Every finding on record at Medilodge of Kalamazoo

This citation pertains to intake #3005153 and #3005264Based on interview and record review the facility failed to ensure a safe discharge for 1 (Resident #103) of 2 residents reviewed for transfer and discharge, when on 5/4/26 at approximately 11:45 pm, Resident #103 was not allowed back into the building upon her return from an evaluation and subsequent diagnosis of a UTI (urinary tract infection) at a local acute care emergency department. This deficient practice resulted in Resident #103 being without food, shelter, medications, or resources for safety; further resulting in Resident #103 experiencing feelings of fear, anger, and mental anguish. Findings include:Resident #103Review of a Face sheet revealed Resident #103 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: acute diastolic (congestive) heart failure (chronic condition where the heart is unable to pump enough blood to meet the body's needs), type 2 diabetes (a metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin) and unspecified abnormalities of gait (walking) and mobility.Review of Nurses' Notes for Resident #103 dated 5/4/26 at 15:23 (3:23pm) revealed Resident presented with altered mental status, not maintaining normal activities or eating and drinking normally. On call and mgmt (sic) notified. Resident sent to (Name Omitted) local emergency department.Review of Prehospital Care Report Summary from (Name Omitted) ambulance service for Resident #103 revealed .5/4/26 call received 14:50:44 (2:50 pm) .patient contact 14:59:44 (2:59 pm) .Left scene 15:35:55 (3:35 pm) at destination: 15:55:19 (3:55pm) .it was noted the patient had difficulties finding words. She would attempt to say a word then say it incorrectly. She was aware the words she was saying were incorrect but was unable to say the correct words.In an interview on 6/9/26 at 2:10 pm, Social Service Director (SSD) O reported Resident #103 was in the building only a short time and was sent all of the sudden to the hospital. SSD O was unsure if Resident #103 returned to the building. SSD O stated we were told she (Resident #103) did not want to accumulate anymore of a bill and did not want to come back to the facility from the hospital. In an interview on 6/9/26 at 2:25 pm, Unit Manager (UM) H reported Resident #103 was very confused and off from her baseline. UM H reported Resident #103 was diagnosed with a UTI at the hospital and she chose to go home from there. UM H reported medically Resident #103 could have returned to the facility from the hospital, but she 'had a balance' (unpaid bill at the facility).In an interview on 6/9/26 at 2:32 pm, Business Office Manager (BOM) M reported when Resident #103 admitted on [DATE] to the facility she did not have active Medicare insurance. BOM M reported Resident #103 had accrued a balance of $3051 from a previous stay that ended in June 2025; and Resident #103 still had that outstanding balance. BOM M reported they did not find out that Resident #103 did not have Medicare insurance until after she was admitted to the facility. BOM M reported Resident #103 went to the hospital on 5/4/26 and did not return to the facility.In a telephone interview on 6/9/26 at 3:55 pm, Resident #103 stated they would not let me back in because I had no insurance. Resident #103 reported she was able to straighten out her insurance, and that she had insurance coverage on 5/4/26, when the facility refused to allow her to return. Resident #103 reported she knew she owed them money and she was working with them on repayment and when she came back from the hospital, the staff was instructed to not let her in the building. Resident #103 stated They were not going to let me in that building, period.In a telephone interview on 6/9/26 at 3:45 pm, Paramedic (PM) S reported he was dispatched to (Name Omitted) emergency department parking lot to escort Resident #103 back into the emergency department after she was denied access at the facility. PM S reported the transport driver had returned to the emergency department parking lot with Resident #103, after the facility refused to allow her to come inside. PM S reported the (Name Omitted) ambulance service had to generate a call for service for PM S to escort Resident #103 into the emergency department since she had been discharged from the same emergency department about an hour before. PM S reported the first crew who originally transported Resident #103, the emergency department staff, the transport driver, nor Resident #103 were notified that Resident #103 was being discharged when she was picked up from the facility.Review of Prehospital Care Report Summary for Resident #103 dated 5/5/26 revealed .call received 00:14:39 (12:14 am).patient contact 00:14:59 (12:14 am).Left scene 00:15:07 (12:15 am).at destination 00:15:08 (12:15 am).Narrative History Text.The patient was being discharged from ER (emergency room) and transported via (Name omitted) to (Name omitted) facility.the facility she was transported from earlier that day. The facility refused to accept the patient back and (Name omitted) returned to the ER with the patient. As the patient is not fully alert and oriented, she needed to be re-registered and admitted to the ER.In a telephone interview on 6/10/26 at 8:01 am, Licensed Practical Nurse (LPN) I reported she was told Resident #103 wanted to go home from the hospital and that was her discharge plan. LPN I reported Resident #103 tried to come back into the facility in the middle of the night, and she was not let back into the building.In a telephone interview on 6/10/26 at 9:29 am, Registered Nurse (RN) G reported she was the nurse working the night shift on 5/4/26 to 5/5/26 when Resident #103 tried to return to the facility. RN G reported she was told in report that 'we weren't supposed to take her back'. RN G reported the hospital called the facility multiple times and she repeatedly told them she was not allowed to take Resident #103 back. RN G reported she called Nursing Home Administrator (NHA) A and was told to turn her (Resident #103) away. RN G reported Resident #103 returned with (name omitted) transport company and she met Resident #103 at the doors of the building and stood out there with her until (name omitted) transport company took her back. RN G stated My hands were tied; they told me not to take her back.In an interview on 6/10/26 at 10:12 am, NHA A reported Resident #103 admitted to the facility on [DATE] and her skilled payer (Medicare insurance) was not active. NHA A reported they spoke to Resident#103 about her patient pay amount, and how they would have to bill for her stay. NHA A reported there was a huge miscommunication with the hospital, and she had a clarifying phone with the hospital the next day. When directly asked if Resident #103 had returned to the facility following an evaluation in the emergency department and was denied re-entry to the building, NHA A stated yes, she (Resident #103) did return to the building and was not let in.Review of Discharge Information for Resident #103 ED (emergency department) visits revealed Discharge information date/time 5/4/26 at 2323 (11:23 pm) Urinary Tract infection.Review of ED Notes/Provider Notes for Resident #103 on 5/5/26 at 12:48 am revealed .Chief Complaint patient present with SNF (skilled nursing facility) placement.just discharged from (Name omitted) ED, (Name omitted) facility sent pt (patient) back and refused to accept her back d/t (due to) not having insurance.Review of Medical Decision Making for Resident #103 dated 5/5/26 from (name omitted ED) revealed .was previously seen here today in the ED and after being transported to (Name Omitted) she was subsequently denied access to the facility as she had been discharged from the facility earlier this morning. According to the patient as well as the paramedics.they were not made aware that the patient was discharged .primary concern for this patient was trying to determine whether or not she could be discharged to (Name omitted) facility or home.PT (physical therapy) note from 4/30/26 reports that patient required placement for further therapy due to weakness.I did try to talk to her about her plan for going home and what would happen if she were to fall at home.mentioned that she does not have a phone at this time because her phone recently broke. This further increased my suspicion that this patient would not be safe to be discharged home.Throughout the ED course, patient did exhibit waxing and waning confusion.This further led me to believe that this would be an unsafe discharge home.Review of Discharge Planning for Resident #103 from (Name Omitted) ED, 5/5/26 Post discharge MSW reached out to (Name Omitted) facility as they state that pt cannot return to their facility due to insurance coverage. (Name Omitted) facility states that pt's insurance expired on 4/30, this was discovered on 5/4 and pt was discharged . Then they sent pt to (Name omitted) ED as pt has had difficulty speaking for the past 3 days. They state pt was discharged at 3:00pm. MSW spoke with (Name omitted) NHA A regarding this, (Name Omitted) NHA A stated she does not know the discharge disposition of pt at this time but believes that she was supposed to go home. (Name Omitted) NHA A did not provide information on the circumstances of the medical needs of the pt after the discharge was completed however states they are two separate things. (Name Omitted) NHA A states that pt is not authorized to return as she was discharged earlier in the day due to insurance and pt does not have new authorization.In a follow up telephone interview on 6/10/26 at 3:10 pm Resident #103 reported she thought she would get more of what she needed by returning to the facility for therapy. Resident #103 reported the facility knew she was coming back from the ED, she arrived very late at night, it was raining, and she had to knock on the door. Resident #103 reported a nurse came to the door and said, I can't let you in. Resident #103 stated I thought she was joking. But then I realized she was serious and I was mad. Resident #103 reported the nurse told her she had no insurance, and Resident #103 stated that wasn't true. Resident #103 stated I was to be blocked from the building and I was, it completely blew my mind; I was upset, and at that point, I had nowhere to go. I had been discharged from (Name omitted) hospital to go to (Name omitted) facility they won't' accept me; it's the middle of the night and I'm in the rain trying to figure out what do I do now. Resident #103 stated The driver took me back to the hospital, because I had no place else to go. I waited for hours, it was such a fiasco, I felt like I had been gutted, they wouldn't take care of me when they said that they would. Resident #103 reported she had no identification, no money, and no information when she left the facility that day. Resident #103 stated I was angry, hurt, upset and scared, I had no place to go, and I had no idea the facility would go this far, but they did not let me back in that building.In a subsequent interview on 6/11/26 at 11:20 am, NHA A reported Resident #103 was never discharged from the facility; she was scheduled to be discharged that day and was transferred to the hospital due to a change in condition and was to discharge from the hospital to home.In a subsequent interview on 6/11/26 at 1:00 pm, SSD O reported there was not a discharge plan in place for Resident #103 at the time she was transferred to the hospital on 5/4/26. SSD O reported Resident #103 had been in the building 'for a brief time, over a weekend' and she had not had a chance to talk to Resident #103 about her discharge plan. SSD O reported they had not had a '72-hour' care conference for Resident #103 before she had transferred from the facility to the hospital.In an interview on 6/11/26 at 1:06 pm, Medical Records/admission (MR/A) LL reported Resident #103's 72-hour care conference was scheduled on Tuesday, May 5, 2026, the day after she was transferred to the hospital. MR/A LL reported when an admission occurs on a Friday, typically the 72-hour care conference was scheduled on the following Tuesday, as they cannot happen before the first 72 hours the resident was in the building.

This citation pertains to intake #3030592Based on observation, interview, and record review the facility failed to ensure residents were assessed to be appropriate for self-administration of medications for 1 (Resident #104) of 1 resident reviewed for medication administration resulting in medications being left unsecured at resident's bedside, residents self-administering medications without staff assessment, and the potential for negative outcomes from taking/instilling too much or too little medications.Findings include:Resident #104Review of a Face sheet revealed Resident #104 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: fracture of right radius (fracture of the right arm) and type 2 diabetes (a metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin).In an observation and interview on 6/9/26 at 9:16 am, Resident #104 was observed pushing the buttons and adjusting his insulin pump. Resident #104 reported he was protective of his pump. Resident #104 reported his insulin was special and hard to get and he managed his insulin pump himself. When asked if the facility assisted him with refilling the cartridge on his insulin pump, Resident #104 reported, no, I do it and it's all in the top drawer; Resident #104 gestured to the dresser stand in the room. Observed in the top drawer was a light blue transparent plastic adapter with two exposed needles and a Humulin R U-500 insulin pen with no label or name on it. Prior to opening the drawer Resident #104 stated Don't reach in the drawer, the needles are exposed and they are on both ends.Review of Resident #104's medical record on 6/9/26 revealed no noted documented self-administration of medication assessment.Review of Nursing admission Evaluation-Part 2 for Resident #104 dated 5/22/2026 at 12:48 pm, and reviewed on 6/11/26 revealed .Does the resident wish to self-administer medications- (answered) No.Review of Care Plan for Resident #104 revealed .Focus-Resident has Dexcom insulin pump, Resident prefers to maintain self.Goal-Resident will have reduced complications related to altered metabolic status . Interventions-administer insulin per orders.all initiated on 5/27/26 and Resident wears insulin pump and dexacom glucose monitor (continuous blood glucose monitoring system).initiated 6/4/26.Review of Medication Administration Records for Resident #104 on 6/11/26 from May and June 2025 revealed no noted documentation indicating any administration of Humulin R U-500 insulin. Review of Order Summary for Resident #104 revealed .Resident uses Dexcom insulin pump per home settings. started on 5/22/26.In an interview and observation on 6/10/26 at 9:52 am, Licensed Practical Nurse F reported she does nothing with Resident #104's insulin pump. LPN F reported Resident #104 has his supplies, he fills the pump, he administers the insulin, and they had extra pen (insulin pens) in the medication room. LPN F demonstrated two boxes labeled with Resident #104's name from a different pharmacy and reported they were his home supply; they were not from the facility's pharmacy.In an interview on 6/10/26 at 9:58 am, Registered Nurse (RN) D reported Resident #104 managed his own insulin pump and he had no idea how it worked.In an interview on 6/10/26 at 10:10 am, Nurse Practitioner (NP) HH reported she allowed Resident #104 to keep his insulin pump while in the facility. NP HH reported she reminded staff to complete the necessary assessments and gave a verbal order to Unit Manager (UM) H for Resident #104's insulin pump and for his Humulin R U-500 insulin to be ordered from the pharmacy. NP HH reported they talked about him managing his insulin pump and she had notified staff that he was able to manage his insulin pump. In a telephone interview on 6/10/26 at 10:48 am, LPN N reported Resident #104 had his insulin pump all under control, his family had his extra supplies, and she does nothing with it.In an interview and observation on 6/10/26 at 12:30 pm, Resident #104 reported the staff had never assessed him for self-administration of medications. Resident #104 indicated all of the same supplies were still in the top drawer of the dresser, and gestured to the dresser where a light blue transparent plastic adapter with two exposed needles and a Humulin R U-500 insulin pen with no label or name on it was again observed and Resident #104 again issued the verbal [NAME] to not reach into the drawer due to exposed needles. In an interview on 6/11/26 at 9:23 am, Minimum Data Set/Registered Nurse (MDS/RN) E reported Resident #104 wanted to use his insulin pump since admission and was assessed able to self-administer medications. MDS/RN E was unable to locate a self-administer medication assessment for Resident #104.In an interview on 6/11/26 at 10:00 Director of Nursing (DON) B reported the physician order for Resident #104's insulin pump was his home settings. DON B was unable to explain what the specifics for Resident #104's home settings. DON B reported Resident #104 managed his insulin pump and he monitored his blood sugar readings and would report the information to the staff. DON B reported any open insulin should be kept locked in the medication cart, not in the resident's room unless there was a secure way to maintain the medication.In an interview on 6/11/26 at 10:00 am, Regional Nurse Consultant (RNC) OO reported Resident #104's insulin pump supplies to refill his insulin pump needed to be stored in a secure manner.In an interview on 6/11/26 at 10:16 am, Um H reported Resident #104 managed his insulin pump. UM H reported she did not complete an assessment for Resident #104 to self-administer medications. UM H confirmed there was not order in place for Resident #104 to self-administer medications. Review of facility policy Medication- Resident Self-Administration of with a revision date of 01/30/2024 revealed .a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.The results of the interdisciplinary team assessment are recorded in the resident's medical record.Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medications.lockable drawers or cabinets are required only if locked storage is ineffective.the medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy.Medications stored at the bedside are reordered in the same manner as other medications.Diabetic residents with attached insulin pumps for glucose control will follow the physician's orders for basal rates and/or bolus doses, blood glucose checks, and changing of infusion sets/tubing, cartridges, reservoirs, or syringes for the insulin and will notify staff of any changes in glucose readings, skin, changes, at the site insertions or pain a the delivery site.

This citation pertains to intake #3030592Based on observation, interview, and record review the facility failed to maintain professional standards of nursing practice for 1 (Resident #104) of 4 resident reviewed for professional nursing standards resulting in ordered medications not being obtained from a pharmacy, no monitoring of home medication use, medications left unsecured at resident's bedside, and the potential for negative outcomes from taking/instilling too much or too little medications.Findings include:Resident #104Review of a Face sheet revealed Resident #104 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: fracture of right radius (fracture of the right arm) and type 2 diabetes (a metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin).In an observation and interview on 6/9/26 at 9:16 am, Resident #104 was observed pushing the buttons and adjusting his insulin pump. Resident #104 reported he was protective of his pump. Resident #104 reported the facility was unable to provide him with his insulin Humulin R U-500 because it was special and hard to get and he had family bring in his supply from home. When asked if the facility assisted him with refilling the cartridge on his insulin pump, Resident #104 reported, no, I do it and it's all in the top drawer.Review of Care Plan for Resident #104 revealed .Focus-Resident has Dexcom insulin pump, Resident prefers to maintain self.Goal-Resident will have reduced complications related to altered metabolic status . Interventions-administer insulin per orders.all initiated on 5/27/26 and Resident wears insulin pump and dexacom glucose monitor (a continuous blood glucose monitoring system).initiated 6/4/26.Review of Medication Administration Records for Resident #104 on 6/11/26 from May and June 2025 revealed no noted documentation indicating any administration of Humulin R U-500 insulin. Review of Order Summary for Resident #104 revealed .Resident uses Dexcom insulin pump per home settings. started on 5/22/26.In a telephone interview on 6/10/26 at 9:15 am, Pharmacy Phone Tech (PPT) Z reported Humulin R U-500 insulin was available through the facility's pharmacy, and that medication was not listed on Resident #104's profile. When queried, PPT Z reported the medication was never ordered or dispensed for Resident #104; the pharmacy had not supplied the facility with Humulin R U-500 for Resident #104.In an interview and observation on 6/10/26 at 9:52 am, Licensed Practical Nurse F reported Resident #104 had his supplies, he filled the pump, he administered the insulin, and the facility had extra pens (insulin pens) in the medication room. LPN F demonstrated two boxes of Humulin R U-500 insulin pens, labeled with Resident #104's name, from a different pharmacy and reported they were his home supply; they were not from the facility's pharmacy.In an interview on 6/10/26 at 10:10 am, Nurse Practitioner (NP) HH reported she allowed Resident #104 to keep his insulin pump while in the facility. NP HH reported she gave a verbal order to Unit Manager (UM) H for Resident #104's insulin pump use per his home settings and for his Humulin R U-500 insulin to be ordered from the facility's pharmacy. NP HH reported she had met with Resident #104 a few days after he admitted and during that meeting, she had observed that he was almost out of insulin in his pump. NP HH reported they talked about him managing his insulin pump and NP HH inquired if Resident #104 had an insulin supply available from home as he needed more in the facility and she knew it would not be delivered to the building before he was completely out. NP HH reported she assured Resident #104 that the facility could obtain his 'rare' insulin from their pharmacy. NP HH reported Resident #104 agreed, and had someone bring insulin to the facility to use until his supply could be delivered from the pharmacy. In a telephone interview on 6/10/26 at 10:48 am, LPN N reported Resident #104 had his insulin pump all under control, his family had his extra supplies, and she did nothing with it.In an interview and observation on 6/10/26 at 12:30 pm, Resident #104 reported the staff had never acquired his insulin and he was still using his supply from home.In an interview on 6/11/26 at 9:23 am, Minimum Data Set/Registered Nurse (MDS/RN) E reported the facility had not ordered any insulin for Resident #104 during his stay.In an interview on 6/11/26 at 10:00 Director of Nursing (DON) B reported the physician order for Resident #104's insulin pump was his home settings. DON B was unable to explain what the specific settings were for Resident #104's home settings. DON B reported she had confirmed the pharmacy had Humulin R U-500 available, but Resident #104 had his own supply. DON B reported Resident #104 managed his insulin pump and he monitored his blood sugar readings and would report the information to the staff. DON B reported her expectations were that staff was monitoring Resident #104's insulin use, pump, and blood sugar readings and that it was documented in his medical record.Review of Resident #104's medical record on 6/11/26 revealed no documentation regarding insulin use via his insulin pump.In an interview on 6/11/26 at 10:00 am, Regional Nurse Consultant (RNC) OO confirmed there was no documentation in Resident #104's record indicating staff was monitoring the use of an insulin pump, or insulin self-administration by Resident #104.In an interview on 6/11/26 at 10:16 am- UM H reported she Resident #104 managed his insulin pump, the staff did not manage it. UM H reported the facility would typically use up all the supplied home medications and then order the next supply from the pharmacy.Review of facility policy Medication- Resident Self-Administration of with a revision date of 01/30/2024 revealed .a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.The results of the interdisciplinary team assessment are recorded in the resident's medical record.Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medications.lockable drawers or cabinets are required only if locked storage is ineffective.the medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy.Medications stored at the bedside are reordered in the same manner as other medications.Diabetic residents with attached insulin pumps for glucose control will follow the physician's orders for basal rates and/or bolus doses, blood glucose checks, and changing of infusion sets/tubing, cartridges, reservoirs, or syringes for the insulin and will notify staff of any changes in glucose readings, skin, changes, at the site insertions or pain a the delivery site.

This citation pertains to intake #3030592Based on observation, interview and record review, the facility failed to ensure nursing staff were adequately trained and evaluated for competencies specifically related to the management of an insulin pump for 1 (Resident #104) of 1 reviewed for the management of an insulin pump. This deficient practice had the potential to result in ineffective medication therapy, complications, and adverse reactions. Findings include:Resident #104Review of a Face sheet revealed Resident #104 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: fracture of right radius (fracture of the right arm) and type 2 diabetes (a metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin).In an observation and interview on 6/9/26 at 9:16 am, Resident #104 was observed pushing the buttons and adjusting his insulin pump. Resident #104 reported he was protective of his pump. Resident #104 reported he managed his insulin pump and the facility staff did not. Resident #104 stated .they don't have a clue how to work this. Review of Care Plan for Resident #104 revealed .Focus-Resident has Dexcom insulin pump, Resident prefers to maintain self.Goal-Resident will have reduced complications related to altered metabolic status .all initiated on 5/27/26 and Resident wears insulin pump and dexacom glucose monitor (a continuous blood glucose monitoring system) .initiated 6/4/26.In an interview on 6/10/26 at 9:52 am, Licensed Practical Nurse F reported she does nothing with Resident #104's insulin pump. LPN F reported she had no idea how Resident #104's insulin pump worked.In an interview on 6/10/26 at 9:58 am, Registered Nurse (RN) D reported he had no idea how Resident #104's insulin pump worked. In a telephone interview on 6/10/26 at 10:48 am, LPN N stated .Resident #104 had his insulin pump all under control, I do nothing with it. LPN N reported she did not know how to work Resident#104's pump.In an interview on 6/11/26 at 9:23 am, Minimum Data Set/Registered Nurse (MDS/RN) E reported the staff did not know how to use Resident #104's insulin pump and she had not provided any staff education or training on an insulin pump.In an interview on 6/11/26 at 10:00am, Director of Nursing (DON) B reported she did not know how to work Resident #104's insulin pump and had not provided any training or education to the nursing staff. When queried, DON B reported she did not know if the staff knew how to manage Resident #104's insulin pump or not.In an interview on 6/11/26 at 10:16 am, UM H reported she did not know how to manage Resident #104's insulin pump.In an interview on 6/11/26 at 11:00 am, Nursing Home Administrator (NHA) A reported the nursing staff had not been assigned, nor completed any competency evaluation related to the management of an insulin pump.

Based on observation, interview, and record review, the facility failed to provide positioning for the prevention of pressure wounds in 1 (R1) of 4 residents reviewed for pressure wounds resulting in the development of a pressure wound. Findings include:According to the Minimum Data Set (MDS) dated [DATE], R1 was unable to complete her BIMS (Brief Interview Mental Status) indicating she was severely cognitively impaired. Her diagnoses included traumatic brain injury (TBI), quadriplegia (paralyzed in all four limbs), and contractures. Section GG-Functional Ability and Goals revealed R1 was dependent for all cares including mobility and positioning. Section M-Skin Conditions revealed R1 was at risk for pressure ulcers/wounds. Observed on 7/7/25 at 2:18 PM, R1 in bed lying on her back. Both legs contracted (pulled up) with knees rubbing/resting together with her heels resting directly on the bed. No wedges or padding underneath her heels, knees, or back to position and off-load her from bony prominences. Two leg braces were on a dresser top. During an observation and interview 7/8/25 at 2:41 PM, R1 was awake in bed with her torso (body) flat on her back and her hips and both legs positioned to her left. No pillows or wedges were being used for positioning or off-loading. Two leg braces were on a dresser top. Registered Nurse (RN) E was providing R1 care. Observed with the RN E, R1's left outer thigh to have a red area with a darker red/purple area in the middle. R1's outer left calf to have a red area with a nickel-sized open area. Underneath the left calf was a blanket with the corner piece directly under the left calf approximately the same size as the open area. RN E stated, The round area looks to be open. There was no pillow or wedge under (R1's) legs or buttocks to off-load. I think Therapy has ordered (R1) something to use but it has not come yet. During an observation and interview on 7/9/25 at 8:25 AM, Certified Nursing Assistant (CNA) V was providing cares for R1 who was dressed including leggings and in her Broda chair (type of high-backed wheelchair). CNA V stated, (R1) was dressed when I came in here to get her ready to go up front. Therapy worked with her this morning. Therapy dressed her and got her in the chair. Observed with CNA V R1's left outer calf. A nickel-sized open area was seen. CNA V stated, I did not know that it was there. No one said anything about this to me this morning. That looks like it is from shearing (a force that acts parallel to the skin's surface, causing the underlying tissue layers to slide against each other. This force, often occurring with pressure and friction, can lead to tissue damage and pressure ulcers). There is nothing on it, no cream or dressing. (R1) should have pillows between her legs, and under her knees and heels to keep things like this from happening. I do not see any extra pillows in (R1's) room to do this. (R1) needs to be positioned and turned by staff.During an observation and interview on 7/9/25 at 8:25 AM, Therapy Y observed R1's left outer calf stating, There is something there on her calf. (R1) cannot position herself and needs assistance to do that from staff. Pillows or wedges could be used to off-load areas of the body to relieve pressure and prevent pressure wounds. There is no wedge or extra pillows in (R1) that I see to aide in positioning (R1).During an interview on 7/9/25 at 8:30 AM, RN E stated, I reported (R1's) skin area on her leg and ordered Zinc (type of barrier cream).Review of R1's Order Summary dated 7/9/25 at 8:45 AM, Zinc Oxide Ointment 10 % Apply to L (left) calf redness topically two times a day for skin condition redness. It was noted the order was placed in R1's medical chart 15 minutes after interview with RN E.Review of R1's MAR/TAR (Medication/Treatment Administration Record) dated July 1-31, 2025, revealed Zinc Oxide Ointment 10 % Apply to L calf redness topically two times a day for skin condition redness -Start Date 07/09/2025 2000. It was noted this treatment was not to be put into place until over 29 hours after the wound was discovered. Review of R1's Care Plan, dated 6/9/25, Focus: at risk for impaired skin integrity, identified goals that included having intact skin. Interventions that were to be implemented to meet and maintain this goal included - assist resident with turning and repositioning as needed (initiated 10/12/2023). - encourage/assist as needed to elevate heels off the mattress as tolerated (initiated 10/12/2023). Further review of R1's Care Plan dated 6/9/25, Impaired Skin Integrity related to and including diffuse traumatic brain injury, quadriplegia, and contractures. The goal indicated the resident was to maintain intact skin. Interventions did not include offering off-loading (process of reducing or redistributing pressure on the affected area to promote healing and prevent further tissue damage) of bony-prominences or areas of body that came into contact of any surface. Review of R1's Progress Notes as of 7/9/25 at 10:32 AM did not have documentation of an opened area on the resident's left outer calf that was discovered on 7/8/25 at 2:41 PM. Review of R1's Skin assessment dated [DATE] at 8:55 AM, indicated a new abnormal skin area was identified to the resident's left lower leg with treatment having been initiated. It was noted this assessment was not documented until the day after the wound was discovered.During an interview and record review on 7/9/25 at 11:00 AM, RN/Unit Manager/Wound Nurse (RN) H stated, I am the Unit Manager for (R1). I saw on the 24-hour report this morning an alert new skin issue for (R1). RN H reviewed R1's Skin assessment dated [DATE] at 8:55 AM and stated, The new skin alert should be reported within 30-60 minutes to the same day it was discovered. I see nothing in (R1's) Progress Notes for a new skin issue. There should be something in Progress Notes. According to (R1's) Care Plans, she is 100% at risk for developing wounds. In her care plan, under at risk for skin integrity, interventions should be followed and they include assist turning and positioning as needed, elevate heels, notify nurse of red areas, NP notified after management on-call is contacted, a non-irritating surface (to prevent shearing) with the RN providing the example of a blanket corner). With continued review of R1's medical records, RN H reported, There is no nurse note for the new skin area. Technically, all nurses can update and adjust the care plan. There is not an updated care plan. RN H Reviewed R1's order summary stating, house stock zinc barrier cream was ordered. House stock does not have to be ordered and should be in stock. Looks like (RN E) ordered it from pharmacy and it is available in the facility's stock supply. The zinc barrier cream was available when (RN E) first saw the red area. The barrier cream should have been applied right away to (R1). Pillows or wedges should be used to keep knees and heels and hips/buttocks from getting sores.Observed on 7/9/25 at 11:20 AM, R1 in Broda chair in same position as 8:30 AM observation. During an interview on 7/9/25 at 1:54 PM, Director of Nursing (DON) B stated, (RN E) completed the skin assessment today and did not do one yesterday (7/8/25). (RN E) did not notify me yesterday of the newly discovered red area on (R1). I had to ask him about it today after I read it in the 24-hour report. Treatment for (R1) was not ordered until today. This should have all been done yesterday.Review of R1 Braden Scale for Predicting Pressure Sore Risk (SCORING: AT RISK 15-18, MODERATE RISK 13-14, HIGH RISK 10-12, VERY HIGH RISK 9 or below) dated:-3/02/25 revealed a score of 12.0 - 5/23/25 revealed a score of 15.0 -12/7/25 revealed a score of 11.0Review of the facility's policy, Pressure Ulcer/Skin Breakdown-Clinical Protocol dated 3/20/2024, revealed, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers . and prevent new ulcers from developing . The plan of care for prevention and/or treatment of PU/PI's will be developed based on the assessments above to include but not limited to; (not all inclusive) . - Turning schedule/off-loading .

