's Pneumococcal Vaccine Consent Form, dated 3/8/23, revealed R24 requested to be given the pneumococcal vaccine. A review of R24's facility immunization records revealed R24 had received the PCV23 (pneumococcal conjugated vaccine 23) on 4/10/15. However, R24 had not received any other pneumococcal vaccines. A review of R24's Medication Administration Records (MAR's), dated 3/8/23 to 5/11/23, failed to reveal that R24 had been given the requested pneumococcal vaccine. R223 A review of R223's Admission Record, dated 5/11/23, revealed R223 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 223's Admission Record revealed multiple diagnoses that included chronic obstructive pulmonary disease (COPD- a lung disease). A review of R223's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/3/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 14 which revealed R223 was cognitively intact. A review of R223's Pneumococcal Vaccine Consent Form, dated 4/27/23, revealed R223 requested to be given the pneumococcal vaccine. A review of R223's facility immunization records failed to reveal if R223 had ever received a pneumococcal vaccine. A review of R223's Medication Administration Records (MAR's), dated 4/27/23 to 5/11/23, failed to reveal that R223 had been given the requested pneumococcal vaccine. During the infection control program review on 05/11/23 at 01:00 PM with the Director of Nursing (DON), a request was made for copies of documentation that indicated R24 and R223 had received their requested pneumococcal vaccines. During an interview on 05/11/23 at 02:30 PM, the DON confirmed R24 and R223 had signed consents to receive the pneumococcal vaccine. She stated neither resident had received the vaccine because they were both Veterans Administration (VA) patients and the facility did not have their immunization records from the VA. She stated the VA does not always add resident vaccine information to the state immunization database. The DON stated the facility had sent requests to the VA to see what pneumococcal vaccine R24 and R223 required and/or which one(s) they had already received and when. The DON stated she has not heard back from the VA regarding their requests. A copy of any documentation that would reveal when the requests for R24's and R223's were sent to the VA was requested from the DON. During a second interview on 05/11/23 at 03:16 PM, a copy of any documentation that would reveal when the requests for R24's and R223's were sent to the VA was requested from the DON. During a third interview on 5/12/23 at 10:30 AM, a copy of any documentation that would reveal when the requests for R24's and R223's were sent to the VA was requested from the DON. The DON stated she had forgotten about the earlier requests, but would get the requested documentation from facility's medical records person right away. During a fourth interview on 5/13/23 at 11:00 AM, the DON provided fax machine confirmation, dated 5/10/23 at 2:22 PM, that the facility had requested R24's and R223's immunization records from the VA. The DON stated she had thought the facility had sent a request to the VA for R24's and R223's immunization records, but when she spoke to the facility's medical records person, she found out that they had not sent one until 5/10/23 (2 months after R24 had requested the pneumococcal vaccine and 2 weeks after R223 had requested the pneumococcal vaccine). A review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccination: Summary of Who and When to Vaccinate information, dated 2/13/23, revealed the CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown. The CDC also stated adults [AGE] years or older have the option to get PCV20 if they have received the PCV13 (but not PCV15 or PCV20) at any age and the PPSV23 at or after the age of [AGE] years old (https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations).

This citation pertains to intake M100132402. Based on interview and record review, the facility failed to operationalize policies and procedures, appropriately assess, monitor, notify pertinent parties, implement meaningful care plans, and thoroughly investigate falls, for 1 (Resident #1), resulting in an inappropriate root cause analysis and interventions that lead to subsequent falls causing harm, serious injury and death. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 is an [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses of dementia, cognitive communication deficit, falls and Parkinson's disease. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed R1 was moderately cognitively impaired and required extensive assistance of 1 staff for transfers, toileting, and personal hygiene. She was not steady without human assistance and had limited range of motion on one lower extremity. R1 had a history of falls upon admission and had falls since admission with a non-major injury. She was not on a toileting program and was frequently incontinent of urine and always incontinent of stool. Review of the Significant Change of Condition MDS dated [DATE] revealed R1 was severely cognitively impaired and required extensive assistance of 1 staff for transfers, toileting, and personal hygiene. She was not steady without human assistance and had no range of motion impairments on any extremity. R1 had falls since admission that consisted of one fall with no injury and one fall with injury. Review of a Fall Prevention Program policy last revised 1/1/22 revealed: 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. 3. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 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. 6. When any resident experiences a fall, the facility will: .d) Notify physician and family. e) Review the resident's care plan and update as indicated. f) Document all assessments and actions. g) Obtain witness statements in the case of injury. Review of a Falls - Clinical Protocol policy last revised 1/1/22 revealed: 1. As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling . 2. Based on the assessment an initial plan of care will be developed and implemented to address identified risk. This will be revised as necessary. 3. The Minimum Data Set (MDS) and subsequent CAAs (Care assessment areas) will be utilized to develop the comprehensive plan of care to minimize fall and injuries from falls. 5. Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include Resident's abilities and deficits, Balance (sitting/standing), Adaptive equipment needs, Proper use of . bathroom safety. 6. In addition, interventions for direct care givers should be placed on the CNA care card or similar format. 8. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. Review of a Nursing Admission Evaluation dated 1/11/22 for R1 indicated the resident was at high risk for falls. Review of the Physical Therapy (PT) Evaluation and Plan of Treatment document for R1 revealed she started care on 1/12/22 for strain of muscle, fascia and tendon of left hip as well and abnormal gait and mobility. The resident could walk 10 feet with supervision and not attempted to walk 50 feet with two turns due to being in an isolation room and unwilling to do laps in her room. The resident was unable to stand without support as needed for 10 seconds and was able to sit unsupported for 30 seconds with no back support. Patient could not stand without upper extremity support with AD as needed for 10 seconds. She was moderately impaired for decision making ability for routine activities. Review of a Practitioner Progress note date 1/12/22 for R1 revealed: Per notes, she has had multiple falls over the last month. Provide a safe and supportive environment. Remind patient to call for help before ambulation. Review of an Incident Report dated 1/17/22 at 10:00 PM revealed R1 had an observed fall when she was found standing with her walker in front of her bathroom and fell backwards when the Certified Nursing Assistant (CNA) stepped towards her. There is suspicion her head was impacted. R1 did not know what happened and was documented as last observed at 9:45 PM sleeping. No documentation indicating other staff who worked this day were interviewed. Another resident name is documented as interviewed but no statement provided. The investigation results indicated the resident was self-ambulating and did not call for assistance. The resident had an abrasion, neurological checks were started, and all notifications were completed. Interventions included encouraging the resident to wear nonskid footwear when out of bed. The physician was notified and the Power of Attorney (POA). The Director of Nursing (DON) and Nursing Home Administrator (NHA) were not notified. Review of an Incident Report dated 1/23/22 at 9:00 PM for R1 revealed she had an observed fall while being toileted. She had a syncope (blacking out or fainting) episode and unable to transfer to the wheelchair and was lowered to the floor. The Environmental Factors documented reports the resident was being transferred to the bathroom when she became weak. She was last seen at 8:30 PM in bed. Immediate interventions were for a Physical Therapy (PT) referral and to wear nonskid footwear. The investigation results documented the resident was being toileted and was noted to sycopole (sic) episode and was lowered to the floor. The resident was noted to have an injury and denied pain/discomfort. The resident had a PT referral and encouraged to wear nonskid footwear while up. The only statement noted is from an unidentified staff member that revealed the Resident being toileted and had syncope episode. She was in and out of being awake and fell asleep. CNA and myself tried to transfer her to wheelchair once she came to, but she was dead weight and difficult to move. We laid her down to the floor and hoyered her to her bed. She was smiling and said she couldn't remember what happened. A brief objective description of the alleged incident revealed Resident had syncope episode on toilet and had to be laid to floor in order to be hoyered. Report is conflicting about the resident being toileted in the bathroom or being transferred to the bathroom. No neurological checks post fall noted. The name of the physician allegedly notified has a first name written with (on call) next to the name. Review of the Electronic Medical Records (EMR) for R1 revealed no progress notes dated for 1/23/22 indicating the resident had a fall and any follow up. No Neurological checks noted. Review of a Practitioner Progress Note dated 1/24/22 for R1 revealed the resident was seen for a follow up of medical conditions and physical therapy progression. This is a frail, elderly individual. She is currently lying in bed resting. She reports mild pain to her left hip. Assessment and Plan: . Frequent falls: Provide a safe and supportive environment. Remind patient to call for help before ambulation. Debility: Encourage participation with therapy as tolerated. Continue to assist with ADLs as needed and provide a safe environment. No documentation acknowledging R1 fell on [DATE] or the practitioner was aware. Review of a Practitioner Progress Note dated 2/4/22 for R1 revealed: . 4. Frequent falls: She continues to have episodes of weakness with nursing staff and therapy. Provide a safe and supportive environment. Monitor vital signs. 5. Debility: Assist with ADL's as needed and provide a safe environment Review of a Practitioner Progress Note dated 2/7/22 at 10:32 AM for R1 revealed: She has had episodes of weakness periodically where she loses her balance. This afternoon, she got up from the toilet unassisted and fell forward, hitting the back of her head on the door frame. She did not lose consciousness. She has a laceration about two inches in length on the back of her head that will need stitches. She will be sent to the hospital for this. Review of an Incident Report dated 2/7/22 at 3:30 PM for R1 revealed she had an unobserved fall when she transferred herself off of the toilet and fell . Immediate intervention was to add grip tape to the floor and a physical therapy referral. One staff members' name was written down as interviewed but no statement provided from that staff member or any other staff who worked. The results from their investigation included: Res was observed on the floor of her bathroom by staff with (wheelchair) next to her footwear in place, call light (within) reach (not) in use. There is a laceration to back of head (with two) staples placed (at emergency room ). (No) further (complaints of) pain/discomfort at this time. At baseline res is A&O (alert and oriented) X 1-2 with poor safety awareness and syncopale (sic) episodes. At this time res is to have grip tape placed to floor and Pt referral made. Will continue to monitor through [NAME]-charting, neuro-checks, (vital signs) and SOC (standard of care). No documentation reflecting how the resident ended up on the toilet and was documented as last seen at 3:30 PM which is the time of this incident. Review of a Hospital emergency room discharge summary dated 2/7/22 at 4:34 PM for R1 revealed the resident arrived with a laceration to the back of her head after a ground level fall while transferring to the toilet. It is unclear whether it was witnessed or not . paramedics reported that she fell in the bathroom while trying to transfer from the toilet. The resident received staples to the 2-centimeter laceration on her scalp. Review of a Nursing Progress note dated 2/17/22 for R1 revealed the daughter of R1 had concerns the resident keeps slipping down in the wheelchair and a request for a wedge cushion. PT recommended a (dycem) to be applied the residents seat on the wheelchair. Review of a Standard of Care (SOC) progress note dated 2/24/22 for R1 revealed: New Fall/Follow-Up: IDT (interdisciplinary team) met to discuss week 2 after recent fall 2/18/22 and assess interventions currently in place. Situation (where/when/what/who): Res was observed on the floor of her bathroom with (wheelchair) next to her and call light within reach and not in use. Injury/No injury: Laceration to head was healed with no recent (complaints of) pain. Bruise right hip that has healed as well. Factors involved (acute condition/environment, ect.): Resident is alert and oriented x 1-2 with poor safety awareness and chooses not to put her call light on for transfers. Notifications: Resident, family, and facility aware at this time. Analysis of intervention to implement new interventions include grip tape was added to the floor and resident has not had another fall since 2/18/22. Referrals: Resident was signed on with Hospice since fall. No incident report provided for 2/18/22 fall. Review of an Incident Report dated 2/26/22 at 6:30 PM for R1 revealed she had an unobserved fall and was found on her left side by her wheelchair in the dayroom. The physician documented as notified is on call. The resident reported she tried to walk or stand to go back to her room. The immediate interventions were to keep her comfortable through the transition process. No staff statements provided. Investigation results are the resident was in the dayroom and wanted to go back to her room after dinner. No complaints of pain initially so resident was assisted to wheelchair with the hoyer lift and then into her bed. When resident was in her bed she complained of pain in left hip/thigh. Xray ordered and showed a non-displaced left femoral neck fracture. Resident has a history of dementia and poor safety awareness and does not remember to ask for assistance with transfers. Declination to transfer to hospital due to hospice status and implemented comfort measures. Review of a Radiology Report dated 2/26/22 at 9:49 PM for R1 revealed she had a nondisplaced left femoral neck fracture. Review of a Hospice Progress Note dated 2/26/22 for R1 revealed Fall Event. A call was placed to Hospice on 2/26/22 at 11:20 PM to notify them the resident had an unwitnessed fall in her room around 6:30 PM. they found pt on the floor, it appears that she had tried to get up from her wheelchair. Pt was complaining of hip pain, so facility did X-rays and found a non-displaced fracture. Also advised that in the future it is best to call near time of fall and before X-rays so they can be discussed with our provider. Review of a Hospice Progress note dated 2/27/22 at 10:15 AM for R1 revealed the Nurse from the facility notified hospice that the resident is reporting nausea and started to vomit and is shaky. She fell and broke her hip yesterday. Review of a Care Plan for R1 revealed on 1/12/22 she is to be toileted with the assistance of one staff member and personal hygiene. On 1/11/22 she is to transfer with the assistance of one staff with walker and gait belt. On 1/12/22, reposition/ambulate as tolerated. On 1/25/22, Up in wheelchair for meals and by the nurses station for supervision and cues. On 1/28/22 a focus for the residents impaired cognitive function was initiated. On 1/28/22, the Resident uses wheelchair to move around room and facility. Review of the Respiratory Care Plan for R1 revealed she has altered respiratory status/difficulty breathing related to chronic respiratory failure with hypoxia initiated 1/12/22 Review of a fall care plan initiated on 1/11/22 revealed: The resident is at risk for falls related to history of multiple falls while at home, chronic respiratory failure, muscle strain, contusion of left hip, Parkinson's, history of right knee replacement, spinal stenosis, anemia, resident will attempt self-transferring without calling for assistance, resident will excuse staff for privacy while in the bathroom. Interventions as follows: 1/11/22- Encourage rest periods as needed to avoid overtiring. 1/12/22- Physical Therapy/Occupational Therapy to evaluate and treat as ordered or as needed. 1/12/22- Provide activities of interest. 1/12/22- Provide activities of daily living such as incontinence care, transfers, ambulation, as written in the activities of daily living plan of care. 1/12/22- anticipate and meet the resident's needs based on nursing assessments. 1/12/22- Determine causative factors of fall and resolve or minimize. 1/12/22- Use gait belt for transfers and walking. 1/12/22- Review information on past falls and attempt to determine cause of falls 1/17/22- Bed in low position when not providing care. 1/17/22- Bed wheels locked at all times, unless transporting or moving. 1/18/22- Encourage resident to wear nonskid footwear on when out of bed. 2/7/22- Grip tape to bathroom floor. Review of a Death Certificate dated 3/4/22 for R1 revealed the cause of death is from a) Medical decompensation following left femur fracture b) fall approximate interval between onset and death was 1 week. Manner of death is Accident from 2/26/22 at unknown time from an unwitnessed fall from standing height. In an interview on 11/29/22 at 1:51 PM, Licensed Practical Nurse (LPN) G reported that on 2/26/22 at 6:30 PM she was first coming to the unit to start working that evening. She remembers being frustrated that the facility left R1 in the day room behind the nurses' station alone because she needed supervision. R1 was so confused and would keep trying to get up from her wheelchair. R1 would try to stand up and walk. She remembers she heard some noise coming from the room behind the nurses' station and when she went to see what the noise was, she saw R1 laying on the floor. LPN G reported she made sure she was alright and then used a mechanical lift to get her off the floor. Then gave her pain medication and put her in bed. When queried if she notified the physician the day of 2/26/22 when R1 fell , LPN G reported she thinks she made several calls to the on call practitioner but not sure if she got a call back, which may be why she just wrote on call under the name of the physician notified. She does remember calling the residents daughter discussing whether or not to do x-rays as well as the Unit Manger who is no longer working at the facility. In an interview on 11/29/22 at 3:30 PM, the Director of Nursing (DON) reported R1 had 19 visits from their practitioners for various reasons from 1/12/22 to 2/9/22. She was having hypotensive episodes and her diuretics and blood pressure medications were discontinued or adjusted. On 1/17/22 she had a witnessed fall, and she was seen by therapy for falls and encouraged to wear nonskid socks. On 1/23/22 the resident had a syncope episode and did not consider lowering the resident to floor as a fall. On 2/7/22, based on the progress note, the resident's niece was present, but did not include that in the fall investigation. This day she went to the hospital and encouraged her wheelchair to be close and in a locked position. Grip tape was also added to the floor and the Nurse Practitioner made some medication changes as well. When asked to clarify the actual events, the DON reported she needed to call the Certified Nursing Assistant (CNA) to find out what actually occurred. No statements from the staff were provided. The DON reported the resident excused the staff from the bathroom for privacy while in the bathroom. When asked to clarify if residents who were high risk for falls could be left alone in the bathroom when they are care planned to be a one person assist, she answered yes. On 2/26/22 the resident was observed in the day room behind the nurses' station on the floor around 6:30 PM and was last seen at 5:55 PM during her meal. The DON expects the staff to call hospice, the physician, and family after a fall incident within a reasonable time. The resident did not complain of pain right away but did have pain after she went to bed. No documentation in the EMR indicating R1 was assessed and educated with comprehension about how to use a call light.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive and person centered care plan for 3 (Resident #29, Resident #37, and Resident #41), resulting in a lack of activities, assistive positioning devices for contractures not utilized and uncontrolled pain to continue without properly being addressed. Findings include: Resident #29 (R29) Review of the Minimum Data Set (MDS) dated [DATE] revealed R29 is a [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) indicates she is moderately cognitively impaired and requires extensive assistance of one to two staff for cares and has limited Range of Motion (ROM) on the upper and lower extremity of one side. R29 is not in a restorative nursing program. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan for R29 revealed: Left hand splint as scheduled, last revised 3/28/19. No specific plan of care for contractures or a flaccidity. During an observation and an interview on 5/9/22 at 12:00 p.m., R29 was in her room sitting in her wheelchair leaning slightly to the left with her left arm drooping to the side of her body and sandwiched between the wheelchair and her leg. Her left hand was in a tight fist position and could not open her hand. R29 did not have a splint in place and reported she did not have it in a splint that morning. The resident was not sure where her hand splints were and reported that sometimes they use a carrot (contracture device) and pulled out the carrot from her drawer. R29 could not recall the last time it was used. When asked when her hand was to be splinted, R29 reported she thought it was at night and reported she did not have it on last night. R29 reported that sometimes a pillow feels better to rest her left arm on but did not have a pillow in place. During an observation on 5/10/22 at 9:11 a.m., R29 was sitting up in her recliner and her left arm drooped to her side with her hand in her lap. No positioning device or splints noted. During an observation on 5/10/22 at 11:44 a.m., R29 was still sitting up in her recliner in the same position with her left arm drooped to her side with her hand in her lap. No positioning device or splint noted. During an observation on 5/10/22 at 12:41 p.m., R29 was sitting in her recliner with her meal tray sitting in front of her with her left arm and hand in the same position as before with supportive devices. During an observation and an interview on 5/11/22 at 8:00 a.m., Certified Nursing Assistant (CNA) G and CNA H reported R29 finds the splints to be uncomfortable and will refuse it or remove it from her hand after it has been there for a while and could not recall a schedule for the splinting or positioning devices. In an interview on 5/11/22 at 8:10 a.m., Licensed Practical Nurse (LPN) I reported R29 refuses her splints all the time and will document in the computer when she refuses them and did not recall informing anyone concerns of her refusing, or any follow up. In an interview on 5/11/22 at 8:33 a.m., the Director of Nursing (DON) reported R29 has been looked at by Physical Therapy and will investigate where her splints are. Review of the Treatment Administration Record (TAR) for R29 dated May 2022 revealed on 5/9/22, the resident is documented as having the splints on that morning and afternoon when the resident reported she did not have them on that morning. R29 is documented as refusing the hand splints five times from 5/1/22 to 5/11/22 with no follow up or education documented. Resident #37 (R37) Review of the Minimum Data Set (MDS) dated [DATE] revealed R37 is a [AGE] year-old female who admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) indicated she is severely cognitively impaired and requires extensive assistance with cares and supervision. Review of the Annual MDS dated [DATE] revealed R37s representative rated the following activities as Very important: listening to music, be around animals, and participating in religious services or practices. Several activities were rated as Somewhat important such as fresh air with good weather and group activities. During an observation and an interview on 5/9/22 at 12:17 a.m., R37 was tearful sitting in her wheelchair at the nurse's station. The nurse reported the resident likes to sit at the nurse's station and hang around. During an observation and interview on 5/10/22 at 9:05 a.m., R37 observed in the dining room in her wheelchair sitting at the table alone tapping the table with one hand and supporting her head with the other. There were no activities that engaged the resident. Certified Nursing Assistant (CNA) A reported R37 likes musical activities and cannot always participate in some of the other activities because of her cognitive abilities. During an observation on 5/10/22 at 11:24 a.m., R37 is observed sitting alone in her wheelchair at the nurse's station. In an interview on 5/10/22 at 11:32 a.m., the Activities Aide (AA) B reported R37 likes musical activities and manicures. AA B remembered a couple musical activities R37 engaged in the last month. In an interview and record review on 5/10/22 at 3:22 p.m., the Activities Director (AD) C provided a list of activities R37 engaged in from 4/10/22 to 5/8/22. There was a total of 7 activities documented, and of those 7, two activities included music and one activity included Faith Reflections. There were several 1:1 activities documented that included fed lunch but could not elaborate what activity occurred during those times. AD C reported that feeding a resident lunch should not be counted as an activity. Review of the Care Plan for R37 revealed: The resident is tearful and anxious at times and possibly related to [CONDITION(S)] ([CONDITION(S)]) and Major Depressive disorder, Pseudobulbar affect. History of suicide attempt. Initiated on 8/26/19. Interventions included giving the resident a red hat she made when she is anxious, agitated or tearful. Family states that she made the hat and it is comforting to her. Resident enjoys being social. Encourage resident to attend activities outside of her room such as exercise group, bingo, and music events. (R37) enjoys talking with staff. Staff to provide 1:1 visits as needed. Resident #41 (R41) Review of the Minimum Data Set (MDS) dated [DATE] revealed R41 is an [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) indicated the resident is severely cognitively impaired compared to her admission assessment on 10/14/21 that indicated she is cognitively intact. R41 is receiving pain medications but no non-medication interventions for frequent pain. The pain limits her day-to-day activities. During an observation and an interview on 5/9/22 at 9:49 a.m., R41 was lying in bed on her back with only a sheet covering her body. The resident complained of having pain all over her body and rated her pain at an 8 out of a 1-10 scale that was all over her body and it hurt to move. R41 reported it was painful to receive care from staff when they move her and reported she had pain in her nerves that hurt to the touch of her arm. R41 was not sure if she was getting pain medications. During an observation and interview on 5/10/22 at 2:08 p.m., the Certified Nursing Assistant (CNA) was in R41's room apply cream to her left underarm and rated her pain at an 8/10 scale. Review of a Nursing Progress note dated 4/2/22 at 1:28 a.m. for R41 revealed the resident had new order placed for [MEDICATION(S)] 5-325 milligram tablet every 6 hours as needed. Review of a Pain Evaluation document dated 4/3/22 for R41 revealed she had moderate pain almost constantly over the past 5 days that makes it hard for her to sleep at night. Her pain was rated at a 7 on a 00-10 pain scale. Her pain impacts her appetite, day to day activities, limits her extracurricular activity, mood and sleeping. The pain is documented in both of her legs, shoulders and hands. She described the pain as intermittent, aching, burning, tingling and throbbing. Moving around makes the pain worse and gives her anxiety. The current treatment to manage her pain is pain medications. No meaningful interventions noted with a follow up re-evaluation. Review of a Care Plan for R41 revealed a Focus for acute/chronic pain related to [CONDITION(S)], [CONDITION(S)], dementia, chronic neck/back pain, recent ankle fracture, osteopenia, [CONDITION(S)] arthritis, GERD (gastroesophageal reflux disease), left shoulder and arm pain initiated on 10/9/22 and last revised 5/9/22. The goal was for the resident to not have any interruption in normal activities due to pain. One new intervention noted on 5/5/22 for medication regimen adjustment (which decreased as needed pain medication frequency and 4/12/22 a warm bottle as needed is to be provided. Then on 5/9/22 the day of entry for this survey and x-ray was to be obtained. Review of a Practitioners Progress note dated 4/15/22 at 1:40 p.m. for R41 revealed: . Her left shoulder is painful and it is difficult for her to elevate her arm to get a look underneath. She consistently holds her arm close to her side . Positive for join pain (Left shoulder). She is not in acute distress. Pain is not addressed in the assessment and plan. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Progress notes dated 5/2/22 at 3:14 p.m. for R41 revealed: Was called to residents room as she was being changed . complains of a lot of pain in her legs, shoulders and neck. Message relayed to the aides on 2nd shift and the nurse on the unit. Review of a Nursing Progress Note dated 5/5/22 for R41 revealed the resident had a [MEDICATION(S)] 5-325 changed to every 8 hours as needed. Review of a Pain Assessment document dated 5/5/22 for R41 revealed she has had an almost constant moderate pain that interferes with her sleep over the past 5 days that interferes with her sleep, day to day activities, extracurricular activities and her mood. Her pain was rated at a 7/10 scale. The pain is in her bilateral legs and shoulders. The pain is described as intermittent, aching, burning, shooting, and throbbing. Her pain is worse when ambulating and changing positions in bed. Her pain is currently treated with scheduled and as needed pain medications. The resident currently manages her pain with a good night's sleep and scheduled pain medications. No new meaningful interventions. Review of a Pain Evaluation document dated 5/9/22 for R41 revealed she has had an almost constant moderate pain in the past 5 days that interferes with her sleeping, day to day activities, limits extracurricular activities, and her mood. She rates her pain at a 9/10 scale. The location of her pain is her left shoulder and bilateral legs. Her pain is described as constant, aching and shooting. The things that made it worse was moving, transferring, getting out of bed, and incontinence care. The resident currently manages her pain with routine and as needed medications, attempts to reposition, dimmed lights, and use of sunglasses. Review of the April 2022 Medication and Treatment Administration Record (MAR/TAR) for R41 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 1000 mg scheduled three times a day for pain ordered 10/9/21. Scheduled [MEDICATION(S)] 200 mg three times a day for nerve pain ordered 12/30/21. [MEDICATION(S)] 5-325 ([MEDICATION(S)] and acetaminophen) ordered as needed every 4 hours for pain on 10/15/22 and discontinued on 4/1/22 then changed to every 6 hours on 4/1/22. Review of the May 2022 Medication and Treatment Administration Record (MAR/TAR) for R41 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 1000 mg scheduled three times a day for pain ordered 10/9/21. Scheduled [MEDICATION(S)] 200 mg three times a day for nerve pain ordered 12/30/21. [MEDICATION(S)] 5-325 ([MEDICATION(S)] and acetaminophen) ordered as needed every 6 hours on 4/1/22 and discontinued on 5/4/22. [MEDICATION(S)] 5-325 changed to every 8 hours as needed on 5/4/22. In an interview on 5/11/22 at 8:37 a.m., the Director of Nursing (DON) reported they referred R41 for palliative services on 5/9/22 and reported that the practitioner has addressed the pain concerns for R41 but could not provide clear documentation with interventions, modifications, plan, or revisions of care to address pain prior to this survey. The DON reported that the resident has not totally utilized her unscheduled as needed pain medications and that is why they have not made any changes to her pain medication regimen. In an interview on 5/11/22 at 11:14 a.m., Nurse Practitioner (NP) F reported R41 admitted to the facility on [MEDICATION(S)] and [MEDICATION(S)]. NP F reported she tried muscle relaxers and [MEDICATION(S)] in the past and felt R41 is not maxing out her as needed medications and would prefer if the resident would ask for the pain medications as opposed to scheduling them. NP F reported when she visits R41, she seems relaxed before she enters the room then more anxious after she enters and acknowledged R41 is often in pain. The pain scale documented in the computer shows low numbers and it is not clear if that is the pain rate before or after medication administration. NP F reported the facility suggested palliative care for R41 this week and she felt that was a good idea.