Based on interview and record review the facility failed to develop policy and procedure to include current standards of practice in regard to pneumococcal (pneumonia) immunizations for 2 (Residents #1 and 10) of 5 residents reviewed for immunizations and the potential for eligible residents to not be offered the PCV21 (Pneumococcal 21-valent Conjugate Vaccine), with the potential of increasing the risk of acquiring, transmitting, or experiencing complications from pneumonia.Findings include:Review of the facility's Pneumococcal Vaccine (Series) policy, Date reviewed/revised: 10/30/2023, stated, It is our (the facility) policy to offer our residents .immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV (pneumococcal polysaccharide vaccine)) . There was no mention of PCV21 in the policy or its existence.Resident #1:Review of Resident #1's immunization report, print date 7/8/25, stated Resident #1 was Not Eligible for the vaccines PCV20 or PCV15, but nothing to address PCV21. PCV21 was not mentioned on the immunization report. PCV23 and PCV13 were noted as having been completed after Resident #1 was aged 65 years or older.Review of the CDC's Pneumococcal Vaccine Recommendations, dated 10/26/2024 and found at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, stated, Recommendation for shared clinical decision-making .Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both .PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old The United States uses 2 types of pneumococcal vaccines. Each individual vaccine helps protect against different serotypes (distinct variation) of pneumococcal bacteria.Pneumococcal conjugate vaccines (PCVs) .PCV15 .PCV20 .PCV21 .Pneumococcal polysaccharide vaccine .PPSV23.Resident #10:Review of Resident #10's immunization report, print date 7/8/25, indicated Resident #10 received PCV13 on 9/10/2016 and PCV23 on 11/05/2014, but nothing was noted regarding PCV15, PCV20, or PCV21. Utilizing the Centers for Disease Control and Prevention Pneumococcal Vaccine Recommendations (https://www2a.cdc.gov/vaccines/m/pneumo/agegroup.html) it stated, Recommendation .Based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose.)During an interview and record review on 07/08/25 at 09:09 AM, Director of Nursing (DON) and Infection Preventionist B confirmed she wasn't aware that the PCV21 had been released and available and stated, I'll have to add that (PCV21) to my grids. (Grids was referring to the pneumococcal vaccine schedule grid/chart from the Centers for Disease Control and Prevention (CDC). DON B reported PCV21 was not available or offered at the facility. DON B reviewed their pneumococcal policy, revised 10/30/2023, and confirmed their policies & procedures didn't mention PCV21 and reported she would reach out to their corporate infection control staff person. The version of the CDC's Pneumococcal Vaccine Timing grid/chart DON B had available and viewed on her computer included PCV20 but didn't include PCV21. A newer version of the pneumococcal vaccine timing grid/chart for adults that includes PCV21 can be found at https://www.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf. The updated version, dated March 2025, included PCV20 or PCV21 as an option. DON B confirmed she had and was viewing a version prior to this one and it only included PCV20; it didn't mention PCV21. Review of the CDC's Shared Clinical Decision-Making PCV20 or PCV21 Vaccination for Adults 65 Years or Older, dated, 09/11/2024, stated, Consider: .increased risk of exposure to PCV20 or PCV21 serotypes may occur among people who are living in: . Nursing homes or other long-term care facilities.Review of Use of 21-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Recommendations of the Advisory Committee on Immunization Practices - United States, 2024, dated 9/12/2024 and found at https://www.cdc.gov/mmwr/volumes/73/wr/mm7336a3.htm#T1_down, stated, What is added by this report? .On June 27, 2024, the Advisory Committee on Immunization Practices recommended 21-valent PCV (PCV21) as an option for adults aged greater than or equal to 19 years who are currently recommended to receive PCV15 or PCV20. PCV21 contains eight serotypes not included in other licensed vaccines. What are the implications for public health practice? Adding PCV21 as an option in the current PCV recommendation is expected to prevent additional disease caused by pneumococcal serotypes unique to PCV21 .

Based on observation, interview, and record review, the facility failed to: 1.) maintain proper infection control practices while utilizing resident shared equipment (a glucometer- a machine that uses a drop of blood to analyze the level of glucose (sugar) in a person's blood stream) during medication administration for 1 (Resident #88) of 5 residents reviewed for medication administration and 2.) ensure appropriate use of Enhanced Barrier Precautions (EBP) in 1 of 12 residents (Resident #1 (R1) reviewed for infection control, resulting in the potential for the spread of infection, cross contamination and disease transmission. Findings include:Resident #88Review of an admission Record revealed Resident #88 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 2 diabetes mellitus with complications (a condition when the body is unable to produce or use insulin correctly resulting in high blood sugar). Review of Order Summary for Resident #88 revealed Accucheck- (blood sugar testing) 2 times a day two times a day call if <70 (less than) or >450 (greater than) . with a start date 6/26/2025 . Humalog Kwik pen 100 unit/ml (Milliliters) solution pen-injector insulin inject 4 units subcutaneously before meals related to type 2 diabetes mellitus . with a start date of 6/19/25 .Lantus SoloStar Subcutaneous Solution Pen-Injector 100 unit/ml (insulin glargine) inject 18 unit subcutaneously one time a day related to Type 2 diabetes . with a start date of 7/1/2025. During an observation on 7/8/25 at 11:22 am, Registered Nurse (RN) E removed Resident #88's Humalog and Lantus insulin pens from the medication cart, removed the pen cap, screwed the safety needle onto the top of the insulin pen, and then placed both insulin pens into the pocket of his shirt. RN E then located Resident #88 in the therapy room, sitting on an exercise machine. RN E was then observed placing the glucometer onto a stool at a countertop next to where Resident #88 was using exercise equipment. RN E was observed preparing Resident #88's right hand for a blood sugar check (the poking of a fingertip with a needle to obtain a drop of blood for sampling on a test strip in a glucometer), RN E retrieved the glucometer from the stool, completed Resident #88's blood sugar check and then replaced the glucometer onto the countertop next to where Resident #88 was sitting. RN E did not have a barrier present between the glucometer and the stool, nor a barrier between the glucometer and the countertop. RN E then retrieved the Lantus insulin pen from his shirt pocket and administered the insulin into Resident #88's abdomen. After the insulin administration, RN E replaced the used insulin pen back into his shirt pocket along with the Humalog insulin pen. RN E returned to the medication cart, removed the needles from both the Lantus and Humalog insulin pens, and replaced them into the medication cart. In an interview on 7/8/25 at 4:14 pm Wound Nurse/Unit Manager (WN/UM) H reported insulin pens should not be put into a pocket. WN/UM H reported that glucometers could be placed directly onto a surface at the resident's side without a barrier. WN/UM H reported that they did not use a barrier between a tabletop and supplies when checking a blood sugar. In an interview on 7/9/25 at 10:46 am, RN E reported the only barrier he needed to use during a blood sugar check was gloves. When queried regarding a barrier to place clean supplies on prior to procedure, RN E I just use the table as the barrier and I hope it's clean. RN E reported he did not use a barrier for supplies when he checked Resident #88's blood sugar, RN E stated the therapy room is a tough place to do a blood sugar check, there is no place to set anything down. When further queried, RN E reported he should not transport insulin in his shirt pocket like he did for Resident #88. In an interview on 7/9/25 at 10:57 am Director of Nursing (DON) B reported her expectation was that a barrier be used when placing supplies down prior to a blood sugar check. DON B stated it can be a paper towel but put something down. DON B reported her expectations were that insulin should never be placed into a pocket for transport before or after administration. DON B reported that her expectations were the same as the facility policy Validation Checklist Glucometer Disinfection related to blood sugar checks.Review of Validation Checklist Glucometer Disinfection provided by DON B with a date of 2022, revealed purpose: to determine if the nurse is performing the procedure in accordance with the facility's standard of practice .7. Provided barrier on clean work surface for device . Resident #1According to the Minimum Data Set (MDS) dated [DATE], R1 was unable to complete her BIMS (Brief Interview Mental Status) indicating she was severely cognitively impaired. Her diagnoses included traumatic brain injury (TBI), quadriplegia (paralyzed in all four limbs), and contractures. Section K-Swallowing and Nutritional Status indicated R1 received nutrition via a feeding tube.During an observation and interview 7/8/25 at 2:41 PM, R1's door held an Enhanced Barrier Precautions (EBP) sign revealing direct care required PPE (personal protection equipment) while providing direct care to the resident. Registered Nurse (RN) E was observed wearing disposable gloves and no other PPE including gown or mask while cleaning the resident's PEG (Percutaneous Endoscopic Gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach) tube insertion site and flushing the tubing with normal saline. RN E did not reply when asked if R1 was on EBP and what PPE should be worn while providing direct care. Review of R1's Order Summary dated 4/1/25 indicated the use of enhanced barriers while performing high-contact (direct care) activity with the resident for tube feeding.

This citation pertains to intake 2590016.Based on interview and record review the facility failed to ensure the designated resident representative was notified of changes for 1 (Resident #501) of 3 residents reviewed for notification of changes resulting in a resident representative being unaware of x-ray results and falls, a resident representative experienced the feeling of uncertainty of how their family member was being cared for at the facility, and the potential for resident representatives to be unable to make timely care decisions. Findings include:Review of Resident #501's admission record, print date 8/20/25, revealed Resident #501 had diagnoses of senile (exhibiting a decline of cognitive abilities) degeneration of brain, dementia (decline in cognitive function), unspecified psychosis (trouble telling the difference between what's real and what's not), cognitive communication deficit, muscle weakness, anxiety, disorientation, and falls. Resident Representative M was listed first under Resident #501's Contacts indicating he was Resident #501's Responsible Party-Financial.Responsible Party - Clinical.POA (Power of Attorney) - Medical (Activated).Emergency Contact #1. Review of Resident #501's most recent brief interview for mental status, dated 7/30/25, was scored 6 which reflected severe cognitive impairment.During an interview on 8/18/25 at 9:59 AM, Resident #501's activated Resident Representative (RR) (resident's responsible person/party) M reported he was not notified of all falls and x-ray results by the facility. RR M reported he was uncertain of how many falls his father (Resident #501) had because he wasn't always contacted. RR M reported he was notified of the fall on 7/21/25 and on 7/22/25 he was told the facility had found a contusion (bruise) on his knee. RR M reported he wasn't notified of x-ray results of the right knee. RR M reported the hospice company (not the facility) called him on 7/25/25 at 7:15 AM to tell him about Resident #501's broken femur stating that was the first he had heard of the fracture. RR M confirmed he learned of the fracture from hospice and not the facility. RR M reported he called the facility and questioned them about their protocol for contacting representatives if a person had a broken bone, informed the facility they hadn't informed him of the fracture, but instead hospice did. RR M reported he expected a call from the facility in addition to hospice.During an interview on 8/20/25 at 10:30 AM, Resident #501's Resident Representative M reported he didn't know if there was an issue if the facility didn't tell him. RR M reported he didn't like not knowing what was going on with his father (Resident #501) and wanted updates so he would know what was going on with his father. RR M reported he wasn't immediately notified of the fall on 7/27/25 by the facility.During an interview on 8/18/25 at 12:50 PM, Nursing Home Administrator (NHA) A confirmed the facility failed to communicate all changes in condition, falls, and x-rays to Resident #501's Resident Representative M and hospice had reported the x-ray result (The x-ray showing a broken bone was completed on 7/24/25 and communicated to Resident Representative M by hospice and not the facility on 7/25/25) that showed a fracture and not the facility themselves. NHA A reported the responsible party should always be called after a fall even if it was in the middle of the night and the facility staff should make immediate notification to the resident representative. When discussing if there were any notes to indicate Resident #501's family wanted hospice to notify them instead of the facility NHA A stated, Not that I'm aware of. No documentation was provided by the end of the survey that indicated hospice should contact Resident Representative M instead of the facility.Review of Resident #501's fall timeline, undated, revealed on 7/22/25 at 11:49 PM the facility's medical doctor was notified of right knee x-ray results, but Resident #501's Resident Representative (RR) M was not. The timeline revealed that on 7/24/25 at 3:04 PM an x-ray showed a fracture of the left femur bone and Resident #501's RR M was not made aware that day. The timeline also indicated RR M was not contacted on 7/27/25 after a fall at 3:25 AM but instead hospice was.Review of Resident #501's Un-witnessed Fall report, dated 7/27/25, stated, Resident was found by aide crouched up on the floor mat right next to his (Resident #501) bed.Agencies/People Notified.Administrator.DON/On Call Nurse.Hospice.Physician. Resident #501's responsible party was not contacted or documented as having been contacted after the fall.Review of Registered Nurse (RN) T's Teachable Moment (an employee write-up), stated, .Date of Incident: 07/27/25.Concern: (RN T) did not notify responsible party of a fall.responsible party must be notified. This was regarding Resident #501's unwitnessed fall on 7/27/25.Review of Resident #501's radiology (imaging such as x-ray) record indicated x-rays were obtained for the right knee on 7/22/2025 (results available/reported 7/23/25 at 1:24 AM) and right hip on 7/24/25 (results available/reported 7/24/25 at 5:44 PM).Review of Resident #501's progress note, dated 7/22/25, stated, Xray on res (resident) R (right) knee was completed at 2345 (23:45;11:45PM) . No available information indicated Resident #501's Resident Representative M was notified of the x-ray on 7/22/25 timely.Review of Resident #501's progress note, dated 7/25/25 at 05:23 AM, stated, Called hospice [hospice company name] and notified them of residents injury and change in condition. The note did not indicate Resident #501's Resident Representative M was notified as well.Review of Resident #501's care plan, print date 8/20/25, revealed .is at risk for/has impaired communication related to cognitive impairment, confusion, dementia.is at risk for falls/injury.terminal prognosis.left hip fracture.Review of the facility's Notification of Changes policy, revised 8/29/2024, stated, The purpose of this policy is to ensure the facility promptly informs the.resident's representative when there is a change requiring notification.Circumstances requiring notification include:.1. Accidents.Resulting in injury.Potential to require physician intervention.Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.Residents incapable of making decisions:.The representative would make any decisions that have to be made.

Based on observation, interview, and record review, the facility failed to support meaningful involvement in activities of choice, for 1 (Resident #14) of 12 residents reviewed for meaningful activities resulting in the potential for feelings of boredom, loneliness, and unmet psychosocial needs. Findings include:Review of an admission Record revealed Resident #14 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Alzheimer's disease, anxiety disorder, major depressive disorder, and unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety.Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 6/2/2025 revealed a Brief Interview for Mental Status (BIMS) assessment should not be conducted due to Resident #14 is rarely/never understood and Resident #14 has memory problems, Resident #14 cognitive skills for daily decision making are 3. Severely impaired-never/rarely made decisions. Resident #14 was severely cognitively impaired.On 7/7/25 at 10:07 am, 11:31 am, 2:38pm, and 7/8/25 at 2:12 pm, Resident #14 was observed sitting in a Broda chair (a high back reclining wheelchair) in what the facility refers to as a sensory room. The sensory room was dark with the blinds closed, it was quiet with no sounds, and an essential oil diffuser (used for aromatherapy) was on the table, not on. Resident #14 was alone in the room at each observation. During an observation and interview on 7/7/25 at 10:07 am, Resident #14 was reclined in her Broda chair, in the sensory room, and Resident #14 was fidgeting with her blanket in her lap. The room was dark, quiet, and Resident #14 was alone. Resident #14 was unable to engage in meaningful conversation and only responded with one-word answers that were not appropriate to the conversation, Resident #14 did respond when spoke to. Resident #14 did not express any noted emotions and appeared stoic and unengaged. During this observation, Director of Nursing (DON) B approached this surveyor and stated, Resident #14 loves to be in the [NAME] room. Review of Care Plan for Resident #14 revealed .Focus . Resident is at risk for altered activity patterns/pursuits related to decline in health status comfort care. Initiated on 9/12/2023 revision on 6/7/2024 . Goal . Resident will accept/interact with others during 1:1 visits for stimulation through the next review as tolerated. Initiated on 9/12/2023 revision on 9/23/2024 . Resident will participate in leisure interests in a group setting for stimulation at lease weekly as tolerated through the next review. Initiated on 7/1/2024 revision on 9/23/2024 . Interventions .1:1 visits from staff and volunteers .sensory stimulation, aromatherapy, being read to from the bible, set up with religious music. Initiated on 9/12/2023 revised on 12/14/2023 .allow resident to make choices/decisions about their preferred activity pursuits initiated 9/12/2023 .Encourage to attend and participate in activity programs at highest functioning level and provide cues/adaptations as needed initiated 9/12/2023 .Involve resident in simple/structured activities with cues/adaptations initiated 9/12/2023 .Offer and encourage resident to accept supplies from the activity cart as desired throughout the day for independent pursuits initiated 9/12/2023 . Resident enjoys music: religious, hymns initiated 9/12/2023, revision 12/14/2023 . Resident's preferred activities are: family visits from her son (Name Omitted), enjoys listening to religious music/hymns or Elvis, pet visits, aromatherapy, being read to from the Bible (used to teach Sunday school) initiated on 9/12/2023 revision on 12/27/2024 .Focus .Resident has an ADL self-care performance deficit related to dementia .dressing: total dependence .eating: dependent on staff .personal hygiene: total dependence .transfers: Hoyer . all initiated 9/12/2023 .Focus . Resident has behaviors as evidenced by resist feedings at time and she also performs acrobatics in her chair and bed occasionally .Interventions .approach resident in a calm manner to avoid frustration and behavior escalation initiated 9/12/2023 .Focus . Resident is at risk for/has an impaired mood/psychiatric status related to dx of major depression and anxiety .Goal . will remain free of signs and symptoms of distress depression, anxiety .Interventions . encourage participation in activities .provide a calm safe environment when resident is emotional and frustrated .resident is calmed by playing religious music . all initiated 9/12/2023 .Focus: Resident has visual impairment .has eyes closed most of the time .Intervention: Announce yourself when entering the resident's room/spaceIn an observation on 7/8/25 at 10:38 am, Resident #14 was in her Broda chair, reclined, in the sensory room with two other residents. One resident was yelling out and each time the resident yelled, Resident #14 was observed flinching demonstrating a physical reaction to the yelling. Resident #14 would verbally respond to the other resident who was yelling with a single word. Neither resident was engaging in a meaningful conversation with the other.In an observation and interview on 7/8/25 at 11:39 am, Certified Nurse Assistant (CNA) C was observed removing Resident #14 from the sensory room. CNA C reported that Resident #14 was placed in the sensory room when she acted out to help her to calm down. CNA C reported that Resident #14 spends time in the sensory room because she remained calm while in there. CNA C reported there should be white noise such as the sound of rain or water, but it was not on. During the interview with CNA C Resident #14 did interject single words as an engagement in the conversation. In an observation and interview on 7/8/25 at 12:19 pm, Resident #14 was observed being assisted to eat lunch in the dining room by CNA C. CNA C reported that Resident #14 was completely dependent on staff for all care including activity participation. CNA C, CNA Q and CNA K all reported that Resident #14 did participate in activities and that the sensory room was Resident #14's activity, they were unaware of any other activity preferences Resident #14 had. CNA K reported that the sensory room kept Resident #14 quiet. During this conversation, Resident #14 would interject single words as an engagement in the conversation. On 7/8/25 at 4:14 pm, Resident #14 was observed sitting in her Broda chair in a reclined position at a table in the dining room during the bingo activity. Resident #14 was heard repeating random words that were being spoken around her.On 7/8/25 at 4:30 pm, Activity Aide (AA) U reported that Resident #14 was never in the bingo activity prior to today. AA U reported Resident #14's could not independently participate in bingo; AA U reported she was playing Resident #14's bingo card for her, and considered Resident #14 to be actively engaged in the activity since Resident #14 was frequently repeating the numbers AA U was calling. AA U reported that occasionally Resident #14 would attend movie activities, but the majority of her time was spent in the sensory room. AA U reported the sensory room had natural light, with fish to watch, and was a calming room for people to get away from their neighbors and have some quiet time. AA U reported when she saw Resident #14 in the sensory room, she would document that Resident #14 had sensory activity for the day. AA U reported Resident #14 liked to socialize, and she would talk when you talk to her. AA U reported that Resident #14 would participate in other activities if she was included in them. AA U reported she was not sure what Resident #14's preferred activities were. Review of Activities Quarterly Progress Note for Resident #14 dated 9/25/2024 and 3/10/2025 revealed .at ease interacting with others, at ease doing planned activities, can't initiate activity . enjoys structured activities . social .activity pursuits, needs prompts/encouragement, preferred setting, day activity room . enjoys social visits .being read to .listening to music .taught Sunday school so she may enjoy being read to from the Bible/Sunday Devotions .social with other when they initiate .staff also offer 1:1 when restless .Review of Activities Evaluation for Resident #14 dated 6/20/2024 revealed .former occupation . taught Sunday school Clubs . active with her church years ago .Finds strength in faith/religion -answer-yes .Religious affiliation Christian . place of worship staff read to her the Sunday Devotions .Activities (the resident enjoys) family friend visits, religious activities, music/talk radio, other sensory room . what self-recreating material is needed Sunday Devotions .Review of Activities Evaluation for Resident #14 dated 6/4/2025 revealed .former occupation . taught Sunday school Clubs . active with her church years ago .Finds strength in faith/religion-answer- yes .Religious affiliation Christian . place of worship staff read to her the Sunday Devotions .Activities (the resident enjoys) family friend visits, religious activities, music/talk radio, other sensory room, being read to, listening to her radio in her room . what self-recreating material is needed Sunday Devotions .In an observation and interview on 7/9/25 at 9:52 am, Resident #14 was observed sitting in her Broda chair, in a reclined position, in the sensory room, alone, with active aroma therapy and ocean sounds. Resident #14 appeared to be stoic and without any engagement. CNA X reported Resident #14 likes the quiet room and that Resident #14 was in there quite a bit. When queried how she knew Resident #14 liked the sensory room, CNA X replied because she doesn't' get wound up. CNA X reported that Resident #14 used to baby-sit children and liked when kids were around but was not aware of any other interests Resident #14 had. CNA X reported that she liked it when Resident #14 was in the sensory room, because she could walk by and watch her. In an interview on 7/9/25 at 9:52 am, CNA Q reported she was new to the building and was not aware of any interest that Resident #14 had. Review of Activity Calendars for the months of April, May, June, July 2025 revealed 3:00 Sunday Devotions on every Sunday for all 4 months. Review of Activity Log for Resident #14 for the moths of April, May, June, and July 2025 revealed April 2025, 11 of 30 days Resident #14's documented activity was the sensory room, no documentation was noted for 9 days, and 0 days had any type of religious activities documented. May 2025, 20 of 31 days Resident #14's documented activity was the sensory room, no documentation was noted for 8 days, and 0 days had any type of religious activities documented. June 2025, 10 of 30 days Resident #14's documented activity was the sensory room, no documentation was noted for 6 days, and 0 days had any type of religious activities documented. July 2025 (through 7/7/25) 5 of 7 days Resident #14's documented activity was the sensory room, and 0 days had any type of religious activities. Review of Behavior Logs for Resident #14 for the Months of May, June, and July 2025 revealed .May 2025, Resident #14 had no documented behaviors for day shift; 3 documented days with behaviors (pushing, grabbing, repeats movements) on afternoon shift, no documented interventions that were tried were noted, but all interventions were documented as ineffective; 7 documented days with behaviors (grabbing, repeats movements, yelling/screaming) on night shift, no documented interventions that were tried were noted, but all interventions were documented as ineffective; 8 shifts were left blank. June 2025, Resident #14 had no documented behaviors for day or afternoon shift; 4 documented days with behaviors (grabbing, repeats movements, yelling/screaming) on night shift, no documented interventions that were tried were noted, but all interventions were documented as ineffective; one shift was left blank. July 2025 Resident #14 had no documented behaviors on any shift through July 8, 2025 .In an interview on 7/9/25 at 1:17 pm Social Service Director (SSD) M, when queried about Resident #14's interests stated, She used to teach Sunday School and is very religious. SSD M reported Resident #14 enjoys music, Sunday Devotions, and bible study. When queried, SSD M reported that bible study was not on the activity calendar and only occurred if she had volunteers to lead the activity, maybe twice a month. SSD M reported that Resident #14 attended Sunday Devotions weekly. SSD M reported Resident #14 had episodes of restlessness and the sensory room helps with that. SSD M reported that staff was very good at utilizing the sensory room for Resident #14. SSD M reported that Resident #14 enjoyed the sensory room, as it appeared to calm her down and she seemed at ease when she was in the sensory room. SSD M reported the sensory room was for sensory stimulation, it was a great tool for behavioral things, and was multi-sensory which included aromatherapy, soothing sounds, and overhead lights were off, shades were drawn, and a person can center themselves, sometimes there was music, but mostly it was white noise such as ocean sounds. When queried regarding the length of time a resident should utilize the sensory room, SSD M replied there is no set amount of them a resident can spend in there. SSD M reported that activities were documented, and the activities Resident #14 participated in should be documented accordingly. SSD M reported when Resident #14 was in the sensory room it was documented as sensory room, and religious activities were documented as religious activities. SSD M reviewed Resident #14's activity participation documentation and confirmed there was no religious activity documented for the months of April, May, June, or July 2025. In an interview on 7/9/25 at 2:02 pm, AA N reported Resident #14 spends most of her time in the sensory room. AA N reported he passes out the Sunday Devotional, which was a printed paper of devotions, but Resident #14 cannot read it, because she was blind, so if he had time when he passed it out her would read her a verse. AA N reported he was not aware of any other religious activities offered to the residents. In an interview on 7/9/25 at 2:05 pm, SSD M reported the facility did not offer any kind of church service activity. The only religious activities offered were volunteer to lead bible study, if they were available, and Sunday Devotions. SSD M reported the residents are asked if they would like a copy of Sunday Devotions and if they would like the staff to read it to them. SSD M reported that Resident #14 was unable to read Sunday Devotions independently. Using the reasonable person concept, though Resident #14 had a decreased ability to verbally express her own thoughts due to her mental diagnoses, the facility had noted Resident #14's strong religious beliefs and previous involvement in religious activities. This religious belief and desired involvement in religious activities has the potential to continue indefinitely while residing in the facility, using the reasonable person concept. As the resident was unable to speak for herself and attempts to contact family for interview regarding her religious beliefs and desired involvement were unsuccessful related to Resident #14 presumed wish to still participate in religious activities.

Based on observation, interview, and record review the facility failed to provide adequate supervision and ambulation device to prevent falls and fall with injury in 1 (R31) of 4 residents reviewed for accidents resulting in injury and the potential of further falls with injury.Findings include:According to the Minimum Data Set (MDS) dated [DATE], R31 scored 5/15 on her BIMS (Brief Interview Mental Status) indicating she was cognitively impaired. Diagnoses included dementia. Section GG-Functional Abilities and Goals indicated supervision was required for walking from 10 to 150 feet. Review of R31's Incident Report dated 2/22/25 at 11:10 PM indicated the resident had a witnessed fall when her feet got tangled together causing her to hit her head on the floor. Upon assessment the resident was found to have an abrasion to her left forehead. The IDT (interdisciplinary team) met with new interventions including therapy to initiate a walker for safety. Review of R31's Care Plan, ADLS or Falls, print date 7/7/25 did not report a wheeled walker had been implemented for the resident's use before or after the resident had fallen causing injury on 2/22/25. Review of R31's Fall assessment dated [DATE] indicating the resident had a fall on this date while attempting to sit in a chair in the lobby. A fall reevaluation indicated a change in gait status and a plan of care review included an equipment modification with the use of a 2-wheeled walker (WW).Review of R31's Care Plan ADLs or Falls did not include equipment modification with the use of a 2-wheeled walker for a fall on 4/11/25. Review of R31's Progress Note dated 4/21/2025 11:45 IDT-Interdisciplinary Progress Note Late Entry: Note Text: IDT met regarding residents fall this am. Resident found in another resident's room on the floor. Resident with history of weakness and cognitive deficits .Review of R31's Incident Report dated 4/28/25 7:20 AM, indicated the resident had a witnessed fall by staff when she fell while walking independently in a hallway when she lost her balance landing on her left shoulder. A bruise to the left should was observed with a pain score of 5/10 upon assessment. Predisposing situation factor was reported as ambulating without assistance or the use of a wheeled walker. Review of R31's Fall assessment dated [DATE] indicated the resident was ambulating independently and fell injuring left shoulder that required x-rays. Review of R31's Progress Note dated 4/28/25 11:21 AM indicated the resident was limiting the use of her left arm/shoulder and stated she had some pain evident by guarding the area. Review of R31's Radiology Results Report dated 4/29/25, indicated the resident had pain in left shoulder after a fall requiring 2 plus views (x-rays) of the left shoulder. Review of R31's Physician Progress Note dated 4/29/25 10:21 AM, indicated the resident had been seen after a fall with complaints of shoulder pain requiring x-rays with negative results for any type of fracture. The resident had been observed ambulating independently, lost her balance fell onto her shoulder. During an observation and interview on 7/7/25 at 2:03 PM, R31 was in her room with nothing on her feet stating, I walk by myself. I used to use a walker. I think I have a walker. No walker, wheeled or otherwise, was visible in the room, closet, or bathroom.Observed 7/8/25 at 2:28 PM, R31 in dining room with a group of peers and the Life Enrichment Director/Social Worker. No wheeled walked was visible. R31 stated, I walked by myself.During an interview on 7/9/25 at 8:35 AM, Therapy Y stated, (R31) should have a walker to use while ambulating.During an observation and interview on 7/9/25 at 8:40 AM, R31 was in bed awake. No walker visible in resident's closet, room, or bathroom. R31 stated, I don't see a walker here. I walk where I need to go.During an observation and interview on 7/9/25 at 8:45 AM, Registered Nurse (RN) E stated, (R31) uses a walker to ambulate. She has had some falls. Observed R31's room with RN E with no walker in the resident's closet, room, or bathroom.During an interview and record review on 7/9/25 at 11:30 AM, Unit Manager (UM) H stated while reviewing R31's medical chart, I think (R31) has had some falls. I saw her walking independently yesterday with no wheeled walker. Her care plan focus for falls does not have an intervention for the use of a wheeled walker. She has walked on her own for the last month I've been here. She has never had a device with her. I see her walking all around the facility independently.Review of R31's Activities of Daily (ADL) Care Plan print date 7/7/25 did not indicate a wheeled walker for had been implemented for the resident's safety until 6/11/25. During an interview and record on 7/9/25 at 1:25 PM, Director of Nursing (DON) B stated while reviewing R31's medical records, (R31) does not have documentation of not wanting to use a wheeled walker. Therapy does a screen after each screen into me. Once I receive the form and take Therapy's suggestion and decide if their recommendations are something nursing wants to implement. For (R31's) fall on 6/10/25, the form was not signed by myself or Therapy. Therapy wanted (R31) to use a rolling walker (wheeled walker) and supervision with ambulation in facility. I do not have any idea when this was written or how medical records would have gotten it without me seeing it. Reviewed 5/12/25 therapy to nursing communication form with recommendation that R31 transfer with a 1 person assist and use a rolling walker. DON B stated, I do not see that this was implemented in (R31's) Care Plan. The facility is very good at putting interventions in a resident's care plan. The Care Plan dated 6/11/25, Focus ADLs has use of rolling walker should have been discussed in morning meetings. I don't know if (R31) has anything in her behavior care plan about not using wheeled walker. I don't see any documentation she won't use the walker. She was non-complainant with getting out of chairs without help but staff should be with her.Review of R31's Therapy to Nursing Communication Form dated 5/12/25 recommends the resident uses 1-person assist and rolling walker. The form was signed by both Therapy and Nursing. Review of R31's Therapy to Nursing Communication Form, undated, recommended the resident use a rolling walker and supervision with ambulation in facility with and without the rolling walker. Review of R31's Therapy Screen dated 6/10/25 recommends the resident uses a rolling walker and supervision while walking. It was noted that neither therapy or nursing had dated or signed the document.

This citation pertains in intake MI00152648 Based on observation, interview, and record review, the facility failed to provide assistance with toileting for 1 (Resident #103) of 5 residents reviewed for activities of daily living (ADL) care resulting in the potential for avoidable negative physical outcomes for resident's who are dependent on staff for assistance. Findings include: Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking and pain in left foot. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 3/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #103 was moderately cognitively impaired. Review of Resident #103's Kardex (Care area report for staff to reference to determine what kind of care residents need) revealed, ADL'S: TOILETING: 2 person assist. TRANSFERS: 2 person assist with sit-to-stand . Review of facility's Incident report dated 4/22/25, revealed, Incident Summary: Staff (Certified Nursing Assistant (CNA) D) allegedly told (Resident #103) to use the bathroom in her pants. That she was not going to transfer her to rest room. Investigation Summary: (CNA D) was suspended pending investigation. (CNA D) was terminated after the allegation was verified All resident with a BIMS of 10 or higher were interviewed and no concerns were raised. Those that could not be interviewed had skin and pain assessment completed. No concerns were found during the audit. All staff are being educated on neglect/abuse and care plans prior to working the next shift . In an observation and interview on 5/13/25 at 3:33 PM, Resident #103 was sitting in her room. Resident #103 reported that she no longer had any concerns with staff at the facility. Resident #103 was unable to recall the details of the incident between her and CNA D. In an interview on 5/13/25 at 3:54 PM, Licensed Practical Nurse (LPN) M reported that she was caring for Resident #103 on 4/22/25. LPN M reported that she had gone into Resident #103's room to administer medications to her. LPN M reported that Resident #103 had asked to use the restroom before LPN M started her intravenous (IV) medication. LPN M reported that she had asked CNA D to assist Resident #103 to the bathroom, and CNA D had reported that she did not know how to transfer Resident #103, so LPN M instructed her to check Resident #103's Kardex and let her know if she needed assistance. LPN M reported that around ten minutes later, CNA D approached her and let her know that Resident #103 was all set. LPN M reported that when she went into Resident #103's room, Resident #103 asked her for help and told her that CNA D told her to just go to the bathroom in her brief. LPN M reported that she further queried Resident #103 and that Resident #103 had confirmed that CNA D had told her that she couldn't take her to the bathroom, and she should pee in her brief and then she would come back to clean her up. LPN M' reported that she asked CNA D if she had told Resident #103 to go to the bathroom in her brief, and that CNA D confirmed that she did tell Resident #103 to go to the bathroom in her brief. LPN M reported that she notified Nursing Home Administrator (NHA) A immediately after CNA D confirmed that she had told Resident #103 to go to the bathroom in her brief. In an interview on 5/14/25 at 8:23 AM, LPN L reported that she had worked with CNA D frequently and was familiar with her. LPN L reported that CNA D was a new CNA, and inexperienced. LPN L reported that she did not have concerns with CNA D and how she interacted with residents, but that CNA D seemed to be afraid to ask staff for help and seemed to get offended easily when staff tried to coach and redirect her. LPN L reported that CNA D was aware of how to review a resident's kardex and knew how to transfer residents, but seemed to hesitate to provide certain care. In an interview on 5/13/25 at 4:17 PM, CNA D reported that she was a new CNA, and had started working at the facility in February 2025. CNA D reported that she had always checked and changed Resident #103, and that she never took her to the restroom. CNA D reported that she had observed staff use a hoyer (machine used to transfer residents with limited mobility) before and she did not trust using it because it looked dangerous. CNA D confirmed that Resident #103's care plan noted that she would use a sit to stand (a device used to assist residents with limited mobility with transfer) but that she was also not comfortable with using the sit to stand on Resident #103, because Resident #103 did not like the sit to stand. CNA D reported that she had explained to Resident #103 that she did not want to assist her to the restroom because she was afraid she would fall, so she asked her to go in her brief. CNA D confirmed that Resident #103 did not want to urinate in her brief, and wanted to transfer to the toilet. CNA D reported that she had always planned to clean Resident #103 up after she soiled herself in her brief. CNA D reported that she should have offered to let Resident #103 use a bed pan since I was not going to transfer her. CNA D confirmed that she did not ask any staff members to help her transfer Resident #103. In an interview on 5/13/25 at 3:06 PM, Nursing Home Administrator (NHA) A reported that she was notified on 4/22/25 by LPN M that CNA D had told Resident #103 to go to the bathroom in her brief instead of taking her to the restroom. NHA A reported that she immediately suspended CNA D and began an investigation into the allegation. NHA A interviewed Resident #103 who confirmed that CNA D asked her to go to the bathroom in her brief. NHA A reported that CNA D did admit to telling Resident #103 to go to the bathroom in her brief, and had said that she did not know Resident #103's transfer status, so she did not know how to transfer her. NHA A reported that she re-educated all staff on 4/22/25 or before they started their next shift on abuse and neglect, and how to find a resident's kardex, which shows the resident transfer status. NHA A confirmed that CNA D had signed off on education in her orientation stating she knew how to transfer residents and review their kardex information. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included educating all staff members in the facility on the abuse policy, kardex information, honoring resident wishes and following the kardex for ADL care, and when to contact the abuse coordinator. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: During an initial kitchen tour on [DATE] at 8:43am, the reach in refrigerator contained the following expired food items: a container of sour cream with a use by date of [DATE], 2 ham sandwiches in plastic bags with use by date of [DATE], and 3, 8 count packages of hamburger buns with use by date of [DATE]. 1 package of hot dog buns dated [DATE] was present with no use by date, upon examination, the hot dog buns were hard to the touch. During the initial kitchen tour on [DATE] at 8:47am, the reach in freezer in the main kitchen area contained a 3-gallon container of vanilla ice cream that had a torn and damaged cardboard lid placed on top of the opening. The lid had a torn opening across it and did not seal the container, which resulted in an opportunity for the food inside to become contaminated. During the initial kitchen tour on [DATE] at 8:56am, the reach in freezer in the dry storage room contained 3 large packages of hoagie style buns that were beyond their expiration date. During an observation on [DATE] at 8:59am, a large bag of fish batter in a paper-based manufacturers bag sat on a shelf with the opened top exposed. The unsealed opening created an opportunity for contamination and exposure to pests. In an interview on [DATE] at 9:06am, Dietary Director (DD) J reported any food that was not properly labeled, dated, and/or stored could pose a threat for the spread of food borne illness. DD J reported food should be stored in sealed containers. DD J reported the food identified as a concern during the initial kitchen tour would be disposed of immediately. 38905 During a tour of the kitchen, at 8:30 AM on [DATE], it was found that a box of nutritional shakes were in the bottom of the reach in refrigerator. The box of shakes was ,d+[DATE] full, with no date to indicate discard of the items. A review of the manufactures label states the shakes are good for 14 days after thaw. During a tour of the dining room refrigerator, with Registered Dietitian W, at 9:25 AM on [DATE], it was observed that multiple items were not dated or held passed their discard date, the following items were observed: an un opened box container of a dozen yogurts with a best by date of [DATE], an open container of thickened pomegranate juice with no date to indicate discard (item states its good for 7 days), a container of a dozen raw shell eggs looking to have come from a home source and not an approved vendor (some eggs cracked and open in case), a plastic container of cut pineapple with a sell by date of [DATE], two deli sandwiches dated ,d+[DATE]-,d+[DATE], and a container of ranch dressing with a best by date of [DATE]. When asked how often the unit should get checked, Dietitian W stated it should get done daily, but I am newer to the facility. According to the 2017 FDA Food Code section ,d+[DATE].11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,(b) Cooked READY-TO-EAT FOOD . According to the 2017 FDA Food Code section ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . During a revisit of the kitchen, at 8:45 AM on [DATE], it was observed that the top gaskets of the two-door victory cooler were found with an accumulation of black debris. Debris could be wiped off when a wiping cloth was run through the surface. During a revisit of the kitchen, at 8:50 AM on [DATE], it was observed that the top portion of the gasket on the two door delfield freezer was found with an accumulation of black debris that was able to be wiped away. During a tour of the dining room refrigeration unit, at 9:27 AM on [DATE], it was found that accumulation of staining and spilling was evident in the unit. A red sticky spot was observed on the bottom shelf. According to the 2017 FDA Food Code section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During a tour of the cook line, at 11:30 AM on [DATE], it was observed that a 14-inch sauce pan and a 12 inch sauce pan was found with excess carbon build up on the inside cooking surface. Accumulation of excess carbon was evident. According to the 2017 FDA Food Code section ,d+[DATE].11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE].

Based on interview and record review the facility failed to provide timely notification to a representative of the Office of the State Long-Term Care Ombudsman for emergency transfer and written notice of transfer for 2 of 2 residents (Resident #2 and #9) reviewed for notification of transfers for hospitalization , resulting in the potential for residents being inappropriately discharged , residents left without an advocate to inform them of their rights, and for the Office of the State Long-Term Care Ombudsman to be unaware of the facilities practices related to transfers and discharges. Findings include: Resident #2: Review of Nurses' Notes dated 12/17/2023 at 3:31 PM, revealed, .Resident is seen sitting on his bed when passing by, resident appears very pale. Resident states where am I? Resident questions why he is here, how he arrived, where he came from. Resident is visibly upset. Vital signs taken- 117/76, pulse 98, respirations 18, temp 98.7, and PSO2 varies from 68-77%. Per NP .- administer oxygen to keep resident >90%, obtain CXR for hypoxia. Resident placed on O2 at 2 L and continues to stat in low 80's. Resident finally reaches 90% when placed on 3L. Resident is advised to rest, use call light when/if he needs to get up and keep O2 on. Resident is then found on floor at 10:45a, having tried to get up on his own he slid to his bottom. see incident report. Resident at this time is noted to have nasal cannula off, its laying on the floor. O2 sat is 77%. Resident is again reminded to keep O2 on, and use call light for assistance. At 11:40 resident is observed up in his electric wheelchair, in the hallway on the phone. Resident again asks where he is, what city, what time of day it is. Resident again assisted with O2. On call provider contacted regarding fall- UA ordered . Review of Resident #2's medical record revealed, Resident was out at the hospital from 12/17/23 to 12/21/23. Review of Pertinent Charting-Infections/Signs Symptoms dated 12/21/2023 at 3:20 PM, revealed, .Event Date: 12/21/2023: Site of infection: PNEUMONIA: Reason on antibiotics/new signs & symptoms: admitted from (Local Hospital) on ABT (antibiotic) for PNEUMONIA and DIVERTICULITIS OF INTESTINE .Intervention(s): Oxygen 2L (liters) NC (nasal cannula), increase fluids .Precautions followed: Standard . Resident #9: Review of Nurses' Notes dated 1/14/2024 at 12:31 PM, revealed, .This RN went to resident's room to check in and discuss going to the ER d/t being weak, lethargic, too weak to stand on her own. Resident states I don't need to go to the hospital, I'm already feeling better. This RN informed resident about her vitals and that it looks like she has an infection she is fighting. Resident states I know I probably and infection, it might be my urine, but I' don't need to be seen. Asked if she had any dysuria, burning, increased frequency. Resident stated she had not symptoms. Still recommended going to the ER to make sure. Resident still refused. Resident stated she will inform staff if she starts to feel worse. Will cont. to monitor . Review of Nurses' Notes dated 1/14/2024 at 2:46 PM, revealed, .Obtained urine sample using [NAME] procedure. Resident tolerated well. Spoke with (staff at shipping facility) regarding pickup scheduled for 1/15/2024 . Review of Nurses' Notes dated 1/14/2024 at 1:12 PM, revealed, .Resident noted to have increased weakness, stated she was unable to transfer to the commode and refused the bed pan. Vitals 120/48 130 20 110.7 and blood sugar 398. Notified on NP (nurse practitioner), new order to send to ER (emergency room ) for eval and treatment. Resident refused to be transferred. Notified NP, new order for CBC, CMP, and UA with C and S. Residents COVID test was negative. Resident informed of new orders . Review of Pertinent Charting-Infections/Signs Symptoms dated 1/22/2024 at 11:18 AM, revealed, .Event Date: 01/15/2024: Site of originally identified infection: sepsis (life threatening complication of infection), .Resident continues on PO Bactrim for sepsis. No s/s of adverse reaction observed or reported . Review of the medical record for Resident #9 revealed, resident went to the hospital on 1/15/24 and returned on 1/18/24. In an interview on 08/01/24 at 10:18 AM, Social Services O reported she does not keep track of or report the emergent transfers to the Ombudsman. In an interview on 08/01/24 at 10:31 AM, Medical Records (MR) G reported the nurses were the ones to follow up with the resident and/or representative for the completion of the documents. Review of electronic correspondence provided by the State Long Term Care Ombudsman dated 7/24/24, revealed the facility was not sending the emergent transfer notices to the local Ombudsman. In an interview on 08/01/24 at 10:38 AM, Unit Manager (UM) L reported if a person was their own person and not an emergent transfer, staff would review the bed hold policy and have them sign if they were able, if it was an emergent transfer it would be sent with the resident. If the resident was not their own person, the facility would contact the representative by phone and review the bed hold policy. After that discussion, if they were unable to come to the facility the nurse would make note on the bed hold and transfer notice of their discussion with the representative. UM L reported the nurse would document in a progress note in the medical record the bed hold and transfer was reviewed. UM L reported both would need to be signed and then scanned into the medical record. Review of Transfer Notice (Resident Expected to Return revealed, .Copies of this notice will be sent to the State Long-Term Care Ombudsman as soon as practicable, but no later than 30 days from the date of Transfer .For any questions, please call the Administrator of the Facility at (telephone number) .

Based on interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 of 2 residents (Resident #2 and #9) reviewed for bed hold, resulting in possible unanticipated expense or the loss of desired room placement in the facility. Findings include: Resident #2: Review of Nurses' Notes dated 12/17/2023 at 3:31 PM, revealed, .Resident is seen sitting on his bed when passing by, resident appears very pale. Resident states where am I? Resident questions why he is here, how he arrived, where he came from. Resident is visibly upset. Vital signs taken- 117/76, pulse 98, respirations 18, temp 98.7, and PSO2 varies from 68-77%. Per NP . - administer oxygen to keep resident >90%, obtain CXR for hypoxia. Resident placed on O2 at 2 L and continues to stat in low 80's. Resident finally reaches 90% when placed on 3L. Resident is advised to rest, use call light when/if he needs to get up and keep O2 on. Resident is then found on floor at 10:45a, having tried to get up on his own he slid to his bottom. see incident report. Resident at this time is noted to have nasal cannula off, its laying on the floor. O2 sat is 77%. Resident is again reminded to keep O2 on, and use call light for assistance. At 11:40 resident is observed up in his electric wheelchair, in the hallway on the phone. Resident again asks where he is, what city, what time of day it is. Resident again assisted with O2. On call provider contacted regarding fall- UA ordered . Review of Resident #2's medical record revealed, Resident was out at the hospital from 12/17/23 to 12/21/23. Resident #9: Review of Nurses' Notes dated 1/14/2024 at 12:31 PM, revealed, .This RN went to resident's room to check in and discuss going to the ER d/t (due to) being weak, lethargic, too weak to stand on her own. Resident states I don't need to go to the hospital, I'm already feeling better. This RN informed resident about her vitals and that it looks like she has an infection she is fighting. Resident states I know I probably and infection, it might be my urine, but I' don't need to be seen. Asked if she had any dysuria, burning, increased frequency. Resident stated she had not symptoms. Still recommended going to the ER to make sure. Resident still refused. Resident stated she will inform staff if she starts to feel worse. Will cont. to monitor . Review of Nurses' Notes dated 1/14/2024 at 1:12 PM, revealed, .Resident noted to have increased weakness, stated she was unable to transfer to the commode and refused the bed pan. Vitals 120/48 130 20 110.7 and blood sugar 398. Notified on NP (nurse practitioner), new order to send to ER (emergency room ) for eval and treatment. Resident refused to be transferred. Notified NP, new order for CBC, CMP, and UA with C and S. Residents COVID test was negative. Resident informed of new orders . Review of the medical record for Resident #9 revealed, resident went to the hospital on 1/15/24 and returned on 1/18/24. In an interview on 7/31/24 at 1:45 PM, Medical Records G reported they do not have the signed bed holds or the transfer notices for the residents when they were sent out to the hospital. The nurses should have made a call to the family about the bed hold. Medical Records G reported there was a packet kept at the nurse's station and would have been sent with the resident to the hospital. In an interview on 08/01/24 at 10:38 AM, Unit Manager (UM) L reported if a person was their own person and not an emergent transfer, staff would review the bed hold policy and have them sign if they were able, if it was an emergent transfer it would be sent with the resident. If the resident was not their own person, the facility would contact the representative by phone and review the bed hold policy. After that discussion, if they were unable to come to the facility the nurse would make note on the bed hold and transfer notice of their discussion with the representative. UM L reported the nurse would document in a progress note in the medical record the bed hold and transfer was reviewed. UM L reported both would need to be signed and then scanned into the medical record. Review of Notice of Bed Hold Policy revealed, .A bed hold means the Center shall not allow another resident to occupy your bed while you are temporarily away from the Center (either due to hospitalization or therapeutic leave) and shall return you to that bed when you return to the Center .The Center will hold your bed upon your request, subject to the following conditions: For private pay residents, we will hold your bed at our daily room and board rate for the number of days you request. If you are unsure of the number of days, we will hold your bed until you notify us to stop .For residents receiving Medicaid, the Michigan Department of Health and Human Services provides the following: HOSPITAL TRANSFERS: Bed holds shall be paid for a maximum of ten days only when the facility's total available bed occupancy is at 98 percent or more on the day the resident leaves the facility. There is no limit to the number of hospital leave days per resident as long as there are no more than ten consecutive leave days per hospital stay .THERAPEUTIC Leave: Therapeutic leave days are limited to a total of eighteen days during a 365-day period .

Based on interview and record review, the facility failed to ensure that residents with a history of trauma received trauma informed care for 1 (Resident #4) of 12 sampled residents resulting in the potential for exposure to trauma triggers and re-traumatization. Findings include: .According to the National Institute on Mental Health, 2019, PTSD is a disorder that some people develop after experiencing a shocking, scary, or dangerous event. It is natural to feel afraid during and after a traumatic situation. This fear triggers many split-second changes in the body to respond to danger and help a person avoid danger in the future. The fight or flight response is typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people will recover from those symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD (Post Traumatic Stress Disorder). People who have PTSD may feel stressed or frightened even when they are no longer in danger . https://www.nimh.nih.gov/health/publications/post -traumatic-stress-disorder-ptsd/ptsd-508-0517201. Review of an Admission Record revealed Resident #4, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: schizophrenia, anxiety disorder, and major depressive disorder, recurrent severe without psychotic features. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 1/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #4 was moderately cognitively impaired. Section D of the MDS revealed Resident #4 experienced feeling down, depressed, or hopeless during 2-6 days of the 14-day assessment period. Review of a Care Plan for Resident #4, with a reference date of 9/21/23, revealed a focus/goal/interventions of: Resident is at risk for/has an impaired mood/psychiatric status related to dxs (diagnoses) (sic) of schizophrenia and anxiety. Goal: Resident will have reduced complications related to altered mood/psychiatric status through the next review. Interventions: . Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.) .Provide a calm, safe environment when resident is emotional and frustrated, and allow time to voice feelings . Review of a Social Services Progress Review with a reference date of 7/15/24 section E, Trauma Informed Care revealed Resident #4 was assessed as not having a diagnosis of post traumatic stress disorder (PTSD), and never experienced physical or sexual assault/abuse. Review of a Behavioral Health Progress Note with a reference date of 6/18/24 revealed Resident #4 was referred to the contractual behavioral health provider for concerns of depression and suicidal ideation. A section titled history of psychiatric illness revealed: Resident's mental health history prior to admission is unknown. Psychiatric diagnoses listed in the note included: anxiety/depression, schizoaffective disorder, bipolar type, schizo-affective, psychosis, and substance abuse history. Review of a Comprehensive Level II Evaluation for Resident #4, with a reference date of 9/19/17, section 4 revealed DSM (Diagnostic and Statistical Manual of Mental Disorders) Diagnoses: AXIS 1 .Post Traumatic Stress Disorder . Section D History of Presenting Problems revealed . Affective Domain: (Resident #4, name omitted) reported .she was physically and sexually assaulted as a child .witnessed domestic violence .in 2005 was taken at gunpoint for three days and .raped .again assaulted by 2014 by a friend . (Resident #4's, name omitted) ability to form emotional relationships has been severely negatively impacted . In an interview on 7/31/24, at 11:39am, Social Services Director (SSD) O reported she coordinated services to support each resident's psychosocial wellbeing. SSD O reported during the assessment process she gathered information from residents, family members, and the comprehensive level II evaluations to identify each residents needs. SSD O reported she also completed referral intake documentation that outlined a resident's mental health history and psychosocial issues when a resident needed behavioral health services. When further queried about Resident #4's needs related to a history of trauma, SSD O reported to her knowledge, the resident did not have a diagnosis of post-traumatic stress disorder, or a history of trauma related to physical or sexual assault. In an interview on 7/31/24 at 1:46pm, Clinical Social Worker (SW) X reported she provided contractual mental health services for Resident #4. When queried about how the clinician generally obtained a resident's psychiatric history, SW X declined to answer but reported she received a referral for services from SSD O and that she and SSD O collaborated to determine a resident's needs. In an interview on 8/1/24 at 8:53am, Certified Nursing Assistant (CNA) K reported she was not aware Resident #4 had a history of trauma or a diagnosis of post-traumatic stress disorder. CNA K reported the resident did become upset at and times and would blurt out I want to die. In an interview on 8/1/24 at 9:31am, Certified Nursing Assistant (CNA) E reported she was not aware Resident #4 had a history of trauma or a diagnosis of post-traumatic stress disorder. CNA E reported she heard Resident #4 talk about bad things that happened to her during her life and the resident reflected on being mistreated by a male in the past. In an interview on 8/1/24 at 11:36am, Director of Nursing (DON) B reported upon review of Resident #4's Comprehensive Level II Evaluation she determined the resident did have a history of trauma and a diagnosis of post-traumatic stress disorder. Review of the facility's policy, Trauma Informed Care with a reference date of 10/23/23 revealed the definitions: Trauma is .an event experienced by an individual as harmful or life threatening .common sources of trauma may include .physical, emotional, or sexual abuse at any age .rape .trauma informed care is a .framework that involves understanding, recognizing and responding to the effects of all types of traumas.