Based on observation, interview, and record review, the facility failed to appropriately evaluate, assess and implement measures for constant moderate pain and develop non-pharmacological interventions or utilize resources to minimize pain for 1 (Resident #41) out of a total sample of 20 residents, resulting in unmanaged constant moderate pain that affects daily activities and the quality of life. Findings include: Resident #41 (R41) Review of the Minimum Data Set (MDS) dated [DATE] revealed R41 is an [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) indicated the resident is severely cognitively impaired compared to her admission assessment on 10/14/21 that indicated she is cognitively intact. R41 is receiving pain medications but no non-medication interventions for frequent pain. The pain limits her day-to-day activities. During an observation and an interview on 5/9/22 at 9:49 a.m., R41 was laying in bed on her back with only a sheet covering her body. The resident complained of having pain all over her body and rated her pain at an 8 out of a 1-10 scale that was all over her body and it hurt to move. R41 reported it was painful to receive care from staff when they move her and reported she had pain in her nerves that hurt to the touch of her arm. R41 was not sure if she was getting pain medications. During an observation and interview on 5/10/22 at 2:08 p.m., the Certified Nursing Assistant (CNA) was in R41's room apply cream to her left underarm and rated her pain at an 8/10 scale. Review of a Nursing Progress note dated 4/2/22 at 1:28 a.m. for R41 revealed the resident had new order placed for [MEDICATION(S)] 5-325 milligram tablet every 6 hours as needed. Review of a Pain Evaluation document dated 4/3/22 for R41 revealed she had moderate pain almost constantly over the past 5 days that makes it hard for her to sleep at night. Her pain was rated at a 7 on a 00-10 pain scale. Her pain impacts her appetite, day to day activities, limits her extracurricular activity, mood and sleeping. The pain is documented in both of her legs, shoulders and hands. She described the pain as intermittent, aching, burning, tingling and throbbing. Moving around makes the pain worse and gives her anxiety. The current treatment to manage her pain is pain medications. No meaningful interventions noted with a follow up re-evaluation. Review of a Care Plan for R41 revealed a Focus for acute/chronic pain related to [CONDITION(S)], [CONDITION(S)], dementia, chronic neck/back pain, recent ankle fracture, osteopenia, [CONDITION(S)] arthritis, GERD ([CONDITION(S)]), left shoulder and arm pain initiated on 10/9/22 and last revised 5/9/22. The goal was for the resident to not have any interruption in normal activities due to pain. One new intervention noted on 5/5/22 for medication regimen adjustment (which decreased as needed pain medication frequency and 4/12/22 a warm bottle as needed is to be provided. Then on 5/9/22 the day of entry for this survey and x-ray was to be obtained. Review of a Practitioners Progress note dated 4/15/22 at 1:40 p.m. for R41 revealed: . Her left shoulder is painful and it is difficult for her to elevate her arm to get a look underneath. She consistently holds her arm close to her side . Positive for join pain (Left shoulder). She is not in acute distress. Pain is not addressed in the assessment and plan. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Progress notes dated 5/2/22 at 3:14 p.m. for R41 revealed: Was called to residents room as she was being changed . complains of a lot of pain in her legs, shoulders and neck. Message relayed to the aides on 2nd shift and the nurse on the unit. Review of a Nursing Progress Note dated 5/5/22 for R41 revealed the resident had a [MEDICATION(S)] 5-325 changed to every 8 hours as needed. Review of a Pain Assessment document dated 5/5/22 for R41 revealed she has had an almost constant moderate pain that interferes with her sleep over the past 5 days that interferes with her sleep, day to day activities, extracurricular activities and her mood. Her pain was rated at a 7/10 scale. The pain is in her bilateral legs and shoulders. The pain is described as intermittent, aching, burning, shooting, and throbbing. Her pain is worse when ambulating and changing positions in bed. Her pain is currently treated with scheduled and as needed pain medications. The resident currently manages her pain with a good night's sleep and scheduled pain medications. No new meaningful interventions. Review of a Pain Evaluation document dated 5/9/22 for R41 revealed she has had an almost constant moderate pain in the past 5 days that interferes with her sleeping, day to day activities, limits extracurricular activities, and her mood. She rates her pain at a 9/10 scale. The location of her pain is her left shoulder and bilateral legs. Her pain is described as constant, aching and shooting. The things that made it worse was moving, transferring, getting out of bed, and incontinence care. The resident currently manages her pain with routine and as needed medications, attempts to reposition, dimmed lights, and use of sunglasses. Review of a Dietary Progress Note dated 5/9/22 at 5:19 p.m. revealed the R41 has fluctuating weights and history of refusing to be weighed. Contributed her weight gain to a sedentary lifestyle and excessive pop intake. Review of the April 2022 Medication and Treatment Administration Record (MAR/TAR) for R41 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 1000 mg scheduled three times a day for pain ordered 10/9/21. Scheduled [MEDICATION(S)] 200 mg three times a day for nerve pain ordered 12/30/21. [MEDICATION(S)] 5-325 ([MEDICATION(S)] and acetaminophen) ordered as needed every 4 hours for pain on 10/15/22 and discontinued on 4/1/22 then changed to every 6 hours on 4/1/22. Review of the May 2022 Medication and Treatment Administration Record (MAR/TAR) for R41 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 1000 mg scheduled three times a day for pain ordered 10/9/21. Scheduled [MEDICATION(S)] 200 mg three times a day for nerve pain ordered 12/30/21. [MEDICATION(S)] 5-325 ([MEDICATION(S)] and acetaminophen) ordered as needed every 6 hours on 4/1/22 and discontinued on 5/4/22. [MEDICATION(S)] 5-325 changed to every 8 hours as needed on 5/4/22. In an interview on 5/11/22 at 8:37 a.m., the Director of Nursing (DON) reported they referred R41 for palliative services on 5/9/22 and reported that the practitioner has addressed the pain concerns for R41 but could not provide clear documentation with interventions, modifications, plan, or revisions of care to address pain prior to this survey. The DON reported that the resident has not totally utilized her unscheduled as needed pain medications and that is why they have not made any changes to her pain medication regimen. In an interview on 5/11/22 at 11:14 a.m., Nurse Practitioner (NP) F reported R41 admitted to the facility on [MEDICATION(S)] and [MEDICATION(S)]. NP F reported she tried muscle relaxers and [MEDICATION(S)] in the past and felt R41 is not maxing out her as needed medications and would prefer if the resident would ask for the pain medications as opposed to scheduling them. NP F reported when she visits R41, she seems relaxed before she enters the room then more anxious after she enters and acknowledged R41 is often in pain. The pain scale documented in the computer shows low numbers and it is not clear if that is the pain rate before or after medication administration. NP F reported the facility suggested palliative care for R41 this week and she felt that was a good idea.

This citation pertains to intake MI- 8526 Based on interview and record review, the facility failed to ensure staff initiated timely and appropriate Cardiopulmonary Resuscitation (CPR) per standards of care, federal regulation, and their own facility policy and procedures, resulting in an immediate jeopardy when one resident (Resident #7), who was a full code (desired full life saving measures), was found unresponsive and in [CONDITION(S)], and nursing staff did not know how to appropriately respond causing a delay in rescue attempts. Resident #7 subsequently passed and this deficient practice placed all residents, who are designated as a Full Code and who suffer [CONDITION(S)], or are found unresponsive, at risk for serious harm and/or death. Findings: Review of the facility policy Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) dated [DATE] and implemented [DATE] reflected The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [CONDITION(S)]. The policy reflected the following: 1. Obtain and/or maintain certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. The licensed nurse on each shift is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 3. There shall be a licensed nurse on each shift who has received training and certification in CPR/BLS. 4. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times . 8. Depending on the underlying cause, the chances of surviving sudden [CONDITION(S)] (SCA) may be increased if CPR is initiated immediately upon collapse. 9. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival. 10. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). The policy indicated 14. Document the following in the resident's medical record (if the victim is a resident): The condition in which the resident was found or the witnessed event; the sequence of resuscitation efforts, including approximate times; the victims response to resuscitation efforts; the approximate time EMS took over; time of death or time the individual was transported .17. If the facility has adopted use of an AED, monitoring and maintenance of equipment will be conducted per manufacturer's instructions. Resident #7 (R7) Review of a facility Admission Record reflected Resident #7 (R7) admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a quarterly Minimum Data Set Assessment (MDS) dated [DATE], R7 was moderately cognitively impaired and needed supervision and set-up help only for transfers, walking and dressing and needed supervision and assistance from one person for toilet use and personal hygiene. Review of a Nurses' Note dated [DATE] at 3:56 PM documented by the Director of Nursing (DON) reflected [R7] was observed with mottling to BUE, face and neck with no pulse and no respiration at approximately 5:05 A.M. Resident was a full code and CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called. First responders arrived to facility at approximately 5:30 a.m. at which (time) they took over CPR of resident. Time of death was called at 6:06 a.m. Family notified and MD notified. Review of a facility staffing schedule for [DATE]-[DATE] reflected that Licensed Practical Nurse (LPN) R and Certified Nurse Aide (CNA) T were working on the unit where R7 was living overnight [DATE] - [DATE]. Registered Nurse (RN) S and CNA U along with CNA V worked in other areas in the facility overnight [DATE] - [DATE]. Review of the employee file for LPN R included a Performance Improvement Form that indicated on [DATE] LPN R was suspended pending investigation. A second copy of the Performance Improvement Form, also dated [DATE] reflected Reason for Counseling/Corrective Action: The investigation from events on [DATE] concluded that you were ineffective in aiding your teammates to render care to a resident and you failed to perform your nursing duties violating Standards of conduct 6.1.2 and 6.24.20. The form also indicated that as a result of the findings, LPN R was terminated. No additional information related to the Performance Improvement Form was found in LPN R's employee file. Additionally, a Certificate of Completion for an online (without an in-person demonstration and skills assessment component) standard CPR/AED course completion dated [DATE] was noted. Review of the employee file for RN S revealed an American Heart Association-First Aid CPR AED card with a recommended renewal date of [DATE]. Review of the facility investigation revealed statements were obtained from LPN R, RN S and CNA T. A statement was not obtained and documented from CNA U. According to the findings summarized by the DON and the Staff Development Coordinator, RN BB, R7 was last observed sleeping between ,d+[DATE]:00 a.m. and at approximately 5:05 a.m., [CNA T] discovered R7 breathless and summoned LPN R who also did not detect a pulse and called RN S. According to the summary statement, LPN R did not initiate CPR, gather the Automatic External Defibrillator (AED) or call 911. The AED was obtained by the DON upon her arrival to the facility and the DON called 911 and began assisting RN S with CPR until Emergency Medical Services (EMS) arrived. The summary indicated R7's time of death was called on scene by the emergency room (ER) physician at 6:06 a.m. During an interview and record review on [DATE] at 1:50 p.m., The DON reported she thought she spoke to CNA U about the events that took place the morning of [DATE] but did not document the interview. According to the DON, CNA U told her LPN R called the nurse desk on another unit looking for help from RN S who was assisting another patient. The DON said she first became aware of the situation when LPN R called her at home. The DON said she lived a few minutes from the facility and that by the time she arrived at the building, 911 had not yet been called and she was the first person to retrieve the AED and bring it to R7's room. The DON also reported that at the time of the incident, neither she nor RN S had current CPR certification and she was not sure if the online course taken by LPN R was an acceptable CPR/AED certification. During a telephone interview on [DATE] at 9:10 a.m., CNA U reported that LPN R called the unit she was working on and asked to speak to RN S and tell her it was an emergency. CNA U said she found RN S in a patient room in the middle of a procedure and told her that LPN R had called and needed her. CNA U indicated that it was not uncommon for LPN R to call asking for emergency assistance from other nurses for situations that were not actual emergencies. CNA U said that LPN R called the unit again 5 minutes later, again asking for RN S to assist with an emergency. CNA U said she never heard a Code Blue paged overhead or any other page over the facility intercom indicating there was an emergency. CNA U said the first she became aware that there was an emergency was when she noticed EMS in the back parking lot. During a telephone interview on [DATE] at 9:25 a.m., CNA T reported she worked on the COVID-19 positive unit where R7 had been moved to on [DATE]-[DATE] and said she sat with R7 from around 2:,d+[DATE]:00 a.m., reassuring her, ensuring she had her oxygen on and left her once she was relaxed and asleep. CNA T said she next observed R7 at approximately 5:00 a.m. and discovered she wasn't breathing. CNA T said when she told LPN R what she found, LPN R panicked and started crying and didn't know what to do. CNA T said LPN R left R7's room and called the other nurse station to get help which was not uncommon. CNA T thought it took RN S about 5 minutes to come onto the COVID unit and instructed CNA T to get the crash cart, but CNA T didn't know where it was. CNA T said that when the DON arrived at the facility, she brought the AED onto the unit. According to CNA T, RN S basically did everything. During a telephone interview on [DATE] at 9:58 a.m., RN S reported she worked overnight [DATE]-[DATE] on the opposite side of the building as the COVID unit where R7 lived. RN S said she was in another patient room providing [CONDITION(S)] suctioning when CNA U informed her LPN R has called needing assistance with an emergency but did not state what the emergency was and requested a call back. RN S said she never heard an overhead page of any kind. RN S said LPN R called again asking for help with an emergency, again not saying what the emergency was. RN S said she walked over to the COVID unit after ,d+[DATE] minutes and discovered CNA T and LPN R standing next to R7, neither performing CPR, LPN R was on the phone with the DON. RN S said she learned R7 was a full code and sent LPN R and CNA T to get a crash-cart but neither of them returned with it. RN S said that CNA T asked if she could take a break and that she had to ask LPN R to help her, but it was clear to RN S that LPN R did not know what to do. RN S said she did not get the AED or call 911 because she had no idea what kind of situation she was walking into. RN S said she performed CPR alone for what seemed like forever but was likely ,d+[DATE] minutes. RN S said that once the DON arrived, they both took turns performing CPR until EMS arrived. On [DATE] at 4:10 p.m., the facility Nursing Home Administrator (NHA) and the DON were informed of a situation of Immediate Jeopardy (IJ) that began on [DATE] at approximately 5:05 a.m. for Resident #7 who was discovered without a pulse and when LPN R, who did not have an approved CPR/AED certification, delayed basic life support for approximately ,d+[DATE] minutes after failing to call a Code Blue, initiate CPR, utilize the AED, call EMS or effectively assist RN S with CPR in a timely manner. R7 was pronounced dead by an ER physician via telephone on [DATE] at 6:06 a.m. This deficient practiced placed all residents who are designated a Full Code and who suffer [CONDITION(S)] or are found unresponsive highly likely to suffer serious harm and/or death. On [DATE] the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE] the facility Medical Director was notified of the incident. 2. The DON and designee completed a chart audit on every resident and compared the advanced directives to the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No inaccuracies were identified during this audit. 3. The licensed nurse who did not perform CPR on the full code resident was suspended pending investigation on [DATE]. 4. All nurses were audited for CPR certification on [DATE]. 8 nurses were identified as expiring (CPR certification) in 2020. 5. The DON and designee educated all licensed nurses on the facility policy and procedure for initiating CPR and location of code status for each resident beginning on [DATE]. Licensed nurses were not permitted to work a shift until education was completed. Nurses on leave will be educated prior to their next scheduled shift. 6. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. 7. Nurses identified as needing re-certification on CPR/AED were recertified on [DATE]. 8. Code Blue drills were initiated on [DATE]. During an observation made on [DATE] at 3:40 p.m., the crash cart located on the Lodge unit was reviewed with LPN W and it was identified that the audit of the crash cart to be utilized in the event of a [CONDITION(S)] was not completed from [DATE]-[DATE] and the audit was documented as done on [DATE] (in the future). Proof of all licensed nurse CPR/AED certification was requested from the facility and a review of all information provided reflected LPN JJ did not have a certification consistent with the requirement meeting both CPR and AED components with a return demonstration skills competency evaluation. A Certificate of Completion was issued to LPN KK on [DATE] and did not reflect an in-person training and skills evaluation component had been met. Although the Immediate Jeopardy (IJ) was removed on [DATE], the facility remained out of compliance at a scope of Pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to State Agency onsite audits identifying non-compliance with the facility policy Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) dated [DATE] and implemented [DATE], and sustained compliance has not been verified by the state agency.

This pertains to Intake M 8278 Based on interview and record review, the facility failed to assess and monitor with a change of condition for 1 (Resident #2), resident reviewed for assessment with change of condition resulting in severe dehydration, acute kidney injury, [MEDICAL CONDITIONS], and aspiration pneumonia that resulted in hospitalization . Findings include: Review of a Face Sheet revealed Resident #2 was a [AGE] year old male admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) indicating he was severely cognitively impaired and required extensive assistance of 2 staff for transfers, limited assistance of one person for eating, and extensive assistance of 2 staff for toileting. Resident #2 was frequently incontinent of bowel and bladder, and weight loss. The Care Assessment Areas (CAA) triggered dehydration/fluid maintenance, pressure ulcers, and urinary incontinence. In an interview on [DATE] at 8:30 a.m., Family Member (FM) 1 reported Resident #2 kept having reoccurring urinary tract infections (UTI's) and when he would visit, Resident #2 was nonresponsive many times even when he would shake him. FM 1 reported he was concerned Resident #2 was becoming resistant to antibiotics. FM 1 reported he tried to reach out to the Nursing Home with his concerns and told him that was just part of residents having dementia, they have their good days and bad days. FM 1 reported he went to a care conference in November after Resident #2 had about ,[DATE] UTI's and wanted to have a proactive approach but felt there was no primary physician in charge making decisions. FM 1 reported he would get phone calls from the facility ,[DATE] times a week usually over the weekend or at night and staff would tell him they did not have enough staff to give Resident #2 the attention that he needed. Resident #2 would be combative at the facility but not at the hospital. The Nursing Home complained Resident #2 had combative behavior but did not help him get his hearing appointment or his eye appointment. When Resident #2 went to the hospital on [DATE], the hospital diagnosed Resident #2 with severe dehydration that led to a [MEDICAL CONDITION], pressure ulcers and pneumonia. He died a few days later. Review of a Hospital Admission and Discharge Summary dated [DATE] to [DATE] for Resident #2 revealed: (Patient) found at (Nursing Home) breathing 42 times a minute with a pulse ox (oxygen saturations) in the 60's-altered mental status, (blood glucose) 116 en route. Staff reported he had altered mental status but is answering some questions in a brief fashion when he arrives. They reported a fever on scene. There was some question of him aspirating due to what looked to be some emesis around his mouth. Assessment/Plan: 1. Probable aspiration pneumonia - Patient is on a dysphagia diet normally. He was found with, what appeared to be, vomitus around his mouth. 2. Elevated troponin, probable NSTEMI (non-ST segment elevation [MEDICAL CONDITION] infarction/[MEDICAL CONDITION]). 3. History of recurrent UTI's (urinary tract infections and VRE ([MEDICATION NAME] resistant [MEDICATION NAME]) infections. 5. Bilateral pressure ulcers on heels - Present on admission. 6. [MEDICAL CONDITION] - due to illness versus progression of dementia. 7. Dementia. 8. Severe dehydration - Patient responding well to fluids. 9. Acute kidney injury, due to #8. Hospital course: He was brought to the (Emergency Department) and found to be responsive only to minimal stimuli and minimally at that. History was obtained from the son who appears reliable. He states that for the past six weeks or more he has seen a decline in his father. He states that his father has been having more episodes of confusion and agitation and that the past several weeks he has not even been able to speak with his father due to his stuporous/unresponsive state. He is not able to fully account for the decline but like some further evaluation should have been done previously. Final Diagnosis: [REDACTED]. [DATE]: Patient remains the same. Spoke with Hospice team and they will be taking over . At the time of discharge the patient remained unresponsive with guarded prognosis. (sic) In an interview with the on [DATE] at 3:54 p.m., the Director of Nursing (DON) reported Resident #2 was unpredictable at times and was hard to pinpoint triggers that agitated him. Resident #2 had [MEDICAL CONDITION], psychotic and had behaviors. In an interview on [DATE] at 7:30 a.m., Certified Nursing Assistant (CNA) U reported Resident #2 had behaviors and was strong and combative. One time he grabbed her arm and would not let go. He was also abusive to another nurse. The Unit Managers were not very helpful, and one nurse demanded that the social worker and the administrator to come to Resident #2's room when he had behaviors. In an interview on [DATE] at 7:45 a.m., Licensed Practical Nurse (LPN) H reported Resident #2 had intermittent aggressive behaviors and just did what he wanted. In an interview on [DATE] at 11:06 a.m., LPN J reported she worked the night shift and early morning when Resident #2 went to the hospital. LPN J reported her shift starts at 10:00 p.m. and received in report from another nurse that Resident #2 was declining and was a full code. LPN J reported she did not really know Resident #2 because he was sleeping when she was on her night shift. LPN J reported the CNA's told her that he was really declining and not acting right, so she had the CNA check his vital signs and to just go look at him. LPN J reported she did not see him on the night shift at all before the staff found him unresponsive. LPN J reported his oxygen saturations were about 60% so she went to get some oxygen and then called the Emergency Medical Response team to transfer Resident #2 to the hospital. LPN J clarified that the day shift nurse told her that Resident #2 was just a little declining and had the CNA check on him and told her that he was okay. LPN J reported she was busy with doing medication passes until about midnight. In an interview on [DATE] at 12:10 p.m., Nursing Home Administrator (NHA) reported the Interdisciplinary Team (IDT) would review incidents in the facility and would address them in Quality Assessment and Assurance (QAA) meetings. If an outcome needed correction, they would make a correction plan. NHA reported he is not aware of any correction action needed regarding the hospitalization of Resident #2. In an interview on [DATE] at 12:15 p.m., the DON reported he was notified of Resident #2 not being responsive the morning on [DATE] and sent to the hospital. The DON reported that Resident #2 was on [MEDICATION NAME] antibiotics that extended until February is to have daily charting for signs and symptoms of infection. There is no temperature charted 72 hours before he was found unresponsive and some of the pertinent charting just revealed Resident #2 was afebrile but no temperature recorded. The DON reported he would expect nurses to prioritize the residents and document over performing medication pass. In an interview on [DATE] at 2:45 p.m., the Registered Dietician (RD) S reported Resident #2 liked cranberry juice and put on his meal ticket he needed 2 glasses of nectar thickened cranberry juice to address his hydration. RD S reported that before he went to the hospital, she noticed he was sleeping more. RS S reported she communicated her concerns with the Physician Assistant (PA) that she noticed a change in Resident #2's condition of sleeping more and not eating as much, and requested she did a medication review. RD S reported the PA did make some adjustments to his medications. Review of a Physician Assistant (PA) progress note dated [DATE] for Resident #2 revealed: ASSESSMENT AND PLAN1. Recent hypotensive episode requiring transfer to the emergency department. He was not admitted . His antihypertensive medicines will be adjusted. I am going to reduce his [MEDICATION NAME] from 0.3 to 0.2. He is only on [MEDICATION NAME] 10 mg. 2. [MEDICAL CONDITION]. We are going to continue his current medications for that. 3. [MEDICAL CONDITION] infection. This has now resolved. 4. [MEDICAL CONDITION] with delusions. Review of a Physician Assistant (PA) progress note dated [DATE] for Resident #2 revealed: I was asked to see this patient to review his medications as his blood pressure has been running a bit lot. He was hypotensive at ,[DATE]. His [MEDICATION NAME] and [MEDICATION NAME] were discontinued. Nursing was instructed to check blood pressure twice daily. Fluids were encouraged as well. Review of all Progress notes for Resident #2 dated from admission to discharge revealed there was no Physician oversight for Resident #2. physician progress notes [REDACTED]. The resident was seen by the Physician Assistant/Nurse Practitioner on [DATE], [DATE], [DATE]. Review of a Urology Progress note for Resident #2 dated [DATE] revealed: .It sounds to me as though the patient has had episodes of near retention that triggers psychotic episodes. He presently has a Foley catheter in place. It does not sound like his prostate issues have been addressed aside from the emergency department and they placed him on [MEDICATION NAME] [DATE] It may be necessary to pursue urodynamics in the setting as well.Treatment: [MEDICAL CONDITION]. Lab: culture, urine, procedure: cystoscopy, Procedure: Foley Cath. (sic) Review of a Hydration Assessment done on [DATE] for Resident #2 revealed a score of 9. A score of 8 or higher may be at risk for dehydration. Review of a Hydration Assessment done on [DATE] for Resident #2 revealed a score of 6. Review of a Weight Summary for Resident #2 revealed: [DATE] weight is 159.4 pounds, [DATE] weight is 153.2 pounds, [DATE] weight is 149.2 pounds, and [DATE] weight is 147 pounds. Review of the Hospital admission weight on [DATE] was 65.4 kg or 143.88 pounds. There was a 6.4% weight loss between [DATE] and [DATE]. There was a 7.78% weight loss between [DATE] and [DATE]. There was an over all total weight loss of 9.79% in less than one month. Review of the Care Plan for Resident #2 revealed: Focus: The resident has potential fluid deficit (related to) cognitive deficits, recurrent infection, initiated [DATE]: Interventions: Monitor for changes in mental status, Monitor/document/report nurse/MD (medical doctor) (as needed) any s/sx (signs and symptoms) of dehydration: decreased or no urine output .new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes.Focus: The resident has potential for nutritional deficits . Interventions: Monitor for signs and symptoms of inadequate fluid status: skin tenting, decreased urine output, .increased/rapid heart rate, increased respirator rate, decrease blood pressure, faint pulse, ect.Monitor/document/report to nurse/MD (as needed) any (signs and symptoms) of pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat. Appears concerned during meals. Monitor/record/report to MD (as needed) (signs and symptoms) of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Offer 2x nectar thickened beverage at meals to aid in hydration status, initiated [DATE].

This citation pertains to intake number MI 578. Based on interview and record review, the facility failed to prevent, monitor and promote the healing of a facility acquired pressure ulcer for 1 resident (Resident #8) reviewed for pressure ulcers. The deficient practice resulted in Resident #8 developing an unstageable pressure ulcer that evolved into a Stage 4. Findings include: The facility provided the policy Pressure Ulcer/Skin Breakdown-Clinical Protocol dated 11/28/17 for review. The policy reflected, 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 unless the individual's clinical condition demonstrates that they were unavoidable .An admission evaluation helps identify at risk of developing a pressure ulcer/pressure injury (PU/PI), and residents with existing PU/PIs. Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. The admission evaluation helps define those initial care approaches . Cause Identification 11. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. as needed . Resident #8 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 admitted to the facility on [DATE] with a readmission date of [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 15 out of 15 which represents Resident #15 was cognitively intact. Resident #8 did not reside at the facility during the onsite survey. The MDS history reflected: -9/27/19 admitted -11/19/19 discharged with return anticipated -11/27/19 readmitted -12/5/19 discharged to the hospital According to a Skin note dated 11/1/19 at 4:47 PM reflected, Resident's right buttock was resting on the edge of the cushion and caused the pressure ulcer. Pressure ulcer measurements of the right buttock first noted on 10/29/19: -10/29/19 5.5 cm x 4.0 cm x 0.0 cm unstageable -11/6/19 7.5 cm x 4.3 cm x 0.0 cm unstageable -11/14/19 6.5 cm x 4.1 x undetermined, unstageable -11/19/19 - 11/27/19 out to the hospital -11/27/19 reflected no pressure ulcer to the right buttock only the coccyx (not identified, measured or staged upon readmission) - 12/4/19 8.0 cm x 5.0 cm x 2.0 cm Stage 4 Pressure ulcer measurements of the coccyx first noted on 11/6/19: -11/6/19 1.5 cm x 2.5 cm x 0 cm Stage 2 -11/14/19 1.0 cm x 1.5 cm x 0.1 cm Stage 2 -out to the hospital from 11/19/19 - 11/27/19 -11/19/19 - 11/27/19 readmission assessment coccyx pressure ulcer, no measurements or staging -12/4/19 healed A record review of the Physician and Nurse Practitioner note from 10/1/19 - 12/3/19 reflected no evaluations of the pressure ulcers nor plans for treatment. According to the October and November 2019 Treatment Administration Record (TAR) reflected the initial treatment order for the right buttock pressure ulcer was dated 11/2/19 (4 days after it was discovered). According to the measurements from 10/29/19 and 11/6/19 the pressure ulcer increased in size. The care plan for skin with an initiated date of 9/27/19 reflected, The resident has and/or is at risk for pressure ulcer/skin breakdown development .Right lower buttock, unstageable pressure ulcer. The interventions consisted of (but not limited to): 10/3/19 Reposition resident in gerichair and in bed every 2 hours or as often as tolerated, and 11/6/19 up down schedule (to help heal pressure areas): Up at 5:30 AM, down at 8:30 AM, up at 11:00 AM, down at 2:00 PM and up at 4:30 PM, down at 7:00 PM. During an interview and record review on 12/20/19 at 12 :45 PM, the DON and Regional Consultant (RC) A answered questions regarding the development of the facility acquired pressure ulcer. The DON stated that Resident #8 admitted to the facility on [DATE] with a Stage 3 pressure ulcer to the coccyx that subsequently healed during his stay. The Surveyor asked when and how the new unstageable pressure ulcer to the right buttock was first noted, the RC A stated, Through a mock survey we identified that we needed to improved skin assessments and wound charting. We did a house sweep and caught it and put it through QAPI (Quality Assurance Performance Improvement) on 10/29/19. When asked when and how was the physician notified, the DON stated that he verbally told the physician about the wound, checked the record but could not find where or if it was documented. When asked when the treatment and dressing ordered for the pressure ulcer was obtained, the RC A and the DON reviewed the records and stated that according to the November TAR it started on 11/2/19 (4 days) after the pressure ulcer was discovered. The DON stated that he expects the staff put the order in the computer and the doctor will electronically sign them. According to the measurements from 10/29/19 and 11/6/19 the pressure ulcer increased in size. When asked if the physician evaluated the wound and if the facility determined if the facility acquired pressure ulcer was avoidable or unavoidable, the RC A stated, I'm not sure if we have the physician document this. The DON stated, I spoke to the doctor about this and he remembers me telling him about the new pressure ulcer but did not have a note about it. The Surveyor reviewed the skin care plan with the DON and requested clarification regarding repositioning every 2 hours and being up in a chair for 3-hour blocks of time. The current standards for practice recommend off-loading every 1-2 hours. The DON stated that Resident #8 may not have always complied with the care plan. When asked if staff document refusals of care, the DON stated yes then checked the record and stated that there weren't any refusals found. There was no additional information provided for review prior to the exit of this survey. The facility failed to prevent the development of an avoidable facility acquired pressure ulcer and promote the healing.