Based on observation, interview, and record review the facility failed to ensure infection control practices were maintained for 2 (Resident #38 and Resident #191) of 2 residents reviewed for catheter care, resulting in the catheter bag and/or tubing being left on the floor and an increased risk of cross contamination and infection. Findings include: Review of Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, Infection Control, 3/25/24, https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html, revealed Summary of Recommendations .III. Proper Techniques for Urinary Catheter Maintenance: Recommendation III.B.2, Keep the collecting bag below the level of the bladder . Do not rest the bag on the floor. Resident #38 Review of a Care Plan for Resident # 38, with a reference date of 7/8/24, revealed a focus/goal/interventions: Focus: Resident has an alteration in elimination related to renal insufficiency; urinary retention, admitted with a Foley Catheter, Goal: Resident will show no signs/symptoms of UTI's through the next review. Interventions: Assist resident with Foley catheter care as needed, keep tubing free of kinks, maintain drainage bad below the bladder level, privacy cover to drainage bag. Review of a list of medical diagnoses for Resident #38 revealed the resident was diagnosed with a urinary tract infection on 7/8/24. During an observation on 7/30/24 at 9:51am, Resident #38 slept in his bed. The urinary catheter bag rested on the floor on the right side of his bed. During an observation on 7/31/24 at 1:14pm, Resident #38 slept in his bed. The urinary catheter bag rested on the floor to the right of his bed. Resident #191 Review of a Care Plan for Resident #191, with a reference date of 7/25/24, revealed a focus/goal/interventions: Resident has a need for indwelling catheter related to Benign Prostatic Hypertrophy (BPH)secondary to obstructive uropathy. Goal: Resident will have reduced catheter-related complications .Interventions: Assist resident with indwelling catheter care as needed. During an observation on 7/30/24 at 11:10am, Resident #191's catheter bag rested on the floor on the left side of his bed. During an observation on 7/31/24 at 1:20pm, the tubing for Resident #191's catheter rested on the floor on the right side of his bed. In an interview on 8/1/24 at 9:31am, Certified Nursing Assistant (CNA) E reported for infection prevention, it was important to ensure the resident's catheter bag did not touch or lay on the floor. In an interview on 8/1/24 at 11:06am, Licensed Practical Nurse (LPN) V reported a resident's catheter bag, privacy bag, and/or tubing should not touch or rest on the floor due to the risk of potential cross contamination. In an interview on 8/1/24 at 11:36am, Director of Nursing (DON) B reported if a resident's catheter bag, privacy bag, or tubing touched the floor, it could increase the risk of cross contamination and infection.

This citation pertains to MI00143151. Based on interview and record review, the facility failed to provide an environment free from physical abuse from staff to one resident (R105) of six residents reviewed for abuse, resulting in physical abuse, and the potential for continued fear, anxiety, and psychosocial harm. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R105 scored 4/15 (severely cognitively impaired) on her BIMS (Brief Interview Mental Status). Section E-Behavior indicated the resident did not have hallucinations or delusions as potential indicators of psychosis or behavioral symptoms. R105 did direct verbal behavioral symptoms towards others that significantly interfered with resident's care occurring 1 to 3 days during the last reporting period. Review of R105's Care Plan, revised 10/17/23, indicated the resident had an ADL (Activities of Daily Living) self-care performance deficit related to and including dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and depression. The goal was to meet the resident's needs using interventions that included: 1-person assist for personal hygiene (initiated 10/16/23), and 2-person assist as resident can be combative for toileting (initiated 2/12/24). Review of R105's Behavior Health Progress Note date of service 1/31/24, revealed, .has a history of depression and Alzheimer's disease prior to facility admission .PASRR/Level 2 dated 3/31/23, indicates resident has no history of intellectual disability, developmental disability, or serious mental illness . Review of R105's Progress Note dated 2/10/24 at 15:54 (3:54 PM), revealed, While receiving report this AM (morning), resident (R106) got my attention and stated, That's the one, that's her. I'll tell you later. There was a night shift CNA (Certified Nursing Assistant) standing in front of (R106). Shortly after (R106) stated, Poor (R105) she's a sweet lady. That shouldn't have happened to her, that girl is mean, real mean. At this time, I asked (R106) if we could speak in private. (R106) informed me he watched the CNA being rough pulling on (R106's) arm yanking her around hitting her. At this time, I contacted the DON. Review of R106's Progress Note 2/10/24 at 15:56 (3:56 PM) revealed, .Potential abuse .report resident was struck in the head . Review of R106's Progress Note 2/11/24 at 12:22 (PM) revealed, Originally identified pain type .monitoring for pain r/t (related to) allegation of abuse. Resident alert, oriented to self. Resident denies pain at this time. Resident answers No, not since the fight. When asked if she is currently experiencing pain. Review of Statement of Witness dated 2/10/24, R105 stated to Director of Nursing (DON) B, That is where I got this bruise. Review of Witness Statement dated 2/12/24, no time indicated, revealed CNA H stated, The incident occurred 2/10/24 at approximately 5:00 AM when the resident (R105) was changed in bed on this morning and she was mildly resistant to care. She started yelling and said You guys are a bunch of (swear word B******) (swear word F***) you guys. After I changed her, I got her up in her wheelchair so I could change her linens for a complete bed change. Staff exited the building at 06:30 AM. The staff (CNA H) was notified of suspension 2/10/24. Review of Witness Statement dated 2/12/24, no time indicated, revealed Registered Nurse (RN) J stated, I heard hollering from down C Hall that I recognized as (R105). I know she can get feisty during her ADL care. I started to go down to help and then quieted down, so I continued my work. Review of R105's Witness Statement dated 2/12/24, no time indicated, stated the date and time of the incident occurred on 2/3/24 at 7:00 AM. Confidential Informant (CI) L stated, I was getting ready to go to breakfast. I heard yelling, Get away from me, leave me alone coming from across the hall (room C9). I came out to the hall and saw a big black Aide (CNA) pulling on the resident's (R105) wrist, slapping her on the face and pulling her hair. I then headed to the nurse's station. As I was waiting at the nurse's station until the Aide and resident went to the dining hall and then I followed. After breakfast I went back to the nurse's station. The staff was speaking to the resident. I do not recall the staff member's name of who I told. I could recognize the Aide again if I saw her. Review of R105's Witness Statement dated 2/12/24, no time indicated, revealed CNA U stated, I didn't see or hear anything. I have no reason to feel my residents were in danger or harm's way. (CNA H) is a loud talker and maybe (CI L misinterpreted (R105's) yelling for the CNA. Review of R105's Skin Assessment, dated 2/7/24 at 16:30 (4:30 PM) indicated there were no new abnormal skin areas. Review of R105's Skin Assessment, dated, 2/10/24 at 10:17 AM, indicated there were new abnormal skin areas, purple/red discoloration to the left and right forearm and back of the right hand. These were no existing abnormal skin areas. Review of R105's Pain Evaluation, dated 2/10/24 at 10:06 AM, indicated the resident stated she had pain and hurting occasionally in the last five days. The resident points to her head to describe the location of her pain. The pain was described as aching, dull, and throbbing. The pain impacted the resident's mood. During an interview on 5/21/24 at 1:00 PM, Nursing Home Administrator (NHA) A stated, The police were contacted regarding the incident with (R106) and a staff member. I got a report number, but the police never came here to investigate. Review of a document received 5/21/24 at 13:34 (1:34 PM), dated 2/10/24 from NHA A revealed, On February 10, 2024, the (name of county) Sheriff's Office was contacted in regards to the alleged abuse with (R105). The officer contacted was (Deputy P). The case number assigned was 24-4745. (Deputy P) took down the incident information, generated a case number and stated no officer would come out unless our investigation warranted further involvement. On 5/21/24 at 2:21 PM, an attempt was made to contact CNA H via telephone. The number was not in service. During an interview on 5/21/24 at 4:02 PM, Licensed Practical Nurse (LPN) K stated, (R105) would scream, yell and non-sense talk. She would have different tones to yelling for different things. (R106) came to me early one morning, when an aide walked by both of use. The resident said, That is her, she is the one that hurt (R105). When the aide walked by, she turned around and looked at him in a weird way. She snapped her head back and glared at him and walked away. He got quiet then. She was a new aide. He said the aide hurt R105, and he had seen her do it. I called the DON right away to report it. According to R106's MDS dated [DATE], the resident scored 15/15 (cognitively intact) on his BIMS. On 5/22/23 at 9:08 AM, a message was left Deputy P to call surveyor with no call back by end of survey 5/23/24 at 5:30 PM. During an observation and interview on 5/22/24 at 10:00 AM, R105 was self-propelling her wheelchair around the nursing station. Surveyor complimented her manicured nails. The resident was smiling while stating she loved her nails and went over to another resident and offered the peer a drink from her Styrofoam drinking cup in a polite manner. During an interview and record review on 5/22/24 at 10:10 AM, NHA A stated, February 10 (2024) was a Saturday. I was at home and got called in to investigate the incident. I asked the CNA (R105) if anything unusual happened during her shift. She told me no. I asked if anything unusual happened with (R105), (CNA H) said the usual behaviors. I asked what she meant by that. She said (R105) was flinging her arms and said F*** you B******(swear words) while I was dressing her. She said she forgot to tell me the resident was displaying behaviors during morning ADL care. (CNA H) did not admit to hitting or pulling the resident's hair). I knew the abuse had to have happened by what (R106) told me because he had a BIMS of 15 (cognitively intact). During an interview on 5/22/24 at 1:42 PM, RN J stated, When I worked with (CNA H) she was a loud and boisterous person. I did not like how she talked to some of the residents. She was rough talking to them. I was at the desk one night; I walked down to her when I heard her talking loud and rough to the resident in room A bed 3. She was saying to the resident, You're not listening You're not staying in bed Stay in bed. She stopped when she saw me. I had talked to her about her verbal tone to other residents also. I told her she had to be gentler. She just shrugged her shoulders. I did not tell management at that time about how (CNA H) talked to the residents. I did not tell management until after the allegation of abuse to (R105). Management should be told when any type of abuse is suspected. I did not know (CNA H) had been rough to (R105) on February 3 (2024) until shift change. No one said anything to me. That is when (R106) told me. Then I saw (R105) had bruises on her arm. (R106) was directly across from (R105) and saw (CNA H) hit R105 on the right side of her head. (R105) told me I don't like that woman, she hit me in the head when I asked her about (CNA H). I did not go down to check on (R105) when she was yelling that night. (CNA U) and I started walking down to (R105's) room when we heard her yelling, but she was done yelling by the time we got there. At that point we had no reason to believe anything had happened because I asked (CNA H) what was going on and she didn't say anything. I did not go in and check on (R105). (R105) yells and can swear quite a bit when she is being changed if staff rushes her. It is better to have two staff when (R105) needs to be changed. That way one staff can talk to her and calm her down when the other staff is changing her. I did say to (CNA H) to ask me to help her with (R105) but that wasn't until after the incident. (R105) makes weird noises but usually can speak well enough to ask for water. She does not yell out unless something is bothering her. (R105) needs someone quiet and not pushy. It was not (CNA H's) first time working with (R105). I believe (R105) yelled out because (CNA H) was too rough with her and went too fast with her. Anytime abuse is suspected it should be reported to the Administrator. During an interview on 5/22/24 at 4:18 PM, R106 stated, I was standing in my doorway in my room, facing (R105's) door, she was yelling and screaming with an Aide grabbing her hands. I looked and saw the Aide grabbing her (R105) hair and jerking her around. The aide slapped her in her face. A heavy-set black girl was the aide. She saw me looking at her shaking my head. She stopped. She followed me to the nurse's desk where I was going to tell the staff what I saw. The resident was (R105). (CNA H asked me if I saw what happened. I told her What do you think. You were loud and mean. The Aide just stared at me. The only thing I got to do was tell a staff, I think a nurse. I did not like what was going on. I felt kind of sick about it. I wondered what the heck is going on and does it go on all the time. No one else was around when it happened. The Aide was by herself, and no other staff was down there to see what she was doing. That was not right. During an interview on 5/23/24 11:13 AM CNA U stated, I work at night 10:30 PM until 6:30 AM. I worked with (CNA H). She was loud; her tone was loud. It was nights and she was loud when the rest of were whispering. (R105) is very hard to approach. You must approach her in a baby/happy tone. There are times she will tell me not to touch her. I recall on 2/3/24, I heard the resident holler. She was yelling that night when (CNA H) was in her room doing cares. She was screaming and yelling louder than usual that night. She was at the end of the hall and the other staff were at the nurse's station. I thought I should go down there to see what the hollering was about and by the time I decided to go down there (R105) had stopped yelling. The CNA did not tell me what happened. (R105) would say Look, Look, she hit me right there pointing to her arm. The next time I worked with her she would repeat the story for a couple of days after it happened. Staff told (CNA H) If you need help come ask for help. It was not criteria until after the incident to take two staff when providing cares. Review of the Psychosocial Outcomes Guide revealed that it is appropriate for the use the reasonable person concept to determine a resident's psychosocial outcome, which may not be readily determined when a resident may not be able to express their feelings, there is no discernable response, or when circumstances may not permit the direct evaluation of the resident's psychosocial outcome. Such circumstances may include, but are not limited to .cognitive impairments, or insufficient documentation by the facility; or when a resident's reaction to a deficient practice is markedly incongruent (or different) with the level of reaction a reasonable person would have to the deficient practice. Reasonable Care is the degree of care that a person of ordinary [NAME] would exercise in the same or similar circumstances. Reasonable Person standard is a legal concept that describes what a fictitious person of ordinary [NAME] would do under the circumstances. Using the Reasonable Person concept, R105 would not have wanted to be left vulnerable to experience the attack by staff in a facility she lived and relied on staff to keep her safe. Resident 105 was able to voice some evidence of harm, and it is reasonable to assume that the resident experienced fear, humiliation, and increased anxiety with behavioral outbursts due to the possibility of being confronted during future encounters of staff diminishing her level of anticipation during ADLs/ personal cares where staff may be which could increase the potential for even more increased anxiety that she could not verbalize but express in behavior(s). Resident 105 would like to have ongoing feelings of wanted socialization if she had not been cognitively impaired. Resident 105 was unable to voice the extent of psychosocial harm experienced, but it is reason to assume that R105 would experience fear, humiliation, anxiety and avoidance due to the possibility of being confronted and attacked; potentially diminishing her level of participation in ADLs which could increase her socialization cognition. Resident 105 would likely have ongoing feelings of fear and anxiety if she had not been cognitively impaired. Review of facility's 5-Day Submission, MI-FRI ID 00054861, stated, .Due to the statement of the resident who witnessed the event, the positive assessment for pain, and bruises present on forearm, the facility is substantiating that some type of physical abuse occurred . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included staff abuse education and auditing staff to resident interactions. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review the facility failed to engage and enrich the residents' quality of life by failing to develop person centered individualized care plan interventions and to provide meaningful preferred activities for 10 residents (Resident #22, #21, #16, #8, #12, #20, #26, #28, #15, and #27) of 10 residents reviewed for dementia care, resulting in the potential for increased behaviors such as wandering, physical and verbal aggression, agitation, and increased potential for adverse outcomes due to cognitive impairment in order to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #22 Review of an Admission Record revealed Resident #22 was a male with pertinent diagnoses which included Alzheimer's disease, early onset, muscle weakness, reduced mobility, cognitive communication deficit, psychotic disorder with delusions, unsteadiness on feet, and abnormalities of gait and mobility. Review of a Minimum Data Set (MDS) assessment for Resident #22, dated 3/14/23, revealed .Documented behaviors included physical behaviors towards staff and also wandering with attempts to leave thru doors .Physical towards staff during care. No patterns with wandering as it occurs throughout the day .Early onset dementia with depression and anxiety; see medical record .Agitation with care .Dx (diagnosis) of early onset Alzheimer's .Section E: Behavior: Wandering impact .A. Does the wandering place the resident at significant risk of getting to a potentially dangerous place .Yes .E1100. Change in Behavior of Other Symptoms .How does the resident's current behavior status, care rejection, or wandering compare to prior assessment? .2. Worse .Section F: Customary Routine and Activities: (Resident #22) finds it important to listen to music - he likes rock and roll and loves to dance, be around animals - always had dogs, enjoys snacks of any kind, gravitates towards where people are on the unit, enjoys taking his walks and sometimes runs, do favorite activities such as hunting, fishing, trucks, and motorcycles, and enjoys going outside . Review of the Care Plan for Resident #22, revised on 8/10/21, revealed, the focus .(Resident #22) has altered thought processes and cognitive changes related to Alzheimer's . with the intervention .Ask yes/no questions in order to determine the resident's needs .Communicate with the resident/guardian/caregivers regarding resident's capabilities and needs .Cue, reorient, and supervise as needed . Review of the Care Plan for Resident #22, revised on 8/10/21, revealed, the focus .The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) cognitive deficits secondary to dementia . with the intervention .Converse with resident while providing care .ensure the activities the resident is attending are: compatible with physical and mental capabilities, compatible with know interests and preferences; Adapted as needed; compatible with individual needs and abilities .Observe for verbal and nonverbal response .review resident's activity needs .The resident needs assistance with ADLs (Activities of Daily Living) as required during the activity .The resident needs assistance/escort to activity functions .The resident's preferred activities are: music (80s rock), enjoys taking walks/touring unit, snacks (juice/coffee & cookies), socializing with other residents & staff during his walks, busy hands, special events, coffee hour (hx (history) of outdoors/hunting, trucks, crossword puzzles & construction) .When experiencing agitation take for a walk, offer snack/drink, allow to vent feelings, offer rest period after lunch .When asking direct questions during activity, phrase questions for a yes or no response. Allow ample response time . Review of an Activities Evaluation dated 3/14/23, revealed .Interested in life/activities 2. Interested .Activities: Beauty/Barber, Cultural events/news, Exercise/Sports, Family/Friend visits, Gardening/Outdoor, Walking, Parties/Social events, Pet events, Music/Talk radio, Other - Motorcycles, Trucks .Attitude: Cooperative, Active, and Social person .Special Considerations: Wanderer, Pain management, and Task segmentation . In an observation on 06/12/23 at 10:39 AM, Resident #22 was observed in the hallway on the memory care unit walking from one end to the other end. Pacing back and forth down the hallway. Review of Nurses' Notes dated 12/23/22 at 6:04 PM, revealed .Resident was previously in other residents room in her bed, staff were assisting female resident back to her room when they observed this resident laying in her bed, they assisted male resident out of her bed as she was yelling at him to get out of her room, male resident started walking down hallway not understanding the situation, short while later female resident came out into hallway grabbed residents arms and was hold them behind him when he was trying to get away he turned around and with a closed fist made contact with female resident's chest . Note: Requested incidents and no incident report provided for this incident. Review of NP/PA (Nurse Practitioner/Physician Assistant) Progress Note dated 6/1/23 at 12:47 PM, revealed .being seen per the request of the staff at the nursing home that pt (patient) appears more agitated and he is not sleeping well at night .Pt has advanced dementia and at this time is unable to make his needs known for the most part .Pt walks in the hallways without any type of assistive device-he does walk with his head bent down .I suspect there are other pt's on the memory care unit that might get pt a bit worked up also .Nursing staff will continue to monitor and report changes . Resident #12 Review of an Admission Record revealed Resident #12 was a female with pertinent diagnoses which included dementia, anemia, pain, and a tendency to fall. In an observation on 06/12/23 at 11:27 AM, Resident #22 went into Resident #21's room exited and entered Resident #12's room who was lying in her bed. Resident #12 was looking at Resident #22 as he stood over her at the right side of the bed where her upper body was. Resident #22 was observed to be side stepping down the right side of Resident #12's bed, to the foot of her bed, along the foot board of her bed, then along the wall and to far right corner of her room. At 11:29 AM, Resident #22 exited Resident #12's room and went to Resident #21's room and proceeded to seat himself sideways in the resident's recliner. Resident #26 Review of an Admission Record revealed Resident #26 was a female with pertinent diagnoses which included Alzheimer's disease, dementia, heart failure, depression, back pain, and obstructive lung disease. In an observation on 06/12/23 at 10:44 AM, observed Resident #26 was angrily raising her voice and was aggressively telling Resident #22 he was stinky and had dandruff. Resident #26 told this writer to not let Resident #22 .get close to the computer otherwise the screen would be covered in dandruff . Staff who were present did not intervene or provide redirection for Resident #26 to remove her from Resident #22's path while he walked in the hallway by the dayroom. Resident #22 proceeded around her and went on down the hallway. In an observation on 06/12/23 at 11:20 AM, Resident #22 was walking in the hallway down by the dayroom headed down to the end of the hallway. Resident #26 was walking in the other direction reporting that Resident #22 stunk, and the staff needed to use .the spray . to get rid of his smell and continued to focus on his smell and how to get rid of it as he continued to walk down the hallway. No staff intervened or provided intervention or redirection to Resident #26 or to assist Resident #22 with an alternative activity. In an observation on 06/12/23 at 11:32 AM, Resident #22 exited his room and stood in the doorway of Resident #12's room. Resident #22 proceeded to turn around and then stood in the doorway of Resident #21's room, then leaned on the door frame and looked down the hallway. No staff were present on the hallway to intervene or determine if Resident #22 was tired and needed to rest. In an observation on 06/12/23 at 11:33 AM, Resident #22 proceeded to enter Resident #12's room and stood at the foot of her bed. Resident #12 was holding up her baby doll and showing it to Resident #22. Resident #22 exited her room and then proceeded back to Resident #21's room. No staff came to intervene during his time entering other resident's rooms. No staff were observed on the hallway. In an observation on 06/12/23 at 11:34 AM, Resident #22 walked up to Resident #21's bed while he was lying in it. There was a fall mat on the left side of the bed, the right side was against the wall. Resident #22 attempted to step up on the fall mat to walk along the side of Resident #21's bed. Resident #22 was unable to step on the mat and walked across the corner of it over to the recliner in Resident #21's room then proceeded out of the room and ambulated down the hallway towards the main entrance of the unit. Resident #12 moved herself to the side of the bed, still in a lying position, leaned over and grabbed the wheelchair which was about 3 feet away and pulled it to the right side of her bed. No staff came to intervene during Resident #22's time entering other resident's rooms. No staff were observed on the hallway. In an observation on 06/12/23 at 11:36 AM, Resident #22 proceeded to enter Resident #21's room, then exited and proceeded to stand in the doorway of Resident #12's room. Resident #12 was touching the wheelchair and Resident #22 walked over to the foot of her bed, and she pushed the wheelchair away from the side of her bed out of her reach all the while she was looking at Resident #22 as he stood in the far right corner of her room. Resident #22 exited her room and stood outside of Resident #21's room and then proceeded to ambulate down the hallway. No staff came to intervene during his time entering other resident's rooms. No staff were observed on the hallway. Resident #20 Review of an Admission Record revealed Resident #20 was a female with pertinent diagnoses which included Alzheimer's disease, anxiety, depression, obstructive lung disease, osteoarthritis, adult failure to thrive, and pain. Resident #28 Review of an Admission Record revealed Resident #28 was a male with pertinent diagnoses which included dementia, diabetes, UTI (urinary tract infection), anxiety, neuropathy (nerve damage), arthritis, and dysphagia. In an observation on 06/12/23 11:47 AM, Resident #26, Resident #20, and Resident #28 were in the day room. Resident #20 had a fidget mat on her lap as her eyes were closed and she was not interacting with the mat. Activities Aide (AA) EE was observed seated at the table talking with Resident #26. In an observation on 06/12/23 at 02:31 PM, Resident #22 was observed walking out of Resident #12's room and into Resident #21's room. The Certified Nursing Assistant (CNA) staff on the unit were providing report to the second shift staff and no staff intervened or redirected Resident #22 away from entering another resident's room. In an observation on 06/12/23 at 02:32 PM Resident #22 was standing just inside the doorway to Resident #21's room by his chair by the door. Resident #21 was on his side facing away from the wall and he had his head covered. Resident #22 was walking towards Resident #21's bed and was positioned at the head of his bed, looked down at the fall mat. Resident #22 waved his hand in the air, made some nonsensical statements, and proceeded to step on the fall mat with his right foot, it moved some as he was unable to raise his foot high enough to step on it, proceeded to walk over the corner of the fall mat while he mumbled and stepped towards the recliner and sat down in Resident #21's recliner. No staff intervened when Resident #22 entered another resident's room. In an observation on 06/12/23 at 02:38 PM, Resident #22 was observed seated on Resident #21's recliner sideways on his left hip, hanging on to the table with his right hand while mumbling to himself. Resident #22 proceeded to remove his hand from the table but did not sit back in the recliner with his back against the back of the chair. In an observation on 06/12/23 at 02:43 PM, CNA H observed Resident #22 and proceeded to assist him with the use of a gait belt to help him up out of the recliner as he was talking to them. Resident #22 was observed leaning forward with his forearms on his knees. In an interview on 06/12/23 at 02:48 PM, Registered Nurse (RN) C reported Resident #22 liked recliners and he would go to the other residents' rooms with recliners and would sit in them. Resident #8 Review of an Admission Record revealed Resident #8 was a female with pertinent diagnoses which included dementia, diabetes, stroke, obstructive lung disease, dysphagia, and cataracts. In an observation on 06/12/23 at 02:59 PM, Resident #28, Resident #22, Resident #26, and Resident #8 were observed in the day room with the Activities Director S doing some folding of washcloths. Resident #22 observed sitting there, not folding the washcloths. He did not appear happy based on his facial expressions and was mumbling to himself. In an observation on 06/13/23 at 10:06 AM, Resident #22's room had a nightstand, with a 3-drawer plastic dresser next to it along the wall in his room. There were no noted pictures, magazines/books, CD player or other items related to his interests and no noted personal items in his room. In an observation on 06/13/23 at 01:20 PM, Resident #22 was observed seated at a table with his left hand on his face with his elbow on the arm rest, and his eyes were closed. Resident #20 was lying in her Broda chair, eyes closed, had her legs drawn up to her body and was covered with a couple blankets. Resident #26 started to raise her voice at Resident #21 about how loud he was and told him to .Shut up . then continued to talk nonsensically. Note: At this time Activities Director S was the only staff on the unit. In an observation on 06/13/23 at 01:35 PM, Resident #26 was seated at the table by the door and was talking to herself about her father, poison oak, and doctor's appointment. Resident #22 got up to walk out of the door and Activities Director (AD) S stopped him as he was close to the exit of the room and redirected him back into the room. Resident #26 started focusing on Resident #22 and began saying he doesn't shampoo his hair, he stinks, and he wasn't going with them to her destination she was talking about. Resident #22 proceeded towards the back part of the room and Resident #26 continued to raise her voice to him and say those statements. AD S walked over to the Styrofoam cups and got Resident #22 a cup to get him a drink. In an observation on 06/13/23 at 01:41 PM, Resident #22 exited the dining/day room and entered Resident #8's room. Resident #22 stood at the foot of her bed, walked along the side of the bed, went to the other side of the room and was touching the wall and looking at items on her rolling table. Resident #22 then exited to Resident #8's room, came over to this surveyor, looked at the computer and made a nonsensical statement, and turned and ambulated down the hallway. In an observation on 06/13/23 at 01:53 PM, Resident #22 was observed standing at the back door looking out the back door windows. As Resident #22 walked back down the hallway, Resident #26 repeatedly stated Resident #22 stinks and he was dirty as he passed her in the hallway. As he proceeded back down the hallway, Resident #26 yelled at him to go home, he wasn't coming with them. Resident #22 walked past her with his head down and he tensed up his body inward as he passed her. Resident #26 reached out to grab him and she stopped as she saw this writer looking at her and continued yelling at him and continued down the hallway with her rant about Resident #22. Note: No staff came to the hallway to observe or intervene in this situation. In an interview on 06/13/23 at 01:58 PM, Licensed Practical Nurse (LPN) P reported the facility was aware Resident #22 was going into other resident's rooms and some residents requested to have the stop sign banner placed over their door entry way to prevent him from entering their room. LPN P reported interventions for him were to check on him frequently when he was wandering, there was also the activity busy hands which has the different locks, knobs and other fidget items, and there were the popper items. Resident #21 Review of an Admission Record revealed Resident #21 was a male with pertinent diagnoses which included stroke, fluency disorder following a stroke, sleep disorder, repeated falls, muscle weakness, reduced mobility, diabetes, anxiety, cognitive communication deficit, chronic pain, senile degeneration of brain, epilepsy, mood disorder, fracture of right acetabulum, fracture of upper end of right humerus, and lower urinary tract symptoms. Review of a current Care Plan for Resident #21, revised on 9/29/21, revealed the focus .The resident has vascular dementia with behavioral disturbance . with the interventions .Administer medications as ordered .use preferred name, identify yourself with each interaction, face the resident when speaking, make eye contact, provide with necessary cues. Stop and return if agitated .Cue, reorient, and supervise as needed .Present just one thought, idea, question or command at a time . Review of a current Care Plan for Resident #21, revised on 3/20/23, revealed the focus .Resident structures his leisure time independently thru own independent activities. Strong preference to stay in his room; can be difficult to engage in activity groups. Prefers nicknames . with the intervention .Resident will continue to make activity preferences/choices .Resident will continue to structure their leisure time independently at the center .Ensure resident has the supplies needed to participate in activities in their room independently. CD player with Cuban music, enjoys snacks delivered to room .Favorite activities include snacks delivered to his room (cookies and coffee and his ethnic snacks), TV, social with others often initiating conversations independently. *ordered him Cuban CDs; also provided resident with CD player. Staff offer room visits as tolerated . Review of an Alert Note dated 2/16/2023 at 3:26 PM, revealed .Behavior occurred - interventions ineffective . Review of an Alert Note dated 2/21/2023 at 6:53 PM, revealed .Behavior occurred - interventions ineffective .behaviors continue/treatments in place . Review of Nurse's Note dated 2/22/23 at 5:48 AM, revealed, .Resistant to CENA care, nurse went in and talked to res and gave snack, res. Calmed down. Review of an Alert Note dated 3/6/2023 at 3:00 PM, revealed .no change in behaviors, all treatments are in place . Review of Nurse's Note dated 3/7/23 at 11:32 PM, revealed, .res yelling out and swatting at CENA during routine HS care .res now resting comfortably with eyes closed . Review of an Alert Note dated 3/12/2023 00:46 AM, revealed .behavior continues, all interventions are in place . Review of an Alert Note dated 3/12/2023 00:48 AM, revealed .behavior continues, all interventions are in place .resident refusing to bathe at this time . Review of Nurse's Note dated 3/17/23 at 1:53 AM, revealed, .resident yelling out . Review of Nurse's Note dated 3/20/23 at 6:28 AM, revealed, .Behavior occurred - interventions ineffective . Review of an Alert Note dated 3/21/2023 05:39 AM, revealed .Behavior occurred - interventions ineffective Review of an Alert Note dated 3/28/2023 01:12 AM, revealed .Behavior occurred - interventions ineffective . Review of an Alert Note dated 4/5/2023 04:38 AM, revealed .Behavior occurred - interventions ineffective . Review of an Alert Note dated 4/10/2023 05:56 AM, revealed .Behavior occurred - interventions ineffective . Review of an Alert Note dated 4/12/2023 06:26 AM, revealed .Behavior occurred - interventions ineffective . Review of an Alert Note dated 4/23/2023 10:57 PM, revealed .Behavior occurred - interventions ineffective . Review of an Alert Note dated 4/19/2023 02:44 AM, revealed .Behavior occurred - interventions ineffective . In an observation on 06/12/23 at 10:51 AM, Resident #21 was observed lying in his bed, facing the window in the room. Review of an Alert Note dated 6/13/2023 at 05:43 AM, revealed .Behavior occurred - interventions ineffective . In an observation on 06/13/23 at 01:20 PM, Resident #21 was observed in the dining/day room vocalizing while in his Broda chair which was reclined, had his left leg up and his right leg hanging over the armrest of the chair. In an observation on 06/13/23 at 01:51 PM, Resident #21 was in his room yelling, hollering out. Note: No staff proceeded to provide interventions. No music was playing nor was the TV on in the resident's room. Resident #16 Review of an Admission Record revealed Resident #16 was a male with pertinent diagnoses which included traumatic brain injury (TBI), insomnia, dementia psychosis, and depression. Review of a current Care Plan for Resident #16, revised on 4/26/23, revealed the focus .The resident has impaired cognitive function/dementia or impaired thought processes r/t (related to) TBI . with the intervention .Ask yes/no questions .Cue, reorient, and supervise as needed .keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion .Present just one thought, idea, question, or command at a time .use task segmentation to support short term memory deficits. Break tasks into one step at a time .Avoid isolation . and the focus .Resident structures their leisure time independently and is involved in structured group activities and/or independent activities . with the intervention .Escort/transport to activities .Invite to activities of interest .Remind resident of activities that are occurring daily . Review of an Activities Evaluation for Resident #16, dated 4/26/23, revealed .Activities: Exercise/Sports, Family/Friends Visits, Gardening/Outdoor, Movies/TV, Music/Talk radio .I watch TV until I fall asleep .Interested in life/activities: cooperative, active .Ambulation: Independent .Special considerations: Task Segmentation, Pain Management . Review of Preferences for Customary Routine and Activities - Section F of the Minimum Data Set (MDS) assessment for Resident #16, dated 4/21/23, revealed .Very important to have snacks available between meals .Very important to listen to music you like - Rock and Roll .Favorite Activities: Outdoors, movies/popcorn, exercise/therapy, seeing his brother and girlfriend, rock n roll music .Very important to go outside when the weather is good - I love it! . Review of the Task - Activities: Daily Routine for last 30 days showed Resident #16 listened to music 4 times, took a walk 4 times, 9 times was noted he was watching TV, Other - 19 times, Resident refused 10 times, and Not applicable 38 times . from observations on all three shift for the previous 30 days. Review of a NP/PA (Nurse Practitioner/Physician Assistant) Progress Note for Resident #16, dated 5/20/23 at 2:43 PM, revealed .Being seen due to over the weekend had increased behaviors .found in another patient's room and took the TV off the nightstand and threw it down onto the floor .Plan: Nursing staff to continue to monitor report changes .Nursing staff to continue to offer distractions activities to help with his behaviors . In an observation on 06/12/23 at 10:39 AM, Resident #16 was observed to be lying on his side, he had a pillow under his shoulder area, and was leaning over the side of his bed touching the bag on the floor. Resident #16 was asking for cookies repeatedly. During multiple observations over the survey, Resident #16 was offered a cookie one time outside of Coffee Hour (a scheduled activity). Resident #16's TV was not on nor was any music playing in the room. In an observation on 06/12/23 at 10:58 AM, Resident #16's roommate was calling out and Resident #16 said something to him, not in a hostile manner and his roommate told him, F*** You!. Resident #16's TV was not on nor was there music playing in his room. In an observation on 06/12/23 at 11:25 AM, Resident #16 was observed lying in his bed on his stomach, with his arms folded under his head. Resident #16's TV was not on nor was there music playing in his room. In an interview on 06/12/23 at 02:48 PM, Resident #16 was observed lying in his bed on his stomach and reported he was not going to the day room for the activity. Resident #16 reported he liked staying in his room. Resident #16's TV was not on nor was there music playing in his room. In an observation on 06/13/23 at 09:34 AM, Resident #16 was observed yelling, Hello!, Hello! Note: No staff responded to Resident #16's vocalizations. Resident #16 stated Hi to this writer who was standing in the hallway, and he reported hopefully he would get up today, and said .See you later . Resident #16 was observed lying in his bed with pajama top and trousers on. In an observation on 06/13/23 at 01:20 PM, Resident #16 was heard to be calling out saying, Hello! How did I get here? Note: At this time the Activities Director S was the only staff on the unit. In an observation and interview on 06/13/23 at 01:32 PM, Resident #16 was noted to be calling out from his room and asking for Help, Could someone come and help me, please? Observed Certified Nursing Assistant (CNA) Z respond to his request. Resident #16 reported that he did not know why he was calling for help. CNA Z reported Resident #16 does call for assistance and when staff respond to his request, he has forgotten what he needs when you come to him and ask him. During multiple observations on the memory care unit from 6/12/23 to 6/14/23, noted the hallway did not have any pictures or items to create a homelike environment on the unit. The visiting room across from the dining/day room had overflow items in it and no seating for visiting/relaxing. The following residents remained in the dining/common area after breakfast with the television on with no volume; Resident #20, #8, and #26. Activities Director S was observed seated in the dining/day room throughout most of the days except when going room to room for coffee hour offering drinks and snacks to those residents who remained in their rooms. The residents were not offered to go outside on Tuesday, June 13, 2023, even though the temperature was 70 degrees as a high. The residents were not offered to go outside on Wednesday, June 14, 2023, even though the temperature was 74 degrees as a high. Review of the June Memory Care Event Calendar for 06/13/23 revealed at 09:30 the scheduled activity was Active Game. In an observation on 06/13/23 at 09:29 AM, Resident #26 was seated in the hallway on a chair with a winter coat on. Resident #20 was observed reclined in her Broda chair with her eyes closed with a fidget mat lying on top of her blankets. Resident #30 was observed seated in his Broda chair, eyes closed, with a fidget mat laid on his lap. Resident #8 was observed seated, with her eyes closed, at a table with a big popper fidget square in front of her. In an interview on 6/12/23 at 02:48 PM, Registered Nurse (RN) C reported the Social Worker duties were split between the Activities Director and Medical Records staff currently. RN C reported CNAs should report behaviors to the nurse and the nurse would contact the provider. In an interview on 06/14/23 at 09:09 AM, Staff Development (SD) I reported if a CNA observed a behavior, they could review Alert charting, or create a Stop and Watch to document in the record. SD I reported if there was verbal aggression between two residents the staff would introduce redirection and separation of the residents. SD I reported staff could try different interventions to interrupt the behavior or stop the behavior. When presented with the fact Resident #22 liked recliners, SD I expressed questioning of why the facility had not tried a recliner in the resident's room to prevent the wandering. SD I reported when Resident #26 gets agitated and verbally aggressive with other residents, an option was to take her off the unit for a walk for a .change of scenery . SD I reported this was the resident's home and we should do things to make it a good place to live and .do anything to make it comfortable for our residents . In an interview on 06/14/23 at 01:19 PM, CNA Z reported the CNAs review the Kardex in the electronic medical record (EMR) for what interventions were in place for the resident. They would also review the alert charting in the EMR which would alert them to changes in the resident's condition, observations of residents to be aware of, etc. In an interview on 06/13/23 at 02:18 PM, Director of Nursing (DON) B reported the expectation would be the nursing staff would assist with the residents' participation in activities, including to go to residents and promote participation in activities. DON B reported she depends on the unit managers, floor nurses to ensure the staff were observing what occurred on the units, by their daily notes, 24-hour reports, and review of documentation would be how she would ensure the behaviors were documented and care plan interventions were implemented. DON B reported the care plan should have individualized interventions to address residents' behaviors and with dementia care. DON B reported staff are to supervise the residents to ensure those who wander rest, or were safe during ambulation. Review of the Admission Packet revealed the form .Consent and Release Form for Activities .to participate in the following activity outings with the Facility . Ball parks .Community centers/events .Fairs .Fishing trips .Libraries .Movies/theatres .Museums .Parks .Picnics .Restaurants .Scenic rides .Schools .Shopping trips .Sight-seeing .Other . Review of Dementia Education for all staff revealed, 12 direct care staff out of 63 staff members failed to complete the required education. 46999 Review of The Needs of Older People with Dementia in Residential Care, Woods & [NAME] (2006), published in the International Journal of Geriatric Psychiatry revealed Determining which activities have high degree of meaningfulness can aide recreation staff in creating programs more likely to promote health and wellness for persons with dementia. Review of Activity Involvement and Quality of Life of People at Different Stages of Dementia in Long Term Care Facilities, [NAME] & Twist (2015), published in Aging Mental Health, revealed Despite a Resident's cognitive status, their activity involvement was significantly related to better scores on care relationships, positive affect, restless tense behavior, social relations and having something to do. Resident #15 Review of an Admission Record dated 9/29/17 revealed Resident #15 was admitted to the facility with the following pertinent diagnoses: Alzheimer's Disease (disease characterized by progressive mental deterioration), muscle weakness, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness, and Major Depressive Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE], Section C revealed Resident #15 was severely impaired (never/rarely made decisions) for daily decision making, continuously had difficulty focusing her attention, and continuously presented with disorganized thinking. Section D revea [TRUNCATED]

This citation pertains to Intake # MI00135264. Based on interview and record review, the facility failed to respond timely to a request for medical records in 1 resident (Resident #38) of 1 resident reviewed for medical record requests, resulting in delayed access to a resident's medical records and dissatisfaction with the services provided. Findings include: Review of the policy/procedure Preparing for Release, dated 2017, revealed .To protect the individual's right to privacy by releasing confidential information only to authorized persons/entities, and only in accordance with Facility policy, federal and state laws .Procedure .Require request to be in writing .Facility must provide access to resident the requested records for inspection within 24 hours excluding holidays and weekends .If family member is the legal representative, follow the same process as requested from the resident . Resident #38 Review of an Admission Record revealed Resident #38 was a female, with pertinent diagnoses which included Alzheimer's disease, arthritis, depression, and high blood pressure. Noted Family Member V was identified as Resident #38's responsible party. Review of a Minimum Data Set (MDS) assessment, with a reference date of 2/10/23, revealed Resident #38 had severe cognitive impairment with behaviors that included inattention and disorganized thinking. Review of a Care Plan for Resident #38 revealed the focus .Resident representative, (Family Member V), involved in care planning . initiated 12/13/21. In an interview on 6/13/23 at 9:39 a.m., Family Member V reported they submitted a written request for Resident #38's medical records in March 2023. Family Member V reported these records have not been provided by the facility. Review of an Authorization for Use or Disclosure of Protected Health Information form for Resident #38, revealed Family Member V submitted a written request for medical records on 3/24/23. The section For Office Use Only was incomplete, with no information noted as to whether or not the request was fulfilled. In an interview on 6/14/23 at 2:26 p.m., Administrator A reported Family Member V submitted a request for Resident #38's medical records. Administrator A unable to provide documentation that this request was fulfilled in a timely manner prior to survey exit.

This citation pertains to Intake # MI00135264. Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the reason for a transfer to the hospital in 3 of 5 residents (Resident #38, #6, & #23) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to not be fully informed of the reason for a hospital transfer and their rights in regard to an appeal hearing. Findings include: Review of the policy/procedure Transfer and Discharge, dated 1/1/22, revealed .It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered .Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) .Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents .Resident status, including baseline and current mental, behavioral and functional status and recent vital signs .Current diagnosis, allergies and reasons for transfer/discharge .The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record .Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand .Provide transfer notice as soon as practicable to resident and representative . Resident #38 Review of an Admission Record revealed Resident #38 was a female, with pertinent diagnoses which included Alzheimer's disease, arthritis, depression, and high blood pressure. Noted Family Member V was identified as Resident #38's responsible party. Review of a Minimum Data Set (MDS) assessment, with a reference date of 2/10/23, revealed Resident #38 had severe cognitive impairment with behaviors that included inattention and disorganized thinking. Review of a Care Plan for Resident #38 revealed the focus .Resident representative, (Family Member V), involved in care planning . initiated 12/13/21. Review of a Progress Note for Resident #38, dated 3/16/23 at 12:54 a.m., revealed .Lab notified facility of critical Sodium level of 164. (Nurse Practitioner) on call notified. Stated to call (Family Member V) to see what he wanted. Called (Family Member V) and explained situation and critical lab. (Family Member V) stated to send resident to (Hospital Name). (Ambulance Service) notified. Paramedic spoke with (Family Member V) after assessing resident. A copy of the DNR (Do-Not-Resuscitate Order) was sent with paramedic. Resident transferred to (Hospital Name). DON (Director of Nursing) notified . Review of Resident #38's medical record revealed no documentation to indicate that a written transfer notice was provided to Resident #38's representative upon her transfer to the hospital on 3/16/23. 41424 Resident #6 Review of an Admission Record revealed Resident #6 was a female with pertinent diagnoses which included bipolar disorder, PTSD (post-traumatic stress disorder), chronic pain syndrome, mild cognitive impairment, sleep disorder, muscle weakness, and diverticulitis (inflammation/infection in one or more small pouches of the digestive tract) of large intestine with perforation and abscess. Review of Nurses' Notes for Resident #6, dated 1/22/2023 at 03:38 AM, revealed .Resident c/o (complained of) abdominal pain since shift started, On-call NP (nurse practitioner) ordered Simethicone x1 time, after giving it resident has emesis x1 undigested food noted. VS (vital signs) temp (temperature) 97.4, PR (pulse rate) 64, RR (respiratory rate) 18, BP (blood pressure) 116/70 noted P.Ox (pulse oximetry) 96% in room air. reposition resident after an hour, rechecked and still could not sleep, c/o lower back pain and uncomfortable in abdomen again, writer notified NP at 3:23 am and notified again resident, could not sleep, worry and nervous then request to go to hospital, order to send her to hospital, LG (Legal Guardian) (Name of Guardian) notified at 3:35am. DON (Director of Nursing) notified. called (Ambulance Service Name) .and transfer resident to (Hospital Name) at 3:52 AM . Review of Resident #6's medical record revealed no documentation to indicate that a written transfer notice was provided upon her transfer to the hospital on 1/22/23. Resident #23 Review of an Admission Record revealed Resident #23 was a female with pertinent diagnoses which included leukemia of B-Cell, Alzheimer's disease, diabetes, adult failure to thrive, pain, stroke, and anemia. Review of Nurses' Notes for Resident #23, dated 1/14/2023 at 03:43 AM, revealed .Lab called at approx (approximately 3:35 a.m.) with a critical hemoglobin of 5.7 for this (resident) NP (Nurse Practitioner) on call (Given name of NP) gave the order to send (resident) to the hospital .residents daughter/POA (power of attorney) was called and a message was left for her. I also called (resident's) substitute decision maker (resident's) granddaughter (Given name) who answered and requested (resident) be taken to (Hospital Name). (Ambulance Service Name) picked (resident) up at (3:45 a.m.) and assisted (resident) via stretcher to (Hospital Name). vitals remained wnl (within normal limits) though resident did appear pale. Resident was alert at baseline prior to leaving. DON .notified . Review of Resident #23's medical record revealed no documentation to indicate that a written transfer notice was provided upon her transfer to the hospital on 1/14/23. In an interview on 6/13/23 at 2:43 PM, Medical Records (MR) F reported there was a packet in a green folder kept at the nurse's station and this was given to the resident when they were taken out to the hospital. Nurses were to have them sign they received the documents (transfer notice and bed hold policy) and resident representatives were contacted to come and sign they received the transfer notice and bed hold information.