Based on interview and record review, the facility failed to provide appropriate care for a dementia resident (Resident #4), resulting in unsupervised, unwanted interactions with aggressive behaviors with other residents Findings include: Review of a Face Sheet revealed Resident #4 is a [AGE] year old female admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Resident #4 was discharged from the facility on 11/18/19 at 1:00 p.m Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) indicating she was severely cognitively impaired and required extensive assistance of one person for locomotion on the unit and supervision of 1 person walking in the corridor. Review of a Face Sheet revealed Resident #5 is a [AGE] year old male admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status indicating he is severely cognitively impaired required 1 person assistance and supervision with walking. Review of a Facility Reported Incident dated 11/17/19 that involved Resident #4 entering Resident #5's room while he was in bed and began pulling his blankets back and poking him in the chest. He called out for help, staff responded and began to assist the female resident (Resident #4) out of his room. At this time, the female resident began yelling and hitting at the CENA (Certified Nursing Assistant) that was trying to assist her. At one point, the female resident bit the CENA on the forearm and at this time the male resident (Resident #5) exited the room and summoned assistance from (another CENA). both residents were assessed with [REDACTED]. (Resident #4) stated that he was sleeping comfortably when he was awoken by a female resident hitting him in the chest (upon further demonstration, it was a poking motion that the resident was demonstrating and saying it is time to wake up. Wake up. He denied any pain and told staff that he continued to feel safe and secure at the facility. Review of a written Summary of interview by the facility with (LPN J) states that she was unaware of the incident as she was in a resident's room. When she was told about the incident, she assessed the residents and no injuries were noted. She was unaware of any physical contact between the residents at that time. Review of a written Summary of interview by the facility with (CNA L): While sitting at the desk charting, I heard someone calling for help. I started walking down the hall to find the source and when I entered room [ROOM NUMBER] (Resident #5's room) I saw (Resident #4) hovering over him, pulling on his blankets. I then stepped between the two of them to prevent her from hitting him, or vice versa. When I did this, (Resident #4) grabbed my right wrist and started yelling at me. She grabbed a tissue box and hit me with it, then bit my right arm by the elbow. I asked (Resident #5) to go get help, and he did. (CNA AA) came a few moments later and was able to redirect (Resident #4) away from me and back to her room. Review of a written Summary of Interview with (CNA AA): stated that he was working on the Lodge (another unit) when (Resident #5) asked him to come help in his room. (CNA AA went with the resident to his room on Great Lakes and upon entering he observed (Resident #4) hitting and yelling at (CNA L). Conclusion: Upon through investigation it was determined that prior to the alleged incident, neither resident was displaying any unusual behaviors from their baseline. (Resident #4) had been pleasant earlier in the day and into the evening and had not displayed any recent signs of aggression. Due to (Resident #4's) advanced dementia increased supervision was provided until her discharge. Due to the reduced BIMS score, (Resident #4) is unable to form intent and therefore the facility does not substantiate abuse. Review of the Incident Report dated 11/18/19 in regard to incident dated 11/17/19: (Resident #4), room [ROOM NUMBER], on 11/17/19 at 4:40 a.m. Brief Description: Bruise observed by family, they notified facility. They sent an emailed picture depicting a bruise on her wrist. Resident had an incident with another resident 11/17/19 which correlates with the area of bruising. Bruising not noted after/during incident. Resident calmed down with staff after incident. Resident transferred to another facility due to aggressive behavior towards staff and residents. Review of a written statement by a staff member from Resident #5 dated 11/18/19 regarding incident on 11/17/19 revealed: Resident #4) across hallway, came into my room and started punching and hitting me in the chest/shoulders and shaking me. I didn't know why; she just woke me up. She kept saying it was time to wake up and I sad leave me alone. Staff came in cause she wouldn't get out or leave me alone. That's when the fight started. (Resident #4) hit the staff with Kleenex box and swatting her and hitting her with her hands and tried to grab the CNA. I was still in bed. Then the CNA told me to go get help because (Resident #4) wouldn't let her go or stop pushing the CNA and hitting her. I went to go get help. Do you feel safe here? Yes. Are you afraid? No. Are you in pain? No. Resident states (Resident #4) should not be here because she hurts people. Review of a written statement by the Director of Nursing for CNA AA revealed: CNA was approached by (Resident #5) who walked to Lodge looking for help in his room. (CNA AA) went to room [ROOM NUMBER] and observed (Resident #4) yelling and swinging at and hitting (CNA L) He states he was immediately able to distract her and talk her down. He said that (Resident #4) stated that all the women were out to get her. Review of a written statement dated 11/17/19 by CNA L revealed: While I was charting, I heard someone yelling. I thought it was 210 but, on my way, down I saw 207 (Resident #4) had her door open, heard yelling again 209 (Resident #5) was asleep, so I checked 209 at first, I didn't see anyone due to bathroom door being open. Once I closed it, I saw 207 hovering over him trying to rip his blankets away. I stepped between 209 and 207 to prevent 207 from hitting 209. When I did this it instantly set her off. She grabbed by (right) wrist and started yelling at me. I calmly tried to redirect her and to get her at least out of 209. In doing so, she grabbed the call light and tried wrapping it around me. When that didn't work, she grabbed both my wrists and started trying to throw me to the floor. She grabbed a tissue box and started hitting me with it. After she started using her fists and started kicking and hitting me more I continued to try getting her out and away from 209. She tried to hit me and throw me on the floor. I had her wrists as she had a hold of mine. In an attempt to throw me on the floor she bit my (right) arm by the elbow area and began pinching my underarm. I had 209 go get some help since she wouldn't let me go and nobody could hear me yelling. She continued to try hitting me in the face, arms, body and try to kick me. My co-worker got her to let me go and I walked away while he got her to calm down. In an interview on 12/19/19 at 5:00 p.m., CNA L reported she was the only CNA working the third shift on the Great Lakes unit that night and was at the nurses' station charting when she heard Resident #5 yelling for help. When CNA L went to his room, she saw Resident #4 standing over him trying to pull off his blanket and telling him to get up. CNA L stood between the two residents to get Resident #4 to leave Resident #5 alone. At that point, Resident #4 started hitting CNA L and was combative. Resident #4 held CNA L's wrists and she would not let go. CNA L asked Resident #5 to try and find help. Resident #5 went to the Lodge unit to get CNA AA who came to assist her. Resident #4 responded well to a male voice which calmed her and redirected her. CNA L reported she did not know where her nurse was on that unit that night and had not seen her for about an hour and a half. CNA L reported she had to deal with Resident #4 alone. When the nurse did come back to the floor, CNA L reported that LPN J just laughed at her and told her better you than me. CNA L reported there was not enough staff during the night shift on the Great Lakes unit due to residents with behaviors and some of the residents should be a 1:1 supervision and fall risks. CNA L reported she addressed her concerns with administration and had complained of LPN J but felt nothing gets done about it. CNA L reported LPN J not getting help from LPN J caring for staff and instead of caring for the resident when they need something, LPN J would put on the call light for the CNA's to answer it. In an interview on 12/20/19 at 11:06 a.m., Licensed Practical Nurse (LPN) J reported she was in another room at the time when the incident between Resident #4 and Resident #5 happened. Resident #4 was a combative patient, wandered everywhere, and was really quick. LPN J reported Resident #4 went into another residents (Resident #5) room and took a blanket when CNA L tried to redirect her, Resident #4 bit her. LPN J thinks at that time Resident #5 left the room to get another CNA to help her and LPN J was notified of the incident after the struggle was over. LPN J reported the night shift has 2 nurses in the building and 1 CNA on each unit. LPN J reported she told the Director of Nursing (DON) that Resident #4 needed 1:1 supervision because she was into everything, not acting right and wandering. Resident #4 was unpredictable, would fine one minute but not the next. LPN J reported that the DON responded with yes we are trying to our best to place her someplace. LPN J reported she does not remember if Resident #4 was ever a 1:1 during her stay at the facility. Review of several email communications provided by the facility regarding the daughter/emergency contact for Resident #4. The daughter had concerns relating to how the facility was caring for Resident #4 who has Alzheimers and Sundowner syndrome (refers to confusion that starts late in the day into the night). Resident #4 and her daughter who is also the Emergency Contact person revealed several concerns of caring for and redirecting Alzheimers patients with sundowners syndrome. An email dated 11/18/19 from the daughter/Emergency Contact person and the facility revealed: . Regardless, due to the incident on Saturday night (11/16/19) . We relied upon your staff and professionalism to have the expertise in handling late stage Alzheimer's care given - as I shared prior and during the admission process plus as we've discussed many times - they require constant engagement during the Sundown period of about 5 p.m. to 4 a.m. Questions: 1. Why were we not immediately notified on Sunday morning of large bruises on my mother's wrist and hand when she was dressed by the staff?? My dad only discovered she was injured when he changed her sweater. Further, we still have not received any notice from anyone that she was injured. Review of a Nursing Progress Note for Resident #4 dated 11/5/2019 at 16:39, Progress Note- General Note Text: I saw (Resident #4) in the vestibule area of the Great Lakes shower room as I was walking the hall. Her eyes were narrowed and lips pursed; she appeared angry. When I came around the half wall to greet her, she told me not to come closer because she was telling him to shape up. I asked her who she was speaking to, and she pointed to a sling hanging on the wall and said, him. She had a small bottle of liquid soap in her hand and was flinging it toward the sling. I got her some rags and helped her wipe the soap off of her hands and the floor. She states that she is angry because there are all these people in(her)house. She believes none of them are any good and they should all be fired. Review of a Progress Noted for Resident #4 dated 10/31/2019 at 12:24 Nurses' Notes Note Text: Pt wandering around building and unable to be redirected. Pt attempted to go out door in Great Lakes x 2. Wanderguard attached. Review of a Nursing Progress Note for Resident #4 dated 11/3/2019 at 10:19 Pertinent Charting- Behavior Note Text: Event date: 11/01/2019 constant wondering, into other residents rooms, going through others belongings. is not always cooperative with redirection. does not sort paper, or items in day lounge. poor safety awareness. Review of a Nursing Progress note for Resident #4 dated 11/4/2019 at 09:15, Pertinent Charting- Behavior Note Text: Event date: 11/01/2019 continual wondering on unit, constant supervision required to maintain safety. No combativeness to this time, resistive at times to redirection. Review of a Nursing Progress noted for Resident #4 dated 11/5/2019 at 09:50, Pertinent Charting- Behavior Note Text: Event date: 11/01/2019, Pt wandering around building. She was found hiding behind door in room [ROOM NUMBER], in the therapy room, in the Great lakes charting room. Re direction temporarily effective for a few seconds. Wanderguard present. Review of a Nursing Progress note for Resident #4 dated 11/8/2019 at 13:01, Pertinent Charting- Behavior Note Text: Event date: 11/01/2019 Earlier in shift Pt wandering in and out of patients rooms. Redirection ineffective. Family present and pt sat with them and talked. Pt then went to dinner and wandered around building. Review of a Nursing Progress note for Resident #4 dated 11/8/2019 at 21:01, Pertinent Charting- Behavior Note Text: Event date: 11/01/2019 resident entering rooms uninvited and upsetting other residents. Redirecting effective at times. Resident became severely agitated towards another resident in hallway. resident was then redirected which was effective. Review of a Nursing Progress note for Resident #4 dated 11/10/2019 at 09:57, Pertinent Charting- Behavior Note Text: Event date: 11/01/2019 Pt walking in other pt rooms and when attempt redirection, pt begins by saying I can do whatever I want here. Pt found in sunrise dining room later opening up all the packets of creamer and sugar and pouring them on table. She also was opening cabinets and going thru cabinets. Redirections ineffective at first but then able to redirect. Pt currently at church. Pt did not sleep during shift at all and per report. Pt had only slept less than 2 hours last night. Will continue to monitor. Review of a Nursing Progress note for Resident #4 dated 11/14/2019 at 13:40, Pertinent Charting- Behavior Note Text: Event date: 11/01/2019, PT (patient) threatening kitchen staff. Pt yelling at another pt in dining room during lunch and becoming aggressive. PT attempt to walk out of 400 door. Wanderguard working. Review of a Nursing Progress note for Resident #4 dated 11/17/2019 at 17:42, Pertinent Charting- Behavior Note Text: Event date: 11/01/2019, Resident was found inside rooms 202, 209, 210, 212 and 216. Resident was redirected to her chair by the nurses station and complied. Review of a Care Plan for Resident #4 revealed: Focus: The resident has a [DIAGNOSES REDACTED]. Interventions: Cue, reorient and supervise as needed. Keep the residents' routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Monitor/document/report (as needed ) any changes in cognitive function . No meaningful person centered interventions in place or revised since admission.

This pertains to Intake M 8278 Based on observation, interview and record review, the facility failed to utilize antibiotic stewardship in 1 (Resident #2), of 3 residents reviewed, resulting in the potential for antibiotic resistance,[MEDICAL CONDITION], and subsequent death. Findings include: Review of a Face Sheet revealed Resident #2 was a [AGE] year old male admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) indicating he was severely cognitively impaired and required extensive assistance of 2 staff for transfers, limited assistance of one person for eating, and extensive assistance of 2 staff for toileting. Resident #2 was frequently incontinent of bowel and bladder, and weight loss. The Care Assessment Areas (CAA) triggered dehydration/fluid maintenance, pressure ulcers, and urinary incontinence. In an interview on [DATE] at 8:30 a.m., Family Member (FM) 1 reported Resident #2 kept having reoccurring urinary tract infections (UTI's)and when he would visit, Resident #2 was nonresponsive many times even when he would shake him. FM 1 reported he was concerned Resident #2 was becoming resistant to antibiotics. FM 1 reported he tried to reach out to the Nursing Home with his concerns and told him that was just part of residents having dementia, they have their good days and bad days. FM 1 reported he went to a care conference in November after Resident #2 had about ,[DATE] UTI's and wanted to have a proactive approach but felt there was no primary physician in charge making decisions. FM 1 reported he would get phone calls from the facility ,[DATE] times a week usually over the weekend or at night and staff would tell him they did not have enough staff to give Resident #2 the attention that he needed. Resident #2 would be combative at the facility but not at the hospital. The Nursing Home complained Resident #2 had combative behavior but did not help him get his hearing appointment or his eye appointment. When Resident #2 went to the hospital on [DATE], the hospital diagnosed Resident #2 with severe dehydration that led to a [MEDICAL CONDITION], pressure ulcers and pneumonia. He died a few days later. Review of a Hospital Lab report with a collection date of [DATE] for Resident #2 revealed: WBC (white blood cell count 5.0, normal range is 3.0 to 11.6) and urinalysis final report indicated there was greater than two organisms; probably contaminate. emergency room documentation revealed Final Diagnosis: [REDACTED]. History of UTI (urinary tract infection), 3. History of [MEDICAL CONDITION] infection. Review of a urinalysis dated [DATE] for Resident #2 revealed there was 75,000 colony forming units/milliliter (cfu/mL), greater than two organisms; probable contaminants. Review of Hospital emergency room Discharge instructions for Resident #2 dated [DATE] revealed: [MEDICATION NAME](antibiotic) and take twice daily for the next 2 weeks. Start [MEDICATION NAME] (medication to shrink enlarged prostate) and an adjunct to [MEDICATION NAME] (medication for high blood pressure) to help with prostate hypertrophy and [MEDICAL CONDITION] symptoms. Discuss with your PCP (Primary Care Physician) regarding medication side effects causing urine retention. emergency room Final Diagnosis 1. Recurrent UTI (urinary tract infection), 2. History of [MEDICAL CONDITIONS], 3. Dementia chronic, 4. Agitation states as acute reaction to exceptional (gross) stress, recurrent. Review of a Urinalysis for Resident #2 done on [DATE] revealed there was 3+ leukocytes, [MEDICATION NAME] were positive, and trace of blood in urine, WBC (white blood cells) >100. No culture and sensitivity provided to show culture and susceptible antibiotics/ possible contaminants. Review of a Nursing Progress Note dated [DATE] for Resident #2 revealed: Attempted to straight cath using sterile technique for post void residual using catheter with curved tip. Able to insert catheter approx . 1 inch when obstruction did not allow catheter to pass further. Bright red blood noted coming from penis. Review of Hospital Discharge Instructions dated [DATE] for Resident #2 revealed: Continue to follow-up with your family doctor and with urology as previously scheduled. Next dose of Keflex antibiotic is at 3 PM tomorrow. Encourage fluids. Return to the emergency department if no urine output in 12 hours, fevers, vomiting, increased confusion or new concerns develop. Review of a Urology Progress note for Resident #2 dated [DATE] revealed: .It sounds to me as though the patient has had episodes of near retention that triggers psychotic episodes. He presently has a Foley catheter in place. It does not sound like his prostate issues have been addressed aside from the emergency department and they placed him on [MEDICATION NAME] [DATE] It may be necessary to pursue urodynamics in the setting as well.Treatment: [MEDICAL CONDITION]. Lab: culture, urine, procedure: cystoscopy, Procedure: Foley Cath. (sic) Review of a Urology Progress note for Resident #2 dated [DATE] revealed: . Looking back I do not find any positive urine cultures.It sounds to me as though the patient has had episodes of near retention that triggers psychotic episodes. He presently has a Foley catheter in place. It does not sound like his prostate issues have been addressed aside from the emergency department and they placed him on [MEDICATION NAME] [DATE] It may be necessary to pursue urodynamics in the setting as well. Review of a Hospital Microbiology urinalysis report with a collection date of [DATE] for Resident #2 revealed the final report completed [DATE] indicated Resident #2 had greater than 100,000 colony forming units per milliliter (cfu/mL) of Proteus mirabilis. Handwritten note in the margin Pt (patient) currently on [MEDICATION NAME] mono ([MEDICATION NAME], an antibiotic) 100 mg (milligram) cap(sul), 1 cap (twice daily) for 14 days, then 1 in evening for 3 months. Please advise new orders needed. [MEDICATION NAME] antibiotic listed as one of two antibiotics highly resistant to Proteus mirabilis. Review of the Medication Administration Record [REDACTED]. Review of a Urinalysis collected [DATE] for Resident #2 revealed: >100. No culture and sensitivity provided to show culture and susceptible antibiotics/ possible contaminants. Review of Urology Orders for Resident #2 dated [DATE] revealed [MEDICATION NAME] ([MEDICATION NAME]) 300 mg twice a day for 14 days. Review of the culture sensitivity revealed [MEDICATION NAME] listed as not susceptible. Review of an Order Summary dated [DATE] to [DATE] for Resident #2 revealed the resident had 22 order entries for antibiotics and antifungals ordered for urinary tract infections, [MEDICAL CONDITION], and infection during this period and some of the antibiotics given along with another antibiotic. The antibiotics included: C-[MEDICATION NAME] 250 mg/5ml started [DATE] to [DATE]. [MEDICATION NAME] (2 orders),[MEDICATION NAME](5 orders), FIRVANQ ([MEDICATION NAME]) (3 orders), fluconazole (1 order), Keflex (1 order), [MEDICATION NAME] (3 orders), and [MEDICATION NAME] (6 orders). Review of the Medication Administration Records and Treatment Administration Records from [DATE] to [DATE] for Resident #2 revealed several entries documented that Resident #2 either refused medication, was sleeping and did not get medications, hospitalized and did not received medications or medication are on hold. Review of the Medical Practitioner Progress notes for Resident #2 provided by the facility revealed from [DATE] to [DATE], Resident #2 's care was not overseen/supervised by a Physician during his stay. The Physician Assistant had visited this resident and addressed concerns related to infections, [MEDICAL CONDITIONS], and behaviors/[MEDICAL CONDITION]. Review of an SBAR (situation, background, assessment, recommendation) Communication Form dated [DATE] for Resident #2 revealed he had a temperature of 100, blood pressure of ,[DATE], oxygen saturations of 66%, and respirations of 41. [MEDICAL CONDITION] pathway indicated Resident #2 was positive for [MEDICAL CONDITION] and not responding and the vitals are abnormal. Review of Hospital Emergency Documentation dated [DATE] for Resident #2 revealed: Increased agitation today with paranoid behavior. Since moving . 2 months ago, the patient has been to the emergency department now 3 times for agitation and changes in behavior and combativeness. These are normally centered around the patient having a new infection namely UTI. Throughout the week there were no reported changes in the patient's behavior until this morning. 911 was called to the nursing home and the patient was found in his room wielding a leg from a wheelchair as well as a gait belt as weapons. Staff was unable to get near the patient for fear of harm. EMS (emergency medical service) was able to subdue the patient .Urinalysis completed, no culture and sensitivity completed. Final Diagnosis: [REDACTED]. History of [MEDICAL CONDITION], 3. Dementia, chronic, 4. Agitation states as acute reaction to exceptional (gross) stress, Recurrent. (sic) Review of Hospital Emergency Documentation dated [DATE] for Resident #2 revealed: . presents today after he had an unwitnessed fall out of a Geri chair. Reportedly he has decreased mental status. This was not witnessed. Patient may be developing UTI here given his urine findings. However, previous cultures were negative showing 2 contaminants Patient was given a dose of [MEDICATION NAME] here and will go home on Keflex 500 mg 3 times daily for 6 days. Final Diagnosis: [REDACTED]. Altered mental status. (sic) Review of Hospital Emergency Documentation dated [DATE] for Resident #2 revealed: . [MEDICAL CONDITION] status with end organ failure and [MEDICAL CONDITION] indicated a need to emergently boluses fluids .Admission diagnosis; 1. Probable aspiration pneumonia, 2. Elevated troponin, probable NSTEMI ([MEDICAL CONDITION]), 3. History of recurrent UTI's and VRE ([MEDICATION NAME] resistant [MEDICATION NAME]), 4. [MEDICAL CONDITION], 5. Bilateral pressure ulcers on heels, 6. [MEDICAL CONDITION] (disorder or disease of the brain), 7. Dementia, 8. Severe dehydration, 9. Acute kidney injury, due to #8. Discharge Diagnosis: [REDACTED]. Elevated troponin, probable NSTEMI, 3. History of recurrent UTI's and VRE infections possible, urine culture clear, 4. [MEDICAL CONDITION], 5. Bilateral pressure ulcers on heels. Spoke with Hospice team and they will be taking over . At the time of discharge the patient remained unresponsive with guarded prognosis.