This citation pertains to intake MI 958. Based on interview and record review, the facility failed to 1.) follow hospital discharge order and apply wound vac per physician order, 2.) notify physician and vascular surgeon prior to implementing a of change in wound orders, and 3.) on 8/3/20 applied wound vac correctly, for 1 of 31 sampled residents (Resident #107), reviewed for quality of care, resulting in an immediate jeopardy when, beginning on 7/29/20, facility staff did not perform a comprehensive assessment on a wound and promptly notify the physician that they were not going to apply the wound vac, contact the physician causing Resident #107 to eventually be readmitted to the hospital during a visit with the neurovascular surgeon on 8/4/20, with neurotic fatty tissue in the wound and wound infections, for debridement and wound revision due to lack of adequate wound treatment. This deficient practice placed all residents with wound at risk for serious harm, injury and/or death. Findings include: Review of Verbal Order Policy dated 12/2017, revealed Verbal orders shall only be given in an emergency or when the Attending Physician is not immediately available to write or sign the order. Entering Verbal/Telephone Order onto Clinical Record: 1. The nurse receiving the verbal order must write it on the physician's orders [REDACTED]. The Physician shall review and countersign verbal orders during his/her next visit. Verbal Orders Based on Protocol: 3. If a treatment, test, or another intervention is included in a protocol that has been reviewed and approved by the Medical Director, then a Nurse may write a verbal order for a situation that is covered by the protocol. Review of Telephone Orders Policy dated 12/2017, revealed verbal telephone orders may be accepted form each resident's Attending Physician. Verbal Telephone Orders: 1. Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc). Orders must be reduced to writing, by the person receiving the order, and recording in the resident's medical record. Medical Record Entry: 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Countersigning Verbal Orders: 3. Telephone orders will be entered into the medical records within the shift the staff receiving the order unless other arrangements by nursing management are provided. Schedule II Drugs: 4. Telephone orders must be countersigned by the physician on the next physician visit. 5. Unless otherwise prohibited by law, verbal telephone orders for Schedule II drugs will e permitted in accordance with facility policy. According to Legal and Ethical Issues in Nursing, 4th Edition, (Guido, G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. According to the Fundamentals of Nursing, 6th edition (Potter-Perry, Mosby, 2005, page 419), The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm clients. The reference goes on to indicate that all orders must be assessed and further clarification from the physician retrieved if necessary. Review of a Admission Record revealed Resident #107 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 8/4/20 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #107 was cognitively intact. Review of the Physician Discharge Summary dated 7/29/20 at 11:58 AM, revealed Admitting Physician (AP) N, Discharging Physician: (name of physician), Treatments - IV hydration, antibiotics: [MEDICATION NAME] and Bactrim, [MEDICATION NAME]; [MEDICATION NAME] and [MEDICATION NAME], anticoagulation: ASA, [MEDICATION NAME] and Xarelto, insulin: surgery: Left common Iliac to Femoral Artery Bypass with Hemoshield via left Retroperitoneal Approach, Partial Explant of Iliac Artery Stent, Endarterectomy of Common Femoral and Profunda Femoral Artery, thrombectomy of Profunda and Branches, placement of Wound Vac in Left Groin 11cm x 2.4cm x 3.0cm. Discharge Exam- Diet as tolerated, diabetic diet, low fat, low cholesterol diet and encourage fluids, Call your Surgeon immediately if you: *Have temperature over 101 degrees Fahrenheit. *Have pus (yellow of tan) drainage or increasing redness of the incisions or wounds. *Have a bad smell coming from the wound or dressing. *Have increased bleeding from the wound. *Have numbness or tingling of the legs or if your legs become, pale, cool or cold. *Have severe pain in your leg that does not go away, even after you have taken pain medication. *Feel side effects from your medication. *Do not feel well for any reason. Wound Care Wound site: Left groin, Wound Vac dressing change every Monday, Wednesday, and Friday and prn. It's ok to shower prior to dressing change. Setting 125 mmHG continuous .Follow up appointment 8/4/20 at 10:30 AM (name and type of specialist office). Review of the Physician order [REDACTED]. Review of the Return to Hospital Care Plan date 7/30/20, revealed Resident #107 was At risk for return to hospital related to diabetes, HTN, open wound, HX of [MEDICAL CONDITION] Date Initiated: 07/30/2020 G o Reduce the risk of return to hospital through hospital related disease process and symptom management Date initiated: 08/03/2020 Interventions * Monitor for signs and symptoms of infections Date Initiated 7/30/20 * Treatments as ordered Date Initiated 8/3/20. During an interview on 8/21/20 at 1:17 PM, LPN Q reported that she admitted (Resident #107) on 7/29/20 and what I did not complete then the next nurse continues the admission. LPN Q reported that she did not put on the wound vac, (Unit Manager/License Practical Nurse Z) gave me the wound vac and I gave it back to him and I ask him to please teach me and he said he would, but he got busy. LPN Q stated Do not recall what kind of dressing the resident had on at that time, when I came back after the weekend there was a different order. During interviews on 8/18/20 at 12:25 PM and 8/20/20 at 8:30 AM, Registered Nurse (RN) D reported that no one updated my training for putting on [DEVICE] and we do not have a skills check off for [DEVICE] so I felt uncomfortable putting the wound vac on (Resident #107) without (Unit Manager/License Practical Nurse (LPN) Z) who was too busy to help or look at the wound until 7/31/20. RN D reported that they were putting a wet to dry dressing on (Resident #107). RN D reported that it was very busy on the hall on 7/31/20 when she went to look at the wound and I felt that the surgeon should be called and updated on the wound, due to the moderate amount of yellow drainage coming from the wound. RN D reported that she wanted UM/LPN Z to come and get measurements before the wound vac went on and at that time he said the wound was not appropriate for a wound vac. RN D reported that she informed (LPN S) who was taking over for her on day shift that (UM/LPN Z) wanted to discontinue the wound vac because he felt it was not appropriate for the wound. RN D reported that she was not there when the dressing was placed on Resident #107. During an interview on 8/19/20 at 3:08 PM, LPN Z reported that (Resident #107) was admitted on [DATE] and if a resident has a wound vac order and the wound vac was not on when the resident arrived at the facility the standing order was a wet to dry dressing when a when vac was not in place. LPN Z reported that he was wound certified and on 7/31/20 he assessed the wound to the left groin for (Resident #107) and decided to change the orders based on the wound presentation; it had exudate, serosanguinous drainage with purulent, which was tough to differentiate between the two, 75 % slough, and I questioned him coming with a wound vac. LPN Z reported that he put orders in and he would discuss with his provider at the next day they are in the facility, and 9 out of 10 time we are doing the right thing. LPN Z reported that he went on vacation the next week after he made the decision and did not discuss the wound with the provider. LPN Z reported that he did not call the vascular surgeons office to tell them about the wound dressing change, because he thought it was a chronic wound. I wasn't under the impression surgery was following him. LPN Z reported that he had read the admission noted from the hospital, and if he was followed by surgery it usually says and I did not see it. LPN Z reported that my wound notes are not available I was pulled so much at the facility that I did not have the opportunity to write the wound notes for (Resident #107), handling everything with covid kept me busy, (tracking weekly employee testing at this time). During interviews on 8/18/20 at 9:10 AM and 8/20/20 at 4:30 PM, LPN S reported that on the morning of 7/31/20 when I came in the night shift nurse said the wound was not appropriate for a wound vac and they (UM/LPN Z) were going to put another dressing on it. LPN S was going off shift and I put in a new order to discontinue the wound vac order. The unit manager was still with the resident, I did not help put the new dressing on the wound, had not seen the wound until that afternoon when therapy told me it was bleeding at 4 PM and I got UM and we found drainage and (UM/LPN Z) changed the order again for what to put on left groin. LPN S reported that the dressing that she removed was a silicone border dressing and I cannot recall what was inside she called (NP AA) for a new order, and was told to always put down Nurse Practitioner (NP) AA even if she spoke to someone else so that NP AA could have access to the order, LPN S reported that it was 5:56 PM when she was getting the new order and she was off at 6 PM so she did not have time to fill out the information with the person she was speaking to. LPN S reported that she did not see an order for [REDACTED]. Review of the Physician order [REDACTED]. Cover with border foam. Every day and evening shift for wound. Created by Licensed Practical Nurse (LPN) S. Review of the Physician order [REDACTED].) Communication method- verbal, reason- order change, ordered by- Phy LL Created by LPN S. During interview on 8/18/20 10:40 AM at and 8/19/20 12:00 PM, NP AA was reviewing doctors progress note written 7/30/20 and reported that (Physician Phy LL) had just changed the diabetic (DM) medications, she did not see that he had changed any wound vac orders, NP AA stated she did not believe he would do that. NP AA reviewed the orders that were in the computer and stated that LPN S had put the order in on 7/31/20 to discontinue (D/C) the wound vac from a verbal order by (Phy LL). NP AA reported that 7/31/20 was a Friday and Phy LL does not work on Fridays so the facility could not have gotten a verbal order from him on that day. NP AA reported that she was on vacation the week of 7/31/20 and could not have taken any order, and have ask the staff to not just sign her name, but to document the person they get the order from in the note section of the orders. During an interview on 8/21/20 at 9:46 AM, NP CC reported that on 7/31/20 at 5:24 PM she did not speak to an (name of LPN S) she was on call all night and only call I received all night was at 11:52 PM about an admission. NP CC reported that sometimes they do not know who is on call and they talk to someone else, she reviewed notes and there is no noted documentation of any other on call personal receiving a call from this facility at the timeframe that (LPN S) documented dressing order change at 5:24 PM on 7/31/20. During interviews on 8/20/20 at 10:45 AM and 12:09 PM, Director of Nursing (DON) B reported that the wound vac was discontinued on 7/31/20 at 1:29 PM. DON B reported that (UM/LPN Z) evaluated (Resident #107) and as I recall he said he spoke to (Phy LL) who agreed with him and gave the order to discontinue the wound vac. DON B reported that our physician prefer we call them first as well as the vascular surgeon, it would depend on what our physician said at this point whether we called the vascular surgeon. DON B reported that (UM/LPN Z) was evaluating the wound, that the wound vac was contraindicated, it was infected, not pulling regular drainage, he did not feel it was helping the wound heal, and not benefiting the healing process. DON B reported that there was no wound notes from (UM/LPN Z) or anyone else for (Resident #107). During an interview on 8/19/20 at 2:50 PM, Admitting Physician (AP) N reported that no one called her to discontinue the wound vac on 7/31/20, and that she did not know that the wound vac had been discontinued until the patients (family member) called and told her. AP N reported that she called the facility on 8/3/2020 and was informed that the order had been changed, was told by the facility that she had changed the order, she informed them she was never called to change the order, and that no one could not tell her how the order was changed. AP N reported that the facility informed her they would put a wound vac on the resident (#107), AP N reported it was put on in a hap hazard fashion, did not fit properly, the resident was crying when he came to his appointment he was in so much pain, the skin around the wound vac looked unhealthy, the wound vac was alarming and beepin, there was an odor, necrotic tissue was noted, and I do not believe the wound vac was working properly. AP N reported the wound to the left groin was infected, the graft that was placed before he went in the nursing home was infected and an antibiotic alone could not help, we had to remove the old graft and place a new graft. AP N stated that when she was called from the nursing home it was about antibiotic concerns, but she was never informed that he was not using his wound vac. AP N reported that they had the hospital case managers involved with discharge planning since he (resident #107) was in a significant amount of pain and needed to use a wound vac, the facility would need to put the wound vac on and manage 5 maybe 6 dressing changes, before his next office appointment. AP N reported that they do not send many residents with [DEVICE] to the facility, but if the facility did not have the qualified staff to do the job why did they take the resident? During an interview on 8/21/20 at 1:17 PM, LPN Q reported that the wound was ok, she was concerned about his abdomen, called the physician and the surgeon on 8/3/20 (suddenly he was distended and there was a touch of bleeding and bruising and it was hard). LPN Q reported that she talked to (the NP) and (name of surgeon), vital signs stable she said keep doing everything we are doing and make sure he comes to his appointment on 8/4/20. LPN Q reported that she did not know if surgeon was aware that he was not on the wound vac at that time. LPN Q reported that then (DON B) came to tell me that we were putting the wound vac back on and (Registered Nurse (RN) MM volunteered to help since I don't know how to do wound vac's, she got the machine all set up and there was no instruction booklet, so she called another building that had a machine and they were able to talk us through the process. LPN Q reported that she was off the next day so was not sure how the machine ran. LPN Q reported that (Resident #107) frequently complained about pain. During an interview on 8/21/20 at 10:00 AM, Registered Nurse (RN) Admission Director Liaison ADL) MM reported that a nurse (LPN Q) came to me on 8/3/20 to ask for help with a wound vac, I ask her why it was not on and she said she had heard it was not appropriate for it. RN MM reported that she found a note that the wound bed was not appropriate. RN MM reported that the nurse (LPN Q) was not sure how to put the wound vac on, she reported having done one before, but was not sure how to do it. RN MM reported that she assisted the nurse (LPN Q) and also did some teaching with her, and called the Unit Manager (LPN Z) to find out why he felt the wound was not appropriate for a wound vac when the resident was admitted to the facility. RN MM reported that she was an RN and used to do wounds and put on [DEVICE], but had not put on a wound vac 2 years prior to putting this one on. RN MM reported that when she looked at (Resident #107's) wound it had good color, was moist, and she felt the wound vac was appropriate for the wound. RN MM reported that she cleaned the wound, cut and put on the black foam, put in the tubing and turned the machine on to continuous suction at 125 mmHg. RN MM reported that the wound vac that was delivered was new to her so she had to contact a UM at another building by phone, since it had been awhile since she had used a wound vac to tell us how to turn on the suction. RN MM reported that she could tell that the machine was on, the lights were on, and you could tell that it was suctioning at that time. RN MM reported that she could not recall exactly where the wound was located since it had been so long, and that she had left the charting up to the nurse (LPN Q). Review of the Nursing Notes dated 8/3/2020, revealed no documentation about wound care. During an interview on 8/26/20 at 12:00 PM, Certified Nursing Assistant (CNA) M reported that (Resident #107) told her to tell the nurse he was in pain on 8/4/20 he was panting he was in so much pain I could see it, I did tell the nurse. CNA M stated I do remember from the time I took care of him that that his wound was not covered but open and he said it was infected and it was bleeding. Review of the Treatment Administration Record (TAR) dated August 2020, revealed Left groin - cleanse with NS, apply dakins half strength as wet to dry dressing. Cover with border foam. every day and evening shift or wound -Start Date- 08/01/2020 0600 -D/C Date- 08/03/2020 1334, 5 opportunities to document treatments (4) documented (1) blank. During an interview on 8/20/20 at 11:00 AM, DON B was not able to explain how the documentation in the TAR could have been missed. The surveyor requested all wound care documentation during the onsite survey 8/18/2020 through 8/27/2020 and was told by DON B that there was no wound notes for (Resident #107). Review of the Psychiatric Consult dated 8/4/2020 at 1:03 PM, revealed Chief Complaint: I was in a bad place back at (name of facility). According to the HPI dictated by the admitting team, Patient is a [AGE] year old male with a history of diabetes, hypertension and [MEDICAL CONDITION] who is here today for follow up regarding his hospitalization after undergoing a left iliofemoral bypass. He has been miserable at the nursing home. For the first 3 days, the only thought him pureed foods and then slowly transition to regular food. He did not have the wound VAC place since admission at the nursing home up until yesterday. After the put it on , his pain has been much more pronounced in the area. He has been having some drainage through his abdominal incision for the last few days as well. He reports that they have not bathe him or given him a sponge bath since his admission. His PICC line dressing has not been changed either that he is aware of. He is teary and depressed and expressed suicidal ideation. Regarding Psychiatric HPI; Patient is reporting he is normally not a depressed or anxious person. However his experience at (name of the facility) wasterroble. While he was there they would not feed him solid foods and did not care for his wound properly. For instance they applied H202 and non-sterile saline against the protocol and did not apply his wound vac until 5 days after his transfer there despite his orders stating otherwise. Pt states that he has been in significant amount of pain as a result and not been able to sleep. After a day or two at (name of facility) he became hopeless and went to a very dark place, pt was markedly depressed and thought his situation would never improve. During this time he barely slept, had poor appetite and started experiencing passive suicidal ideation (SI). Pt was also experiencing A empty and anxious feeling during this time period. He states that he has never felt like this before in his life. Now that his is at (name of hospital) pt states he is starting to feel a little better but is still very down. He is denying any current suicidal thoughts at the time of the interview and does not want his family visiting as long as he has a sitter because he does not want them to know he became that way. He did not endorse is directly but he does appear to be ashamed/guilty of having made these statements. At no time did he have a plan to attempt suicide and he has no prior attempts. Pt states his biggest reasons for living is his kids and grand-kids Review of the Vascular Surgery History and Physical Note dated 8/4/20 at 3:00 PM, revealed (name of Resident #107) is a [AGE] year old male who presents with worsening left groin wound. He has a past medical history of [REDACTED].stroke (2013) TIA ([MEDICAL CONDITION]) (12-2013) and [MEDICAL CONDITION]. Physical Exam- Blood Pressure 144/75 (high) Appearance: He is obese. He is ill-appearing. He is not diaphoretic. Abdominal: Comments: Abdominal incision with mild induration in the middle aspect, ecchymosis, and drainage. Two staples kept intact and rest removed. Right groin healing with no tenderness or drainage noted. Left groin with induration along medial and inferior aspect of the wound, [DIAGNOSES REDACTED], mild odor, significant slough and [MEDICATION NAME] in wound bed. Plan: Will obtain CT scan to further evaluate for fluid collections or abscesses .Depending on CT findings, patient may need an operative debridement for his left groin. He is understanding of this. Review of Operative Note dated 8/6/2020 at 6:30 PM, revealed Preoperative Diagnosis 1. Left groin wound breakdown 2. Concern for infected bypass graft Postoperative Diagnosis: [REDACTED]. Sartorius flap coverage of graft in left groin 3. Wound VAC placement in left groin (10cmx4cmx3cm) 4. Abdominal wound debridement of necrotic fat tissue 5. Evacuation of abdominal wall/incisional hematoma 6. Placement of Wound VAC in abdominal incision (21cmx6.5cmx4cm). Narrative: (name of Resident #107) is a [AGE] year-old male who presented with increasing pain in the left groin with incisional changes along his abdominal incision as well as breakdown of his left groin wound. He had an elevated white count on admission and a CT scan was performed. The CT scan showed fluid collections in the groin, abdominal wall with gas present suggestive of infection. He was recommended to have a debridement performed as well as possible sartorius flap for graft coverage in the groin .Findings: Hematoma present in the abdominal wall incision with no gross purulence or odor identified. Cloudy serosanguineous fluid noted in the left groin with no gross purulence identified. Fat necrosis present in both wound beds. Review of the Consult for Infectious Disease dated 8/7/20 at 3:43 PM, revealed Reason for Consult: Presumed postoperative infection with retained hardware. Assessment/Plan Antibiotics [MEDICATION NAME] start 7/27 continue [MEDICATION NAME] start 8/6 continue [MEDICATION NAME] start 8/6/continue . Microbiology: Left groin wound (surgical site): 8/6 Rare staph aureus - reincubated Left groin tissue: 8/6: Moderate staph aureus, acinetobacter baumanni, rare [DIAGNOSES REDACTED] pneumoniae, few [MEDICATION NAME] faecalis. Abdominal incision #1: 8/6: Rare staph aureus - reincubated. Abdominal incision: 8/6: Acinetobacter baumanni - reincubated. Patient is a [AGE] year-old male with a past medical history of [REDACTED]. Patient is currently postop day 1 from debridement of the left groin with sartorius flap past over graft and wound VAC. Necrotic fat tissue was evidenced in the abdominal was incision as well as left groin, no purulence noted. Patient was place on broad-spectrum antibiotics, cultures were collected. Presumed postoperative infection with retained hardware History of [MEDICAL CONDITION] with critical limb ischemia of the left lower extremity status [REDACTED]. [DEVICE] in place over abdominal incision as well as left groin wound. Cultures returning growing multiple bacteria including gram-positive's, and gram-negative's as well as Pseudomonas and MSSA of note. Patient of does have a history [MEDICAL CONDITION] on left groin as well as mixed anaerobes. As patient has retained hardware the left graft patient will require suppressive therapy as ling as graft continues to be retained. Continue broad-spectrum antibiotics, patient will likely need 4 to 6 weeks of IV antibiotic prior to initiation of suppressive therapy. Consideration should be given to alternative surgical approaches . Review of the Operative Notes dated 8/15/20 at 4:38 PM, revealed Preoperative Diagnosis: [REDACTED]. Debridement of abdominal and left groin wound 3. Placement of wound vac to abdominal and left groin wound. Narrative: (Name of Resident #107) is a [AGE] year-old male who presented with worsening left groin wound. He was taken to the operating room for exploration after a CT scan showed fluid collections with gas present. The fluid did not appear to be grossly purulent but cultures were taken. Cultures were polymicrobial (multiple specimens of microorganisms). He was recommended to have the graft removed as the graft can get seeded with bacteria and become difficult to treat. Risks, benefits, and complications were reviewed. Informed consent was obtained. Findings: Clear drainage around the bypass graft in groin noted with no odor, Minimal fluid around graft in the abdomen, Wound vac abdomen 20.0 x 2.0 x 2.0 cm, Wound vac groin 9.0 x 4.5 x 2.0 cm. On 8/21/20 the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy that began on 7/29/20 due to the facility's failure to follow the physician's discharge order, contact the physician and consult the vascular surgeon prior to implementing a non-ordered dressing, and correctly apply a wound vac. A written plan for removal for the immediate jeopardy was received on 8/21/2020 and the following was verified on 8/25/2020 and 8/27/2020: 1. On 8/21/2020, skin assessments were completed on residents residing in the facility and treatment orders were reviewed to ensure appropriate. There are no residents residing in the facility that require a negative pressure device (Wound Vac). 2. On 8/21/2020, new admissions for the last 30 days sere reviewed to ensure orders for wound re were transcribed correctly. 3. On 8/21/2020, consults for the last 30 days were reviewed to ensure new orders/recommendations for wound care have been reviewed with the MD and transcribed to the resident record. 4. On 8/21/2020, the Administrator and DON reviewed the policies and procedures for order entry and competency training for negative pressure devices. 5. Beginning on 8/21/2020, licensed nurses are being re-educated on order entry/transcription, when to consult a specialist for order changes, and the application of a negative pressure device. Licensed nurse staff will not work without receiving education. 8 of 11 nurses have received training on order entry, transcribing orders and when to consult a specialist for order changes. Vendor providing negative pressure device, provided training to Regional Clinical Directors (RDC) and Staff Development Nurse (SDC). Facility will not accept admissions requiring a negative pressure device until competency training has been completed. 6. Education completion by Regional Clinical Directors, Staff Development Nurse or Director of Nursing (DON). 7. Beginning on 8/21/2020, new admissions and residents with consults will be reviewed by the Interdisciplinary Team (IDT) to ensure that orders are entered for negative pressure devices. 8. Beginning on 8/21/2020, the nurse manager will complete a direct care observation of residents with new orders for negative pressure devices to ensure they are being followed. 9. Weekly for one month and then monthly the DON/designee will conduct an audit of residents with negative pressure devices to verify that treatments are applied per order. 10. If a resident requires a negative pressure device the assigned staff will be reevaluated for competency prior to giving and accepting the assignment. Although the immediate jeopardy was removed on 8/21/2020, the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