This citation pertains to intake number MI 859 This citation has 2 Deficiency Practice Statements, A & B. DPS (A) Based on observation, interview, and record review, the facility failed to identify risk factors, initiate interventions, and had delayed assessment of a new skin issue for 1 of 4 sampled residents (Resident #100) reviewed for pressure ulcers, out of a total sample of 5 residents, resulting in the development of a facility acquired unstageable pressure ulcer for Resident #100. Findings include: Review of the facility policy and procedure for Prevention of Pressure Ulcers, revised [DATE], revealed General Guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extend period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue .Interventions and Preventive Measures: General .4. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging .Interventions and Preventive Measures: Residents with Risk Factors .1. Risk Factor - Moisture .c. Provide clean, unwrinkled sheets .3. Risk Factor - Bed-Fast .d. Consider off-loading pressure hourly if the head of the bed is greater than 30 degrees .4. Risk Factor - Chair-fast .c. Change position at least q (every) 1 hour . Review of the facility policy and procedure for Repositioning, revised ,[DATE] and reviewed ,[DATE], revealed General Guidelines: .5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing .Interventions: .3. For residents with a Stage I or above pressure ulcer, q 2 hour turning may be inadequate .5. If ineffective, the turning and repositioning frequency may be increased. Resident #100 Review of an Admission Record for Resident #100 revealed she was an [AGE] year old woman originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed on [DATE] revealed a Brief Interview for Mental Status (BIMS) revealed a score of ,[DATE] indicated Resident #100 was cognitively intact. Review of Resident #100's Braden Scores (An assessment tool for predicting the risk of pressure ulcers) revealed: [DATE] 14.0 Moderate Risk for skin breakdown. [DATE] 14.0 Moderate Risk for skin breakdown. [DATE] 18.0 Low Risk for skin breakdown. [DATE] 11.0 Moderate Risk for skin breakdown. [DATE] 13.0 Moderate Risk for skin breakdown. [DATE] 12.0 Moderate Risk for skin breakdown. [DATE] 11.0 Moderate Risk for skin breakdown. [DATE] 12.0 Moderate Risk for skin breakdown. Review of a Skin assessment dated [DATE] revealed, Are there any new abnormal skin areas? NO. Are there any existing abnormal skin areas? NO. Licensed Practical Nurse (LPN) W signed and acknowledged that she conducted a full skin assessment and no new abnormal skin areas were observed. Review of Resident #100's focus of the care plan as it was last updated prior to development of the pressure ulcer, revised [DATE] revealed: Focus: The resident is at risk for pressure ulcer development/impaired skin integrity r/t impaired mobility, occasionally incontinent, hx: non-Hodgkin's [MEDICAL CONDITION]. Review of a Skin Observation Task from the electronic medical record revealed, a new red area was charted on [DATE] at 2:11 a.m by Certified Nurse Aide (CNA) V. Review of a Skin assessment dated [DATE] revealed, Are there any new abnormal skin areas? NO. Are there any existing abnormal skin areas? NO. LPN W signed and acknowledged that she conducted a full skin assessment and no new abnormal skin areas were observed. This Skin Assessment was struck out on [DATE] with a reason code of inaccurate information. Review of a wound note dated [DATE] revealed, Thickness/stage: Unstageable. Tissue Type: Slough. Measurements (cm): L 1.0 x W 0.50. Wound Bed Description: Slough 100%. Treatment: Hydrogel and border gauze daily and PRN. Signed, Unit Manager L. Review of a Skin assessment dated [DATE] revealed, Are there any new abnormal skin areas? YES. List sites of any new abnormal skin areas: mid-coccyx, measuring 1cm x .5cm. Are there any existing abnormal skin areas? NO. Signed by Unit Manager L. In a telephone interview on [DATE] at 11:51 a.m., Licensed Practical Nurse (LPN) W stated, I know she has a wound on her coccyx. Her dressing changes are on 1st shift. I'm 2nd shift. CNA H told unit manager when she saw the wound. Sometimes I'm called to the other side and so I do my documentation later in the shift. I didn't know there was skin breakdown when I did the skin assessment. So the next day I struck it out and put the right information in. In an interview on [DATE] at 2:12 p.m. CNA H reported that on 2nd shift on [DATE], Resident #100 told her she was sore on her bottom. CNA H stated, So I toileted her, and opened up her cheeks and that's when I saw it. It had a green-ish type of stuff on it. It was open and about dime-sized. I think I reported it to the unit manager. In a telephone interview on [DATE] at 3:30 p.m., LPN W stated I can't remember which CNA, but she told me there was a little area on Resident #100's bottom, and the CNA said she would put some cream on it. I should've looked at it. CNA H then looked at it during toileting and noticed it was more of a concern. When Resident #100 was on the other side of the building she was always in her wheelchair. Even at night she would ask staff to put her in her chair. Resident #100 barely ever slept in her bed for the entire shift. She would call her family and tell them she wasn't comfortable, she couldn't sleep, in pain. I would hear that in report .When I do skin assessments I look over the whole body in general. Then I look at pressure points likes hips, shoulders, elbows. If a CNA brings an area of concern, then you do a more in depth look, like spread cheeks, lift folds, etc. If no area of concern are brought up when a CNA does a skin check, then you do your general overview. That's why when CNAs shower, they need to tell you any areas of concern. I'm sorry, sometimes that is how things are overlooked. In an observation on [DATE] at 10:18 a.m., Resident #100 was in her recliner chair which was in an upright position. No pillow was observed under resident's bottom. In an observation on [DATE] at 11:40 a.m., Resident #100 was in her recliner chair which was in an upright position. No pillow was observed under the resident's bottom. Resident #100 reported that she had been in her recliner since about 9:30 a.m. Resident #100 did not report any that any off loading had taken place. In an observation on [DATE] at 12:27 p.m., Resident #100 was in her recliner chair which was in an upright position. No pillow was observed under the resident's bottom. In an observation on [DATE] at 2:33 p.m., Resident #100 was in her recliner chair which was in an upright position. No pillow was observed under the resident's bottom. In an interview on [DATE] at 11:10 a.m., CNA M stated, We just repositioned her from her left side to her right side when she is in bed. But they are getting her up for therapy right now. CNA M reported that to off load while in the recliner, it's hard to do, but they could place a pillow on one side of her bottom and then alternate it to the other side of her bottom. In an observation on [DATE] at 11:27 a.m., Resident was observed up in her wheelchair with Occupational Therapist. In an observation on [DATE] at 11:53 a.m., Resident #100 was up in her wheelchair in her room. In an observation on [DATE] at 12:32 p.m., lunch tray was delivered to Resident #100 who was up in her wheelchair, in her room. Review of Resident #100's complete care plan, revised [DATE] revealed: - Focus: The resident is at risk for pressure ulcer development/impaired skin integrity r/t impaired mobility, occasionally incontinent, hx: non-Hodgkin's [MEDICAL CONDITION], head of bed elevated as needed related to sleep apnea. Unstageable wound to coccyx. - Goal: The resident's risk of significant skin injury will be reduced/minimized through the review date. - Interventions: Evaluate nutritional status. Serve diet as ordered, monitor intake and record. initiated [DATE]. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Lower extremity ACE wraps as ordered and tolerated. initiated [DATE]. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Initiated [DATE]. Skin inspections by CNA during cares and showers/baths. Report changes to licensed nurse immediately. Initiated [DATE]. The resident needs reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. initiated [DATE]. The resident requires (SPECIFY: type) cushion when in wheelchair. initiated [DATE]. The resident requires a cushion when in wheelchair. revised [DATE]. APM (alternating pressure mattress). initiated [DATE]. In an interview on [DATE] at 3:43 p.m., CNA M reported she doesn't remember off-loading Resident #100 from her recliner on 1st shift on [DATE]. CNA M stated, She did eat breakfast in her wheelchair yesterday and went to the bathroom. I don't remember charting on her. Review of the Turn/Repositioning task in the electronic chart revealed CNA M was the only CNA to chart on Resident #100 on the 1st shift of [DATE], and had documented N/A for the Turn/Repositioning task for [DATE]. In a telephone interview on ,[DATE] at 5:00 p.m., CNA S reported that she didn't remember any new areas of concern on Resident #100 prior to the wound on her bottom being discovered. CNA S stated, I know that sometimes because we're so busy or because we're short staffed, nurses do not always check skin if the CNAs say there's no new problems-they'll take the CNA's word for it. I remember when I toileted Resident #100 on [DATE] there was so much cream on her bottom I didn't have to apply more, I couldn't even see her bottom. Resident #100 didn't have a bowel movement at that time, so I didn't wipe the cream off, I just patted her dry . The CNAs from the other side said she's always up and down in the night, not sleeping and up in her wheelchair. In an observation on [DATE] at 8:37 a.m., Resident #100 was in her wheelchair. A dark blue cushion was beneath her. It was approximately 1 inch in thickness, and easily [MEDICATION NAME]. CNA M reported she didn't know what kind of cushion it was, or what kind of cushion Resident #100 should have. Resident #100 then stated, I keep sliding in this chair. CNA M stated, Yeah, that cushion seems a little bit more slippery than some of the others. In an interview on [DATE] at 11:57 a.m., Registered Nurse C stated, I don't know what cushion she's supposed to have. I'm only down here one time a month. It's my weakest side. I can check her kardex. RN C checked Resident #100's kardex. RN C stated, I don't see it in here. I'll check the care plan. RN C checked Resident #100's care plan. RN C stated, It just says requires a cushion when in wheelchair. In an interview on [DATE] at 12:06 p.m., Family Member FF stated, Now she has a bed sore as of last Tuesday (,[DATE]) or Wednesday (,[DATE]). She never had difficulty sleeping before coming to the facility. Now (Resident #100) calls all the time. She lived by herself, she never called, she did great. She complains of her bed and just being there. I'm not aware of any sleep apnea- no, she doesn't have that. In an interview on [DATE] at approximately 1:30 p.m., CNA V reported, the new red area she documented on her skin observation task on [DATE] for Resident #100 was on her bottom. CNA V stated, Yes, I think I reported it to RN X. I don't know if the nurse checked on it. When I came to work on Thursday I noticed a patch on it. I applied creams we use. I ordinarily apply creams, the nurses do the patches. In an interview on [DATE] at 8:08 a.m., RN X reported that CNA V did not notify him of any new skin areas. RN X stated, I was not aware of any new skin issues. If a CNA sees a new area they are to notify a nurse to look at it right away, under no circumstance should a CNA apply lotion or treatment of [REDACTED]. In an interview on [DATE] at 9:00 a.m. OT DD reported that the facility has a couple different kinds of wheelchair cushions. The Roho cushion and the gel cushion can be used for wounds. Resident #100 should have a gel cushion. OT DD stated, I evaluated her Wednesday in the afternoon. I remember we were looking for a gel cushion for her because we received dark blue cushions and we aren't big fans of them. The foam doesn't offer enough support. Most people have the gel cushions which are black and yellow. I don't have any extra Roho cushions to show you, they're all under people. Review of a facility provided timeline of Resident #100's wound development revealed, wound found on [DATE]. Interventions before wound: pressure-reducing mattress, cushion in wheelchair, weekly skin inspections, turn every 2 hours, nutrition evaluation, monitor food intake, labs as ordered. In an interview on [DATE] at 10:05 a.m., Director of Nursing, B indicated that the above interventions before the wound are standards of care that are provided to every resident. During an observation on [DATE] at 8:25 a.m., Certified Nursing Assistant M (CNA M) entered Resident #100's room, no hand hygiene was performed. CNA M put on gloves and assisted Resident #100 to the bathroom. CNA M pulled down Resident #100's pants and revealed a border gauze bandage to a coccyx pressure sore. Resident #100's coccyx and surround tissue was redden, the pressure sore had a pink ring surrounding a white core of tissue. Registered Nurse C (RN C) re-dressed the pressure sore, with hydrogel and border gauze. In an interview on [DATE] at 8:45, RN C indicated does not know what stage Resident #100's coccyx pressure sore was, I'm not good at staging. DPS (B) Based on observation, interview, and record review, the facility failed to report new areas of skin concerns in a timely manner, provide care consistent with professional standards to prevent the development and worsening of pressure ulcers in 2 residents (Resident #102, Resident #103) of 4 residents reviewed for pressure ulcers, out of a total sample of 5 residents, resulting in the development and worsening of pressure ulcers and the potential for introducing infection to the wound sites for Resident #102 and #103. Findings include Resident #102 Review of an Admission Record for Resident #102 revealed he was an [AGE] year old man originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed on [DATE] revealed a Brief Interview for Mental Status (BIMS) revealed a score of ,[DATE] indicated Resident #102 was moderately cognitively impaired. In an observation on [DATE] at 12:15 p.m., Resident #102 was up in a geri-chair in the dining room next to Certified Nursing Assistant (CNA) R. Resident #102 fed self. Motioned to this surveyor to come over, asked in a loud voice, What are you doing here? In an observation on [DATE] at 3:53 p.m., Resident #102 was in bed with eyes closed. Head of bed was elevated to approximately 45 degrees. In an observation on [DATE] at 8:42 a.m., Resident #102 was in his bed, and the head of the bed was elevated up past 45 degrees. Next to the resident was a white board and on it was written, It's time to sleep. In an observation on [DATE] at 11:19 a.m., Resident #102 was up in his geri-chair near the nurses' station. In an observation on [DATE] at 11:55 a.m., Resident # 102 was up in his geri-chair near the nurses' station. In an observation on [DATE] at 12:49 a.m., Resident # 102 was in his bed with the head of the bed elevated at approximately 45 degrees. Review of a facility provided Timeline for Resident #102 revealed, Wound found: [DATE] stage 1 pressure ulcer right buttock, stage 3 pressure ulcer left inner buttock superior .Wound found: [DATE] stage 2 pressure ulcer on left inner buttock inferior, worsened left superior/upper inner buttock . Wound worse [DATE] now unstageable pressure for left inner buttock inferior. Intervention after worsened. Turn side to side when in bed. Body pillow to help with repositioning. Root cause: Terminal diagnosis, life expectancy less than 6 months. In an interview on [DATE] at 1:35 p.m., CNA U reported that she first saw the new large reddened area to one side the Resident #102's buttocks, and new small area on the other side of his buttocks on [DATE]. She reported that she told the nurse, but couldn't remember which one. Review of a Skin Observation Task in the electronic medical record revealed, CNA O recorded No new areas on [DATE] on the shift that followed CNA U's discovery of the new red area. In an interview on [DATE] at 11:31 a.m., CNA O stated, I don't recall being told of any new areas of redness to Resident #102's bottom. I'm usually on the other side. I don't remember documenting. Maybe I helped him in bed, but I don't do his peri-care. If I charted no new areas, then I didn't see anything. Review of a Skin Observation Task in the electronic medical record revealed, CNA R recorded a new Open Area on [DATE]. Review of a Nutrition evaluation dated [DATE] revealed, Tolerating no added salt, pureed diet order, oral intake is 87% averaged over 37 meals. Resident needs supervision/cues with meals in the dining room. No issues chewing or swallowing. Receives supplement 120 ml twice a day, intake average of 89% and (frozen supplement treat) as an afternoon snack, intake average 85%. Review of Resident #102's care plan, initiated [DATE] and revised on [DATE], revealed: Focus: The resident is at risk for development/impaired skin integrity . Goal: The resident's risk of significant skin injury will be reduced minimized . Interventions: Alternating pressure mattress (APM), revision [DATE] -follow facility policies/protocols for the prevention/treatment of [REDACTED]., -The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested, .revision [DATE] -Up and down schedule, Resident is to be up in geri chair for meals and then back to bed to rest . to minimize pressure on buttock wounds revision on [DATE] Review of Resident #102's care plan, initiated [DATE] and revised on [DATE], revealed: Focus: The resident has ADL (activities of daily living) self-care performance deficit . Goal: The resident will improve current level of function . Interventions: BED MOBILITY: The resident requires assistance by (X2) staff to turn and reposition in bed Q (every) 2 hours and as necessary, revision on [DATE] . Review of Nursing Evaluation Data V7, Section C. Skin Conditions dated [DATE], revealed Resident #102 had redness noted to coccyx. Review of the untitled acquired pressure sore documentation for Resident #102 , dated [DATE], by Unit Manager E (UM E)), revealed: 1. Right inner buttock, Stage I pressure sore, granulation tissue, skin intact, measuring length 2.0 x width 2.0 cm, non blanchable, located between buttocks. (e-signed [DATE]) 2. Left inner buttock (superior), Stage III pressure sore, 50% slough tissue, skin intact, light serosanguinous exudate, measuring length 3.5x width 3.0 cm, (e-signed [DATE] ). Review of the untitled acquired pressure sore documentation for Resident #102, dated [DATE], by UM E revealed: 1. Right inner buttock, Stage I pressure sore, granulation tissue, skin intact, measuring 2x2 cm, non blanchable, located between buttocks (e-signed [DATE] ). 2. Left inner buttock (superior), Stage III pressure sore, 95% necrotic tissue, skin intact, no exudate, measuring length 2.0x width 2.5 cm (e-signed [DATE]) 3. Left inner buttock inferior, Stage II pressure sore, granulation tissue, skin intact, moderate serosanguinous exudate, measuring length 0.5 x width 0.4 cm (e-signed [DATE]). Review of the untitled acquired pressure sore documentation for Resident #102, dated [DATE], by UM E, revealed: 1. Right inner buttock, Stage I pressure sore, [MEDICATION NAME] tissue, skin intact, measuring length 1.0 x width 1.5 cm, non blanchable (e-signed [DATE]). 2. Left inner buttock (superior), unstageable pressure sore, necrotic tissue, skin intact, serosanguinous exudate, measuring length 2.0x width 1.8 cm. General comments: .thin ring of maceration around upper half of wound. Center has opened this week 0.5 x0.5 . (e-signed [DATE]). 3. Left inner buttock inferior, unstageable pressure sore, 100% necrotic tissue, skin intact, no exudate, measuring length 1.7 x width 0.4 cm (e-signed [DATE]). During an observation on [DATE] at 10:30 a.m., Resident #102 was lying flat on back in alternating pressure mattress (APM) bed, with the head of bed elevated greater than 30 degrees. During an observation on [DATE] at 11:30 a.m., Resident #102 was lying flat on back in an APM bed, with a pillow positioned under left buttock and the head of bed elevated to greater than 30 degrees. Registered Nurse F (RN F) and Unit Manager E (UM E) entered room to assess and change Resident #102's pressure dressing to left and right buttock. UM E did not perform hand hygiene prior to donning gloves. UM E assisted RN F by rolling Resident #102 on to right hip. UM E and RN F determined Resident #102 had a bowel movement. RN F exited Resident #102's room to gather supplies and more assistance. UM E stepped away from Resident #102 and Resident #102 was instructed to continue to lay on the right side. RN F returned with CNA G. CNA G did not perform hand hygiene and then donned gloves. CNA G saturated two wash cloths with water and soap at the sink and carried both wash cloths to Resident #102's bed. CNA G placed both wet wash cloths on the incontinence pad Resident#102 was laying on. CNA G removed the brief to expose the bowel movement covering Resident #102's buttocks and dressing to right buttock. Resident #102's gluteal folds, scrotum, and tissue surrounding the three pressure ulcers were reddened. Resident #102's buttocks had redness and indention's from the incontinence brief and pad and Resident #102's upper back had redness and indention's from the wrinkled sheets. CNA G cleaned the stool from Resident #102's buttocks and removed the pressure sore dressing with soiled gloves. CNA G tried several times pulling the soiled brief from under Resident #102's right hip and broke the soiled brief. No hand hygiene or glove change was observed. CNA G did not replace the incontinence pad. CNA G wedged a clean brief under Resident #102's right hip, then removed the soiled gloves, removed the trash, and exited the room touching resident objects and door handle. No hand hygiene was observed. During an observation on [DATE] at 12:00 p.m., UM E and RN F examined and measured Resident #102's pressure sores located on left and right buttock. 1. Right buttock, intact skin, and redness present, non blanchable in some areas. 2. Superior left buttock sore was circular with a moist gray ring of skin surrounding a black open core, measuring 2.0 cm X 1.8 cm. 3. Inferior left buttock sore was intact skin, black and circular, measuring 1.7 cm X 0.4 cm. During an observation on [DATE] at 12:15 p.m., RN F rolled Resident #102 flat on back, placed a pillow under left buttock, a pillow between knees, floated heels, and elevated the head of bed to 30 degrees. During an observation on [DATE] at 1:00 p.m., Resident #102 was lying flat on back in APM bed, with the head of bed elevated greater than 30 degrees. CNA G moved the pillow from under the left buttock to the right buttock and dragged Resident #102, with ,[DATE] tugs, to the center of the bed using the incontinence pad. Resistance with each tug observed. No assistance was used. CNA G boosted Resident #102 up in bed, tugging the incontinence pad ,[DATE] times from the head of the bed. Resistance with each tug observed. No assistance was observed. During an observation on [DATE] at 1:20 p.m., CNA G fed Resident #102 in bed with the head of the bed greater than 45 degrees. During an observation on [DATE] at 3:00 p.m., Resident #102 was lying flat on back in APM bed, with the head of bed elevated to greater than 30 degrees. During an observation on [DATE] at 4:10 p.m., Resident #102 was lying flat on back in APM bed, with the head of bed elevated to greater than 30 degrees. During an observation on [DATE] at 8:27 a.m., Resident #102 was seated upright, in front of the nurse's desk, in a geri chair, with a pillow under right buttock below blue cushion. During an observation on [DATE] at 10:20 a.m., Resident #102 was seated reclined, in front of the nurse's desk, in a geri chair, with a pillow under right buttock below blue cushion. During an observation on [DATE] at 11:05 a.m., Resident #102 was seated upright, in a geri chair, with a pillow under right buttock below blue cushion, headed to an activity in dining room. During an observation on [DATE] at 11:40 a.m., Resident #102 was seated upright, in a geri chair, in Sunset dining room, pillow was under left buttock. During an observation on [DATE] at 12:30 p.m., Resident #102 was seated upright, in a geri chair, in Sunset dining room, pillow was under left buttock. During an observation on [DATE] at 1:15 p.m., Resident #102 was lying partially on right side with pillow behind upper back. Body pillow on chair against the wall. In an interview on [DATE] at 12:42, CNA G indicated Resident #102 has been up in geri chair since before breakfast and has not laid down today. Resident #102 has not needed a brief change. CNA G indicated when Resident #102 was in the geri chair, changed Resident #102's position while in geri chair from reclining to upright every couple of hours. CNA G' indicated also wedges a pillow under the buttocks, moving left to right every couple hours. CNA G indicated Resident #102 preferred to lay on back in bed but would lay on side if encouraged. Resident #102 preferred the head of bed raised for comfort but only needed it raised a little bit. CNA G indicated could move resident up in bed alone but technically 2 people are required to boost Resident #102 in bed. CNA G indicated that sometimes it is a struggle to move Resident #102 up in bed alone but they are low on staff. CNA G indicated has never been educated on how to use the APM bed. CNA G indicated did not know alternating pressure mode could cause more friction or shear when transferring or adjusting resident position in bed. CNA G indicated did not know there was a different modes the bed could be changed to assist with transfers, CPR and resident care. CNA G indicated the facility has many residents on APM beds and education about the APM could be useful and benefit the staff and residents. Review of the PressureGuard APM (alternating pressure mattress) Family, Owner's Manual, PressureGuard APM2 with Deluxe 5800 Control Unit PressureGuard APM2, revealed: Head of Bed Elevation: Lifting head of the bed more than 30 degrees puts the skin over the sacrum at high risk for breakdown due to a concentration of weight on this area of the body in this position. We advise limiting raising the head of the bed to no more than 30 degrees, and limiting the amount of time spent in that position. Patient repositioning to change pressures on the body remains a basic need in patient care . STATIC: This mode provides powered flotation, in which the system continually adjusts as necessary to maintain patient support at the chosen comfort level. Caregiver may prefer this mode for transfers, dressing changes, feeding, and related activities .AUTOFIRM: Press the AUTOFIRM button to automatically inflate the mattress to the maximum level for 30 minutes. The pressure will return to the previously set level after 30 minutes. This may be used for patient transfers, ADL's (activities of daily living) and CPR .Bed Linens: .Multiple layering of linens or underpads beneath the patient should be avoided for the prevention and treatment of [REDACTED]. In an interview on [DATE] at 1:05 p.m., UM E and UM L indicated the interventions in place to prevent new or worsen pressure sores for Resident #102 were a new blue cushion for geri chair, alternating pressure bed (mattress), positioning every 2 hours, up in geri chair for meals and back in bed after meals. UM E indicated expectations for Resident #102 position change every 2 hours would be alternating pillow from left buttock to right buttock. Resident #103 Review of an Admission Record for Resident #103 revealed he was an [AGE] year old man originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed on [DATE] revealed a Brief Interview for Mental Status (BIMS) revealed a score of ,[DATE] indicated Resident #103 was cognitively intact. In an in (TRUNCATED)

This citation refers to intake M 0463 and Mi 464 This citation has 2 Deficiency Practice Statments, A & B DPS A Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement and ensure the safety in 1 of 11 sampled residents (Resident #101) reviewed for safety and supervision, from a total sample of 11, resulting in an Immediate Jeopardy when on [DATE] at approximately 8:30 p.m., Resident #101 exited the facility, unbeknownst to facility staff, and was found at approximately 8:44 p.m., 0.5 miles down the road from the facility. This deficient practice placed 5 residents, identified as risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of a Face Sheet revealed Resident #101 was an [AGE] year old female originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #101 with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 out of a total possible score of 15, which indicated she was moderate cognitively impaired. Review of an Incident Report dated [DATE] at 8:44 p.m., revealed Resident #101 was observed by housekeeping member on (named street corner). She had her electric Wheelchair During an observation and interview on [DATE] at 10:15 a.m., Maintenance Director (MD) E reported there were 3 entrances at the facility that detect Code Alert alarms. The evening of [DATE], the door alarms would be deactivated once the code was punched in, including the Code Alert alarms that were worn by the residents who had them. In an interview on [DATE] at 12:14 p.m., Licensed Practical Nurse (LPN) C reported that on [DATE] she had just made a telephone call around 8:30 p.m. when she saw Resident #101 in her motorized scooter near the nurses' station. LPN C reported Resident #101 had been at the nurses' station calling her son all day. LPN C reported that she remembered that Laundry Attendant (LA) D left the facility around 8:35 to go home. LPN C reported that LA D had then called her to check if Resident #101 was in the facility because he had just drove past someone down the street that resembled Resident #101. LPN C reported she then looked for Resident #101, who was missing and called an Amber alert. LPN C reported going outside and by then LA D had been redirecting Resident #101 back to facility while walking beside her. LPN C was not exactly sure how Resident #101 got out of the building. LPN C reported that Resident #101 had a Code Alert bracelet on her scooter and may have followed a visitor out of the building. LPN C reported that when the alarm code was entered, it deactivated the Code Alert alarm as well. LPN C reported there were no alarms that went off to alert staff that Resident #101 was near a door trying to get out of the facility. In an interview on [DATE] at 12:40, LA D reported clocking out from work around 8:35 p.m. on [DATE]. LA D reported having a friend pick him up and he was the passenger in the car while driving down the busy, 4 lane road with a median in the middle. LA D took a right out of the parking lot and drove down the street when he noticed there was a flashing light object bumping on the sidewalk that caught his attention. As he drew closer, LA D saw a motorized scooter with a headlamp on the front with a person who looked like Resident #101, but was not completely sure it was Resident #101. LA D then called the facility and talked to LPN C who verified that Resident #101 was not in the building after looking for her. LA D reported that the street was a busy street and he was not able to stop right away. LA D had turned around down the road and met Resident #101 near the corner, which was ½ mile down the road from the facility. LA D reported it was dark outside and cooler temperatures and did not want to startle Resident #101. When it was confirmed Resident #101 was missing, LA D got out of the car and slowly walked up towards Resident #101 and redirected Resident #101 back to the facility. LA D reported LPN C met him and Resident #101 at the end of the driveway. LA D reported that Resident #101 said she wanted to go to her home which had a fireplace. LA D reported Resident #101 had crossed about 3 to 4 side streets along the way and the sidewalk was bumpy mostly due to grass growing in the cracks. In an interview on [DATE] at 2:45 p.m., Certified Nursing Assistant (CNA) F reported the last time she saw Resident #101 on [DATE] was between 8:00 and 8:30 p.m CNA F reported she was caring for another resident when she saw Resident #101 on her motorized scooter going down the hall. CNA F reported she did not hear any alarms and was unaware of any residents missing until an Amber Alert was called. In an interview on [DATE] at 3:05 p.m., CNA G reported she worked [DATE] on White Pines Hall on second shift and last saw Resident #101 around 3:00 p.m She was unaware of resident missing until an Amber alert was called and did not recall hearing an alarm going off to alert that a resident went out the door. CNA G reported she did not know how Resident #101 got out of the door. In an interview on [DATE] at 3:17 p.m., CNA H reported she worked second shift on [DATE] on Windmill Island and last saw Resident #101 around 8:00 p.m. CNA H was getting another resident ready for bed when she saw Resident #101 driving down the hall in her motorized scooter. CNA H was not aware Resident #101 got out of the building until an Amber Alert was called. CNA H did not hear a door alarm sounding to indicate a warning that a resident was leaving the building. In an observation on [DATE] at 2:00, the street where Resident #101 was found was 0.5 miles down the road from the facility and there were 4 side streets that Resident #101 would have crossed before LA D had stopped to redirect her back to the facility On [DATE], Administrator A was notified of an Immediate Jeopardy that began on [DATE] when Resident #101, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On [DATE], this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On [DATE], following this event, Resident #101 was assessed for injury with no abnormal findings noted. Both the physician and family were notified. 2. On [DATE] an audit of current residents residing in the facility was completed to ensure current residents were safe and accounted for. 3. From [DATE] to [DATE] residents residing in the facility had new Risk Of Elopement/ Wandering Review completed by licensed nurses to verify accuracy of risk. Five out of seventy residents were found to be at risk of elopement. 4. On [DATE] residents residing in the facility who were identified as being at risk for elopement per the Risk Of Elopement/Wandering Review form were reviewed by the nursing leadership to review current elopement risk, orders requiring documentation, care plan, and Kardex to ensure appropriate assessment and intervention were in place. In addition those residents assessed as requiring a code alert device had their devices validated for placement, expiration date and function by licensed nurses. 5. On [DATE] an audit was completed by DON B to verify to verify that all residents at risk for elopement had an elopement photo sheet in place. 6. On [DATE], door alarm function was checked and will continue to be checked daily to verify proper function utilizing the facility map with alarmed doors identified by numbers which require signatures attesting to functionality. 7. On [DATE], an IDT meeting was held to review the Risk for elopement, orders requiring documentation, care plan, and Kardex to ensure appropriate assessment and interventions were in place. 8. On [DATE] an Elopement Care Audit tool was completed. The care audit tool includes validation of code alert checks for function and placement, Elopement risk book with photos, elopement risk assessments, care plans, and door alarm response. 9. On [DATE], at 00:30am, a code amber drill was conducted to validate that employees on the schedule were able to complete the procedure per policy. 10. Elopement drills were conducted on all three shifts as follows: a. [DATE] 00:30am b. [DATE] 13:30pm c. [DATE] 16:30pm. 11. On [DATE] addition to the 2 signs in front entrance and both back entrances and courtyard exits an additional sign was placed before entering the front door, viewable upon entrance, alerting persons that exit the facility not to assist residents outside without checking with the nurse. 12. On [DATE], a letter was sent to Resident Representatives by NHA A, to alert them not to allow a resident to go outside unless they are their family member of responsibility. 13. On [DATE], The Elopement Prevention and Management Program was reviewed by the NHA A and DON B and deemed appropriate. 14. On [DATE], an Ad Hoc QAPI meeting was held to review the elopement prevention process and plan. The Medical Director reviewed the plan with the Administrator on [DATE]. 15. On [DATE] visitor entrances/exits were placed under direct supervision until [DATE] until assessment of the alarm function could be conducted by Riverview. 16. On [DATE], the front door code alert system was changed to require a separate code to deactivate the Code Alert system by Riverside. The back entrances remained under observation until the same process was completed on [DATE]. 17. On [DATE], reeducation was provided by the Staff Development Coordinator/designee related to the facilities Elopement Prevention Policies and Procedures which included prevention and management, reporting responsibilities, maintaining door alarms and wander control systems, responding to alarms and ensuring doors are secured when passing through and no employee was allowed to work without receiving education. 18. Licensed nurses were checked off on checking the placement and function of the personal alarm device. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity actual harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency, all education had not yet been completed regarding elopement, and Resident #106 (below) had a fall with fracture and the facility was found to have deficient practice. DPS B Based on observation, interview and record review, the facility failed to prevent a fall in 1of 11 sampled residents (Resident #106) reviewed for accidents, from a total sample of 11 residents, resulting in injury and hospitalization . Findings include: Review of a Face Sheet for Resident #106 revealed a [AGE] year old female originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with a reference date of [DATE] revealed a Brief Interview for Mental Status which indicated severe cognitive impairment. Resident #106 self-propelled via wheelchair and transferred with 1 assist. Review of a Fall Risk assessment dated [DATE] revealed a score of 18. (A score greater than 10 is a high risk.) Review of the Falls care plan dated [DATE] revealed Resident #106 was at risk for falls due to being unaware of safety needs, confusion, gait/balance problems, and a history of falls. The care planned goal was to reduce the risk of serious injury in the event of a fall. Interventions included to anticipate the needs of the resident, dycem to wheelchair - check Q (every) shift for placement, appropriate footwear (nonskid). Review of an incident/accident report statement dated [DATE] at 12:00 a.m. revealed that Resident #106 was found lying on the floor of the Great Lakes Shower room by Certified Nursing Assistant (CNA) KK with the door closed and lights off. I was in the charting room charting and heard a faint help me. I didn't see Resident #106 at the nurses' desk where she was last. I checked on certain rooms and saw the empty wheelchair outside of the door. I opened it and discovered her lying next to the bath tub. The last time I saw her was about 5 minutes minimum or 10 minutes maximum since I was trying to quickly chart it. She was at the nurse's station sitting still. Review of a statement from the incident accident report from [DATE] regarding Resident #106 revealed: Registered Nurse (RN) LL reported; This nurse was called to the Great Lakes shower room after my CNA heard the resident calling for assistance. Upon entering a non-lighted room, I saw the resident laying on her left side next to the rack in the shower room. Assess guest for injury, noted smaller than 2.0 centimeter (cm) circular s.t. on left elbow and 1.5 cm diameter pinkish bruise noted on left outer knee. Resident allowed elbow to be cleaned with normal saline but refused any further treatment. Assess for range of motion and neuro checks decreased at 12:00 a.m., it could not be determined to have any further injury, fracture, or dislocation. Resident said ow-ow but stated this no matter where we were touching her. RN LL also reported in this report: This nurse observed resident propelling down the hallway past 10:00 p.m. until time of incident around 12 a.m., she is not always up at this time, but sometimes she is up in the hallway at this time. Any other information that is important to know? Resident has dementia and is impulsive. Review of a Hospital Discharge Summary Final Report dated [DATE] revealed Resident #6 was admitted on [DATE] and discharged on [DATE]. Hospital Course: .was found to have severe left hip pain. Was evaluated in the emergency room found to have an acute pathological fracture of her left femoral neck following a fall Subsequently a consult was made to hospice family decided on hospice care. Patient was transitioned to hospice care in hospital started on oral liquid morphine and liquid Ativan .plan for discharge to skilled nursing facility with hospice . Review of the Falls care plan for Resident # 6 dated [DATE] and revised on [DATE] revealed an added intervention included keypad lock to shower room doors. Review of an email on [DATE] at 7:12 a.m. from MD E to NHA A revealed: Subject: regarding keypads for shower room: I just ordered them, you will need to approve them. Not cheap, $517.70 for all 4. It usually takes about a week for them to come in, they are ordered directly from the Manufacturer. During an observation on [DATE] at 2:41 p.m., the shower room in the White Pines unit shower room was wide open, with a Hoyer lift sitting in the doorway. During an observation on [DATE] at 2:57 p.m., the shower room in the Light House/Lodge unit shower room was wide open and had a wheelchair with damp towels and a shirt draped over it. No staff observed in the hallway. During an observation and interview on [DATE] at 3:00 p.m., Maintenance Director (MD) E was installing a digital lock on the White Pines unit shower room door, and reported the new digital locks came in late the night before and that the shower rooms should have been closed when not in use. During an observation on [DATE] at 3:04 p.m., Windmill Island unit shower room was closed with a digital lock on it. During an observation and on [DATE] at 3:05 p.m. Great Lakes unit shower room had a digital lock installed and the door was closed. In an interview on [DATE] at 3:10 p.m. Licensed Practical Nurse (LPN) C reported she didn't think there was a policy on the shower doors being opened or closed when not in use. Then at 3:36 p.m. she came to this surveyor and reported there was a policy on the shower room doors and that the doors were to be closed and locked. In an interview on [DATE] at 4:00 p.m. Nursing Home Administrator (NHA) A reported there was no policy for the shower room doors. When During an observation on [DATE] at 9:40 a.m., the shower room on the Lighthouse unit had a digital lock on the door and the door was wide open. During an observation on [DATE] at 7:40 a.m., the shower room on the White Pines unit was open and the lights were off. The digital lock was installed on the door. In an interview on [DATE] at 3:30 p.m., CNA AA reported Resident #6 was unpredictable and had taken care of her for 4 years. CNA AA reported that they are working with less CNA's now and does not feel there is enough staff to care for the residents. Review of Nursing Progress Notes dated [DATE] at 10:56 p.m. revealed: Patient expired at 10:00 p.m. On [DATE] at 4:00 p.m., CNA KK was contacted and not able to talk at that time. CNA KK did not return a telephone call to this surveyor.

This citation pertains to intake MI 022. Based on interview and record review, the facility failed to ensure that 1 (#104) of 3 sampled residents, of a total sample of 12 residents, did not develop avoidable pressure sores, resulting in Resident #104 developing 2 pressure sores on his buttocks and 1 pressure sore on his right heel while he was at the facility. Findings include: Review of Resident #104's medical record revealed a [AGE] year old male who had been admitted to the facility on [DATE] and discharge home on 12/31/12. He had [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated he was cognitively intact, with no behavior concerns, had not rejected care, required extensive assistance of 2 persons for transfers, dressing, hygiene, was totally dependent on one person for locomotion, and had no skin breakdown. Review of Resident #104's skin integrity assessment: prevention and treatment plan of care dated 12/4/12 revealed he was at risk related to impaired mobility with interventions all dated 12/4/12 to include monitor dietary intake and weight, offer bedpan and urinal, use moisture barrier, use lift sheet to move resident, maintain good hydration, keep skin clean and dry, apply topical skin protectant. There were no documented changes to Resident #104's skin plan of care after 12/4/12. Review of facility admission skin assessment for Resident #104 dated 12/3/12 revealed Resident #104 had a splint on his right wrist, steri strips on a surgical area on his right hip, a calloused area on the bottom/front of his left foot and no other skin concerns documented. The skin assessment was signed by LPN #28. Review of Pressure Ulcers Care Area Assessment (CAA) dated 12/12/12 revealed Resident #104 needed a special mattress or seat cushion to reduce or relieve pressure, was at risk for pressure ulcers due to immobility, depression, pain. Review of Nutritional Status Care Area Assessment (CAA) dated 12/10/12 for Resident #104 revealed Resident #104's estimated Kcal needs were 2600 to 2700 calories with 95 to 115 grams of protein daily and was not meeting his needs with his current diet providing 2190 and 82 grams of protein. The CAA indicated a nutritional supplement was to be added to Resident #104's diet three times daily which would have added 1125 calories and 39 grams of protein with a goal to provide adequate nutritional support to promote healing. Review of Nutrition progress notes for Resident #104 revealed one progress note dated 12/10/12 which reviewed Resident #104's diagnoses, his choice not to eat breakfast, but to eat lunch and dinner, and repeated information stated in CAA dated 12/10/12. Review of the entire chart for Resident #104 did not reveal any other Nutrition progress notes. Review of nurse's note's for Resident #104 dated 12/13/12 at 8:00 pm revealed Resident #104 had excoriation to bilateral buttocks. Nurse's note dated 12/14/13 indicated new order for EPC to buttocks twice daily until healed. Nurse's note dated 12/17/12 at 1:00 pm for Resident #104 indicated he had EPC to buttocks, skin assessment showed no new skin issues, he was weak and wand to lay down and rest. Nurse's note dated 12/19/12 at 10:00 am indicated Resident #104 complained of bottom causing pain, EPC cream to bottom, will call doctor for new orders for pain in bottom. Nurse note on same day at 3:09 pm indicated a new order was given for Tylenol 650 milligrams (mg) every 6 hours as needed. Nurse's note for Resident #104 dated 12/23/12 at 12:00 am indicated a large brown calloused area on Resident #104's left heel, with next shift notified. Review of nurse's note's for Resident #104 dated 12/23/12 at 11:30 pm revealed Resident #104 complained of pain in his butt, had had sores on his coccyx. Review of a treatment record for Resident #104 for the month of December 2012 revealed on 12/24/12 RN #19 documented no new skin issues noted for Resident #104. Facility skin grid for Resident #104 dated 12/26/12 indicated Resident #104 had an unstageable pressure ulcer on his right heel 2.5 centimeters (cm) long and 3 cm wide. Review of the entire medical record for Resident #104 did not reveal a completed facility skin grid for either pressure sore on Resident #104's buttocks. Review of the entire medical record for Resident #104 did not reveal any documentation of the size, appearance, depth, or drainage amount of either pressure sore on Resident #104's buttocks. In an interview on 4/16/13 at 3:10 pm, RN #19 stated when she did the skin assessment of Resident #104 on 12/24/12, she went into the shower room where he was sitting in the shower and scanned him over real quick while he was sitting in the shower. RN #19 stated she must have missed the unstageable ulcer on Resident #104's heel, which was documented on a skin grid two days later. In an interview with Social Worker #20 (SW #20) on 4/17/13 at 1:30 pm, SW #20 stated the social worker is notified when a resident refuses care, the Social Worker is to deal with the issue by talking with the resident or addressing the reason for the refusal of care by the 2:00 pm management meeting, document in the resident's medical record in the Social Work progress notes what had been done about the resident's refusal of care, and then report in the 2:00 pm meeting what had been done about the resident's refusal of care. When the surveyor asked SW #20 about Resident #104, SW #20 could not recall any specific concerns regarding Resident #104 and stated he was only in the care conference on 12/10/12 to facilitate the meeting. SW #20 stated if Resident #104 or the family had any concern's with a certain department, he (SW #20) would bring that department to the resident's room. In an interview on 4/17/13 at 11:00 am, Registered Nurse #19 (RN #19) stated she did provide regular care for Resident #104 during the day shift while he was in the facility. RN #19 stated Resident #104 had developed any open skin areas during the time he was losing weight and RN #19 stated he had developed open areas on both buttocks and one on his heel. RN #19 stated Resident #104 did lay in bed all the time and refused to get out of bed. The surveyor asked if Resident #104 had a special bed or mattress and RN #19 stated he didn't have a special mattress, just a longer bed because Resident #104 was so tall. In an interview on 4/17/13 at 12:45 pm, the surveyor asked DM #24 to review Resident #104's nutrition plan of care and progress notes and then asked DM #24 what interventions had been attempted to ensure adequate nutrition and address the skin breakdown of Resident #104 and DM #24 stated he was on vitamins and minerals along with protein supplements. The surveyor stated those interventions were in place on admission, and again the surveyor asked what dietary interventions were added once Resident #104 showed signs of skin breakdown and DM #24 stated none. Review of Resident #104's nutritional risks plan of care dated 12/10/12 revealed Resident #104 was at nutritional risk related to consuming less than 75 percent, abnormal labs, high blood pressure, laxative use, resident verbalized choice of not liking to eat breakfast which has potential to affect nutritional status, with a goal of maintaining stable nutritional status and interventions to include regular diet, monitor weights per policy, encourage fluids, monitor labs as ordered, vitamin and/or minerals as ordered, supplements as ordered, encourage family to bring in favorite foods. There were no updated to the nutrition care plan after 12/10/12. In an interview on 4/18/13 at 2:30 pm, LPN #32 (licensed nurse) stated she provided regular care for Resident #104 while he was at the facility and did remember him and his wife. LPN #32 stated Resident #104 did complain of loss of appetite and did appear visibly to lose weight. LPN #32 stated Resident #104 stated he did want to lose weight but didn't want to do it that way. LPN #32 stated Resident #104 did not refuse weights or care, and that Resident #104 was very cooperative with care and compliant. LPN #32 stated Resident #104 would joke with staff and was pleasant. LPN #32 stated she remembered Resident #104 did develop pressure sores on his bottom and one on his heel a couple of weeks after he got there. In an interview on 4/17/13 at 4:10 pm, facility Director of Nursing #2 (DON #2) reviewed Resident #104's medical record for documentation of skin concerns. The surveyor asked DON #2 if she had any evidence that she could provide to the surveyor to show that the three pressure sores Resident #104 developed while in the facility from 12/3/12 to 12/31/12 were unpreventable. DON #2 stated she wasn't even aware that Resident #104 had pressure sores until the surveyors had entered the facility and requested Resident #104's record. DON #2 stated she did not have anything further than what was in Resident #104's record. The surveyor asked DON #2 if there was documentation somewhere of the pressure sores on Resident #104's buttocks and DON #2 stated no, if it wasn't in the record it wasn't done by the nurses. Review of the facility weekly skin assessment policy with a revision date of April 2009, revealed a weekly skin assessment is required which included a head to toe visualization of the residents skin. If an area of impairment is identified it is to be monitored weekly using the facility skin grid form. The policy also indicated significant changes were to be documented in the nursing progress note, notify responsible party and document the notification. #

This citation pertains to intake MI 022. Based on interview and record review, the facility failed to monitor the nutritional status and prevent a significant weight loss for 1 (#104) of 3 sampled residents of a total sample of 12 residents, resulting in a 17.7 pound weight loss in 20 days and Resident #104 developing 3 pressure sores. Findings include: Review of Resident #104's medical record revealed a [AGE] year old male who had been admitted to the facility on [DATE] and discharge home on 12/31/12. He had [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated he was cognitively intact, with no behavior concerns, had not rejected care, required extensive assistance of 2 persons for transfers, dressing, hygiene, was totally dependent on one person for locomotion, and had no skin breakdown. Review of Nursing Comprehensive Admission Data Collection and Assessment form for Resident #104 dated 12/3/12 revealed Resident #104 was 6 foot 5 inches tall and 232.5 pounds. Review of Resident #104's facility weight change report indicated his initial weight on 12/6/12 was 232.5 pounds. The weight change report indicated Resident #104 was weighed again on 12/7/12 with a weight of 227 pounds, on 12/10/12 at 230.5 pounds, and again on 12/26/12 at 214.8 pounds. Review of Nutritional Status Care Area Assessment (CAA) dated 12/10/12 for Resident #104 revealed Resident #104's estimated Kcal needs were 2600 to 2700 calories with 95 to 115 grams of protein daily and was not meeting his needs with his current diet providing 2190 and 82 grams of protein. The CAA indicated a nutritional supplement was to be added to Resident #104's diet three times daily which would have added 1125 calories and 39 grams of protein with a goal to provide adequate nutritional support to promote healing. Review of Nutrition progress notes for Resident #104 revealed one progress note dated 12/10/12 which reviewed Resident #104's diagnoses, his choice not to eat breakfast, but to eat lunch and dinner, and repeated information stated in CAA dated 12/10/12. Review of the entire chart for Resident #104 did not reveal any other Nutrition progress notes. Review of Resident #104's food acceptance revealed 12/11/12 he refused all of his meals and his evening snack, on 12/12/12 he refused his breakfast and lunch and ate less than half of his dinner, on 12/13/12 he at less than half of his dinner, on 12/14/12 refused his breakfast and ate less than half of dinner, 12/15/12 refused all meals, 12/16/12 refused breakfast and ate less than half of his lunch, 12/17/12 at half of breakfast and dinner and refused his lunch, on 12/18/12 he refused breakfast at less than half of his lunch, ate half of his dinner, on 12/19/12 at half of his breakfast and dinner and lunch was not documented, on 12/21/12 he refused his lunch, on 12/23/12 he at half of his breakfast and less than half of his lunch, on 12/24/12 he at less than half of his breakfast and lunch. Review of the nurse's notes for Resident #104 did not reveal documentation of any replacement meal offered when Resident #104 refused his meals. Review of nurse's note's for Resident #104 dated 12/13/12 at 8:00 pm revealed Resident #104 had excoriation to bilateral buttocks. Review of nurse's note's for Resident #104 dated 12/23/12 at 11:30 pm revealed Resident #104 complained of pain in his butt, had had sores on his coccyx. Facility skin grid for Resident #104 dated 12/26/12 indicated Resident #104 had an unstageable pressure ulcer on his right heel 2.5 centimeters (cm) long and 3 cm wide. Review of Social Work notes revealed a social work progress note dated 12/10/12 indicated a "care conference" with Resident #104 and his wife related to him not eating "enuff" (sic) with dietary addressing a new meal plan. There were no further social work notes in Resident #104's medical records. In an interview with Social Worker #20 (SW #20) on 4/17/13 at 1:30 pm, SW #20 stated the social worker is notified when a resident refuses care, the Social Worker is to deal with the issue by talking with the resident or addressing the reason for the refusal of care by the 2:00 pm management meeting, document in the resident's medical record in the Social Work progress notes what had been done about the resident's refusal of care, and then report in the 2:00 pm meeting what had been done about the resident's refusal of care. When the surveyor asked SW #20 about Resident #104, SW #20 could not recall any specific concerns regarding Resident #104 and stated he was only in the care conference on 12/10/12 to facilitate the meeting. SW #20 stated if Resident #104 or the family had any concern's with a certain department, he (SW #20) would bring that department to the resident's room. In an interview on 4/17/13 at 11:00 am, Registered Nurse #19 (RN #19) stated she did provide regular care for Resident #104 during the day shift while he was in the facility. RN #19 stated Resident #104 was visibly losing weight, refusing to eat, and his clothing was getting so loose on him that his wife (Resident #104's wife) had to go buy him new clothes. RN #19 stated Resident #104 would repeated stated he wanted to lose weight, but not this way. The surveyor asked RN #19 if she ever contacted the physician or the facility Dietary Manager to notify them of Resident #104's visible weight loss and RN #19 stated she did not, because she left that up to the Dietary Manager. The surveyor asked RN #19 what nursing did when Resident #104 refused his meals and RN #19 stated a supplement shake was offered to Resident #104 if he took less than 25 percent of his meal. When the surveyor asked RN #19 if Resident #104 consumed the supplement shake, RN #19 stated she couldn't not remember. The surveyor asked RN #19 if Resident #104 had developed any open skin areas during the time he was losing weight and RN #19 stated he had developed open areas on both buttocks and one on his heel. In an interview on 4/15/13 at 3:55 pm, the surveyor asked Dietary Manager #24 (DM #24) if she remembered Resident #104 as a resident who had been in the facility and DM #24 stated yes, he was the one had had supplements three times a day. The surveyor asked DM #24 if Resident #104 had experienced any weight loss while in the facility from 12/3/12 to 12/31/12 and DM #24 stated she didn't think so as she brought Resident #104 up on her computer screen. After DM #24 reviewed Resident #104's weights on the computer in her office, she stated she believed Resident #104 had received enough nutrition on the supplements he was drinking even if he didn't eat his meals. The surveyor asked DM #24 what was done about Resident #104 losing weight while he was in the facility and DM #24 asked for time to review Resident #104's chart. The surveyor agreed to meet with DM #24 after she had the opportunity to review the medical record of Resident #104. In an interview on 4/17/13 at 12:45 pm, DM #24 stated the first time she was aware of Resident #104's weight loss issue since 12/10/12 was when she observed Resident #104 walking in the hall with therapy on 12/25/12 and thought he looked very thin, like he had lost weight. DM #24 stated the problem was the nurses did tell her what was going on. DM #24 stated Resident #104 had refused to be weighed due to pain and she didn't see all of the residents in the facility everyday because she was too busy, so the only way she would have known Resident #104 had lost that much weight was if the nursing staff had informed her, which they did not. The surveyor reviewed Resident #104's food acceptance with DM #24 and asked DM #24 what had been done to maintain Resident #104's nutritional status and weight when he was refusing meals and DM #24 stated Resident #104 would have been offered supplement shakes. The surveyor asked DM #24 if Resident #104 accepted the supplement shakes and DM #24 accepted the shakes and DM #24 stated she didn't know. The surveyor asked DM #24 to review Resident #104's nutrition plan of care and progress notes and then asked DM #24 what interventions had been attempted to ensure adequate nutrition and avoid weight loss for Resident #104 and DM #24 stated other than the supplements, she had no answer. Review of Resident #104's nutritional risks plan of care dated 12/10/12 revealed Resident #104 was at nutritional risk related to consuming less than 75 percent, abnormal labs, high blood pressure, laxative use, resident verbalized choice of not liking to eat breakfast which has potential to affect nutritional status, with a goal of maintaining stable nutritional status and interventions to include regular diet, monitor weights per policy, encourage fluids, monitor labs as ordered, vitamin and/or minerals as ordered, supplements as ordered, encourage family to bring in favorite foods. There were no updated to the nutrition care plan after 12/10/12. In an interview on 4/18/13 at 2:30 pm, LPN #32 (licensed nurse) stated she provided regular care for Resident #104 while he was at the facility and did remember him and his wife. LPN #32 stated Resident #104 did complain of loss of appetite and did appear visibly to lose weight. LPN #32 stated Resident #104 stated he did want to lose weight but didn't want to do it that way. LPN #32 stated Resident #104 did not refuse weights or care, and that Resident #104 was very cooperative with care and compliant. LPN #32 stated Resident #104 would joke with staff and was pleasant. LPN #32 stated she remembered Resident #104 did develop pressure sores on his bottom and one on his heel a couple of weeks after he got there. #

This citation pertains to intake MI 903. Based on interviews, and record review, the facility physician failed to monitor and treat a resident (#102) with an elevated blood sugar (greater than 500) in 1 (#102) of 12 sampled residents, from a total sample of 12 residents, resulting in Resident #102 being transferred and admitted to the hospital on [DATE]. Findings include: Resident #102: Review of Resident #102's medical record revealed a [AGE] year old female who was admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her facility [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she was severely impaired with cognitive skills, did not ambulate, and required extensive assistance of one person for eating and hygiene. Review of Resident #102's physician orders [REDACTED]. Resident #102's January 2013 physician orders [REDACTED]. Review of Resident #102's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"HI", on 1/28/13 at 9:00 pm was "HI", on 1/29/13 at 8:00 am was 423, on 1/29/13 at 7:00 pm was "HI", on 1/30/13 at 8:00 am was 406, on 1/30/13 at 8:30 am was 368, on 1/30/13 at 12:00 pm was 455, on 1/30/13 at 1:00 pm was was 359, on 1/31/13 at 11:40 am was 351. Review of Resident #102's physician orders [REDACTED]. Review of nurse's notes for Resident #102 dated 1/22/13 at 11:00 pm, signed by RN #23, indicated Resident #102's blood sugar was 421 at 9:00 pm, doctor was notified, no new orders were received. Review of physician orders [REDACTED]. A Physician order [REDACTED]. A Physician order [REDACTED]. A nurse's note for Resident #102 dated 1/28/13 at 7:30 pm indicated Resident #102's blood sugar was reported on the glucometer as "HI", the physician was notified, new orders received for [MEDICATION NAME] 70/30 insulin. The nurse's note for the same date at 9:00 pm indicated Resident #102's blood sugar still reported as "HI", physician notified, [MEDICATION NAME] R given, recheck and notify physician at 11:00, and that the third shift nurse was notified. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. Review of laboratory results for Resident #102 dated 1/31/13 revealed her blood glucose level to be 358 (normal 65 - 110), her BUN (blood urea nitrogen) 94 (normal 7 - 29), her creatinine 2.39 (blood creatinine level shows how well kidneys are working with normal 0.40 - 1.20), Sodium 161 (normal 136 - 144), and white blood cell count (indication of infection) 14.7 (normal 3.3 - 10.3). Urine test for Resident #102 dated 1/29/13 indicated no [MEDICATION NAME] present in her urine. Review of Resident #102's facility documented intake of fluids revealed and average daily intake of fluid for the months of 12/13 to 4/11/13 to be 1800 cc's (cubic centimeters). In the 10 prior to Resident #102's discharge to the hospital on [DATE], Resident #102's documented average fluid intake per day was 1746 cc's. Review of Hospital emergency physician note dated 2/1/13 revealed [DIAGNOSES REDACTED]. Diabetes mellitus poorly controlled. 2. Mild [MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. 4. Severe [MEDICAL CONDITION]. 5. Severe [MEDICAL CONDITION] (high sodium). 6. Severe dehydration. Review of Hospital History and physical documentation dated 2/1/13 revealed assessment and plan to include 1. [MEDICAL CONDITION]ly due to severe dehydration. 2. Acute kidney injury, again likely due to severe dehydration. 3. Diabetes Mellitus with [MEDICAL CONDITION] with blood sugars of 421 on arrival. 4. Urinary tract infection present on admission. 5. Leukocytosis, likely secondary to urinary tract infection. In an interview on 4/16/13 at 2:15 pm, the surveyor asked physician #18 if a resident was at risk when their blood sugar was over 400 and physician #18 stated if the patient was okay, you just want to lower the blood sugar. During the interview, Physician #18 reviewed Resident #102's physician orders, medication administration sheets, physician notes, and nurse's notes for January and February 2013 with the surveyors. Physician #18 stated on 1/22/13 he did order to give Resident #102 [MEDICATION NAME] 70/30 mix 4 units for a blood sugar of 507 and have the blood sugar rechecked in one hour. He stated he did not order Regular insulin, but slower acting insulin mixed with regular insulin because it worked quickly and Resident #102 was a brittle diabetic and her blood sugars could "bottom out". Physician #18 stated he did not order any insulin for Resident #102 when RN #23 called him and reported her (resident #102) blood sugar was still 421 at 9:00 pm on 1/22/13 was because he wanted to let the insulin Resident #102 had been given at 8:00 pm work through the night. When the surveyor asked Physician #18 why he would not order blood sugar checks for Resident #102, or monitor her blood sugar to see if the insulin worked and her blood sugar went down through the night, physician #18 did not answer. During the interview, Physician #18 stated on 1/28/13 in the evening he was contacted by nursing staff regarding Resident #102 having a blood sugar that read "HI" on the blood sugar machine and he ordered the mixed insulin first, then Regular insulin (fast acting) two separate times to be give to Resident #102 for a second reading of "HI" on the blood sugar machine and a third reading of 492. The surveyor had Physician #18 review his specific order dated 1/28/13 at 11:45 pm, which indicated not to recheck Resident #102's blood sugar after being given Regular (fast acting) insulin for a blood sugar of 492. When the surveyor asked Physician #18 if he stated earlier that Resident #102 could "bottom out" as a brittle diabetic if given Regular Insulin, Physician #18 stated yes. When the surveyor asked Physician #18 why he would specifically order staff not to recheck Resident #102's blood sugar after being given 2 separate doses of Regular insulin for blood sugars of "HI" and 492, Physician #18 stated "That's a tough question for me." and then stated it would stress the resident to wake her and increase her blood sugar. Physician #18 stated he didn't think Resident #102 having extremely high blood sugars over an extended period of time had anything to do with her becoming severely dehydrated and being admitted to the hospital. Physician #18 stated usually it's because a patient is not taking in enough fluids. According to the University College of Medicine, Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose, hyperosmolarity, and little or no ketosis. With the dramatic increase in the prevalence of type 2 diabetes and the aging population, this condition may be encountered more frequently by family physicians in the future. Although the precipitating causes are numerous, underlying infections are the most common. Other causes include certain medications, non-compliance, undiagnosed diabetes, substance abuse, and coexisting disease. Physical findings of hyperosmolar hyperglycemic state include those associated with profound dehydration and various neurologic symptoms such as coma. The first step of treatment involves careful monitoring of the patient and laboratory values. University of Illinois College of Medicine, Peoria, Illinois , USA. 2005 May 1;71(9):1723-30 Hyperosmolar Hyperglycemic State (HHS) is when blood glucose rises to dangerously high levels without [MEDICATION NAME] in the urine. HHS is usually seen in the older patients with type II diabetes. Excessive urine output due to the extremely high glucose levels leads to dehydration and [MEDICAL CONDITION]. Hemphill, R. (2012) Hyperosmolar Hyperglycemic State. http://medicine.medscape.com/article/ 05-overview #

Complaint Intake Number: MI 320 Based on observation, interview, and record review, the Facility failed to provide the necessary care and services (assessment of injuries and changes in condition) to maintain the highest practicable physical well-being in 2 of 6 residents in the sample (#101, #105) resulting in a delay of treatment for [REDACTED].#105). Findings include: Resident #101 Per the Hospital Consultation Note dated 7/24/12 Resident #101 had surgery that day for fusion of lumbar vertebrae and was sent to the intensive care unit after surgery. Per the admission nursing assessment dated [DATE], Resident #101 was admitted at 5:00 p.m., was alert and oriented to person, place and time; a mechanical lift was used during transfers and she did not walk. Per the Physical Therapy Notes dated 8/13/12, Resident #101 ambulated with a rolling walker, maintained standing balance, demonstrated bilateral lower extremity strength and full range of motion against gravity, safely completed all functional transfers, and rated her pain "2" on a scale of 1-to-10 however on 8/15/12 she rated the pain in her right leg "9" on a scale of 1-to-10. Review of the Incident Report dated 8/14/12 at 5:25 a.m. revealed Resident #101 was found "on one knee bent over the toilet" with feces on her foot. Per the Incident Report dated 8/14/12 at 5:00 p.m. revealed Resident #101's husband said she had fallen "her knees gave out." Per the Interdisciplinary Team (IDT) Note dated 8/14/12 at 3:25 p.m. Resident #101 had an "episode of loose stool while attempting to get to the bathroom" and slipped in the stool at 5:25 a.m. and no injury was noted. There was no IDT Note regarding the fall at 5:00 p.m. on 8/14/12. Review of Resident #101's Nurses' Notes revealed no mention of either fall or documentation of an assessment for possible injuries from either fall in the Nurses' Notes dated 8/14/12. Review of the Ambulance Run Sheet dated 8/15/12 revealed Resident #101 experienced pain in her hip and pelvis after a fall the day before (8/14/12). Per the Hospital emergency room notes dated 8/15/12, Resident #101 who had had a "recent lumbar surgery and postop [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clot)" and was taking the anti-coagulants [MEDICATION NAME] and [MEDICATION NAME] had fallen on the morning of 8/14/12 and complained of "right lower extremity pain." Examination and tests in the emergency room revealed Resident #101 had a "nondisplaced right fibula fracture," bleeding at the site of her back surgery (lumbar fusion), a hemoglobin of 6.4 (norm-12.0-15.0) and an INR (measure of blood coagulant) of 4.1 (range for treatment of [REDACTED]. Resident #101 was given intravenous narcotic pain medications and blood [MEDICAL CONDITION]. In an interview on 12/06/12 at 2:55 p.m. Physical Therapist #16 said on 8/15/12 Resident #101 was "acting differently" than she had on 8/13/12 and "complained of pain. She was such a different person. She had been ambulating well-doing longer distances." In an interview on 12/06/12 at 3:12 p.m. Physical Therapy Assistant #17 said on 8/15/12 Resident #101's daughter said Resident #101 fell on [DATE]. Physical Therapy Assistant #17 said Resident #101 was not able to participate in therapy on 8/15/12 and he "reported the changes" to the Director of Nursing. Per the Occupational Therapy Notes dated 8/13/12 Resident #101 was able to safely perform bed to chair transfer with minimal assistance however on 8/15/12 prognosis for further progress was decreased to "fair" due to "Resident's pain in leg has increased..." Per the Nurses' Notes dated 8/15/12 Resident #101 was "dragging" her right leg and was unable to ambulate. ( ) Resident #105 Per the Minimum (MDS) data set [DATE] Resident #105's [DIAGNOSES REDACTED]. "General Trauma Interventions: Keep the victim lying down or in the position in which he or she is found..." (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby.). "Spinal injuries include fractures, contusions, and compressions of the vertebral column, usually the result of trauma to the head or neck. The real danger lies in possible spinal cord damage...The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage." Stabilization of the head and neck is done prior to moving the victim to prevent secondary injuries such as paralysis from destabilization of a cervical vertebrae fracture..." (Diseases: Causes and [DIAGNOSES REDACTED].). Pennsylvania: Springhouse.). Per the Nurses' Notes dated 11/20/12, Resident #105 was found lying on the floor in front of his wheelchair with a bruise and abrasion to his left forehead. Staff members lifted him from the floor via a mechanical left. In an interview on 12/10/12 at 9:18 a.m., Licensed Practical Nurse (LPN) #20 said he saw Resident #105 lean forward and fall face first onto the floor on 11/20/12 but did not write an incident report or Nurses' Note because he was not the nurse working on Resident #105's unit. LPN #20 said he "did not see" Resident #105's "head hit" the floor "but he had to because there was a welt on his head when I got down to him." Review of the Nurses' Notes dated 12/02/12 at 18:45 (6:45 p.m.) revealed Resident #105 was "trying to get out of chair" and fell "forward hitting left forehead to the floor." The note indicated that the nursing staff put him into his bed. Review of the Nurses' Note dated 12/02/12 revealed "Unable to do neuro (neurological) check due to the fact Resident (Resident #105) is not alert and oriented enough to know and follow directions." There was no documented evidence the nurse conducted a neurological assessment such as examination of Resident #105's pupils to determine if they were equal in size (which does not require a person have the cognitive ability to follow directions). The Professional Standard of Quality for performing complete neurological assessment is to assess the level of consciousness, pupil response, hand grasps, movement of extremities, pain response and vital signs. (Nursing Care for Neurological Patients, Sweethaven Services, 2006) Per the Nurses' Notes dated 12/02/12 at 19:00 (7:00 p.m.), Resident #105 exhibited signs of closed head injury when he "threw up in bed." Resident #105 was sent to the hospital and returned on 12/06/12 under hospice care. Attempts to identify the nurse who authored the note dated 12/02/12 were unsuccessful. On two occasions Resident #105 was placed at risk of secondary injury following falls with known head injury when nursing staff lifted him from the floor instead of stabilizing his head and neck, applying a cervical collar, lifting him with the use of a back board onto a stretcher and transporting him to the hospital via ambulance for further examination. In an observation on 12/06/12 at 1:50 p.m. Resident #105 was asleep in his bed. Resident #105 did not awaken to knocking on his door, knocking on his bedside table, or calling his name. In an observation on 12/10/12 at 11:35 a.m. Resident #105 was asleep in his bed. Resident #105 did not awaken to knocks on his door or to his name called out loudly. There was a large yellowing bruise to Resident #105's left forehead. ( )

This citation pertains to intake number MI 926. Based on observation, interview, and record review, the facility failed to prevent a significant medication error in 1 of 4 sampled residents (Resident #101) resulting in two hypoglycemic (low blood sugar-normal blood sugar as defined by the American Diabetic Association is 90 -130mg/dl before meals) episodes and Emergency Department services with admission to the hospital for monitoring. Findings include: According to The Mosby Medical Encyclopedia, (1992), [DIAGNOSES REDACTED] is defined as "a less-than-normal amount of sugar in the blood, usually caused by being given too much insulin..." Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #101's ability to make daily decision was cognitively intact, speech was clear, he was able to express ideas, wants, and clearly comprehends others. Review of the Admission Medication Ordered dated 8/16/12, revealed insulin ([MEDICATION NAME] LONG-Acting) 28 Units Subcutaneous (beneath the skin) Injection Bedtime.. Review of Physician Interim Orders dated 8/30/12 (no time), revealed change "[MEDICATION NAME] to 22 Units at lunch, 6 Units Q HS (every hour of sleep), start 8/31 (sic)", the physician wrote and signed the order and Unit Manager (UM) #4 signed and dated the order on 8/30/12 (no time). In an interview on 9/14/12 at 1:05 PM, Registered Nurse (RN) #19 reported 8/30/12 was very busy 2nd shift, UM #4 returned to the facility to assist, RN #19 told UM #4 there were time sensitive orders to be completed, and UM #4 updated Resident #101's new Medication Administration Record (MAR) for 9/1/12, but had not put the new physician order [REDACTED]. RN #19 reported that she did not verify the 9/1/12 MAR because UM #4 always does the MAR change overs at the end of the month, but she updated the August 2012 MAR to reflect the change from 28 units of [MEDICATION NAME] at HS to 22 units of [MEDICATION NAME] at lunch and 6 units at HS, the new order was to start on 8/31/12. RN #19 reported the physician had been in the facility on 8/30/12 and Resident #101 spoke to the physician about splitting his [MEDICATION NAME] dose to twice a day like he was taking at home. After speaking with Resident #101, the physician wrote an order for [REDACTED]. RN #19 reported the original dose of 28 units of [MEDICATION NAME] per day for Resident #101 remained the same, he would just have the dose split per the new order to twice a day. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED].#4. Review of the Facility Incident Report - 24 Hours submitted 9/5/12, revealed Resident #101 became hypoglycemic and was not currently at the facility, The Facility Incident Report revealed that on 9/4/12 at 9:00 AM, it was identified that physician orders [REDACTED]. "Standards are those actions that ensure safe nursing practice. To ensure safe medication administration the nurse should be aware of a nursing standard called the six rights of medication administration. all medication error can be linked, in some way to an inconsistency in adhering to the six rights of medication administration". The six rights of medication administration include: 1) the right medication, 2) the right dose, 3) the right client, 4) the right route, 5) the right time, 6) the right documentation. The right documentation was added to the traditional five rights of medication administration to increase medication safety. (Fundamentals of Nursing, 6th edition, 2005, pgs. 841-843). Review of the Progress Notes dated 9/3/12 (no time), revealed Resident #101 "had a hypoglycemic episode at 0400 A BS 58 was given a glass of orange juice and a cup of milk and a container of yogurt BS rechecked before [MEDICAL TREATMENT] at 0515 A was 68 gave him another glass of orange juice and sent with a can of nepro (nutritional supplement)". Review of Diabetic Protocol (no date) revealed "physician to be notified of blood sugar results less than 70 or greater than 400, if blood sugar less that 70 initiate diabetic protocol immediately...". In an interview on 9/14/12 at 11:10 AM, Licensed Practical Nurse (LPN) #15 (a second shift nurse) reported Resident #101 was new to her, and after giving 60 units of [MEDICATION NAME] 2 days in a row at HS Resident #101 stated before she administered the dose on 9/3/12 that 60 units of [MEDICATION NAME] seemed like too much insulin. LPN #15 reported that she verified the hand written order on the current MAR, verified 60 units of [MEDICATION NAME], and felt since the new orders are checked by 2 nurses the MAR was correct. LPN #15 reported she did not investigate Resident #101's question that he was receiving too much [MEDICATION NAME] and check the physician's orders [REDACTED]. LPN #15 reported she was "too new to the facility and did not know the residents well and it did not click that on 8/31/12 she had given 6 units of [MEDICATION NAME] to Resident #101 since 6 and 60 are similar". Review of the Clinical Skills Development "Principles of Medication Administration" dated 2004, revealed "3. Right Dose Verify the dose provided against the MAR. Question - If there's a question, where do you check to verify the order? Answer - (physician's orders [REDACTED]. Review of the SBAR (SituationBackgroundAssessmentRequest) dated 9/4/12 at 0110 (1:10 AM) revealed Resident #101 heard to be moaning, was minimally responsive to pain only, skin cool and clammy, and diaphoretic (increased sweating).The SBAR revealed BS was 23, at 0115 (1:15 AM) the physician was contacted, and a new order to administer 1 mg [MEDICATION NAME] and send to the Emergency Department (ED) if not improving was received, at 0120 (1:20 AM) the ambulance crew arrived at the facility, at 0130 (1:30 AM) glucose was administered per the ambulance crew through an intravenous (IV) line established by the ambulance crew, at 0145 (1:45 AM) Resident #101 still responding poorly and was transported to the ED. The SBAR revealed at 0730 AM Resident #101 was returning to the facility from the ED. In an interview on 9/13/12 at 9:05 AM, RN #8 reported that on 9/4/12 he sent Resident #101 out to the hospital after finding him (resident #101) to be not right and the Certified Nursing Assistant (CNA) had reminded him that Resident #101's BS was low the prior morning. RN #8 reported he did a BS check (results were 23) he confirmed the results with a second BS check (also 23), the physician was called, and Resident #101 was sent to the ER. RN #8 reported speaking with Resident #101's father after 6:00 AM on 9/4/12, who informed RN #8 that Resident #101 had called earlier on the evening of 9/3/12 because he felt the nurse had given him too much [MEDICATION NAME]. RN #8 reported after speaking with Resident #101's father he pulled the Medication Administration Record for August 2012 (the previous month) and saw Resident #101 was receiving 6 units of [MEDICATION NAME] at night. RN #8 reported that Resident #101 had been getting 60 units of [MEDICATION NAME] since the beginning of the new [DATE]/1/12 not 6 units as in the prior month's MAR. RN #8 reported that he informed Director of Nursing #14 about the significant medication error with the [MEDICATION NAME] for Resident #101. Review of the SBAR dated 9/5/12 at 2000 (8:00 PM), revealed a late entry for 9/4/12, Resident #101 returned to the facility from the ED at approximately 0730 (7:30 AM), used the restroom and transferred into bed. The SBAR revealed Resident #101 ate breakfast in his room and at approximately 0945 (9:45 AM) a CNA alerted RN #20 that Resident #101 was nonresponsive but his eyes were open. The SBAR revealed Resident #101's BS was 23, a CNA called Director of Nursing #14 to Resident #101's room, 911 was called, BS rechecked (results were 21), the ambulance crew arrived at 10:00 AM took over care, and Resident #101 was transferred to the ED. Review of the Unscheduled Physician Emergency Dictation dated 9/4/12 at 1040 (10:40 AM), revealed that Resident #101 was presenting with [DIAGNOSES REDACTED] and that Resident #101 had been seen earlier in the morning but that the facility had not informed the ED physician that Resident #101 had received an overdose of his insulin; but did report it when Resident #101 was transferred for the second time. Review of the Unscheduled History and Physical dated 9/4/12 at 1410 (2:10 PM), revealed Resident #101 was seen in the ED earlier this morning at about 2:00 AM for [DIAGNOSES REDACTED], was treated and discharged at about 6:50 AM, and returned to the ED at about 10:40 AM with another episode of [DIAGNOSES REDACTED]. The Unscheduled History and Physical revealed Resident #101 received 1 amp (50 ml) of D50 (50% sugar mix) at the facility and another amp of D50 on the way to the ED, Resident #101 states he usually received 22 units of [MEDICATION NAME] at noon and for the last couple of days an additional night dose of 60 units of [MEDICATION NAME] was given, which should have been 6 units for a total of 82 units of [MEDICATION NAME] a day instead of 28 units. The Unscheduled History and Physical revealed Resident #101's assessment/plan "1. Refractory [DIAGNOSES REDACTED] most likely due to overdosing of insulin...2) Diabetes type I: Under previous good control with A1c (lab test to measure average blood glucose) of 6.3 (The American Diabetes Association recommends an A1C less than 7 percent for most adults with diabetes). Control complicated by #1...." In an interview and observation on 9/12/12 at 2:10 PM, Resident #101 was observed resting in bed with oxygen administered via nasal canula at 2 liters. He was dressed appropriately for the day with the call light within reach. Resident #101 reported that when the nurse was giving his evening dose of insulin, she informed him that she would be giving him 60 units and he told her he thought that was too much. Resident #101 closed his eyes and stopped speaking to this surveyor, then stated he was tired as he had [MEDICAL TREATMENT] earlier in the day. In an interview on 9/14/12 at 1:05 PM, Registered Nurse (RN) #19 reported that the problem with the MAR's was not fixed as of 9/12/12. RN #19 reported that another resident (#104) had an order for [REDACTED]. RN #19 stated that there was no stop date indicated in the MAR and the [MEDICATION NAME] was given beyond 9/7/12. RN #19 reported she did draw a line and write STOP in the MAR, but did not write it up as a medication error. In an interview on 9/14/12 at 1:30 PM, Regional Director of Operation #3 reported that when the MAR's were reviewed after the insulin medication error, they were only checking the hand written orders, the previous orders sent from the pharmacy on the updated MAR were assumed correct and not verified. Regional Director of Operations #3 confirmed that a STOP date of 9/8/12 was on the August 2012 MAR and should have been updated to the September 2012 MAR for Resident #104's [MEDICATION NAME] order. #