This citation pertains to MI 085 . Based on interview, and record review the facility failed to ensure residents received care and services consistent with professional standards for the prevention of pressure ulcers in 3 of 3 residents (Resident #101, #105, and #102), reviewed for pressure ulcers, from a total sample of 12 residents, resulting in skin impairment and the potential for the worsening or development of new pressure ulcers. Findings include: Review of the facility's Pressure Ulcers/Pressure Injury Prevention and Treatment Clinical Protocol, dated , revealed .Purpose .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; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .Change of condition/New skin alteration .a. Complete head to toe skin assessment, document in the medical record . a. Complete head to toe skin assessment, document in the medical record; b. Notify Physician; c. Obtain new orders as needed .e. Complete new Norton's Plus scale . g. Update plan of care to reflect any new risks, goals, and interventions .With each dressing change, or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI(s) be documented. At a minimum, documentation should include the date observed, location, staging, size (perpendicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; exudate, if present; type (such as purulent/serous), color, odor, and approximate amount; Pain, if present: nature and frequency (e.g., whether episodic or continuous); Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and description of the wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate . Resident #101 Review of the Face Sheet revealed Resident #101 was a [AGE] year-old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of Resident #101's Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was cognitively intact. In an interview on 5/8/20 at 3:00 PM, Infection Control Preventionist (ICP) K indicated managed the wounds at the facility. ICP K indicated rounded on all wounds once a week and documents wound measurements and descriptions on a wound care third-party website. ICP K indicated Resident #101 has multiple areas of impaired skin on his stomach, coccyx, lower legs, heels and feet. Resident #101's lower leg skin impairment were mostly related to [MEDICAL CONDITION] (blockage of lymphatic vessesls that leads to fluid retention), vascular issues (lack of adequate circulation), and chronic bilateral heel pressure wounds. ICP K has had his bilateral legs (mid-foot to knee) wrapped once a week since he admitted (May 2019). ICP K indicated was the only nurse Resident #101 permitted to treat his legs and heel pressure wounds. Review of Resident #101's April Treatment Administration Record (TAR) revealed the order .Cleanse Lower legs and feet with [MEDICATION NAME] solution (antimicrobial skin wash), rinse and pat dry. Apply collagen (non-adhering dressing for wounds with drainage) to both heel ulcers covered with [MEDICATION NAME] ag (cover bandage for wounds with drainage). Apply lachydrin lotion to lower legs and feet. Wrap with cotton underpad wrap, wrap with coban. DO NOT cover the toes with coban (elastic bandage). Cover toes with dry dressing. every day shift every Fri -Start Date- 03/27/2020 (6:00 AM)-Hold Date from 04/22/2020 (1:07 PM) . No treatment in the TAR was marked as completed for the entire month of April (0 of 4 treatment days). Review of Resident #101's Wound Assessments revealed no assessment or description of Resident #101's bilateral heel pressure wounds for the month of April (completed weekly, 0 of 4). Review of Resident #101's electronic medical record (EMR) revealed no documented assessment or description of Resident #101's bilateral heel pressure wounds for the month of April. Review of Resident #101's wound assessment (documented on a third party wound care website) on 4/11/20 revealed he had a new .left calf wound .Length/Width/Depth .1.5/1.5/0.1 cm .[MEDICATION NAME] (as wounds heal [MEDICATION NAME] cells grow across the wound surface from edges to close wound, seen in stage II or greater pressure wounds) . The assessment also revealed a new .right calf wound . Length/Width/Depth . 0.5/0.5/0.1 cm .[MEDICATION NAME] . No description or diagram of the approximate location (lateral, upper, lower calf) was documented, and no staging, or wound type was documented for either calf wounds. For each calf wounds the treatment performed was .wash with [MEDICATION NAME], collage to heel and calf, foam AG to open areas, wrap with cotton underwrap . Review of Resident #101's Physician's Orders revealed no dressing order for the newly discovered bilateral calf pressure ulcers on 4/11/20 (the only related order found was for lower leg wraps and heel treatment dated 3/27/20). Review of Resident #101's April and May Treatment Administration Record (TAR) revealed no treatments for Resident #101's bilateral calf pressure wounds (due to no physician order). Review of Resident #101's Care Plan revealed no new skin integrity care plan interventions were added with the discovery of the bilateral calf pressure ulcers. The last updated intervention for the skin integrity care plan was 5/8/19 (admitted ). Review of Resident #101's Norton's Plus Scale assessments revealed no new assessment completed after the 4/11/20 discovery of Resident #101's bilateral calf pressure wounds. In an interview on 5/8/20 at 3:30 PM, ICP K indicated in mid-April (4/11/20) new bilateral wounds were discovered on Resident #101's calves. The new wounds began as moisture and shearing (pressure applied to tissues in the body due to forces moving in opposite directions) but later (4/11/20) developed into pressure wounds. ICP K indicated implemented a new dressing for the calf wounds that would be done at the same time as Resident #101's legs and heels were dressed (no physician order). ICP K indicated did not write a progress note alerting other staff that Resident #101 had new wounds or a new dressing treatment. ICP K indicated Resident #101 probably developed the wounds because he sits in a recliner all day and night and his calves are in contact with the recliner and the under sheet that covers the recliner. ICP K indicated that sheet collects moisture from Resident #101 sweating and drainage from his pannus wounds; the sheet transferred moisture to his lower leg dressings. ICP K indicated did not initiate any new care plan interventions to prevent the worsening of the calf wounds or development of new wounds. In an interview on 5/14/20 at 9:30 AM, Former Director of Nursing SS (FDN) indicated was on leave for a month and returned to the facility approximately March 15th. FDN SS indicated prior to the leave wound care was managed well. After returning from leave FDN SS indicated wound care management had slipped. FDN SS indicated had a difficult time balancing day to day operations, supervising wound management, and preparing for the impending COVID-19 outbreak. FDN SS indicated was not notified by ICP K Resident #101 had developed two new pressure wounds on 4/11/20. FDN SS indicated should have been notified and the staff would have met for an interdisciplinary meeting, implemented new care plan interventions, consulted our physicians, and ordered treatment. Review of Resident #101's electronic medical record (EMR) revealed Resident #101 was transferred from the facility April 22nd to the emergency room (ER) for a positive COVID-19 test result. Resident #101 returned to the facility later that evening. Resident #101 was moved from his room on Unit A to a new room on Unit B the COVID positive unit. Resident #101 was sent back to theER on [DATE] morning and was admitted until 5/7/20. Review of Resident #101's assessment Return from Leave and Transfer In (returned from ER) dated 4/22/20, revealed .Are there any new abnormal skin areas? .yes .List site(s) of any new abnormal skin areas .(area to list was blank, no site or areas listed) .Treatment initiated? .yes .Specify treatment initiated .see TAR . No refusals to observe skin was documented. Review of Resident #101's assessment Skilled Daily - Medically Complex - V 4 dated 4/23/20, revealed .Skin abnormal skin conditions (this box was checked yes) .Describe skin condtions . Various areas Bil lower legs, Under Panus Groin with tx (treatment) in place . No refusals to observe skin was documented in EMR. Review of Resident #101's TAR for April revealed Resident #101 had 5 separate skin treatment orders to prevent further skin breakdown for his groin folds, left and right side of his pannus (flap of excess skin, fat and tissue at the bottom of the abdomen), legs, heels, under his pannus, and coccyx. The TAR has hold dates for all the skin treatments as 4/22/20 (date Resident #101 transferred to the ER). These treatments were not restarted on 4/22/20 (when returned from the ER) and were not active from 4/22/20 to 4/30/20 (admit back to the hospital). Skin treatments were not restarted for Resident #101 for 7 days and the facility did not document 24 physician ordered skin treatments. In an interview on 5/14/20 at 2:00 PM, ICP K reviewed Resident #101's TAR for April and indicated did not restart Resident #101's skin and wound treatment orders when he returned from theER on [DATE]. The treatment orders were resumed on 5/8/20 when he returned from his hospital admission. Review of Resident #101's weekly skin assessments revealed the last documented skin assessment was 4/8/20. No refusals of skin assessments found in progress notes for April. Review of Resident #101's wound assessments revealed Resident #101's last wound assessment was done on 4/17/20. The left calf wound had reduced in sized to 1.0 x 1.0 cm and the right calf wound had resolved. Review of Resident #101's Wound Notes from hospital admission, dated 4/30/20, revealed Resident #101 presented to the hospital with .Pressure Injury Stage .DTPI (A deep tissue pressure injury is an intact purple or marron area caused by damage or pressure to soft tissues under the skin) . Wound Site Assessment .Maroon .100% dark maroon .Wound Length . 1.0 cm .Wound Width .1.0 cm . to the posterior left calf. On the right calf . Wound Length . 7 cm .Wound Width .8 cm . No documentation or assessment of either of these or any otheres areas of impaired skin integrity were found in the facility EMR or in the third party wound care website since 4/17/20. Review of Resident #101's Admission Record revealed Resident #101 returned from his hospital stay on 5/7/20. Resident #101's May TAR revealed Resident #101 had a dressing treatment done to his bilateral heels on 5/8/20 by Registered Nurse NN (RN). No wound assessment or wound description was found documenting the condition of Resident #101's calves or bilateral heel wounds. No treatment was ordered to address Resident #101's bilateral calf wounds. Review of Resident #101's assessment Skilled Daily - Medically Complex - V 4 dated 5/9/20 (2 days after return from hospital admission), revealed .Skin abnormal skin conditions (this box was checked yes) .Describe skin condtions .Multiple diabetic ulcers to BLE . No refusals to observe skin was documented in EMR. Review of Resident #101 Wound Assessment done 6 days after re-admission, dated 5/13/20 revealed .Right Calf . Acquisition: Reoccurring . First Observed: 4/11/20 .Type of Wound: Pressure . Stage: 3 . Length (cm) 9 . Width (CM) .8 . Depth (cm) 0.3 . In an interview on 5/14/20 at 2:00 PM, ICP K indicated the last time Resident #101's legs and heel pressure ulcers were treated and assessed at the facility was on 4/17/20. ICP K indicated did not assess Resident #101's legs after returning from theER on [DATE] and did not assess him 4/24/20 on his next scheduled treatment date. ICP K indicated did not document on the TAR that any of Resident #101's calves or heel treatments were completed. ICP K indicated on 5/13/20 evaluated Resident #101's calves and heels for the 1st time since 4/17/20. ICP K indicated the DTPI identified on Resident #101's left calf in the hospital was resolved and the wound identified in the hospital on Resident #101's right calf has reopened and was now a stage 3 pressure wound. This citation pertains to MI 173. Resident #105 Review of a Admission Record revealed Resident #105 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 7/4/19 revealed staff conducted the Assessment for Mental Status to determine the cognitive skills for daily decision making indicated Resident #105 were moderately impaired, and on 4/4/20 a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #105 was cognitively moderately impaired. Review of the General Nursing Note dated 5/3/2020 at 1:32 PM revealed Resident refusing to eat and drink. Checked pulse ox due to cough and appearing to have difficulty breathing. Pulse ox between 79-90. Attempted x3 to reach on call Nurse Practitioner (NP) received an ok to have oxygen available for resident as needed Review of the General Progress Note dated 5/3/2020 at 5:36 PM, revealed Resident transferred to (name of hospital) via (name of ambulance) per families request. Paperwork, med list, (do not resuscitate) DNR, (power of attorney)POA, Facesheet, sent with resident. Resident was on nonrebreather when left facility. Review of the Hospital Wound Ulcer Incision Assessment - Text dated 5/4/2020 at 9:00 AM and revised at 3:38 PM, revealed Registered Nurse documented Wounds. Incision/Wound Care Wound 1: Wound 1 Type: Pressure injury; Wound 1 Present on admission: Yes; Status-Wound: Current; Wound 1 Location: Coccyx; Wound 1 Location Detail: Medial; Pressure Injury Stage-Wound 1: Suspected Deep Tissue Injury; Incision/Wound Care Wound 2: Wound 2 Type: Pressure injury; Wound 2 Present on admission: Yes; Status-Wound 2: Current; Wound 2 Location: Buttock; Wound 2 Location Details: Right; Wound 2 Description: Ecchymotic (a discoloration of the skin resulting from bleeding underneath); Wound 2 Drainage Amount: None; Pressure Injury Stage-Wound 2: Suspected Deep Tissue Injury; Incision/Wound Care Wound 3: Wound 3 Type: Pressure Injury; Wound 3 Present on admission: Yes; Status-Wound 3: Current; Wound 3 Location: Hip; Wound 3 Location Detail: Right; Wound 3 Description: Other: Adherent foam is in place; Wound 3 Drainage Amount: None. Incision/Wound Care Wound 4: Wound 4 Type: Pressure Injury; Wound 4 Location: buttock; Wound 4 Location Detail: Left; Wound 3 Description: Ecchymotic; Wound 4 Drainage Amount: None; Pressure Injury Stage-Wound 4: Suspected Deep Tissue Injury. Review of the Hospital Wound Ulcer Incision assessment dated [DATE] at 12:38 PM, revealed Wound Consult documented Incision/Wound Care Wound 1: Wound 1 Type: Pressure injury; Wound 1 Present on admission: Yes; Status-Wound: Current; Wound 1 Location: Coccyx; Wound 1 Purple Percentage: 100%; Wound 1 Location Detail: Medial; Wound 1 Odor: Odor free; Wound 1: Ecchymotic; Pressure Injury Stage-Wound 1: Suspected Deep Tissue Injury; Wound 1 Surrounding Tissue: Denuded (to make naked), Fragile; Dressing Condition/Intervention (Barrier Cream); Incision/Wound Care Wound 2: Wound 2 Type: Pressure injury; Wound 2 Present on admission: Yes; Status-Wound 2: Current; Wound 2 Location: Buttock; Wound 2 Purple Percentage: 100%; Wound 2 Location Details: Right; Wound 2 Odor: Odor free; Wound 2 Description: Ecchymotic; Wound 2 Drainage Amount: None; Pressure Injury Stage-Wound 2: Suspected Deep Tissue Injury; Wound 2 Surrounding Tissue: Denuded, Fragile; Dressing Condition/Intervention Wound 2: (Barrier Cream); Incision/Wound Care Wound 3: Wound 3 Type: Pressure Injury; Wound 3 Present on admission: Yes; Status-Wound 3: Current; Wound 3 Location: Hip; Wound 3 Purple Percentage: 100%; Wound 3 Location Detail: Right; Wound 3 Odor: Odor free; Wound 3 Description: Ecchymotic; Wound 3 Drainage Amount: None; Pressure Injury Stage-Wound 3: Suspected Deep Tissue Injury; Wound 3 Surrounding Tissue: Fragile, Pink; Dressing Condition/Intervention Wound 3 Foam Adherent. Review of the Hospital Wound Ostomy Continence Note dated 5/4/2020 at 12:44 PM, revealed Wound Consult, Patient skin assessed at bedside in Covid-19 unit. Patient is positive for Covid-19. Patient turned and skin assess with (name of Registered Nurse). Patient noted to have deep tissue pressure injury to coccyx, left buttock (SIC) and right hip. The left hip has surrounding blanchable [DIAGNOSES REDACTED] from laying on that side prior to turn. The buttocks and perineal area have mild denuding from IAD (Incontinence Associated [MEDICAL CONDITION]). The patient is malnourished and his skin is very fragile. Recommend adherent foam to right hip for pressure reduction and barrier cream to the buttocks, coccyx and perineal areas. A pressure reduction overlay has also been ordered for the bed to help reduce pressure Review of the Hospital Wound Ostomy Continence Note dated 5/8/2020 at 2:13 PM, revealed Wound assessment, Wound assessed at bedside. Message from (name of Registered Nurse) in regards to possible worsening of deep tissue injury to right buttock. On admission the pressure injury was noted to be a deep tissue pressure injury. This has now evolved into an unstageable pressure injury. An unstageable pressure injury will most likely, evolve into a stage 3 or 4 when the wound base is clean. At this time there is a thin layer of fibrous tissue covering the wound bed. A Waffle cushion has been ordered since the patient is no longer on a critical care bed surface Will follow up early next week. Review of the Nursing Admission Evaluation (Re-Admission) dated 5/9/2020 at 6:20 PM, revealed 1. Skin a. Does the resident have any identified skin conditions/wounds? (Yes) b. 25) (Site) Right trochanter (hip), (Type) Pressure, (Units of measure: Centimeters) 2.5 Length 1.2 Width Stage 1-- 32 (Site) Left Buttock, (Type) Pressure, (Unites of measure: Centimeter) 3.2 L 2.7 W Stage 2. Review of the Skin assessment dated [DATE] at 4:20 AM, revealed Description weekly skin assessment A. Skin Evaluation 1. Are there any new abnormal skin areas? (no) 2. confirmed that a full skin assessment and no new abnormal skin areas were observed. 5. Are there any existing abnormal skin areas? (no). In an interview on 5/14/20 12:57 PM, Licensed Practical Nurse (LPN) ZZ reported that on A hall where there are still skin assessments weekly you would just put on the (personal protective equipment) PPE. LPN ZZ reported that the User Defined Assessment (UDA) board was to remind staff when scheduled assessment are due, so when she logs into the compute it will pop and show what skin assessment are due and will pop up red if past due. LPN ZZ reported that the first shift nurse also let her know what skin assessments she did not do, sometimes, but LPN ZZ reported she will generally look and see what she needs to do. LPN ZZ reported that Resident #105 ended up going to the hospital on the 5/3/2020 and she was new to the A-hall and shifts had been changed and medication pass may have taken extra long. LPN ZZ reported that (Resident #105) was defiant when taking medication, could be aggressive to care with Certified Nursing Assistant's (CNA's) changing his clothing doing incontinent care, but that she did not recall CNA's reporting any concerns with his bottom. LPN ZZ reported that she did not do the skin assessment that was due on 5/1/2020. In an interview on 5/14/20 at 1:42 PM, LPN AB reported that (Resident 105) has a habit of refusing care and medication, and has a general decline, due to his refusal of care. LPN AB reported that prior to (Resident #105) going to the hospital on [DATE], we attempted to do skin assessments, but trying to take care of the critically ill patients with high temperatures, keeping those temps down, and other basic needs like hydration's which required extra fluids, became more of a priority and a focus. LPN AB reported we attempted to turn residents timely which would help prevent wounds and skin breakdown and also did check and change the residents. In an interview on 5/14/20 at 3:33 PM, CNA D reported that (Resident #105) has to be rolled, will say that his back hurts, that prior to going to the hospital his right hip was red. CNA D reported that (Resident #105) had been treated by therapy for pain in that right hip and a sore last year, but that the right side was the side (Resident #105) liked to lay on. CNA D reported that the nurses were aware that the right hip was red, the computer charting done gives a spot to document if I see something new to me and if I told the nurse. Review of the Behavior Record from 4/23/20 - 5/7/20, revealed no documented behaviors for Resident #105. Review of the Activity of Daily Living (ADL) Care Plan dated 8/11/19, revealed · The resident needs activities of daily living assistance related to: Activity Intolerance, Deconditioning, Impaired balance. Often declines care and will decline therapy as well. He prefers to remain in room in w/c and needs encouraged to leave his room. Often asks for alcohol and has hx of ETOH abuse. Resident with history of declining incontinence care. Revision date 8/11/19 Goal · ADL Care needs will be met throughout his stay Revision on: 04/16/2020 Interventions · BED MOBILITY: The resident can turn independently in bed, he has a body pillow that he repositions himself for comfort Revision on: 01/09/2020 · BED MOBILITY: The resident is able to manage bed mobility by use of enabler bars to assist in bed positioning. Revision on: 04/16/2020 · PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assist x1 Revision on: 10/17/2018. Review of the History of Pressure Ulcer Development Care Plan dated 4/18/19, revealed, · The resident has history of pressure ulcer development. Has thin fragile skin. He has history of low [MEDICATION NAME] levels and is thin in statue secondary to ETOH abuse prior to admission. Revision on: 04/18/2019 Goal · The resident skin alterations will resolve without complications Revision on: 04/16/2020, Interventions · Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 12/29/2017 · Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 12/29/2017. Review of the Norton Plus Pressure Ulcer Scale dated 4/2/20 at 6:00 AM, revealed Resident #105 was a moderate risk for pressure ulcers. Risk Factors 1. Physical Condition (Fair) 2. Mental State (Alert) 3. Activity (chair bound) 4. Mobility (very limited) 5. Incontinence (double incontinence) B. 1. [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. 5 or more medication (yes). Review of the Medication Administration Record [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Interdisciplinary Nursing Notes dated 1/22/20 through 5/5/20, revealed no documentation that Resident #105 was refusing care. Resident #102 Review of an Admission Record revealed Resident #102 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/13/20, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated the resident was cognitively intact. Further review of Resident #102's MDS assessment, dated 3/13/20, revealed no documented skin conditions, which included pressure ulcers, skin tears, and Moisture Associated Skin Damage (MASD). Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 4/23/20, revealed no documented skin conditions, which included pressure ulcers, skin tears, and MASD. Review of the Care Plan for Resident #102 revealed the focus .has hx (history) of pressure ulcer development to the following areas (left and right buttock), r/t (related to) Immobility (related to left AKA (above knee amputation) and right BKA (below knee amputation)), DM (diabetes) type 2, [MEDICAL CONDITION] and history of declining assistance with repositioning, history of declining assist with care and getting out of bed . initiated 12/14/17, and revised 4/18/19. Review of the interventions for this focus revealed no new interventions were implemented since 12/15/17, and no existing interventions were revised since 8/11/19. Review of the Care Plan for Resident #102 revealed the focus .Resident has a non-pressure wound abrasion(s) to the following areas left gluteal fold. Resident continues to refuse treatment to area. Education has been provided regarding risks of no treatment . initiated 1/3/20, and revised 1/30/20. Interventions included .administer medications/treatments as ordered - see electronic health record for specific instructions. Observe for effectiveness and complications . initiated 1/3/20, and .observe lesion weekly, during treatments and when necessary. Notify physician as needed of worsening . initiated 1/3/20. Review of the interventions for this focus revealed no new interventions were implemented and no existing interventions were revised since 1/3/20. Review of the Wound History for Resident #102, dated 1/3/20, revealed .Right Buttock .Open .Length / Width / Depth: 1.4 / 1.3 / 1.0 cm .Thickness/Stage: N/A .Tissue Type: Granulation .Exudate Type: Color: Sero-sanguinous .Wound Bed: Granulation .Surrounding Skin: Maceration .Acquired: Reoccurring .Type of Wound: MASD (Moisture Associated Skin Damage) .Odor: Yes .Exudate Amount: Heavy .Primary Dressing: Calcium Alginate Ag 12 Rope with Silver Dressing, QD (once a day) .Secondary Dressing: per resident choice, QD .Education provided to resident about risks of not having a covering to wound. Educated on risks of refusing dressing changes and not turning and positioning as recommended. Resident verbalized understanding that failure to follow treatment orders and not turning and repositioning could result in infection which could lead to osteo[DIAGNOSES REDACTED],[MEDICAL CONDITION] and eventually death. No concerns noted from resident. NP (Nurse Practitioner) notified of wound . Review of a Skin Assessment for Resident #102, dated 3/11/20, revealed .Resident did not allow Nurse to view bottom. Treatment is in place to bottom . Review of a Skin Assessment for Resident #102, dated 3/18/20, revealed .Resident has ongoing Right gluteal fold abrasion. Resident is non-compliant with dressing changes . Review of a Skin Assessment for Resident #102, dated 3/27/20, revealed .Abrasion to Left gluteal fold. Non-compliant with dressing changes. TX (treatment) per TAR . Note this area is opposite what was noted on the previous skin assessment. Review of a Skin Assessment for Resident #102, dated 4/3/20, revealed .Ongoing abrasion to Left buttock. TX (treatment) per TAR. Resident is non-compliant with dressing changes . Review of a Skin Assessment for Resident #102, dated 4/10/20, revealed .Open area to Left and right buttocks. TX (treatment) per TAR. Resident non-compliant with dressing changes . Note open area is now noted on both the right and left buttocks. Review of a Skin Assessment for Resident #102, dated 4/17/20, revealed .Resident non-compliant with dressing changes to his buttocks. Two abrasions noted to either side of his buttocks . Review of a Skilled Daily - Medically Complex assessment for Resident #102, dated 4/20/20, revealed .Abnormal skin conditions .ongoing wound to bottom. treatments in place and implemented . Review of a Skilled Daily - Medically Complex assessment for Resident #102, dated 4/22/20, revealed .Abnormal skin conditions .Ongoing wound treatment to buttock. Resident choose not to allow this nurse to assess . Review of the Wound History for Resident #102, dated 4/24/20, revealed .Right Buttock .Open .Length / Width / Depth: 1.4 / 1.3 / 1.0 cm .Thickness/Stage: N/A .Tissue Type: Granulation .Exudate Type: Color: Sero-sanguinous (sic) .Wound Bed: Granulation .Surrounding Skin: Maceration .Acquired: Reoccurring .Type of Wound: MASD (Moisture Associated Skin Damage) .Odor: Yes .Exudate Amount: Heavy .Primary Dressing: Calcium Alginate Ag 12 Rope with Silver Dressing, QD (once a day) .Secondary Dressing: per resident choice, QD .Measurements noted are from 1/3/20. Resident has consistently declined staff to observe or measure buttocks wounds. Will continue to re-approach. NP aware of refusals . Review of an Orders - Administration Note for Resident #102, dated 4/26/20, revealed .Resident on back stated did not want to lay on his side. Buttocks area red, macerated, excoriated .Buttocks to mid thigh red and macerated with no drainage noted, tender to touch. Reviewed with resident staying off his back and originally declined and then agreed to turning on his right side. resident is a 2 assist to turn and reposition .Resident uses turn assist bar however, is extensive assist with turning and re positioning . Review of an Order Summary Report for Resident #102, dated 5/1/20, revealed an active physician order to .Cleanse open areas on bilat buttocks with ns, pat dry - apply thin layer of [MEDICATION NAME]/AG wound gel. every 4 hours for protection . with a start date of 8/12/19. Review of an Order Summary Report for Resident #102, dated 5/1/20, revealed an active physician order to .Right gluteal fold: Cleanse with ns, pat dry, fluff with silver alginate rope. every day shift . with a start date of 1/4/20. In an interview on 5/12/20 at 4:16 p.m., Licensed Practical Nurse (LPN) K stated in regard to Resident #102's wounds .He initially let me assess them (the buttock wounds). Once I told him the treatment, he wouldn't let me assess them again. He wouldn't let the nurses treat the wounds or assess the wounds . LPN K reported there were times when Resident #102 would allow the nursing staff to observe the buttock wounds, and stated in regard to the wounds worsening .it did progress . LPN K reported the wounds .started as moisture and shearing. He did not change positions .wouldn't turn side to side .He was very particular with his care . LPN K reported Resident #102 .was very anti-male . and preferred female caregivers. LPN K reported skin assessments were scheduled weekly, as Resident #102 would allow. LPN K reported the nurses and CNA's would notify him of changes in the con (TRUNCATED)