This citation pertains to MI 511. Based on interview and record review, the facility failed to ensure 1 of 4 sampled residents (#101), from a total sample of 4 residents was treated with dignity and respect, resulting in Resident #101 urinating on himself, being severely humiliated, and signing himself out of the facility against medical advice due being upset about the incident. Findings include: Review of Resident #101's medical record revealed a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated that he was cognitively intact and required an extensive assist of 2 persons for transfers and toilet use, and was occasionally incontinent. According to Resident #101's ADL/mobility plan of care dated 3/6/12, Resident #101 was identified to require 2 person assist with a SARA lift (lift used to assist a resident to a standing position). During a telephone interview on 5/7/12 at 4:00 P.M., Resident #101 stated he recalled the incident on 3/7/12 when they could not get him to the bathroom. Resident #101 stated the nurse answered his call light on the 3-11 P.M. shift, he was semi-ambulatory and he was 6'3" and a big guy so they needed a lift to help him stand. Resident #101 stated, "they knew I had a UTI (urinary tract infection), and had to go often." Resident #101 stated there was no lift available so he had to wet himself. Resident #101 stated, "I was completely humiliated." At that point during the interview Resident #101 became upset, stopped talking to the surveyor and stated, "I'm just going to let my wife tell you the rest." During a telephone interview on 3/7/12 at 4:00 P.M., Resident #101's wife stated her husband asked to go to the bathroom between 7:00 P.M. and 8:00 P.M., the girl he asked looked for a lift to get him up and there was none available so, she told him that he would have to wait. Resident #101's wife stated that Resident #101 could not wait so the nurse tried to get someone else to help transfer him to the bathroom but while waiting her husband ended up being incontinent. Resident #101's wife also stated that her husband was humiliated and afraid that visitors would see him. Resident #101's wife stated the nurse asked her to stay with her husband because he was upset, and that Resident #101 was shaking and teary eyed because he was so upset. Resident #101's wife stated that her husband was so upset about the incident that he wanted to go home. Resident #101's wife stated she didn't understand why they just didn't give him a urinal. During an interview on 5/8/12 at 3:15 P.M., Director of Nursing (DON) #1 stated shortly before Resident #101 left the facility against medical advice she spoke with Resident #101 and he stated to her, "I don't want to be here." Review of Resident #101's facility "discharge against medical advice" form dated 3/8/12 at 4:05 P.M., revealed Resident #101 left the facility at his own insistence against the advice of the facility and his attending physician. Risks and potential complications included: falls, rehospitalization related to unresolved bladder problems,[MEDICAL CONDITION] related to urinary tract infection. During an interview with Certified Nurse Aide (CNA) #10 on 5/8/12 at 2:23 P.M., CNA #10 stated that she was informed by the Licensed Practical Nurse (LPN) #12 that Resident #101 requested to use the bathroom. CNA #10 informed Resident #101 that no lift was available to take Resident #101 to the bathroom. CNA #10 stated Resident #101 ended up wetting his pants before a lift became available. CNA #10 stated that Resident #101 was very upset about wetting himself and having to wait, so LPN #12 told Resident #101 he would be taken to the whirlpool tub to be cleaned as soon as a lift was available. The surveyor asked CNA #10 how long it took for a lift to become available and CNA #10 stated approximately 30-45 minutes. The surveyor asked CNA #10 if she offered Resident #101 a urinal and CNA #10 stated she didn't think of it. During a telephone interview on 5/9/12 at 10:00 A.M., LPN #12 stated that she answered Resident #101's call light and notified CNA #10 of Resident #101's request to use the bathroom, but CNA #10 was caring for another resident. LPN #12 stated Resident #101 was becoming upset and stated he needed to use the bathroom immediately and could not wait. LPN #12 stated she went to another unit to request help with transferring Resident #101. LPN #12 stated when she returned to Resident #101's room with another staff member, she could not recall if Resident #101 had already been incontinent of urine, but Resident #101 was blaming her for wetting himself. Later during the interview, LPN #12 stated that Resident #101 had been incontinent in his pants while waiting for assistance. LPN #12 stated she apologized to Resident #101 and his wife for the incident and told Resident #101 that he would be taken to the whirlpool tub to be cleaned up when a lift became available. When the surveyor asked LPN #12 how long it was before a lift was available for Resident #101, LPN #12 stated she could not recall. During an interview on 5/8/12 at 3:30 P.M., the Surveyor asked the facility Director of Nursing #1 for any documentation of Resident #101 refusing to use a urinal. On 5/8/12 at 4:00 PM, the Director of Nursing stated to the Surveyor there was no documentation of Resident #101 refusing to use a urinal. During the facility exit on 5/8/12 at 4:10 P.M., Administrator #2 stated that she was just informed that Resident #101 refused the urinal. Review of Resident #101's medical record did not reveal a plan of care for behaviors, or refusals of care, or refusal to use a urinal. &

THIS CITATION PERTAINS TO INTAKE MI 371. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ADEQUATE FLUID INTAKE TO MAINTAIN HYDRATION FOR 1 (#101) OF 4 SAMPLED RESIDENTS, OF A TOTAL SAMPLE OF 4 RESIDENTS, RESULTING IN RESIDENT #101 BECOMING SEVERELY DEHYDRATED AND BEING TRANSFERRED TO THE HOSPITAL WITH [DIAGNOSES REDACTED]. FINDINGS INCLUDE: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] AND WAS discharged TO THE hospital on [DATE]. THE FACILITY [DIAGNOSES REDACTED]. HER MINIMUM (MDS) data set [DATE] DOCUMENTED RESIDENT #101 REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR DRESSING, EATING, TOILETING AND PERSONAL HYGIENE. RESIDENT #101'S NUTRITIONAL RISKS PLAN OF CARE DATED 2/10/12 INDICATED SHE WAS AT RISKS FOR DEHYDRATION WITH RESIDENT #101 TO BE A PHYSICAL ASSIST WITH MEALS, MONITOR WEIGHTS WEEKLY, MONITOR LABS AS ORDERED, MONITOR FOR SIGNS AND SYMPTOMS OF DEHYDRATION - LABS, MED PASS 120 CC'S THREE TIMES A DAY, AND MONITOR INTAKE OF MEALS ON CARE TRACKER. FACILITY WEIGHT CHANGE REPORT FOR RESIDENT #101 INDICATED RESIDENT #101 WEIGHED 194 POUNDS ON ADMISSION 1/30/12, AND ON 2/15/12 RESIDENT #101 WEIGHED 184 POUNDS, WITH A LOSS OF 10 POUNDS. NURSE'S NOTES FOR RESIDENT #101 DATED 1/30/12, 1/31/12, 2/1/12, 2/2/12, 2/3/12, 2/5/12, 2/6/12, 2/7/12, 2/9/12, 2/11/12, 2/12/12, 2/13/12, 2/15/12, 2/16/12, AND 2/17/12 DOCUMENTED THAT RESIDENT #101 WAS ALERT TO SELF, AND ABLE TO MAKE HER NEEDS KNOWN. FACILITY NUTRITION RISK DATA COLLECTION AND ASSESSMENT FOR RESIDENT #101 DATED 2/10/12, LISTED AN ESTIMATED FLUIDS TO MEET NEEDS AS 2204cc's TO 2645cc's . IN AN INTERVIEW ON 3/14/12 AT 9:25 AM, THE DIRECTOR OF NURSING (DON #2) STATED ALL FLUID INTAKE FOR RESIDENTS IS DOCUMENTED IN CARE TRACKER SYSTEM. THE SURVEYOR REQUESTED ALL FLUID INTAKE DOCUMENTATION FOR RESIDENT #101 FROM THE DIRECTOR OF NURSING. REVIEW OF FACILITY MEAL AND FLUIDS CHART DETAIL REPORT FOR RESIDENT #101 REVEALED DURING RESIDENT #101'S STAY AT THE FACILITY FROM 1/30/12 TO 2/18/12 ,WHEN SHE WAS TRANSFERRED TO THE HOSPITAL, SHE ONLY RECEIVED THE CALCULATED AMOUNT OF FLUIDS TO MEET HER NEEDS (2204cc's TO 2645cc's) ONE TIME ON 2/16/12 WHEN SHE RECEIVED 2260cc's. THE FLUID DETAIL FOR RESIDENT #101 ALSO REVEALED THAT RESIDENT #101 RECEIVED LESS THAN 1000cc's OF FLUID ON 2/1/12, 2/3/12, 2/4/12, 25/12, 2/6/12, 2/7/12, 2/11/12, 2/12/12, AND 2/18/12 (9 OUT OF 20 DAYS). DURING AN INTERVIEW ON 3/14/12 AT 11:30 AM, THE DIRECTOR OF NURSING (DON #2) AGAIN STATED THAT ALL FLUIDS RECEIVED BY THE RESIDENTS IN THE FACILITY ARE DOCUMENTED IN THE CARE TRACKER SYSTEM. DON #2 STATED THAT WHEN THE FLUIDS ARE GIVEN TO EACH RESIDENT IT IS IMMEDIATELY DOCUMENTED INTO THE COMPUTER. FACILITY NURSE'S NOTES DATED 2/18/12 WITH TIME OF 10-6 INDICATED RESIDENT #101 WAS CRYING OUT IN PAIN AND WAS GIVEN PAIN MEDICATION. NURSE'S NOTES DATED 2/18/12 AT 3:00 PM INDICATED RESIDENT #101 WAS CRYING OUT IN PAIN, GIVEN PAIN MEDICATION AND HAD A PULSE OX (BLOOD OXYGEN LEVEL) OF 86 PERCENT (NORMAL 95 TO 100 PERCENT), HER LUNG SOUNDS WERE DECREASED, AND HER LOWER LIP WAS BLEEDING. FACILITY NURSE'S NOTES AT 4:00 PM INDICATED RESIDENT #101'S PULSE OX (BLOOD OXYGEN LEVEL) WAS 85 PERCENT ON 2 LITERS OF OXYGEN, THE PHYSICIAN WAS NOTIFIED AND RESIDENT #101 WAS SENT TO THE HOSPITAL. REVIEW OF FACILITY physician progress notes [REDACTED].#101 DATED 2/8/12 REVEALED THE SECTION FOR GASTROINTESTINAL, TONGUE AND ORAL CAVITY, MUSCULOSKELETAL AND SKIN ASSESSMENT WERE BLANK. REVIEW OF FACILITY physician progress notes [REDACTED].#101 DATED 2/12/12 REVEALED THE SECTION FOR CARDIOVASCULAR, [MEDICAL CONDITIONS], GASTROINTESTINAL, TONGUE AND ORAL CAVITY, MUSCULOSKELETAL AND SKIN ASSESSMENT WERE BLANK. physician progress notes [REDACTED]. REVIEW OF FACILITY physician progress notes [REDACTED].#101 DATED 2/13/12 REVEALED ALL ASSESSMENT SECTIONS WITH THE EXCEPTION OF CONSTITUTIONAL AND VISION WERE BLANK WITH WOUND ASSESSMENTS AND TREATMENTS DOCUMENTED BY THE PHYSICIAN. REVIEW OF THE ENTIRE CLOSED RECORD FOR RESIDENT #101, WHICH WAS PROVIDED TO THE SURVEYOR BY THE FACILITY, REVEALED ONE SET OF laboratory results dated [DATE], WITH A GLUCOSE OF 76 (NORMAL 60 TO 110), A BUN OF 37 (NORMAL 7 TO 20) AND SODIUM LEVEL OF 133 (NORMAL 135 TO 147). REVIEW OF HOSPITAL RECORDS FOR RESIDENT #101 REVEALED A HOSPITAL PHYSICIAN HISTORY AND PHYSICAL FOR RESIDENT #101 DATED 2/18/12 WHICH INDICATED LABORATORY VALUES TO INCLUDE A SODIUM LEVEL OF 172 (NORMAL 135 TO 147), GLUCOSE (BLOOD SUGAR) 185 (NORMAL 60 TO 110), AND BUN OF 72 (NORMAL 7 TO 20). THE HISTORY AND PHYSICAL INDICATED A PHYSICIAN ASSESSMENT OF: 1. "METABOLIC [MEDICAL CONDITION] - MULTIFACTORIAL SECONDARY TO UREMIA (A CLINICAL SYNDROME ASSOCIATED WITH FLUID AND ELECTROLYTE IMBALANCES. THE TERM UREMIA LITERALLY MEANS URINE IN THE BLOOD), [MEDICAL CONDITION] (HIGH LEVEL OF SODIUM IN THE BLOOD) AND UNDERLYING INFECTION." 2. "SEVERE [MEDICAL CONDITION] -SECONDARY TO MARKED DEHYDRATION. THE PATIENT'S FREE WATER DEFICIT IS 11.1 LITERS AND HER SODIUM SHOULD BE CORRECTED SLOWLY TO ENSURE SHE DOES NOT DEVELOP LIFE-THREATENING CEREBRAL [MEDICAL CONDITION]. WE WILL RECHECK A BMP AND THE PATIENT WILL BE PLACED ON D5 HALF NORMAL SALINE AT 100 MILLILITERS AN HOUR. AT THIS RATE IT WILL TAKE A LITTLE OVER NINE DAYS TO NORMALIZE THE SODIUM. HER [MEDICAL CONDITION] CARRIES A VERY HIGH MORTALITY RATE AND IS LIKELY A RESULT OF NO ACCESS TO WATER." IN AN INTERVIEW ON 3/15/12 AT 4:00 PM, THE DIRECTOR OF NURSING (DON #2)STATED RESIDENT #101 WAS OBTUNDED WHILE AT THE FACILITY(SLEEPY AND VERY DIFFICULT TO AROUSE) AND THAT IS WHY SHE DIDN'T DRINK ENOUGH. THE SURVEYOR INFORMED DON #2 THAT THE NURSE'S NOTES FOR RESIDENT #101 DOCUMENTED THAT RESIDENT #101 WAS ABLE TO MAKE HER NEEDS KNOWN AND WAS ALERT. DON #2 STATED, "I TOLD YOU OUR DOCUMENTATION IS BAD". DON #2 STATED RESIDENT #101'S HYDRATION STATUS WAS MONITORED THROUGH LABS, WEIGHTS, THE CARE TRACKER DOCUMENTATION, PHYSICIAN ASSESSMENTS, AND DISCUSSION OF RESIDENT #101'S FLUID INTAKE IN THE MORNING MANAGER'S MEETING. THE SURVEYOR STATED TO DON #2 THAT ONLY ONE LABORATORY RESULT WAS LOCATED IN THE MEDICAL RECORD OF RESIDENT #101, WHICH WAS DATED 2/1/12, THAT THE CARE TRACKER DOCUMENTATION SYSTEM DOCUMENTED THAT RESIDENT #101 HAD NOT RECEIVED ADEQUATE FLUIDS ACCORDING TO THE PARAMETERS SET BY THE FACILITY, AND THAT RESIDENT #101 HAD LOST 10 POUNDS FROM HER admission date of [DATE] TO 2/15/12. ON 3/15/12 AT 4:15 PM, DON #2 STATED SHE COULD SHOW THE SURVEYOR DOCUMENTATION OF WHERE THE HYDRATION STATUS OF RESIDENT #101 WAS REVIEWED IN THE MORNING MANAGER'S MEETING. REVIEW OF THE MORNING MANAGER'S MEETING MINUTES WITH DON #2 IN THE OFFICE OF DON #2, REVEALED NO DOCUMENTATION OF RESIDENT #101'S HYDRATION STATUS BEING DISCUSSED. THE SURVEYOR ASKED DON #2 WHAT WAS DONE BY THE FACILITY TO ASSURE ADEQUATE HYDRATION FOR RESIDENT #101. DON #2 STATED ABOUT A WEEK AFTER RESIDENT #101 GOT TO THE FACILITY "WE" TOLD THE FAMILY SHE WASN'T DRINKING OR EATING ENOUGH AND "WE" OFFERED TO SEND RESIDENT #101 TO THE HOSPITAL, BUT "THE FAMILY DIDN'T WANT TO". IN A TELEPHONE INTERVIEW ON 3/16/12 AT 12:45 PM, RESIDENT #101'S SON-IN-LAW STATED THE FACILITY ABSOLUTELY DID NOT EVER OFFER TO SEND RESIDENT #101 TO THE HOSPITAL FOR ANY REASON. RESIDENT #101'S SON-IN-LAW THEN STATED HE WANTED THE SURVEYOR TO TALK WITH HIS WIFE (RESIDENT #101'S DAUGHTER) BECAUSE SHE WAS AT THE FACILITY EVERY DAY, BUT THAT HE (SON-IN-LAW) WOULD NEED TO INTERPRET BECAUSE THE DAUGHTER ONLY SPOKE SPANISH. THROUGH THE INTERPRETATION OF THE SON-IN-LAW, RESIDENT #101'S DAUGHTER STATED WHEN SHE VISITED HER MOTHER (RESIDENT #101), SHE WOULD COMPLAIN ABOUT BEING THIRSTY. RESIDENT #101'S DAUGHTER STATED THE REASON RESIDENT #101 DIDN'T GET ENOUGH TO EAT OR DRINK WASN'T BECAUSE SHE DIDN'T WANT IT, BUT BECAUSE THE STAFF WOULDN'T TAKE THE TIME TO HELP HER (RESIDENT #101) EAT. RESIDENT #101'S SON-IN-LAW STATED HIS WIFE USED TO GO TO THE FACILITY, FEED RESIDENT #101, AND SHE WOULD EAT AND DRINK JUST FINE. RESIDENT #101'S DAUGHTER BECAME VERY UPSET WHEN THE SURVEYOR ASKED HER IF THE FACILITY EVER OFFERED TO SEND HER MOTHER (RESIDENT #101) TO THE HOSPITAL BECAUSE SHE WASN'T EATING OR DRINKING ENOUGH, AND STATED ABSOLUTELY NOT. RESIDENT #101'S DAUGHTER STATED THE ONLY TIME THE FACILITY SAID ANYTHING ABOUT THE HOSPITAL WAS WHEN THEY CALLED TO SAY THEY WERE SENDING HER (RESIDENT #101) TO THE HOSPITAL. ON 3/16/12 AT 12:10 PM, IN A TELEPHONE INTERVIEW, THE FACILITY ADMINISTRATOR ASKED THE SURVEYOR TO INTERVIEW THE DIETARY MANAGER OF THE FACILITY. IN A TELEPHONE INTERVIEW ON 3/16/12 AT 12:15 PM, FACILITY DIETARY MANAGER # 4 (DM #4) STATED SHE, ALONG WITH NURSING, WAS RESPONSIBLE FOR MONITORING THE HYDRATION STATUS OF RESIDENTS IN THE FACILITY. DM#4 STATED SHE HAD REPORTED TO THE DIRECTOR OF NURSING THAT RESIDENT #101 WAS NOT GETTING ENOUGH FLUIDS. According http://medical-dictionary.thefreedictionary.com/p/osmolality, serum osmolality is "a measure of the number of dissolved particles per unit of water in serum... Measurement of the serum osmolality gives information about the hydration status within the cells because of the osmotic [MEDICATION NAME] that is constantly being maintained on either side of the cell membrane (homeostasis). Water moves freely back and forth across the membrane in response to the osmotic pressure being exerted by the molecules of solute in the intracellular and extracellular fluids. Serum osmolality reflects the status of hydration of the intracellular as well as the extracellular compartments and thus describes total body hydration". Normal adult blood osmolality is 285 to 296 mOsm/kg H2O with greater than 296 defined as dehydration. Serum Osmolality is calculated using the following formula: (2 x (NA) + (BUN/2.8) + (Glucose/18). THE LAB RESULTS FROM 2/1/12 (SHORTLY AFTER ADMISSION) FOR RESIDENT #101 CALCULATE HER SERUM OSMOLALITY AT 283, OR NOT DEHYDRATED. THE LAB RESULTS FROM 2/18/12 FOR RESIDENT #101 CALCULATE HER SERUM OSMOLALITY AT 380, OR SEVERELY DEHYDRATED. #

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROMOTE HEALING OF TWO HEEL PRESSURE ULCERS FOR 1 OF 15 (#1) SAMPLED RESIDENTS, RESULTING IN THE POTENTIAL FOR INCREASED PAIN, INFECTION, FAILED HEALING, SPREADING NECROSIS AND AMPUTATION OF A LOWER EXTREMITY. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION FACE SHEET, RESIDENT #1 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE TRANSFER RECORDS DATED 9/13/2010, HE WAS admitted TO THE FACILITY FROM AN ACUTE CARE FACILITY FOLLOWING MAJOR medical complications [REDACTED]. ACCORDING TO THE STAFF, HE HAS HAD MULTILE PREVIOUS ADMISSIONS. ON 4/14/2011 AT APPROXIMATELY 4:00 P.M., A REVIEW OF THE MOST RECENT FULL MDS (MINIMUM DATA SET, A RESIDENT ASSESSMENT TOOL), WITH AN ASSESSMENT REFERENCE DATE OF 12/18/2010, TOOK PLACE. RESIDENT #1 HAD INTACT COGNITION (DECISION MAKING SKILLS) AND WAS NOT DISPLAYING ANY SIGNS OF MOOD OR DEPRESSION DISORDER. RESIDENT #1 REQUIRED THE ASSISTANCE OF ONE PERSON FOR TRANSFERING AND AMBULATING IN HIS ROOM. AMBULATION IN THE HALL DID NOT OCCUR. RESIDENT #1 REQUIRED THE USE OF A WHEELCHAIR FOR MOBILITY AROUND THE FACILITY. THE MDS ALSO IDENTIFIED RESIDENT #1 AS NOT STEADY AND ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE FOR MOVING FROM A SEATED TO STANDING POSITION, WALKING, TURING AROUND, MOVING ON AND OFF THE TOILET AND SURFACE TO SURFACE TRANSFERS. THE MDS IDENTIFIED RESIDENT #1 AS HAVING FREQUENT PAIN THAT MAKES IT HARD FOR HIM TO SLEEP AT NIGHT AND IT DOES LIMIT HIS DAY TO DAY ACTIVITIES. RESIDENT #1 WAS IDENTIFIED ON THE 12/18/2010 MDS AS HAVING (2) STAGE TWO PRESSURE ULCERS THAT HAD DEVELOPED IN THE FACILITY. THE MDS REVEALED A PRESSURE REDUCING DEVICE FOR THE BED, ULCER CARE, AND APPLICATION OF DRESSINGS TO THE FEET. AFTER MULTIPLE REQUESTS, A QUARTERLY MDS WAS GIVEN TO THIS SURVEOR ON 4/14/2011. THE QUARTERLY MDS HAD AN ASSESSMENT REFERENCE DATE OF 3/1/2011. THIS MDS IDENTIFIED ONE OF THE HEEL PRESSURE ULCERS AS A STAGE THREE WITH NECROTIC (DEAD, BLACK TISSUE) AND THE OTHER HEEL PRESSURE ULCER AS UNSTAGABLE WITH NECROTIC TISSUE. THE CLINICAL RECORD ALSO REVEALED RESIDENT #1 HAD (2) HEEL PRESSURE ULCERS. AN INTERVIEW WITH THE DIRECTOR OF NURSING (STAFF " B " ) TOOK PLACE ON 4/15/2011 AT 8:15 A.M. IN THE CONFERENCE ROOM. STAFF " B " STATED THAT RESIDENT #1 WAS ON A SPECIALTY PRESSURE REDUCING MATTRESS, THE PODIATRIST WAS FOLLOWING HIM EVERY OTHER WEEK, EDUCATION WAS PROVIDED, THE RISKS AND BENEFITS WERE EXPLAINED, SPECIALTY BOOTS WERE PROVIDED FOR PRESSURE REDUCTION ON HIS HEELS AND BRIDGING OF HIS HEELS WAS PUT INTO PLACE. AN INTERVIEW WITH RESIDENT #1 TOOK PLACE ON 4/14/2011 AT 4:30 P.M. IN HIS ROOM. RESIDENT #1 APPEARED ALERT AND ORIENTED. HE WAS INDEPENDENTLY MOBILE IN HIS WHEELCHAIR. RESIDENT #1 WAS ASKED WHY HE HAD DEVELOPED WOUNDS ON HIS FEET. RESIDENT #1 RESPONDED THAT HE FEELS IT WAS BECAUSE HE HAD USED HIS HEELS TO PROPEL HIS WHEELCHAIR. HE ALSO STATED THAT HE USES THE BALLS OF HIS FEET NOW. RESIDENT #1 WAS ASKED IF HE USES THE WEDGE PILLOW TO ELEVATE HIS FEET AT NIGHT AND HE STATED THAT HE DOESN'T LIKE TO BECAUSE IT MAKES HIS FEET COLD. RESIDENT #1 WAS ALSO ASKED IF HE HAD HIS SPECIALITY BOOTS IN THE ROOM. HE WAS ABLE TO TELL THIS SUREYOR WHERE THEY WERE BUT A NURSE PRESENT IN THE ROOM HAD TO RETREIVE THEM FROM THE TOP SHELF OF HIS CLOSET AS HE WAS NOT ABLE TO REACH THEM FROM HIS WHEELCHAIR. RESIDENT #1 WAS ASKED IF HE WEARS HIS BOOTS AT NIGHT AND HE RESPONDED, " NOT SO MUCH ANY MORE BECAUSE I USUALLY FORGET TO PUT THEM ON. " ON 4/13/11 AT APPROXIMATELY 4:00 P.M., A REVIEW OF SKIN INTEGRITY CARE PLAN, AND THE CARDIOVASCULAR/CIRCULATORY CARE PLAN, AND THE INFECTION CARE PLAN FAILED TO INCLUDE ANY INTERVENTIONS FOR REMINDING AND ASSISTING RESIDENT #1 WITH APPLYING HIS SPECIALITY BOOTS. THE CARE PLAN ALSO FAILED TO IDENTIFY THE BRIDGING OF HIS HEELS WHEN IN BED OR ASSISTING HIM TO KEEP HIS FEET WARM WHEN USING THE WEDGE PILLOW. THE NURSE AID CARE GUIDE IS AN INSTRUCTION SHEET USED TO DIRECT THE CARE OF THE RESIDENTS FOR NURSE AID QUICK REFERENCE. ACCORDING TO UNIT MANAGER, STAFF " P " , THE CARE GUIDE IS CREATED FROM THE CARE PLAN AND SHOULD MATCH THE CARE PLAN. IT IS PLACED ON THE INSIDE DOOR OF THE RESIDENTS CLOSET. RESIDENT #1'S CARE GUIDE FAILED TO INSTRUCT THE NURSE AID TO ELEVATE RESIDENT #1'S FEET AT NIGHT ON A WEDGE PILLOW. THE CARE GUIDE FOR RESIDENT #1 ALSO FAILED TO DIRECT THE NURSE AID TO ASSIST RESIDENT #1 WITH OBTAINING HIS SPECIALTY BOOTS AND APPLYING THEM AT NIGHT. A REVIEW OF THE PODIATRIST PROGRESS NOTES TOOK PLACE ON 4/14/2011 AT APPROXIMATELY 4:00P.M. AND REVEALED THE FOLLOWING NOTES: 3/23/2011 " DEBRIDED AND CLEANED ULCER BOTH HEELS. THESE ARE EXPANDING IN SIZE. " ALSO IN THE PODIATRIST NOTES, " ...NEED TO CONTINUE TO ENCOURAGE PATIENT TO WEAR BRACES (BOOTS) ... " . 4/6/2011 " RIGHT HEEL IS IMPROVED ...LEFT HEEL WORSE WITH NECROSIS SPREADING. " ALSO IN THE SAME NOTE, " ...I SPOKE WITH HIM AT LENGTH REGARDING THE NEED TO HEAL THESE ULCERS OR THESE WOUNDS COULD PROGRESS TO AMPUTATION. " ( )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROTECT 1 (#2) OF A OF 2 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 15 RESIDENTS FROM SIGNIFICANT INJURY RESULTING IN A HIP FRACTURE. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET FOR RESIDENT #2, DATED 4/30/10, THE UNDATED [DIAGNOSES REDACTED]. WITH FURTHER INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE HIP FRACTURE IT WAS DISCOVERED RESIDENT #2 HAD FALLEN A TOTAL OF 8 TIMES IN MAY, JUNE, JULY AND AUGUST OF 2010 BEFORE FALLING AND FRACTURING HER HIP IN SEPTEMBER. SHE ALSO HAD A SKIN TEAR IN AUGUST 2010. REVIEW OF THE 9 ACCIDENT/INCIDENT REPORTS PROVIDED BY THE FACILITY REVEALED THAT ON 3 OCCASIONS THE ALARM ATTACHED TO THE RESIDENT WAS NOT SOUNDING, THE INTERVENTIONS ON THESE REPORTS STATED "REPLACED ALARM", "ALARM BATTERY REPLACED", AND "ALARMS PLACED THAT WERE FUNCTIONING PROPERLY." ON THE REPORT DATED 5/2/10 THE "IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS" STATED "RESIDENT PLACED ON 15 MINUTE CHECKS." THE 5/16/10 REPORT, UNDER THE "SECTION B-FINAL DISPOSITION CAN A TREND BE IDENTIFIED "YES"... DOCUMENT RATIONALE TO SUPPORT DECISION: RESIDENT IS INDEPENDENTLY MOBILE IN W/C (WHEEL CHAIR) AND COGNITIVELY IMPAIRED. RESIDENT HAS TREND OF NOT UTILIZING CALL LIGHT, ...; RESIDENT ON 15 MINUTE CHECKS." HOWEVER THE "TIME OF INCIDENT" WAS DOCUMENTED AS 4:45 PM AND THE "LAST TIME CARE PROVIDED" WAS HAND WRITTEN IN AS "3 PM". THE 5/26/10 ACCIDENT/INCIDENT REPORT INDICATES THE TIME OF THE INCIDENT WAS 0430 (4:30 AM), THERE IS NO TIME LISTED AS "LAST TIME CARE PROVIDED" BUT THE DOCUMENTATION INDICATED THE "TIME LAST TOILETED" AS "0230" (2:30 AM), TWO HOURS PRIOR TO THE INCIDENT. "SECTION B-FINAL DISPOSITION" STATES 'RESIDENT ON 15 MINUTE CHECKS." THE 6/14/10 INCIDENT/ACCIDENT REPORT STATES TIME OF INCIDENT "0000" (MIDNIGHT), "LAST TIME CARE PROVIDED" AS "2211 (10:11 PM), ALMOST 2 HOURS PRIOR TO THE FALL. UNDER "SECTION B" IT STATES "OTHER: PHARMACY REVIEW OF MEDS; 15 MINUTE CHECKS." ACCORDING TO ANOTHER ACCIDENT/INCIDENT REPORT, ON 7/5/10 RESIDENT #2 fell AT 9:15 AM, THE LAST TIME CARE WAS PROVIDED WAS 8:30 AM, 45 MINUTES BEFORE. THE "IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS: ....CONTINUE 15 MINUTE CHECKS..." ON 7/28/10 AN ACCIDENT/INCIDENT REPORT WAS COMPLETED AT 2200, THE "LAST TIME CARE PROVIDED" WAS DOCUMENTED AS 9:00 PM. THE "IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS" WAS "RESIDENT AGAIN ASKED TO PUT CALL LIGHT ON WHEN SHE WANTS TO GET UP." THE 8/2/10 ACCIDENT/INCIDENT REPORT STATES THE TIME OF THE INCIDENT WAS 12:30 PM, THERE IS NO TIME DOCUMENTED FOR "LAST TIME CARE PROVIDED", IT STATES APPROXIMATE TIME SINCE LAST MEAL AS 12:00 PM AND "TIME LAST TOILETED" AS 11:00 AM. THE "IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS" STATES "UPON RISING TAKE TO THE B/R (BATHROOM) & BEFORE & AFTER MEALS." FOR THE "DOES RESIDENT KNOW WHAT CAUSED THE INCIDENT" IT STATES "RES (RESIDENT) STATED SHE THOUGHT SHE COULD WALK." AND FOR "COMPLIANT WITH PRESCRIBED ASSISTIVE DEVICES?" IT STATES "RES HAS NEVER BEEN COMPLIANT (WITH) USING CALL LITE." THERE IS NO DOCUMENTATION OF THE RESIDENT HAVING BEEN CHECKED ON EVERY 15 MINUTES. THE MINIMUM DATA SET (MDS) WITH AN ASSESSMENT REFERENCE DATE OF 5/3/10 FOR RESIDENT #2 INDICATED THE FOLLOWING: A FAMILY MEMBER WAS RESPONSIBLE FOR DECISION MAKING, RESIDENT #2 HAD SHORT TERM AND LONG TERM MEMORY PROBLEMS (i.e.. SHORT-TERM MEMORY OK--SEEMS/APPEARS TO RECALL AFTER 5 MINUTES WAS CODED AS 1=MEMORY PROBLEM. AND LONG-TERM MEMORY WAS CODED AS A 1=MEMORY PROBLEM). RESIDENT #2 WAS CODED UNDER "COGNITIVE SKILLS FOR DAILY DECISION-MAKING AS MODERATELY IMPAIRED -- DECISIONS POOR, CUES/SUPERVISION REQUIRED". THE SECTION FOR PHYSICAL FUNCTIONING AND STRUCTURAL PROBLEMS HAD RESIDENT #2 CODED AS REQUIRING EXTENSIVE ASSISTANCE (FULL WEIGHT-BEARING SUPPORT) OF ONE PERSON FOR BED MOBILITY, TRANSFERS, LOCOMOTION ON AND OFF THE UNIT, DRESSING, TOILETING, AND PERSONAL HYGIENE. HER BALANCE WHILE STANDING WAS CODED AS PARTIAL PHYSICAL SUPPORT DURING TEST OR STANDS BUT DOES NOT FOLLOW DIRECTIONS FOR TEST. UNDER THE DISEASE [DIAGNOSES REDACTED]. THE COGNITIVE RAP INDICATES SHE IS "VERY FORGETFUL." THE ADL FUNCTIONAL REHABILITATION POTENTIAL RAP STATED "SHE HAS SHORT TERM MEMORY DEFICITS AND REQUIRES FREQUENT CUEING FROM THE STAFF REGARDING HER SAFETY NEEDS." THE FALL RAP STATED "RESIDENT HAS SHORT TERM AND LONG TERM MEMORY DEFICITS....NURSING STAFF REMINDS RESIDENT FREQUENTLY TO CALL THE NURSE FOR ASSIST WITH HER MOBILITY NEEDS, AS SHE IS VERY FORGETFUL AND TRIES TO SELF TRANSFER." THE "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" DATED 4/30/10 WAS REVIEWED ON 4/13/11. UNDER THE "ASSESSMENT" HEADING THE FOLLOWING WAS INDICATED: "UNSTEADY, POOR WEIGHT BEARING, EXHAUSTION, WEAKNESS, PULSE IRREGULARITIES, BOWEL INCONTINENCE, BLADDER INCONTINENCE, DEMENTIA." THE GOAL "WILL BE FREE OF A SERIOUS INJURY IF A FALL WOULD OCCUR" WAS DATED 4/30/11. UNDER THE HEADING "INTERVENTIONS" THE FOLLOWING WAS INDICATED (ALONG WITH OTHERS): "SUPERVISION (DESCRIBE): 15 MINUTE CHECKS 5/2/10" AND "LEAVE FOR NO MORE THAN 10 MINUTES ALONE IN ROOM" DURING THE QUALITY ASSURANCE INTERVIEW WITH THE ADMINISTRATOR (STAFF "C") ON 4/15/11 AT APPROXIMATELY 12:00 PM, IT WAS REVEALED THAT, UPON REVIEW OF THE PREVIOUS YEAR, THERE WAS A HIGH NUMBER OF FALLS AND THAT THERE DIDN'T APPEAR TO HAVE BEEN AN IDENTIFICATION OF A ROOT CAUSE FOR ANY OF THE FALLS. ( )

This citation pertains to intakes #MI 155 and MI 812 Based on observation, interview and record review the Facility failed to provide supervision and assistive devices (seat belt and personal alarms) for 1 of 4 sampled Residents (#111), resulting in Resident #111 being left in her room, alone with the door closed and her seat belt not secured properly and fell to the floor and sustained head injuries that required her to be transferred to the hospital due to a Facial Fracture and 7 sutures on her right eyebrow. Findings include: Review of the Facility Incident Report, dated 3/6/11 at 8:35 PM, revealed Resident #111 was observed on the floor, in her room. There was a laceration noted on her right eyebrow and her cheek was swollen. Resident #111 was alert with decreased level of consciousness, according to the report. Ice was applied to her eyebrow and cheek. Resident #111's respirations were rapid and recorded as 24 breaths per minute (normal is 16-20). The Paramedics were called and transferred Resident #111 from the floor to the stretcher. The Nurse Practitioner and Family were notified. The Care Guide was checked, according to the report, and the mats were supposed to be next to the Resident when she was up in her wheelchair and in her room, but they were not. Her seatbelt was to be on when she was up and in her wheelchair also but it was not. The report continued to indicate that "large mats were added to the TAR (Treatment Administration Record), and placed in front of wheelchair as an intervention to prevent another serious injury due to a potential fall. Review of the clinical record face sheet revealed Resident #111 was a [AGE] year old woman, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was coded as completely dependent on staff for all Activities of Daily Living. An observation on 4/8/11 at 9:00 AM revealed Resident #111, in the dining room, being fed her breakfast. There was a scar on her right eyebrow that was approximately 2 inches long with scars of holes on each side of the laceration scar where sutures had been. After breakfast Resident #111 was brought to her room by a CNA. An interview was attempted with the resident, but it was difficult to understand her due to her [DIAGNOSES REDACTED].. Resident #111 was not able to elaborate on the accident that occurred on 3/6/11 when she fell and fractured her face. CNA "B", in an interview on 4/8/11 at 9:05AM said that Resident #111 had fractured her right eye cavity when she fell to the floor in her room. CNA "B" said the second shift CNA "K " , who no longer worked at the Facility, was getting her ready for bed and left her in her wheelchair with her seat belt off. CNA "K" left the room to get a mechanical lift to transfer her to bed, and after she (CNA "K") was gone, Resident #111 fell to the floor. CNA "B" said Resident #111 was "purple and black" on her right cheek and was not able to eat anything the next day because she was so sore. CNA "B" tested Resident #111's seat belt for the Surveyor and an alarm sounded immediately when the belt was opened to test. CNA "B" said Resident #111, "has a whole new wheelchair now." CNA "B" pointed out the anti roll backs that were placed on her wheelchair after the fall. CNA "B" said Physical Therapy made the changes to her wheelchair. Review of the Facility's "Care Delivery Guide" for Resident #111 revealed instructions for nursing to "apply the seat belt at all times when up in wheelchair and door open at all times when up in wheelchair until anti roll backs are placed and mats received to go in front of wheelchair. " The Care plan was dated as revised on 3/8/11. In an interview on 4/8/11 at 10:00AM, CNA "A" said, she was assigned to care for Resident #111 on 3/6/11, in the evening (2:30PM-10:30PM). CNA "A" said she was taking care of a Resident (not on the sample), and CNA "K" came in and asked if she needed help with any of the Residents on her assignment. CNA "A" said she only had Resident #111 left. CNA "A" told CNA "K" she could start to get Resident #111 ready and she would be in to help her as soon as she was finished with the Resident she was caring for at the time. CNA "A" said that Resident #111 was transferred with the mechanical lift transfer and said it required two people. CNA "A" said it took approximately 15 minutes to finish care of the Resident she was with before she (CNA "A") went to Resident #111's room. CNA "A" said she noticed Resident #111's door was closed so she knocked because she assumed CNA "K" was in the room with Resident #111. CNA "A" explained that Residents "are not supposed to be left in their room, alone, with the door closed if they have alarms on (are a fall risk)" and Resident #111 was a fall risk. CNA "A" said she opened the door and saw Resident #111, lying on the floor with her face on her side and there was blood on the floor next to her head. CNA "A" said the blue pad (used to cushion a fall), was up against the wall, not next to Resident #111 where she had left it. CNA "A" said she ran for help and got Licensed Practical Nurse (LPN "D") and LPN "H". CNA "A" said there were no alarms sounding and Resident #111 had her pajama top on. CNA "A" said the last time she saw Resident #111 was after supper and she was sitting in her room, the door was open and the blue pad was next to her wheelchair. CNA "A" said she checked Resident #111's seat belt alarm before supper and it was working properly but indicated that it was not turned on when she entered the room and found her on the floor. In an interview on 4/8/11 at 12:30PM, LPN "D" said she was passing the 8:00 PM medications on 3/6/11 on the unit where Resident #111 lived, when CNA "A" came up to her and said there was an emergency. LPN "D" was the only Nurse assigned to the unit Resident #111 lived on. LPN "D" said she stopped passing medications and ran over to Resident #111's room and saw Resident #111 on the floor, "in a pool of blood." LPN "D" said, "the blood had already coagulated. It was like yogurt consistency. It was a lot of blood." LPN "D" said she was the first Nurse to respond and saw Resident #111 alert and moaning, as in pain. LPN "D" said she assessed her, took vital signs and they appeared to be normal. LPN "D" said LPN "H" came and assisted and called Emergency Medical Services (EMS) and they arrived within minutes and took the resident to a local Hospital. LPN "D" said she reported the incident to the Administrator and the Director of Nursing. LPN "D" said the seat belt was not fastened to Resident #111 prior to her fall because it was in the wheelchair closed when she arrived in the room and there was no alarm sounding when she arrived. When asked if she wrote out a witness statement, LPN "D" said no, one was typed by the old Administrator and I saw some errors and asked them to correct them and then I signed it. When presented with the un-signed, type written paper that was meant to represent LPN "D"s witness statement, LPN "D" said, "this is not the corrected copy. LPN "D" said that there were errors in the statement and that is why she had them correct them. There was no other statement in the Facility's entire investigation file for LPN "D". The Director of Nursing (DON) was asked, in an interview on 4/8/11 at 1:00PM, if she had another witness statement for LPN "D". After looking through her files and her computer, the DON said that she could not find any other statement from LPN "D" related to the investigation of Resident #111s fall on 3/6/11. In a phone interview on 4/8/11 at 1:40PM, LPN "H" said she worked on 3/6/11 and was passing medications on a different unit that Resident #111 lived on. LPN "H" said she stopped passing the medications and went to Resident #111's room due to the emergency at approximately 8:30PM. LPN "H" said Resident #111 was laying on the floor, on her belly, and the left side of her face was on the floor. There was a moderate amount of blood on Resident #111 and the floor. LPN "H" said she checked the seat belt after they assessed her and the alarm light was not on as it should have been. The blue mat was not on the floor as it should have been either, LPN "H" said. LPN "H" said she was not the first one to enter Resident #111s room. In a phone interview on 4/8/11 at 1:21 PM, CNA "E" said she went to the Hospital with Resident #111 on 3/6/11 at approximately 8:30AM. CNA "E" said Resident #111"twinged" when they put stitches in her. CNA "E" said the Physician at the Hospital said she fractured her eye socket bone and they sent her back to the Facility the same evening with antiseptic to prevent an eye infection. Review of the Facility's nurse's notes dated 3/7/11 at 1:15AM revealed Resident #111 returned from the Hospital. Neurological checks were recorded as being done and within normal limits. The note revealed Resident #111 had an incident where she slid out of her wheelchair. Sutures (did not have number), noted on right eyebrow, "eye was swollen, almost shut and purple. Right cheek and upper lip with visible swelling and bruising." According to the nurse's notes, Resident #111's mother was called and wanted information about the incident. The note revealed Tylenol was given for pain. Review of the physician progress notes [REDACTED]." Further review of the notes revealed the fracture was of the "Maxillary Sinus." Review of the Facility's progress note dated 5/13/10 revealed that Resident #111's mother requested that mats be placed on the floor of her bedroom when Resident #111 is left unattended. Review of the care plan for Resident #111 dated 3/8/11 revealed the problem, "Prophylaxis for Maxillary Fracture." The intervention was Amoxicillin 500mg (an antibiotic) by mouth three times a day for 10 days. Review of the care plan dated 3/14/11 for fall revealed the following interventions: "floor mats in front of wheelchair when Resident in room watching TV and Door open to room at all times when Resident is up in wheelchair. Buckle seat belt when up in wheelchair at all times. On 3/8/11 anti tip bars placed on wheelchair." Review of the Occupational therapy notes dated 3/10/11 revealed that the goal was to educate the Nursing staff on the proper positioning of Resident #111 as well as the proper application of safety devices to eliminate the risk of falls while she was in a wheelchair. Review of the Facility's "Nutrition risk data collections" revealed Resident #111's fall of 3/6/11 was addressed due to the potential for weight loss as a result of facial fracture causing pain with chewing. The dietary note indicated that Resident #111's diet consistency needed to be changed to softer foods to accommodate Resident #111. Review of the Facility's "Safety Device Data Collection" sheet was completed and signed by the DON on 3/20/11. The form indicated that a Seat Belt with an alarm would be utilized for Resident #111. Review of the TAR revealed Resident #111's sutures were removed on 3/14/11, however the record did not note the number of sutures removed. CNA "K" was called for an interview twice but not able to be reached. Review of her personnel file revealed CNA "K" was hired on 5/19/09. She was terminated for "gross misconduct related to an investigation" on 3/14/11 regarding the incident of Resident #111. Other disciplinary actions in CNA "K"s file included not providing HS snacks on 1/23/11 and on 8/31/10, for not transferring a Resident properly when using a mechanical transfer device. The report said other CNAs complained that they felt uncomfortable working with her CNA "K". Review of the Hospital emergency room Computed Tomography of the maxillofacial area on 3/6/11 due to the fall, revealed Resident #111 with the following conclusion: Right Maxillary Ant rum Anterior Wall Fracture with associated Hemorrhage and Hematoma. At the exit conference on 4/13/11 at 1:00PM, the DON presented a witness statement from LPN "D" that was signed. The Surveyor was unable to verify the statement with LPN "D" because LPN "D" had been interviewed 6 days prior. On 4/13/11 the Facility had a new DON. At the exit conference, the new DON questioned the concern the Surveyor had regarding a lack of supervision by the Facility. The new DON expressed to the Surveyor that she felt the Supervision, to assure that Residents are provided the safety devices and appropriate transfer techniques to assist in the prevention of falls, was like "babysitting" the CNAs because "they have been given training." Review of the Hospital emergency room (ER) records dated 3/6/11 at 9:21PM revealed the ER description of present illness: "fell out of wheelchair landing face first on floor and sustaining laceration above right eye and hematoma to right cheek." Laceration measured 3CM and Resident #111 expressed pain. According to the ER report, under "procedures," indicated that a 2-layer closure of the laceration on her right eyebrow included 11 sutures. The CT showed a fracture of the anterior wall of her right maxillary sinus, which was mildly displaced. The treatment was antibiotics and suture removal in "about 7 days." ( )

This citation pertains to intake number MI 597. Based on observation, interview, and record review the facility failed to maintain an adequate hydration status in 1 of 11 sampled residents (Resident #103) resulting in dehydration. Findings include: The signs and symptoms of fluid volume deficit and dehydration include: 1) from 2%-20% loss body weight, 2) headaches and dizziness, lethargy, confusion, and disorientation, 3) sunken dry eyes, 4) sticky, dry mucous membranes, 5) low blood pressure, 6) hyperactive bowel sounds with diarrhea, 7) decreased body temperature, 8) dry, flushed, cold, clammy, decreased elasticity of the skin, and 9) dark colored urine with an increase in concentration. (Fundamentals in Nursing, Potter & Perry, 2005, pgs. 1150-1151). The Clinical Process Guidelines for Maintaining Hydration and Electrolyte Balance indicate that when staff and practitioners identify situations where an individual's hydration is at risk or may be impaired, they should seek additional information such as current or subsequent changes in food or fluid intake, the level of consciousness, mental status, urine output, or rapid or sudden changes in body weight. For hydration, the amount and rate of weight change are relevant, 1 liter of fluid = 1 kilogram = 2.2 pounds. (MDCH, 11/8/05) Resident #103 Review of the Face Sheet, the Minimum Data Set ((MDS) dated [DATE], and the hospital Discharge Summary dated 10/8/10 revealed Resident #103 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Discharge Summary indicated Resident #103 had a PEG (percutaneous endoscopic gastrostomy) feeding tube surgically placed on 10/1/10. The MDS revealed Resident #103 had severe cognitive impairment and had daily behaviors not directed toward others. Resident #103 was totally dependent on staff for his food and fluid needs. Review of the Nutritional Risk Data Collection and Assessment form dated 10/9/10 revealed Resident #103 daily fluid needs were based on 25 ml/kg body weight per day for a total of 2,443 ml's estimated daily fluid needs. The general guideline for determining fluid needs is based on a 30 ml/kg of body weight. Resident #103's body weight was 215 pounds or 97 kilograms on admission, putting his total daily fluid needs at 2,910 ml's of fluid daily (97 kg. x 30 ml. = 2,910). Review of the Nursing Comprehensive Admission Data Collection and assessment dated [DATE] revealed Resident #103 had a foley catheter in place that was draining clear yellow urine. Review of the Clinical Record revealed Resident #103 was frequently agitated, fidgeting in bed, pulling on both the PEG tube and the foley catheter tubing, and rolling out of bed. Review of the Progress Notes dated 10/13/10 at 9:30 a.m. revealed Resident #103's foley catheter was draining dark amber urine. Review of the Vital Signs sheet revealed Resident #103 had below normal temperatures on 10/13/10 of 95.6, 95.3 on 10/27/10 95.0, on 10/28/10, and 95.3 on 10/31/10. Review of the nurses Progress Notes for the same days revealed no documentation of abnormal vital signs, documentation that Resident #103 had increase agitation, and on 10/27/10 at 4:30 a.m. the nurse documented his catheter draining clear, dark urine. On 10/28/10 at 9:00 a.m. the nurse documented Resident #103 had very dry skin on his lower extremities. On 10/29/10 at 2:00 a.m. the nurse documented Resident #103 seemed agitated and had rust colored urine. Review of the Laboratory Report dated 10/29/10 revealed Resident #103 had a urinary tract infection with [MEDICAL CONDITION] (MRSA - a difficult to treat bacterium). Review of the Physician's Interim Orders dated 10/22/10 at 5:00 p.m. revealed Resident #103 was ordered [MEDICATION NAME] (antibiotic) 250 mg 3 times per day for 3 weeks prescribed for [MEDICAL CONDITION] (bacterium in the colon that causes diarrhea). Review of the Urinalysis Laboratory Report dated 10/29/10 and received at the facility on 10/31/10 revealed Resident #103's urine specific gravity (shows concentration level of urine) was greater than or equal to 1.030 (normal is 1.002-1.030). Mosby's Diagnostic and Laboratory Test Reference, 9th Edition, (2002, pg. 429) revealed a urine specific gravity of greater than 1.026 indicates decreased fluid intake and dehydration. Review of the Medication Administration Record (MAR) dated 11/10 revealed Resident #103 was receiving a continuous tube feeding at 90 ml's/hour for 20 hours daily with 400 ml's of water flushed down his PEG tube every 6 hours. The orders were highlighted (indicating the order was discontinued) and hand written on the MAR was "rewritten 11/5/10". Review of the Nutrition Recommendation Form dated 11/3/10 revealed a recommendation from the Dietary Manager for Resident #103's tube feeding to change from a continuous timed tube feeding to a [MEDICATION NAME] (single, large dose) feeding with 60 ml's of water before and after each feed. The recommendation was signed by the physician on 11/5/10 with instructions for 2 cans of Glucerna (tube feeding formula) [MEDICATION NAME] four times daily with 120 ml's of water flush through the PEG tube before and after each feed. Review of the rewritten MAR dated 11/10 revealed Resident #103 was to receive Glucerna, 2 cans, 4 times daily as a [MEDICATION NAME] feed and a water flush of 120 ml's before and after each feed. There was no additional orders for fluid documented on the MAR. An observation on 11/10/10 at 10:10 a.m. revealed Resident #103 was lying on his mattress with dark yellow urine draining from his foley catheter. Review of the Nutritional Progress Note dated 11/18/10 revealed Resident #103 was receiving Glucerna 1.2 caloris, 2 can [MEDICATION NAME], 4 times daily with 120 ml's water flush down the PEG tube before and after each feeding. The Registered Dietician (RD) calculated Resident #103 was receiving 1,529 ml's of fluid from the Glucerna and 960 ml's of fluid from the water flushes for a total of 2,489 ml's of fluid daily. The RD noted Resident #103's had some abnormal laboratory values as of 10/18/10 with no new labs to review. Resident #103's weight was documented as 195 pounds (88.6 kg) on 11/17/10, a twenty (20) pound or 9.3% loss of body weight (a sign of dehydration) since admission on 10/8/10. The RD documented that Resident #103's "current enteral (PEG tube feeding) regimen should be appropriate to meet estimated nutritional needs". An observation on 11/23/10 at 10:18 a.m. revealed Resident #103 was lying in bed with dark amber color urine draining from his foley catheter. In an interview on 11/23/10 at 10:29 a.m. Licensed Practical Nurse (LPN) #2, assigned to Resident #103 that day, reported she was unaware that he had dark amber urine draining from his foley catheter. In an interview on 11/23/10 at 10:52 a.m. Unit Manager #1, in charge of Resident #103's unit, reported she was unaware that Resident #103's foley catheter was draining dark amber urine. On 11/23/10 at 11:20 a.m. the Dietary Manager (DM) and Surveyor # reviewed Resident #103's clinical record. The DM indicated Glucerna 1.2 provided 192 ml's of water per can of fluid and Resident #103 received 8 cans daily for a total of 1,536 ml's of fluid provided daily from Glucerna 192 x 8 = 1,536). Resident #103 was receiving 120 ml's of fluid before and after each feeding, 4 times per day for a total of 960 ml's of fluid from the daily water flushes (120 x 2 x 4 =960). The DM and surveyor agreed that Resident #103 was receiving 2,496 ml's of water daily. At 30 ml's per kilogram of weight (per the standard fluid figures), Resident #103 required 2,659 ml's of fluid daily, indicating that Resident #103 had a 163 ml's fluid deficit per day since 11/5/10 (18 days) for a total fluid deficit of 2,934 ml's. In an interview on 11/23/10 at 11:20 a.m. the DM reported that Resident #103 should have received 35 ml's/kg of body weight daily to meet his fluid needs because of a recurrent urinary tract infection and chronic diarrhea due to [MEDICAL CONDITION] (bacteria that causes diarrhea). Upon review of the clinical record, DM calculated Resident #103 should have been receiving 3,101 ml's of fluid daily based on his current weight (88.6 x 35 = 3,101). Resident #103 was at a fluid deficit of 605 ml's of fluid daily (3,101 - 2,496 = 605) for a total fluid deficit of 10,890 ml's as of 11/23/10. The DM called the Registered Dietician to request new orders for water flushes and laboratory work. There had been no new laboratory orders for Resident #103 since 10/18/10 for measuring his kidney function, protein levels, or electrolyte levels. In an interview on 11/23/10 at 11:41 a.m. the RD stated, "I was not aware he still had diarrhea. I knew he was recently off antibiotics but didn't know he still had diarrhea. I thought my calculations were correct, obviously I was wrong." The RD reported she reviews the clinical record and talks with nursing staff when reviewing a residents dietary needs. The RD stated, "He should have been figured at 35 ml's per kilogram of weight if he had a urinary tract infection and diarrhea. I must have missed it." ( )

This citation pertains to intake number MI 284 and MI 0636. Based on interview and record review, the facility failed to ensure residents were able to meet their highest practicable physical, mental, and emotional well-being in 4 of 7 sampled residents (Resident #100, Resident #101, Resident #102, and Resident #103) resulting in: 1) Resident #100 having a fall with a [MEDICAL CONDITION] hip and 2 subsequent dislocations of the right hip, 2) Resident #101 not receiving [MEDICATION NAME] (medication to increase heart contractility to improve heart failure symptoms and to control an irregular heart rate) for 4 days due to a medication transcription error and a delay in treatment after having stroke-like symptoms, 3) Resident #102 having bleeding after abdominal surgery, while on a blood thinner, that was not reported to the physician in a timely manner, and 4) Resident #103 having a delay in treatment after increased bleeding and lethargy was noted by facility staff for 4 days resulting in Resident #103, after having a fall, becoming unresponsive and required emergent transfer to the hospital. Findings include: Resident #100 Review of the Face sheet, the Minimum Data Set ((MDS) dated [DATE], and the Resident Assessment Protocol (RAP) dated 8/6/10 revealed Resident #100 was admitted to the facility on [DATE] with liver [MEDICAL CONDITION] (liver failure), ascites (fluid in the abdomen from liver failure), bacterial peritonitis (infection of the lining of the abdomen), and acute kidney failure. Resident #100 required limited assistance of one person with transfers, ambulation, and toileting. Resident #100 had indicators of [MEDICAL CONDITION]-periodic disordered thinking that included episodes of disorganized speech. Resident #100 required partial physical support while standing and had an unsteady gait requiring use of a walker. The RAP for Activities of Daily Living Functional Rehabilitation Potential revealed Resident #100 was impulsive and was not safety conscious, staff were to monitor resident. Review of the Accident/Incident Report dated 8/3/10 at 3:20 p.m. revealed Resident #100 had walked away from the bathroom door after closing it. The Certified Nurse Aide (in the bathroom with another resident) heard a scream and a loud crash outside the door. Resident #100 was found on the floor bleeding from cuts on her head and her right arm. Resident #100 complained of pain in her hips and was unable to straighten her lower legs. Resident #100 had struck her head on the closet. Resident #100 had signs/symptoms of a right [MEDICAL CONDITION]. Resident #100 was sent to the emergency department for evaluation. Resident #100 was admitted to the hospital with [REDACTED]. Section B - Final Disposition of the Accident/Incident Report revealed the incident was documented as being related to restroom use. There was no change to Resident #100's plan of care or new interventions put in place to prevent recurrences. Review of the Hospital Patient Discharge Instructions with the hospital admitted [DATE], revealed Resident #100 was to ambulate and complete activities of daily living (ADL's) with stand-by assistance using a walker and be 50% weight bearing on her right leg. Resident #100 required cueing to follow hip precautions. Review of the Facility's guide Activities of Daily Living: Hip Precautions revealed precautions post total hip replacement included: no lying on the surgical side, do not cross your legs, do not bend more than 90 degrees at the waist, do not lift the knees higher than the hips, no twisting of the operated leg, no turning the feet inward or outward - keep the toes pointing midline with the nose, avoid low toilets or chairs that cause bending of the hip greater than 90 degrees. When getting in bed, sit on the edge of the bed then scoot the hips around to face the foot of the bed. Lift the surgical leg onto the bed while scooting the hips towards the center of the bed, do not use the other leg. When getting out of bed, scoot the hips to the edge of the bed, lower the non-surgical leg to the floor, the lower the surgical leg to the floor. Scoot to the edge of the bed. Do not bed greater than 90 degrees to get in or out of the bed. To avoid hip dislocation, follow hip precautions for at least 12 weeks and avoid twisting and extremes in bending for life. Review of the Medication Administration Record, [REDACTED]. There was no documentation to remind facility staff to follow hip precautions for Resident #100 from 8/3/10 until 9/1/10. The Treatment Administration Record dated 9/10 revealed an order was transcribed for facility staff to follow total hip precautions. In an interview on 9/28/10 at 10:50 a.m. the Director of Physical Therapy reported the therapy department does not tell the nursing staff when residents are on hip precautions, that is should be in the physician's orders [REDACTED]. Review of the Care Delivery Guide (used Certified Nurse Aides to know residents needs) revealed no documentation regarding Resident #100's ordered hip precautions. Review of the Progress Notes (nurse's notes) in the clinical record revealed documentation that Resident #100 was forgetful and confused at times. Resident #100 required continued reminders to use the call light and ask for assistance with her ADL's. Review of the Progress Notes (nurse's notes) dated 8/20/10 at 9:30 a.m. revealed Licensed Practical Nurse (LPN) #1 heard Resident #100 yelling out in pain in her room. LPN #1 entered the room to find Resident #100 lying on her left side in bed screaming in pain. Certified Nurse Aide (CNA) #1 was in the room delivering her breakfast tray. CNA #1 reported to LPN #1 that Resident #100 went to sit on the edge of the bed and fell over screaming. Resident #100 was sent to the hospital for a dislocated hip and returned to the facility on [DATE] at 6:45 p.m. Review of the Outpatient Discharge Instructions from the hospital dated 8/20/10 revealed Resident #100 was to wear a right hip flexion/abduction brace at all times, have no hip flexion greater than 90 degrees, and no crossing of her legs. The hip flexion/abduction brace provides hip stability in flexion (bending) and abduction/adduction (moving away/moving towards the center line) to maintain alignment of the hip. In an interview on 9/28/10 at 12:10 p.m. CNA #1 stated, "She (Resident #100) went to swing her legs over the bed and just yelled. I guess she should have been on hip precautions." CNA #1 reported not helping or cueing Resident #100 on hip precautions she should be following. In an interview on 9/28/10 at 1:35 p.m. LPN #1 stated, "When I entered the room, her pain was a 10 on a scale of 1-10. I got an order to send her to the hospital." LPN #1 reported Resident #100 was on hip precautions and required consistent reminding of those hip precautions. Surveyor # asked what hip precautions were taught to Resident #100, LPN #1 was unsure of exactly what hip precautions were other than no bending greater than 90 degrees. In an interview on 9/28/10 at 2:31 p.m. CNA #2 stated, "I never taught her (Resident #100) about hip precautions, I believe the nurse's do that. I never received education from the facility on hip precautions. Everything I know about hip precautions came from family telling me and from talking with other CNA's." CNA #2 reported Resident #100 had no alarms in place prior to her fall on 8/3/10. CNA #2 stated, "She was supposed to be one person assist but she was not consistent with call light use. She was not cognitively intact enough to not have alarms, there should have been an alarm in place." In an interview on 9/28/10 at 3:55 p.m. CNA #3 reported not remembering what was included in hip precautions and stated she would have to relearn it. CNA #3 stated, "I know we're not supposed to move them though." In an interview on 9/28/10 at 4:00 p.m. CNA #4 reported that hip precautions were that they had to put on gowns and gloves when caring for a resident. CNA #4 reported working at the facility for 4 months. In an interview on 9/28/10 at 3:58 p.m. Physical Therapy Assistant (PTA) #1 stated, "Facility staff are given instructions on hip/knee precautions if they ask but I believe the nurse educator teaches it on orientation to the facility." In an interview on 9/29/10 at 10:40 a.m. LPN #3 stated, "I think hip precautions include a pillow between the legs in bed and having assistance when getting in and out of bed, but I'd have to ask therapy to be certain. I had the information when oriented to the facility but I can't recall any additional training on it since then." LPN #3 reported working at the facility for 2 years. In an interview on 9/29/10 at 2:45 p.m. CNA #7 stated, "Hip precautions include putting a pillow between their legs in bed, resident is dependent for lifts, and we have to be very careful." CNA #7 was unable to recall any additional information regarding hip precautions. In an interview on 9/20/10 at 10:00 a.m. Resident #100 stated, "The first time my hip dislocated, they brought my tray and set it up on the table. I had gotten up independently from bed prior to this day." In an interview on 10/6/10 at 11:20 a.m. Physical Therapist (PT) #1 stated, "I did not educate the CNA's or nurses on hip precautions and they did not ask. The resident (Resident #100) required assistance getting in and out of bed. She was not to be independent in her room because she required reminding and multiple cues to stay on track." Review of the Progress Notes (nurse's notes) dated 8/26/10 at 9:15 a.m. revealed LPN #1 was informed by CNA #6 that Resident #100 was in a lot of pain. Resident #100 was assessed by LPN #1. Resident #100 stated she was in pain but not as much as when she previously dislocated her hip. Resident #100 continued getting ready for her orthopedic appointment. Review of the Progress Notes (nurse's notes) dated 8/26/10 at 11:45 p.m. revealed LPN #1 received a call from the orthopedics office informing her that Resident #100's right hip was again dislocated and she was being transferred to the hospital. In an interview on 9/20/10 at 10:00 a.m. Resident #100 stated, "The second time my hip dislocated, the aide was helping me (to get up from bed) and took both my feet at once and turned me in bed. I felt a twinge, I said "ow". I got in my wheelchair to make a phone calls and when I came back, I couldn't get up, they had to help me. By the next morning I couldn't move. I had an orthopedic appointment so I went to it and they sent me to the hospital. I had to have hip surgery again. I just want to know why they didn't prevent my [MEDICAL CONDITION] to begin with, I was so confused back then (on 8/3/10) when I fell ." ( ) Resident #101 Review of the Face sheet revealed Resident #101 was admitted to the facility on [DATE] after a right total knee replacement. Resident #101 had a history of [REDACTED]. Resident #101 was alert and oriented to person, place, and time. Review of the Extended Care Facility (ECF) Transfer Order Form dated 6/5/10 revealed Resident #101 admission medication order should have included [MEDICATION NAME] 0.125 mg one tablet to be taken orally daily. Resident #101 was not to continue Fish Oil or Tylenol upon admission to the facility. Review of the physician's orders [REDACTED]. There were orders for Tylenol 650 mg every 4 hours as needed and for Fish Oil (omega -3 that can increase risk of bleeding) 1000 mg to be taken twice daily. There was only one nurse signature on the admission orders [REDACTED]. According to Mosby's Nursing Drug Reference 2007 (pgs. 359-361) [MEDICATION NAME] is used to increase the force of contraction in the heart and to decrease heart rate. In oral form, the onset of action is 1/2-2 hours, a peak of 6-8 hours, and a duration in the body of 3-4 days. The medication should not be stopped abruptly without physician notification. According to the Manufacturer's instructions (GlaxoSmithKline, August 2009) it takes 1-3 weeks to a steady state of the drug in the blood stream with oral administration. Review of the Interim Orders dated 6/6/10 revealed a telephone order signed by Registered Nurse (RN) #6 that Resident #101's admission orders [REDACTED]. Review of the Physician's Progress Note dated 6/7/10 revealed Resident #101 was seen by the nurse practitioner and there was no change in the medications prescribed and that the medications for his history of diabetes, hypertension, and [MEDICAL CONDITION] should be continued as TF (transfer orders). In an interview on 10/14/10 at 3:15 p.m. RN #6 stated, "I was the weekend manager then and I was doing as much as I could for admissions. I transcribed the orders. Nurse's are supposed to double check the medications the resident was discharged on after the orders were transcribed, that did not happen. The [MEDICATION NAME] was not transcribed. The nurse who was passing medications or the charge nurse should have double checked the transcription, that is the policy in the facility. Review of the Progress Notes (nurse's notes) dated 6/10/10 from 2:00 p.m. - 10:00 p.m. (no specific time) revealed Resident #101's family member informed RN #7 that he was "unable to grasp a drink and had dropped it two separate times and displaying signs and symptoms decrease motor control in his upper extremities, more so on the right side. Also noted slurred speech. Resident usually alert and oriented - wife concerned or possible TIA ([MEDICAL CONDITION] - mini stroke). Resident #101 was sent to the hospital per resident and wife request." Review of the ambulance run sheet dated 6/10/10 revealed the ambulance was dispatched to the facility at 7:12 p.m., was on scene at 7:15 p.m., and Resident #100 arrived at the hospital at 7:41 p.m. Review of the emergency room Record dated 6/10/10 revealed Resident #100 was having stroke-like symptoms that began around 6:15 p.m that included "knocking a glass over a glass with his dominant right hand twice and stated he did not feel right. He then had difficulty finding words and started slurring his speech. Upon arrival to the emergency department, the patient's symptoms have resolved.". Resident #100's documented current medication list did not include [MEDICATION NAME]. Resident #100 was diagnosed with [REDACTED]. In an interview on 10/13/10 at 8:30 a.m. RN #7 reported not knowing how long Resident #101 was having stroke-like symptoms prior to notifying the physician. RN #7 stated, "There were a lot of other things going on at that time. I was very busy. I kept trying to call the manager, Director of Nursing, and physician but I got no response. The wrong phone number was posted on the wall for the physician. I intended to get him out sooner, but I kept getting distracted. I finally got ahold of someone who gave me the correct phone number of the physician. I told myself if something like this were to happen again, I just call an ambulance." In an interview on 10/5/10 at 8:45 a.m. a family member stated, "He (Resident #101) said to the nurse "I think I'm having a stroke". I told them they needed to call 911 but they said they needed to call the doctor since it's protocol. For several days after the incident, his speech wasn't right and he was unable to find words." In an interview on 10/6/10 at 4:00 p.m. the Administrator stated, "We did admit to his (Resident #101) spouse that we made a mistake in the transcription of the medication orders and in not sending him out to the hospital immediately after the beginning of his symptoms." ( ) Resident #102 Review of the face sheet revealed Resident #102 was admitted to the facility on [DATE] and readmitted on [DATE] with a history of a stroke with left sided weakness, diabetes mellitus, dementia, and recent abdominal surgery. Review of the Hospital Reconciliation Physician order [REDACTED].#102 International Normalized Ratio (INR) blood level was greater than 2.5. The INR level is used to check the effectiveness of blood thinner medications. Resident #102's INR level was ordered to be checked on 9/24/10. [MEDICATION NAME] has a narrow INR therapeutic range of 2.0-3.0. Review of the Interim Orders dated 9/22/10 at 4:00 p.m. revealed the nurse received an order indicating "all admission orders [REDACTED]. Change sliding scale (insulin) to standing orders sliding scale". Review of the Laboratory Report dated 9/23/10 revealed Resident #102 had his INR checked on 9/23/10, one day prior to the original hospital admission order that was approved by the nurse practitioner. Resident #102's INR level was 1.7, sub-therapeutic. The report was faxed to the physician. Review of the Interim Orders dated 9/23/10 at 1:00 p.m. revealed an order for [REDACTED]. Review of the Laboratory Report dated 9/27/10 revealed Resident #102's INR level was critically high at 6.5. Review of the Progress Notes (nurse's notes) dated 9/27/10 (no time) revealed the physician was notified of Resident #102's INR results. The nurse received an order to discontinue the [MEDICATION NAME], hold the [MEDICATION NAME] through 9/30/10, redraw for an INR level on 9/30/10, and notify the physician of the results. No other information was provided to the physician per the nurse's note. The Interim Orders dated 9/27/10 indicated the order was received at 1:30 p.m.. Review of the Progress Notes (nurse's notes) dated 9/27/10 at 2:30 p.m. revealed Resident #102 had a small area on the incision on his lower abdomen that was oozing blood. The incision was cleansed and the dressing was reinforced. There was no documentation of the nurse calling the physician or nurse practitioner to inform them about Resident #102's bleeding. Review of the Progress Notes (nurse's notes) dated 9/27/10 at 10:00 p.m. revealed Resident #102 had a blood nose and slight bleeding from his abdominal incision. The nurse reinforced the steri-strips (thin adhesive strips used to assist in wound closure) on the wound. There was no documentation the physician or the nurse practitioner were notified. Review of the Progress Notes (nurse's notes) dated 9/28/10 at 10:00 p.m. revealed Resident #102 remained in bed most of the day. Resident #102 had bleeding from his lower abdominal incision. At 6:00 p.m., the ambulance was called and Resident #102 was transferred to the hospital for evaluation. In an interview on 9/29/10 at 4:40 p.m. Resident #102's family member stated, "When the CNA helped him into the bathroom and saw him bleeding down his stomach she stated "I don't think this looks right". I went and got the nurse and the Administrator was walking by who said they'd call the physician. He (Resident #102) had been bleeding a couple days." The family member stated, "Based on the paperwork I got when he left the hospital on 9/22, he was supposed to have his INR drawn on 9/24. He'd been on 1.5-2 mg [MEDICATION NAME] at home for the last [AGE] years. I was told they raised his [MEDICATION NAME] level (after the 9/23/10 blood draw) and thought they should have checked his INR level long before 9/27/10. That dose was awfully high for him." In an interview on 9/29/10 at 4:45 p.m. Registered Nurse (RN) #5 stated, "When I looked at the wound on his abdomen today, it was literally squirting blood out." In an interview on 9/29/10 at 12:55 p.m. the Nurse Practitioner (NP) stated, "I did not receive a phone call from the nursing staff about his (Resident #102's) bleeding on 9/27/10, only about the elevated INR level of 6.5. I did get a call on 9/28/10 about the bleeding and had him sent to the emergency room . Since the emergency room sent him back after getting Vitamin K (blood clotting medication) he should have safe, but nursing staff did not call to ask for further orders after the emergency room sent him back." ( ) Resident #103 Resident #103 was no longer at the facility at the time of the investigation. Review of the Face sheet and the [DIAGNOSES REDACTED]. Review of the Fall/Injury Assessment: Prevention and Management Plan of Care dated 8/21/10 revealed Resident #103 was at risk for falls related to an unsteady gait, poor weight bearing ability, and weakness. Resident #103 required the assistance of 2 persons with transfers and ambulation. Interventions included generalized supervision, a high/low bed, and to have the wheels on the bed locked. Per the Physician's Progress note dated 9/1/10 revealed Resident #103 was alert and oriented to person, place, and time but was lethargic with generalized fatigue and increased yellowing of the skin due to jaundice from liver failure. Review of the Progress Notes (nurse's notes) dated 9/4/10 at 9:00 a.m. revealed Resident #103 was given a shower. It was reported by the Certified Nurse Aide (CNA) that Resident #103 was not following directions well and was totally dependent on the CNA for her shower. At 11:30 a.m. the nurse documented Resident #103 was sleepy and her mother reported Resident #103 was not opening her eyes much. At 10:00 p.m. the nurse documented Resident #103 had decreased eye contact, sleepy, with decreased verbalization. Resident #103 was fed by her family as she would not feed herself. There was no documentation of physician notification regarding Resident #103's change of condition. Review of the Progress Notes (nurse's notes) dated 9/5/10 at 8:00 a.m. revealed Resident #103 would wake up when her name was called but was very sleepy. Review of the Progress Notes (nurse's notes) dated 9/6/10 at 11:30 a.m. revealed Resident #103's family was in and expressed concern over how sleepy she was. Resident #103 would respond to her name but then fall back asleep easily. Review of the Progress Notes (nurse's notes) dated 9/6/10 at 4:30 p.m. revealed Resident #103 had to be fed her afternoon medications. Resident #103 was alert to self only and appeared drowsy. At 5:00 p.m. the CNA reported to the nurse that Resident #103 was bleeding from her mouth. At 7:00 p.m. the nurse documented the physician was notified of Resident #103's bleeding from the mouth and decreased mental status (decreased orientation). The physician ordered for Resident #103 to have blood drawn on 9/7/10. At 7:30 p.m., the nurse informed Resident #103's family of the new order who stated she had seen a mental status change in Resident #103 for the last 3 days. Review of the Vital Signs - Individual Flowsheet revealed Resident #103's average blood pressure was 118/76. Resident #103's blood pressure on 9/7/10 at 9:30 a.m. was documented as 88/62 (normal blood pressure is 120/80). Review of the Progress Notes (nurse's notes) dated 9/7/10 at 11:00 a.m. revealed documentation of Resident #103 being very lethargic and "blood pressure is running low..." Resident #103 had dried blood noted on her mouth and nose. At 11:45 a.m. Resident #103 was found on the floor by the CNA lying on her right side, confused and very lethargic. Resident #103 responded to some verbal stimuli. Review of the Accident/Incident Report dated 9/7/10 at 11:40 a.m. revealed Resident #103 was found in her room, on the floor, on her right side with blood coming out of her nose and mouth. Resident #103 was unresponsive, her left pupil had a sluggish reaction to light. Resident #103 was held in a flat, straight position until the ambulance arrived. The report revealed Resident #103 was having lethargy and confusion prior to the incident. Resident #103 was transported to the hospital. Section A and Section B of the Accident/Incident Report (used for the investigation of the incident) revealed the final disposition of the incident was an "extensive history of liver failure with high ammonia levels". There was no documentation of an investigation into the cause of the fall or what could be done to prevent further occurrences. Review of the Ambulance Run Sheet dated 9/7/10 revealed Resident #103 was "found unresponsive by staff on the floor. Unknown how patient got to floor. Patient had decrease level of consciousness (LOC) over weekend". Resident #103's was measured at a 10 on the Glasgow Coma Scale. (According to the Centers for Disease Control and Prevention, the Glasgow Coma Scale (GCS) was designed and should be used to assess the depth and duration coma and impaired consciousness. A GCS score of 9 to 12 indicates a moderate head injury.) Resident #103 was transported to the hospital. Review of the Hospital Unscheduled History and Physical dated 9/7/10 revealed Resident #103 presented to the hospital after being found on the floor with blood draining from her nose and mouth in the facility. Resident #103 had been less coherent and confused for the last 2 days. Resident #103's neurological assessment revealed Resident #103 could move all extremities but was she did not follow any commands and her speech was garbled and incoherent. Resident #103's CT scan of the head revealed areas suspicious for acute or very recent parenchymal hemorrhage (bleeding into the brain) of the parietal lobe of the brain. Resident #103's CT scan of the cervical spine showed soft tissue swelling at level C2-C3 and an area in front of the cervical spine that appeared to be an acute hemorrhage. Resident #103 was diagnosed with [REDACTED]. Resident #103 was discharge from the hospital on [DATE] on Hospice in stable but critical condition for comfort care. In an interview on 10/6/10 at 2:25 p.m. Registered Nurse (RN) #2 reported Resident #103 had no mats on the floor or safety alarms in place on her bed at the time of the incident. RN #2 stated, "She had a blood nose for a couple of days prior to her fall." RN #2 reported that Resident #103 should have been sent out to the hospital on [DATE] because of her bleeding and lethargy. In an interview on 10/6/10 at 1:15 p.m. Licensed Practical Nurse (LPN) #5 stated, "When I got report from the third shift nurse, she had told me she (Resident #103) had a bad weekend. I was told about the blood on her nose and mouth they had seen. I was told the doctor was aware and had ordered blood to be drawn. I was concerned and wondered why the doctor only ordered labs. I was waiting to notify the physician of her condition and low blood pressure until her blood work came back." In an interview on 10/6/10 at 12:20 p.m. CNA # 14 reported she had checked on Resident #103 and noticed blood in her nose and pooling of blood in her mouth. CNA #14 reported informing the nurse at 6:30 a.m. on 10/6/10 of Resident #103's condition. CNA #14 stated, "The resident (Resident #103) was lethargic the day before her fall (9/6/10) on 9/7/10 and I told the nurse, she felt it was no big deal. She was having increase confusion in her daily conversations." CNA #14 reported that Resident #103 required the assistance of one person with her activities of daily living because of an unsteady balance and weakness. In an interview on 10/8/10 at 10:00 a.m. the Medical Director (Resident #103's assigned physician) stated, "I ordered the labs to check on her platelets because of her history of bleeding due to liver [MEDICAL CONDITION]. She was lethargic with low blood pressure and should have had some interventions." The Medical Director reported being unaware of Resident #103's low blood pressure reading. The Medical Director stated, "She was a full code and needed to have everything possible done to save her. When someone comes in like this who is destined to die, it can bear weight in the judgements made by facility staff." ( )

This citation pertains to intake number MI 636. Based on interview and record review, the facility failed to ensure nursing staff followed the standards of care and facility policy regarding medication transcription in 2 of 7 sampled residents (Resident #101 and Resident #103) resulting in Resident #101 not receiving a prescribed medication for 4 days and Resident #103 having a delay in treatment after increased bleeding and lethargy was noted by facility staff for 4 days. Findings include: According to the Fundamentals of Nursing, 6th edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005 page 419) the physician should write all orders, and the nurse must make sure that they are transcribed correctly. According to "The LTC Health Information Practice and Documentation Guidelines", Version 1.0, September, "Transcription of orders is the responsibility of the professional nurse...the nurse must sign off on the order and retain responsibility for accurate transcription". According to the Mayo Foundation for Medical Education and Research, 1998-2010, retrieved online on 10/22/10, "It should be noted when signs and symptoms of a stroke begin, because the length of time they have been present may guide treatment decisions. Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear. Call 911 or your local emergency number right away. Every minute counts. Don't wait to see if symptoms go away. The longer a stroke goes untreated, the greater the potential for brain damage and disability. To maximize the effectiveness of evaluation and treatment, it's best that you get to the emergency room within 60 minutes of your first symptoms." The profession standard of quality for notifiying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated 6/29/04). Resident #101 Review of the Face sheet revealed Resident #101 was admitted to the facility on [DATE] after a right total knee replacement. Resident #101 had a history of [REDACTED]. Resident #101 was alert and oriented to person, place, and time. Review of the Extended Care Facility (ECF) Transfer Order Form dated 6/5/10 revealed Resident #101 admission medication order should have included [MEDICATION NAME] 0.125 mg one tablet to be taken orally daily. Resident #101 was not to continue Fish Oil or Tylenol upon admission to the facility. Review of the physician's orders [REDACTED]. There were orders for Tylenol 650 mg every 4 hours as needed and for Fish Oil (omega -3 that can increase risk of bleeding) 1000 mg to be taken twice daily. There was only one nurse signature on the admission orders [REDACTED]. According to Mosby's Nursing Drug Reference 2007 (pgs. 359-361) [MEDICATION NAME] is used to increase the force of contraction in the heart and to decrease heart rate. In oral form, the onset of action is 1/2-2 hours, a peak of 6-8 hours, and a duration in the body of 3-4 days. The medication should not be stopped abruptly without physician notification. According to the Manufacturer's instructions (GlaxoSmithKline, August 2009) it takes 1-3 weeks to a steady state of the drug in the blood stream with oral administration. Review of the Interim Orders dated 6/6/10 revealed a telephone order signed by Registered Nurse (RN) #6 that Resident #101's admission orders [REDACTED]. Review of the Physician's Progress Note dated 6/7/10 revealed Resident #101 was seen by the nurse practitioner and there was no change in the medications prescribed and that the medications for his history of diabetes, hypertension, and [MEDICAL CONDITION] should be continued as TF (transfer orders). In an interview on 10/14/10 at 3:15 p.m. RN #6 stated, "I was the weekend manager then and I was doing as much as I could for admissions. I transcribed the orders. Nurse's are supposed to double check the medications the resident was discharged on after the orders were transcribed, that did not happen. The [MEDICATION NAME] was not transcribed. The nurse who was passing medications or the charge nurse should have double checked the transcription, that is the policy in the facility." Review of the Progress Notes (nurse's notes) dated 6/10/10 from 2:00 p.m. - 10:00 p.m. (no specific time) revealed Resident #101's family member informed RN #7 that he was "unable to grasp a drink and had dropped it two separate times and displaying signs and symptoms decrease motor control in his upper extremities, more so on the right side. Also noted slurred speech. Resident usually alert and oriented - wife concerned or possible TIA ([MEDICAL CONDITION] - mini stroke). Resident #101 was sent to the hospital per resident and wife request." Review of the ambulance run sheet dated 6/10/10 revealed the ambulance was dispatched to the facility at 7:12 p.m., was on scene at 7:15 p.m., and Resident #100 arrived at the hospital at 7:41 p.m. Review of the emergency room Record dated 6/10/10 revealed Resident #100 was having stroke-like symptoms that began around 6:15 p.m that included "knocking a glass over a glass with his dominant right hand twice and stated he did not feel right. He then had difficulty finding words and started slurring his speech. Upon arrival to the emergency department, the patient's symptoms have resolved.". Resident #100's documented current medication list did not include [MEDICATION NAME]. Resident #100 was diagnosed with [REDACTED]. In an interview on 10/13/10 at 8:30 a.m. RN #7 reported not knowing how long Resident #101 was having stroke-like symptoms prior to notifying the physician. RN #7 stated, "There were a lot of other things going on at that time. I was very busy. I kept trying to call the manager, Director of Nursing, and physician but I got no response. The wrong phone number was posted on the wall for the physician. I intended to get him out sooner, but I kept getting distracted. I finally got ahold of someone who gave me the correct phone number of the physician. I told myself if something like this were to happen again, I just call an ambulance." In an interview on 10/5/10 at 8:45 a.m. a family member stated, "He (Resident #101) said to the nurse "I think I'm having a stroke". I told them they needed to call 911 but they said they needed to call the doctor since it's protocol. For several days after the incident, his speach wasn't right and he was unable to find words." In an interview on 10/6/10 at 4:00 p.m. the Administrator stated, "We did admit to his (Resident #101) spouse that we made a mistake in the transcription of the medication orders and in not sending him out to the hospital immediately after the beginning of his symptoms." ( ) Resident #103 Resident #103 was no longer at the facility at the time of the investigation. Review of the Face sheet and the [DIAGNOSES REDACTED]. Per the Physician's Progress note dated 9/1/10 revealed Resident #103 was alert and oriented to person, place, and time but was lethargic with generalized fatigue and increased yellowing of the skin due to jaundice from liver failure. Review of the Progress Notes (nurse's notes) dated 9/4/10 at 9:00 a.m. revealed Resident #103 was given a shower. It was reported by the Certified Nurse Aide (CNA) that Resident #103 was not following directions well and was totally dependent on the CNA for her shower. At 11:30 a.m. the nurse documented Resident #103 was sleepy and her mother reported Resident #103 was not opening her eyes much. At 10:00 p.m. the nurse documented Resident #103 had decreased eye contact, sleepy, with decreased verbalization. Resident #103 was fed by her family as she would not feed herself. There was no documentation of physician notification regarding Resident #103's change of condition. Review of the Progress Notes (nurse's notes) dated 9/5/10 at 8:00 a.m. revealed Resident #103 would wake up when her name was called but was very sleepy. Review of the Progress Notes (nurse's notes) dated 9/6/10 at 11:30 a.m. revealed Resident #103's family was in and expressed concern over how sleepy she was. Resident #103 would respond to her name but then fall back asleep easily. There was no documentation of physician notification regarding Resident #103's change of condition. Review of the Progress Notes (nurse's notes) dated 9/6/10 at 4:30 p.m. revealed Resident #103 had to be fed her afternoon medications. Resident #103 was alert to self only and appeared drowsy. At 5:00 p.m. the CNA reported to the nurse that Resident #103 was bleeding from her mouth. At 7:00 p.m. the nurse documented the physician was notified of Resident #103's bleeding from the mouth and decreased mental status (decreased orientation). The physician ordered for Resident #103 to have blood drawn on 9/7/10. At 7:30 p.m., the nurse informed Resident #103's family of the new order who stated she had seen a mental status change in Resident #103 for the last 3 days. Review of the Vital Signs - Individual Flowsheet revealed Resident #103's average blood pressure was 118/76. Resident #103's blood pressure on 9/7/10 at 9:30 a.m. was documented as 88/62 (normal blood pressure is 120/80). Review of the Progress Notes (nurse's notes) dated 9/7/10 at 11:00 a.m. revealed documentation of Resident #103 being very lethargic and "blood pressure is running low..." Resident #103 had dried blood noted on her mouth and nose. At 11:45 a.m. Resident #103 was found on the floor by the CNA lying on her right side, confused and very lethargic. Resident #103 responded to some verbal stimuli. Review of the Accident/Incident Report dated 9/7/10 at 11:40 a.m. revealed Resident #103 was found in her room, on the floor, on her right side with blood coming out of her nose and mouth. Resident #103 was unresponsive, her left pupil had a sluggish reaction to light. Resident #103 was held in a flat, straight position until the ambulance arrived. The report revealed Resident #103 was having lethargy and confusion prior to the incident. Resident #103 was transported to the hospital. Section A and Section B of the Accident/Incident Report (used for the investigation of the incident) revealed the final disposition of the incident was an "extensive history of liver failure with high ammonia levels". There was no documentation of an investigation into the cause of the fall or what could be done to prevent further occurrences. Review of the Ambulance Run Sheet dated 9/7/10 revealed Resident #103 was "found unresponsive by staff on the floor. Unknown how patient got to floor. Patient had decrease level of consciousness (LOC) over weekend". Resident #103's was measured at a 10 on the Glasgow Coma Scale. (According to the Centers for Disease Control and Prevention, the Glasgow Coma Scale (GCS) was designed and should be used to assess the depth and duration coma and impaired consciousness. A GCS score of 9 to 12 indicates a moderate head injury.) Resident #103 was transported to the hospital. Review of the Hospital Unscheduled History and Physical dated 9/7/10 revealed Resident #103 presented to the hospital after being found on the floor with blood draining from her nose and mouth in the facility. Resident #103 had been less coherent and confused for the last 2 days. Resident #103's neurological assessment revealed Resident #103 could move all extremities but was she did not follow any commands and her speech was garbled and incoherent. Resident #103's CT scan of the head revealed areas suspicious for acute or very recent parenchymal hemorrhage (bleeding into the brain) of the parietal lobe of the brain. Resident #103's CT scan of the cervical spine showed soft tissue swelling at level C2-C3 and an area in front of the cervical spine that appeared to be an acute hemorrhage. Resident #103 was diagnosed with [REDACTED]. Resident #103 was discharge from the hospital on [DATE] on Hospice in stable but critical condition for comfort care. In an interview on 10/6/10 at 2:25 p.m. Registered Nurse (RN) #2 stated, "She had a blood nose for a couple of days prior to her fall." RN #2 reported that Resident #103 should have been sent out to the hospital on [DATE] because of her bleeding and lethargy. In an interview on 10/6/10 at 1:15 p.m. Licensed Practical Nurse (LPN) #5 stated, "When I got report from the third shift nurse on 9/7/10, she had told me she (Resident #103) had a bad weekend. I was told about the blood on her nose and mouth they had seen. I was told the doctor was aware and had ordered blood to be drawn. I was concerned and wondered why the doctor only ordered labs. I was waiting to notify the physician of her condition and low blood pressure until her blood work came back." In an interview on 10/6/10 at 12:20 p.m. CNA # 14 reported she had checked on Resident #103 and noticed blood in her nose and pooling of blood in her mouth. CNA #14 reported informing the nurse at 6:30 a.m. on 9/7/10 of Resident #103's condition. CNA #14 stated, "The resident (Resident #103) was lethargic the day before her fall (9/6/10) on 9/7/10 and I told the nurse, she felt it was no big deal. She was having increase confusion in her daily conversations." In an interview on 10/8/10 at 10:00 a.m. the Medical Director (Resident #103's assigned physician) stated, "I ordered the labs to check on her platelets because of her history of bleeding due to liver [MEDICAL CONDITION]. She was lethargic with low blood pressure and should have had some interventions." The Medical Director reported being unaware of Resident #103's low blood pressure reading. The Medical Director stated, "She was a full code and needed to have everything possible done to save her. When someone comes in like this who is destined to die, it can bear weight in the judgements made by facility staff." ( )