This citation pertains to MI 884 and MI 1886 . Based on observation, interview and record review, the facility failed to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines and facility policy to prevent the spread of Covid-19 in 17 of 22 sampled residents (Residents #101, #107, #111, #108, #115, #104, #110, #117, #118, #120, #119, #112, #106, #103, #100, #113, and #114) reviewed for infection control, resulting in an immediate jeopardy when, beginning on beginning on 4/23/2020, facility staff did not implement established infection control standard interventions to provide care for, and prevent the spread of Covid-19 to staff members and residents in the facility. This deficient practice placed all residents at risk for serious harm and/or death. On 4/28/2020 at 1:20 PM, the Nursing Home Administrator was verbally notified and received written notification of the Immediate Jeopardy that was identified on 4/23/20 due to the facility's failure to implement infection control precautions for confirmed COVID -19 positive residents, to inform staff of newly COVID-19 positive residents, and instruct staff to don appropriate PPE when caring for these COVID -19 positive residents. A written plan for removal for the immediate jeopardy was received on 4/30/20 and the following was verified on 5/1/20. 1. On 4/23/20, the 11 residents that tested positive were placed into precautions per CDC guidance on the isolation hall .Facility started moving the residents once rooms on isolation hall were ready at approximately (4:30 PM). Staff members were notified that 11 residents were being moved due to positive test results. Administrator validated that there were appropriate and sufficient amounts of PPE available on the isolation hall to care for the influx of residents. Residents continue to be monitored for symptoms of infection. 2. On 4/23/20 the care plans, orders, and kardex for identified residents were updated to reflect the need for isolation. 3. Beginning on 4/23/20, at (2:00 PM), the Administrator and DON reviewed the need for isolation and proper PPE with the facility staff, which includes aides, temp aides and support aides. No staff has worked without receiving this review 81 of 117 employees have been notified. 4. On 4/23/20 at (6:00 PM), the Administrator, DON, and Unit Manager conducted rounds to ensure that appropriate PPE was available for staff and it was in use. 5. On 4/23/20 at (6:00 PM), the Administrator, DON, and Unit Manager were educated regarding requirements for isolation related to COVID-19 and notification of staff by .Regional Clinical Director. 6. On 4/23/20, residents that reside in the facility were reviewed by the IDT to ensure necessary precaution were in place and staff were wearing appropriate PPE. Following the review residents were in proper isolation with appropriate PPE worn by staff. 7. Beginning on 4/23/20, residents that are considered suspicious for COVID illness will be reviewed with MD/NP and placed into droplet precautions, with their orders, care plans and kardex updated, per CDC guidance. 8. Direct care observations audits will be conducted by the Infection Preventionist/Designee weekly starting on 4/29/20. Audits will be completed on all shifts weekly for 4 weeks and then a minimum of monthly on all shifts. Audits will be reviewed by QAPI and continue until substantial compliance is maintained. 9. Admissions/readmissions will continue to be evaluated per CDC guidelines and the medical record will reflect interventions based on their current assessment. 10. On 4/30/20 at (2:30 PM) education with staff was initiated by the Administrator/designee regarding infection control implementation processes. No staff will work without receiving education. Although the immediate jeopardy was removed on 5/1/20 after the facility began to implement the local health department recommendations, the facility remained out of compliance at a scope of widespread with a severity of no actual harm but the potential for more than minimal harm that is not immediate jeopardy due to all facility staff had not yet received education and the state agency had not yet verified sustained compliance. Findings include: Review of the facility's Coronavirus Surveillance policy, dated 3/11/20, revealed .Coronavirus is [MEDICAL CONDITION] that causes mild to severe respiratory illness .COVID-19 (short for coronavirus disease 2019) is a new respiratory disease caused by a novel (new) coronavirus .What is currently known is that it is spread person-to-person, mainly between people who are within 6 feet of one another through respiratory droplets produced when an infected person coughs or sneezes .This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness What is currently known is that it is spread person-to-person, mainly between people who are within 6 feet of one another through respiratory droplets produced when an infected person coughs or sneezes .The Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations .Heightened surveillance activities will be implemented to limit the transmission of COVID-19 . Staff shall follow established procedures when COVID-19 is suspected .Considerations for managing residents with suspected or confirmed COVID-19 infection .Use clinical features and epidemiologic risk for making a determination that COVID-19 infection is suspected. Test for COVID-19 in accordance with current CDC guidelines . Review of the facility's Isolation Gown Use during Infection Outbreaks policy, dated 4/10/20, revealed .The use of isolation gowns during infection outbreaks will be in accordance with current CDC guidelines . Review of the State of Michigan Operations Manual, revealed .RECOGNIZING, CONTAINING AND REPORTING COMMUNICABLE DISEASE OUTBREAKS .Refer to CDC guidelines for current recommendations on standard and transmission-based precautions .INFECTION CONTROL POLICIES AND PROCEDURES .The facility must develop and implement written policies and procedures for the provision of infection prevention and control. The facility administration and medical director should ensure that current standards of practice based on recognized guidelines are incorporated in the resident care policies and procedures . Review of the Centers for Disease Control and Prevention website, updated 4/13/20, revealed .If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance includes detailed information regarding recommended PPE . HCP (Health care providers) who enter the room of a patient with known or suspected COVID -19 should adhere to Standard Precautions and use a respirator (or facemask if a respiratory is not available), gown, gloves, and eye protection (droplet precautions) . If there are shortages of gowns, they should be prioritized for: aerosol generating procedures .care activities where splashes and sprays are anticipated .high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP. Examples include: . dressing . bathing/showering .transferring .providing hygiene .changing linens .changing briefs or assisting with toileting .device care or use . https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html In an interview on 4/22/20 at 1300, Nursing Home Administrator (NHA) A and Infection Control Preventionist (ICP) C indicated the facility had 17 COVID-19 residents. NHA A indicated the facility created a COVID -19 positive hall on Unit D that adhered to droplet precautions. The 17 COVID-19 positive residents had been moved from Unit D to Unit B. NHA A indicated the remaining residents on Unit D with negative COVID-19 test results were deemed presumptive COVID-19 positive due to the potential of communal spread of COVID -19. NHA A indicated Unit D residents were placed in droplet precautions, and staff were required to don gown, gloves, and a face mask at all times when working on the hall. ICP C indicated on Unit A Resident #102 had tested positive for COVID-19 and Resident #103 was exposed to a COVID-19 resident from Unit D; and both of these residents remain on Unit A and were placed on droplet precautions. ICP C indicated have tested a total of 41 residents from Unit A and C, suspecting those residents were also exposed to COVID-19 through communal living. Units A and C were not placed on droplet precautions. During an observation on 4/22/20 at 9:35 AM, there were no signs on Unit D's interior door visable from the nursing unit, (presumptive COVID-19 positive hall) that indicated to staff and visitors that Unit D's residents were under any kind of transmission-based precautions and no one should enter without instructions on PPE use. In an interview on 4/22/20 at 2:00 PM, NHA A indicated Unit D did not have signage that indicated the hall was on isolation or transmission based precautions NHA A indicated there should be a sign on Unit D's indicated this and no one should enter through that door without speaking to a staff member. In an interview on 4/23/20 at 9:10 AM, NHA A indicated 13 of 41 residents that were tested from Unit A and C had tested COVID-19 positive. NHA A indicated Unit A had 5 COVID- 19 positive residents (#100, #101, #102, #103, and #112) and Unit C had 8 COVID-19 positive residents (#104, #105, #106, #107, #108, #109, #110, #111). NHA A indicated Residents #101 and #103 were already in droplet precautions due to exposure. NHA A indicated would move the 11 other COVID-19 positive residents to Unit B and place them in droplet precautions. In an interview on 4/23/20 at 10:30 AM, NHA A indicated the facility has had 4 staff members who had tested positive for COVID-19. NHA A reported they would not test anymore of their staff members for COVID-19. In an interview on 4/23/20 at 10:40 AM, met with NHA A, ICP C, Director of Nursing B (DON), and Regional Nurse Consultant 2 BB (RNC 2). NHA A indicated she was not going to test staff members for COVID-19 but would instead require all staff to wear a N95 mask (respiratory mask) and wear a gown throughout the facility to protect residents not infected with COVID-19 from staff potentially infected but asymptomatic. In an interview on 4/23/20 at 11:40 AM, Health Department Director CC (HDD) indicated would come to the facility and hold an event to test all staff members at the facility. HDD CC indicated would use the health department's test kits and the testing would be free. HDD CC indicated it strongly recommended the staff testing to determine a timeline to know when to potentially lift isolation precautions, to track staff to resident exposure to [MEDICAL CONDITION], to track spread through the building, and to determine where infection control education could be directed. In an interview on 4/23/20 at 11:50 AM, NHA A indicated received the offer from the Health Department regarding a staff testing event for COVID-19. NHA A later indicated at 1:00 PM that the facility choose not to allow the COVID-19 testing event to occur. During an observation on 4/23/20 at 12:15 PM, no staff on Unit A, Unit C, or in common areas were observed wearing gowns to protect residents from potentially being exposed to COVID -19 positive staff. During an observation on 4/23/20 at 10:00 AM, on Unit A the newly diagnosed COVID-19 Residents #100, #101 and #112 did not have signs (i.e. Please see nurse before entering room) on their doors alerting staff that those residents were COVID-19 positive. No bins of PPE were observed outside their rooms or anywhere on the hall. Resident #101 Review of a facility Admissions Record revealed Resident #101 was an [AGE] year-old female originally admitted to the facility on [DATE] that was diagnosed positive for COVID-19 on 4/23/20. During an observation on 4/23/20 at 10:15 AM, Certified Nursing Assistant O (CNA) on Unit A entered COVID-19 positive Resident #101's room to give care. CNA O did not don a gown or eye wear to provide care. In an observation and interview on 4/23/20 at 10:05 AM, Nurse Educator E (NE) was working on Unit C and indicated 8 of 20 residents on Unit C had tested positive for COVID-19 earlier that morning. No signs (i.e. Please see nurse before entering room) were observed on Resident #104, #105, #106, #107, #108, #109, #110, or #111's doors alerting staff which residents were COVID-19 positive. No bins of PPE were observed outside of the COVID-19 positive rooms nor were they observed in any other space on Unit C. Review of a facility Admissions Record revealed Resident #116 was a [AGE] year-old female originally admitted to the facility on [DATE] that was diagnosed positive for COVID-19 on 5/1//20. During an observation on 4/23/2020 at 12:20 PM, blue surgical gown and yellow gown where hanging on the left inside wall as you step into Resident #101's room on a white hook next to the plastic box holding the glove box. The gowns were touching the back of the TV, the side and back of a three-drawer dresser, colored pictures on the wall, power cords for the electronic items, and the resident's waste receptacle. Resident #101 was sitting in a wheelchair facing the TV and the door entry and she proceeded to perform coughing with no mask placed to cover her mouth. Resident #101 was approximately 5 feet away from the entry door which was left open at this time and during multiple observations on this date. Certified Nursing Assistant T donned the blue surgical gown by grabbing it from inside the door of the resident's room without gloves on. No face shield was donned prior to entering the room to assist roommate, Resident #116 with care. CNA T assisted Resident #116 to use the restroom, back to bed and to get situated prior to exit. Upon exit from the room, CNA T hung the blue surgical gown back on the white hook behind the Resident #101's TV. No sanitization of the gown occurred and it was hung back up on the white hook on the wall. CNA T utilized hand sanitizer after exiting the room, which was hung on the wall in the hallway. Resident #107 Review of a facility Admissions Record revealed Resident #107 was a [AGE] year-old male originally admitted to the facility on [DATE] that was diagnosed positive for COVID-19 on 4/23/20. In an observation on 4/23/20 at 10:10 AM, on Unit C Resident #107 was pacing up and down the hall. Temporary Nursing Assistant R (TNA) followed Resident #107 up and down the hall redirecting him from entering other resident rooms and pounding on both exit doors on opposite ends of the hall. TNA R was not wearing a gown or gloves when frequently touching and redirecting Resident #107. No sanitization of areas that Resident #107 repeatedly touched was observed. In an observation on 4/23/2020 at 11:00 AM, Registered Nurse (RN) E was observed assisting Resident #107, in the hallway by the nursing station room, with wearing a facial mask. RN E was observed not wearing a gown, gloves, or goggles/face shield. Registered Nurse (RN) E did not utilize use of appropriate personal protective equipment (PPE) when encountering a COVID-19 positive resident. In an observation on 4/23/2020 at 11:00 AM, Temporary Nurses Aid (TNA) R was assisting Resident #107 with applying hand sanitizer. TNA R was observed not wearing a gown or gloves. TNA R did not utilize use of appropriate personal protective equipment (PPE) when encountering a COVID-19 positive resident. Resident #111 Review of a facility Admissions Record revealed Resident #111 was an [AGE] year-old female originally admitted to the facility on [DATE] that was diagnosed positive for COVID-19 on 4/23/20. During an observation and interview on 4/23/20 at 1:30 PM, on Unit C no signs were observed on any COVID-19 positive resident's doors. No bins of PPE were observed outside of the COVID-19 positive rooms. CNA X and O entered COVID-19 positive Resident #111's room. CNA X and O provided a bed bath and incontinence care for Resident #111. Neither CNA wore a gown or eye protection. CNA O indicated was not instructed by management to wear a gown or eyewear when providing care for Resident #111 and asked, should we be?. CNA X indicated was not instructed by management to wear a gown with all residents to protect the residents from staff transmitted COVID-19. During an observation on 4/23/20 at 2:00 PM, on Unit C staff members were placing signs on doors to indicate which residents were COVID-19 positive. No PPE bins were observed on the Hall. Resident #108 Review of a facility Admissions Record revealed Resident #108 was a [AGE] year-old male originally admitted to the facility on [DATE] that was diagnosed positive for COVID-19 on 4/23/20. During an observation on 4/23/20 at 2:15 PM, Housekeeper EE (HK) entered COVID-19 positive Resident #108's room for a daily cleaning. No gown or eye protection were observed. HK EE cleaned within 1 foot of Resident #108 seated in a wheelchair. HK EE placed hands on Resident #108's wheelchair armrest and squatted down to pick debris off the floor. Resident #115 Review of a facility Admissions Record revealed Resident #115 was a [AGE] year-old male originally admitted to the facility on [DATE] that was considered presumptive positive for COVID-19 on 4/21/20 and test results were pending. Resident #115's roommate was Resident #107 who had tested COVID-19 positive on 4/23/20. Resident #115 was retested and was COVID-19 positive on 4/29/20. During an observation on 4/23/20 at 2:20 PM, TNA R on Unit C paced up and down the hall arm and arm with Resident #115. No gown was observed or eye protection. Resident #104 Review of a facility Admissions Record revealed Resident #104 was a [AGE] year-old female originally admitted to the facility on [DATE] that was diagnosed positive for COVID-19 on 4/23/20. During an observation on 4/23/20 at 2:25 PM, COVID-19 positive Resident #104 was on her hands and knees in the threshold of her room. NE E assessed Resident #104 and determined it was safe to transfer her. NE E and CNA X assisted Resident #104 off the floor and into her wheelchair. No gowns or eye protection were observed. In an interview on 4/23/20 at 3:00 PM, Nurse Educator (NE) E indicated Resident #104 was not hurt and sometimes put herself on the floor; it was not a emergency. NE E indicated was aware Resident #104 was COVID-19 positive and indicated should have used a gown and eye protection when assisting Resident #104. During an observation on 4/23/20 at 2:35 PM, CNA G entered COVID-19 positive Resident #104's room to provide care and did not use a gown or eye protection. Resident #110 Review of a facility Admissions Record revealed Resident #110 was an [AGE] year-old female originally admitted to the facility on [DATE] that was diagnosed positive for COVID-19 on 4/23/20. During an observation on 4/23/20 at 2:50 PM, on Unit C, COVID-19 positive Resident #110 was seated in the dining area without a face mask on, within approximately 2 feet from 2 other residents that tested COVID- 19 negative. The residents touched the same communal objects in the dining room (puzzles, plastic toys, and the table). No distancing was observed or sanitization of the communal objects or the resident's hands were observed. During an observation on 4/23/20 at 2:55 PM, on Unit C empty bins to store PPE were placed on hall. No PPE was stocked inside the bins. During an observation on 4/23/20 at 2:57 PM, COVID-19 positive Resident #107 paced up and down Unit C, grabbing handrails, banging on exit doors, and touching the keypad to input the exit code. No sanitization of surfaces observed. Presumptive COVID -19 Resident #115 followed behind Resident #107 touching the handrails, exit doors, and keypad. Both residents were observed to continually circle the hall for approximately 10 minutes. During an observation on 4/23/20 at 5:30 PM, Office Manager EE (OM) entered Unit C wearing a gown, indicated was moving Resident #110 to the COVID positive Unit B. Resident #110 was seated in the hallway in her wheelchair with NE EE standing directly behind her touching her wheelchair, no gown or gloves were observed. OM EE placed a mask on Resident #110's face. OM E had no gloves and no hand hygiene was observed. OM EE began pushing Resident #110's wheelchair down the hall with no gloves. NE E stopped OM EE and advised OM EE to put on gloves and find Resident #110's foot pedals. OM EE donned gloves, no hand hygiene was observed prior to donning. CNA G stood to the right of Resident #110's wheelchair, indicated her foot pedals were located on the back of the wheelchair. CNA G with no gown or gloves removed the foot pedals from the bag, placed the foot pedals on Resident #110's wheelchair, squatting directly in front of her touching her legs and shoes to place pedals. OM EE exited Unit C and took Resident #110 to Unit B. On 4/30/20 returned to the facility to review the the immediate jeopardy removal plan. In an interview on 4/30/20 at 10:30 AM, ICP C indicated 12 of 15 residents on Unit A were now displaying signs and/or symptoms of COVID-19. The facility decided to test and presume those 12 residents were COVID-19 positive and place them in droplet precautions on 4/29/20. ICP C indicated the remaining 3 residents were not placed-on droplet precautions. ICP C indicated presumptive COVID-19 positive Resident #115 from Unit C was confirmed to be COVID-19 positive on 4/29/20 and moved to the droplet isolation Unit B. This was Unit C's 9th COVID-19 positive resident. ICP C indicated the remaining residents on Unit C had not been placed on droplet precautions. ICP C indicated all residents on Unit D were COVID-19 positive except for 4 female residents. Those 4 female residents were placed were placed in rooms together and their rooms had negative signs on their doors. ICP C indicated on Unit D the staff wore the same gowns in out of all the COVID positive rooms to preserve PPE. ICP C indicated to protect the COVID-19 negative residents from further COVID-19 exposure, prior to entering the negative rooms the staff should remove their dirty gowns, hang them on a hook outside the room, and perform hand hygiene. ICP C indicated the staff should enter the negative room, don the clean gown found hanging on the back of the door, don gloves, and provide care. ICP C indicated to exit the staff should doff the clean gown and gloves, hang the gown back up inside the room, perform hand hygiene, and don the dirty gown hanging outside the room. In an interview on 4/30/20 at 10:30 AM, ICP C was on Unit A and indicated after contacting the Health Department today went ahead on their recommendation to place the remaining 3 of 15 residents from Unit A (not showing signs or symptoms) on droplet precautions. ICP C indicated was on the hall ensuring all 15 residents had signs on their doors and PPE bins outside their rooms. In an interview on 4/30/20 at 2:00 PM, NHA A indicated on Unit C there were several sets of roommates where one roommate tested positive for COVID-19 and one roommate tested negative for COVID-19. NHA A indicated did not place both roommates in droplet precautions and presume that the negative roommate was COVID-19 positive due to exposure. NHA A indicated moved the COVID-19 positive residents to the droplet isolation Units B and D. NHA A indicated contacted the Health Department and they advised if there was no COVID-19 positive resident on Unit C, then did not have to put the COVID-19 negative roommates in droplet precaution. In an interview on 5/1/20 at 10:15 AM, Health Department Registered Nurse SS (HD RN) indicated the facility did not call the morning of 4/29/20 (9th positive on Unit C) and inquire whether the facility should place the roommates of COVID-19 positive residents in droplet precautions. HD RN SS indicated would have recommended placing the roommates on droplet precautions, as well as, the rest of Unit C due to communal exposure. HD RN SS indicated the facility called on 4/30/20 at approximately 5:00 PM after 12 residents on Unit A displayed signs and symptoms of COVID-19 were tested . HD RN SS indicated recommended not testing anymore residents and consider the entire building presumptive COVID-19 positive and place everyone in droplet precautions. In an interview on 5/1/20 at 11:50 AM, Health Department Medical Director TT (HD MD) indicated the facility has not been forthcoming with reporting of COVID-19 positive test results and deaths. HD MD TT indicated the facility has the responsibility to report communicable disease deaths within 2 hours of the death to the Health Department. HD MD TT indicated the facility was behind on reporting COVID-19 related deaths by 6 to 7 days. HD MD TT indicated the facility had struggled to communicate the timeline of the COVID-19 illness and its progression throughout the facility. During an observation on 4/30/20 at 11:15 AM, CNA MM was on Unit A (presumptive positive droplet precautions) and in a resident's room wearing a gown and gloves. CNA MM' exited the room, answered the call light in the adjacent room, exited, and entered a room across the hall to answer another call light. CNA MM wore the same gown and gloves to each room and no hand hygiene was observed before or after entering each room. Resident #117 Review of a facility Admissions Record revealed Resident #117 was a [AGE] year-old female originally admitted to the facility on [DATE] that was considered presumptive positive for COVID-19 on 4/29/20 and test results were pending. Results for the COVID-19 testing were confirmed positive between 5/1/20 and 5/5/20. During an observation on 4/30/20 at 11:25 AM, CNA T entered Resident #117's room with a mask, a gown on and no gloves. CNA T squatted down next to Resident #117's wheelchair, placing both hands on the wheelchair arm. CNA T picked up Resident #117's call light from the floor and pinned it to the resident's gown and patted her hand. No hand hygiene observed on exit. Resident #118 Review of a facility Admissions Record revealed Resident #118 was a [AGE] year-old female originally admitted to the facility on [DATE] that has tested negative for COVID -19. During an observation on 4/30/20 at 12:20 PM, lunch was served on Unit D, that was in droplet precautions, with 4 COVID-19 negative residents that required clean gowns for entry into their rooms. CNA NN, G, and TNA OO were delivering lunch to the residents. Lunch was served from a double shelved pushcart. The meals were prepared from the kitchen in a clamshell Styrofoam container and those containers were piled up in no order on the bottom shelf. Several cardboard boxes were placed on the top shelf of the cart and the boxes contained packaged drinks, plastic cutlery, and packaged snacks. The staff would hand carry each lunch container and cutlery to the rooms and then ask the residents which kind of drink and snack they wanted. All three staff members wore the dirty gowns, picked up the lunch containers and cutlery and dropped food to the COVID-19 positive rooms first. The staff with dirty' gowns on, then leaned against the boxes of drinks and snacks, and reached into the boxes to remove desired items. Minimal hand hygiene was observed between delivery of food into COVID-19 positive rooms and the pushcart. The four lunch containers for the COVID negative rooms were almost at the very bottom of the container pile. The staff serving lunch had to handle the lunch containers for the negative COVID-19 residents multiple times to search for the COVID positive resident's food. During an observation on 4/30/20 at 12:30 PM, COVID -19 negative Resident #118 was seated in bed, on the outside of her door was a large sign that said Negative. CNA NN entered Resident #118's room with the dirty gown on and gloved hands. No gown change into the clean gown, removal of used gloves, or hand hygiene was observed. CNA NN opened Resident #118's lunch container and place it on her overbed table and raised the table to eating height. CNA NN opened Resident #118's plastic cutlery and mustard and placed the cutlery and mustard inside the open lunch container touching the inside of the container with gloved hands. CNA NN doffed gloves and exited Resident #118's room. CNA NN retrieved a water cup off the pushcart and brought it back to Resident #118, no gown change or hand hygiene observed. Resident #120 Review of a facility Admissions Record revealed Resident #120 was a [AGE] year-old female originally admitted to the facility on [DATE] that has tested negative for COVID -19. During an observation on 4/30/20 at 12:45 PM, CNA NN exited Resident #118's room, answered a call light in a COVID positive room and touched the overbed table and wheelchair. No hand hygiene was performed when entering or exiting the room. CNA NN walked to the pushcart of food, picked up a lunch container and plastic cutlery; and placed these items just inside COVID -19 negative Resident #120's room (on the outside of the door was a large sign that said Negative). No hand hygiene was observed. CNA NN returned to the pushcart to the boxes and removed a fruit cup and a drink. CNA NN entered Resident #120 's room with same dirty gown and delivered the drink and fruit cup; and assisted Resident #120 with setup. No hand hygiene was observed or removal of dirty gown prior to entry to a clean or negative room. In an interview on 4/30/20 at 12:50 PM, CNA NN indicated did not change out of the dirty gown into a clean gown to enter Resident #118 or #120's room. CNA NN indicated forgot they were COVID-19 negative and needed a different gown. Resident #119 Review of a facility Admissions Record revealed Resident #119 was an [AGE] year-old female originally admitted to the facility on [DATE] that has tested negative for COVID -19. During an observation on 4/30/20 at 12:35 PM, Resident #119 was lying in bed in her room, on the outside of her door was a large sign that said Negative. CNA F entered Resident #119's room wearing with a dirty gown. No hand hygiene was performed, and no gloves were donned. CNA F leaned against Resident #119's bed, assisted Resident #119 to a seated position, adjusted her pillows, blankets, and handled her bed remote. CNA F exited Resident #119's room and walked to the pushcart, found her lunch container and brought it back to her room. No hand hygiene was observed or dirty gown removal. CNA F setup and fed Resident #119 in the dirty gown with no gloves. Review of Coronavirus Surveillance policy reviewed/revised on 3/11/2020 revealed, .6. Residents will be monitored for signs and symptoms of coronavirus illness: fever, cough, shortness of breath. The physician will be notified immediately, if evident. Staff shall follow established procedures when COVID-19 is suspected. 7. Considerations for managing residents with suspected or confirmed COVID-19 infection: a. Use clinical features and epidemiologic (TRUNCATED)

This citation pertains to intake number MI 221. Based on interview and record review, the facility failed to transfer a resident safely, in one of three residents reviewed for falls (Resident #31), resulting in a fracture, pain, and surgery. Findings include: Resident #31 (R31) R31's electronic admission record indicated he admitted to the facility from an acute care hospital on [DATE] and had the [DIAGNOSES REDACTED]. R31's Brief Interview For Mental Status (BIMS), a short performance-based screener for nursing home residents, assessment dated [DATE] was a score of 14, indicating he was cognitively intact (Scale 13-15). R31's Nurse Admission assessment note dated 7/02/19 reflected the use of a walker and two person assist was recommended by R31's spouse and the hospital for transfers and ambulation. In review of R31's incident report and witness statement dated 7/02/19 at 11:30 PM, the same day as his admission to the facility, the certified nurse assistant (CNA) reflected she was informed by the second shift CNA that R31 was able to transfer and walk independently. The same statement reflected she answered R31's call light, he got out of bed, started to ambulate to the bathroom with his wheeled walker and once in the bathroom his foot slid, and he leaned forward. The same statement indicated the CNA assisted the resident to the floor in the bathroom and alerted staff that additional help was needed. The same report revealed the action taken was to update R31's care plan. In review of R31's Nurse Progress Note dated 7/02/19 at 11:53 PM revealed the new intervention to prevent future falls, was a two person transfer with one to guide wheelchair behind. In review of R31's Fall Risk Care Plan, dated 7/03/19, instructed two person transfer with one person behind with wheelchair. During an interview with the Director of Nursing (DON) B on 8/15/19 at 1:09 PM, she indicated R31 fell on [DATE], before a care plan was in place. DON B stated in the same interview, when a resident was admitted , nurse completed a basic assessment and would refer to hospital records for appropriate transfer status. In review of R31's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 7/03/19, R31 exhibited inadequate toe clearance, forward lean of trunk and his dynamic standing balance (ability to balance while moving or changing between positions) tolerance was 30 to 40 seconds. The same evaluation indicated R31 required moderate assistance (patient performed about 50 percent of the work necessary to move) for transfers with a front wheeled walker. During an interview with occupational therapy assistant (COTA) [NAME] on 8/15/19 at 12:50 PM, she stated R31 fell prior to their evaluation on 7/03/19. Nursing determined he was safe for one person assistance for transfer, therapy was not in agreement on that. During the same interview, COTA [NAME] stated therapy recommended a 2 person transfer with walker, 1 person assisted with walking with gait belt and walker; and the other person followed with a wheelchair for R31. COTA [NAME] stated they never changed or modified their recommendation while R31 was a resident at the facility. COTA [NAME] stated they always used a gait belt during therapy with R31, it was a standard thing. COTA [NAME] stated in the same interview, the purpose of the wheelchair was for R31 to sit down if he became dizzy. According to the website Drugs.com at <https://www.drugs.com/cg/how-to-use-a-gait-belt.html>; a gait belt was a safety device used to help someone move, such as from a bed to a chair, and to prevent a fall. In review of R31's incident report and witness statements dated 7/04/19 at 8:30 AM, R31 was in the process of being assisted to the bathroom by two persons, was wearing a gait belt, with one CNA in front and one CNA in back of the resident (a wheelchair was not used to follow behind him if he became unbalanced). The same report indicated R31 became dizzy, fainted, was lowered to the floor, and sustained a skin tear on his right forearm during the fall. The same report indicated to prevent reoccurrence, a teachable moment was completed with the CNA's in following R31's Kardex (care plan). During an interview, on 8/15/19 at 2:25 PM with CNA G, she stated she transferred R31 on 7/04/19 prior to his fall. CNA G stated in the same interview, she had read the Kardex before she transferred R31 and it did not say anything about using a wheelchair. CNA G stated on 7/04/19, she and another CNA transferred R31 with a gait belt and walker, and then lowered him to the floor after he fainted. In review of R31's Fall Risk Care Plan, date initiated 7/03/19, revised on 8/02/19, he was a two person transfer with one person behind with wheelchair. R31's Progress Note dated 8/2/19 at 1:24 PM reflected resident complained of falling on 8/01/19, and hitting his back and buttocks, and pain. The same note indicated an x-ray was planned. In review of R31's Skilled Daily progress note, dated 8/02/19 at 2:54 PM, R31 had increased pain from fall on 8/01/19, and was unable to get to the bathroom without assistance. In review of R31's x-ray report dated 8/03/19 at 8:37 AM, there was no compression fracture or spondylolisthesis (slipping of vertebra) of the spine. The Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.16, (MONTH) (YEAR), indicated individuals with impaired balance and unsteadiness during transitions and walking were at increased risk for falls. The same source indicated a previous fall, especially a recent fall, recurrent falls, and falls with significant injury were the most important predictors of risk for future falls and injurious falls. In review of R31's incident report and witness statements dated 8/03/19 at 9:00 AM, R31 .felt dizzy and shaky when CNA took him to the bathroom, slid himself down the walls of the bathroom, and sustained a bruise. The same report indicated his pain level, on a scale of 0 to 10, (Zero meaning no pain, and 10 meaning the worst possible pain), his pain was at a 7. In review of R31's progress notes dated 8/03/19 at 9:54 AM, R31 fell on [DATE] at 9:00 AM and was accompanied by a CNA to the bathroom using his walker. The same note reflected R31 suddenly felt dizzy and was trembling. R31 leaned on the wall of the bathroom and gradually slid down to the floor in the bathroom. Bruises were noted on R31's right elbow and index finger. R31 complained of pain on his buttocks radiating to his legs and back. The same progress noted revealed R31 needed to be transferred with two assist and his wheelchair with one person standing behind the wheelchair during transfer and a gait belt should be used at all times during transfer. During an interview on 8/15/19 at 12:35 PM, Registered Nurse (RN) C stated he thought one staff person was transferring R31 when he fell on [DATE]. RN C stated in the same interview, he did not check R31's Range of Motion (ROM) after his fall. On 8/15/19 at 2:01 PM, CNA F was interviewed regarding R31's fall on 8/03/19 at 9:00 AM, and stated she had not transferred R31 prior to 8/3/19, she had forgot her gait belt at home, and did not use a gait belt during the transfer with R31. CNA F stated in the same interview, R31 had lost his balance when ambulating to the bathroom with his walker, and she lowered him to the floor with her left arm under R31's left armpit. CNA F stated R31 complained that his bottom hurt after the fall. A Teachable Moment was attached to R31's incident report completed with the CNA's regarding R31's transfer status; two person transfer with gait belt and follow with 1 person behind with a wheelchair due to resident history of feeling dizzy. R31's progress notes dated 8/3/19 at 4:31 PM, reflected he was transferred to the emergency room for evaluation due to increasing pain in the sacral area (triangular bone at the base of the spine) on 8/03/19 at 4:12 PM. R31's hospital history and physical dated 8/3/19, revealed he presented to hospital with history of recurrent [MEDICAL CONDITION] (temporary loss of consciousness caused by a fall in blood pressure); R31 had passed out and fell to the floor in the presence of a nurse aide, at the nursing home. The same history and physical indicated R31 complained of bilateral hip pain and low back pain initially after the first fall, but after the second fall the pain was much worse. The same history and physical indicated R31 at baseline was using a walker and after his second fall he was not able to walk with a walker. The same history and physical revealed a computed tomography (CT) of the lumbar spine revealed an acute fifth lumbar vertebra (L5) compression fracture. Consultation Notes dated 8/05/19 revealed the plan for R31 was to be admitted for pain control and vertebral augmentation (stabilize fractured vertebra with goal of reducing pain). R31 had a kyphoplasty (injection of bone cement into a compressed vertebra) completed on 8/05/19.

Based on interview and record review the facility failed to prevent staff to resident abuse, in 1 of 6 residents (Resident #5) reviewed for abuse, from a total sample of 7 residents, resulting in the potential for physical and psychosocial harm. Findings include: Review of the facility's Abuse Prevention Program, dated 2/22/18, revealed, Our residents have the right to be free from abuse .Our facility is committed to protecting our resident from abuse by anyone .Abuse- The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish Abuse Identification and Training: Our abuse prevention/intervention education program includes, but is not necessarily limited to, the following: .*assisting or rotating staff working with difficult or aggressive residents, *monitoring staff on all shift to identify inappropriate behaviors toward residents, *assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect . Review of the facility's Resident to Resident Abuse and Catastrophic Events policy, dated 11/28/16, revealed, All forms of abuse, including .catastrophic events must be reported immediately to the Nursing Supervisor, the Director of Nursing Services and to the Administrator .A catastrophic reaction is an excessive reaction to something that may seem inconsequential to the caregiver .Actions to be taken for a catastrophic reaction: .Simpl(ify) the environment by reducing extra people .distract the person .Do not try to reason with the person. Trying to reason with them may only make things worse . Review of the Face Sheet revealed Resident #5 was an [AGE] year-old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was severely cognitively impaired and was an assist of 1 staff for ambulation and an assist of 2 staff for transfers and bathing. Review of Resident #5's care plan revealed a problem focus The resident has the potential to be agitated can become physically aggressive, hitting, kicking, sitting self on floor, refuses care .wandering throughout (unit) including other resident rooms, r/t (related to) Dementia ., Date initiated 8/16/16. The care plan interventions were The resident needs personal space when agitated .Revision on 8/16/18 .The resident reacts to touch by .yelling .Revision Date on: 8/16/16 .When resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress if possible .If response is aggressive, staff to walk calmly away (if safe to do so), and approach later . Revision on: 8/29/16. Review of Resident #5's incident report, dated 5/23/18 at 9:05 AM, revealed .Discoloration observed to residents R (right) upper arm, just above antecubital space . (sic) Review of the facility's investigation of Resident #5's bruised upper arm the facility determined, Investigation Conclusion: .It was established that the 3 CENA's (Certified Nursing Assistants) that identified the bruise did not report it likely caused the bruising .The CENA's held the resident's arms and pushed on his abdomen to get him into the wheelchair, tilted him back in the wheelchair to transport him to his room and held him down to change him. The resident's care plan was not being followed and the facility's policy for responding to catastrophic reactions was not being followed . There was no indication in the facility investigation on whether care provided by the nursing staff was periodically monitored, including for residents with challenging behaviors, to ensure training provided prior to the incident was being followed and potential for caregiver burnout was being monitored. In an interview on 6/21/18 at 2:10 PM, CNA F verified Statement of Witness as correct and accurate. CNA F indicated worked 5/22/18 on the 1st shift. The last time CNA F cared for Resident #5 was around 1:30 or 2:00 PM, and that Resident #5 did not have any bruising on his upper arms then. CNA F indicated returned to work the next morning, 5/23/18, and provided care. CNA F noted new bruising to his right upper arm and reported it to the nurse immediately. In an interview on 6/21/18 at 1:20 PM, CNA R indicated worked 2nd shift on 5/22/18 and has worked at the facility for 4 years. CNA R indicated has worked with Resident #5 on a routine basis and Resident #5 was prone to aggressively resisting care and was very hard to redirect. CNA R indicated has always approached Resident #5's care with 3 care givers. CNA R indicated 1 person to hold his hands, 1 person to hold his feet and 1 person to provide incontinence care and that everybody takes care of (Resident #5) like this, ask the other aides and nurses. CNA R stated that on 5/22/18 Resident #5 wandered into a female resident's room and refused to leave. CNA R, CNA S, and CNA T entered the female resident's room to redirect Resident #5. Resident #5 would not exit the female Resident's room when requested. CNA R stated CNA S and CNA R assisted Resident #5 into a wheelchair. CNA R stated each aide stood behind Resident #5, held his upper arm and guided him into the wheelchair and the third CNA pushed his abdomen until he sat down. CNA R indicated provided incontinence care at least twice that night and both times CNA T', CNA S, and CNA R helped. CNA R indicated Resident #5 was kicking, hitting and thrashing, so 1 aide held his hands, 1 aide held his feet, and 1 aide cleaned him up during the incontinence care. CNA R state that she noticed the bruises on Resident #5's arm later that night but forgot to report it. Interview on 6/21/18 at 1:35 PM, CNA T indicated does not know how Resident #5 got into the wheelchair on 5/22/18. CNA T indicated once Resident #5 was in the wheelchair he became more agitated and CNA S tilted the wheelchair back and all 3 of us took Resident #5 to his room. CNA T stated, We performed incontinence care for (Resident #5). 1 person held his legs, 1 person held his arms and the other cleaned him up. We cleaned him up again (second time) that night in the same manner. CNA T indicated Resident #5 was often combative and usually used 3 aides in this manner to clean him up. CNA T indicated she noticed on 5/22-5/23/18 am that Resident #5 had a bruise on his arm but forgot to report it. Review of CNA S's Statement of Witness, dated 5/23/18, revealed .We had to sit him down in wheelchair .I don't remember how we got him into chair, then we took him down to his room, me and (CNA T) .He was being combative and had BM was everywhere. I held (Resident #'5's) hands while (CNA R) changed him. (CNA T tried to keep him from kicking .I noticed (Resident #5) had a bruise after we changed him for the second time. (CNA T) and (CNA R) also saw the bruise. Attempts were made to contact CNA S by this surveyor, but the attempts were unsuccessful. In an interview on 6/21/18 at 2:50 PM, CNA Q indicated has worked at the facility for [AGE] years and in Resident #5's unit for 6 months. CNA Q indicated Resident #5 could be very resistive to care, combative and difficult to redirect. If Resident #5 could not be redirected from another resident's room, CNA Q would stay to ensure the other resident's safety and leave Resident #5 alone. CNA Q indicated would never force a resident to do anything, Resident #5 usually could be distracted with snacks and talking to him. CNA Q indicated when performing incontinence care that she never used 3 people, as it would make Resident #5 more agitated. Usually, 2 staff assist Resident #5 in care, 1 to help him and 1 to soothe or distract him. CNA Q indicated if found an injury on a resident, must report to nurse immediately. In an interview on 6/21/18 at 3:05 PM, CNA J indicated when trying to remove Resident #5 from a room or situation would call him by name and request him to leave, if that did not work re-approach in a few minutes with another care giver. If he refused and became agitated, would ensure his safety and the safety of the other residents but give him space and leave him alone. In an interview on 6/21/18 at 3:35, Licensed Practical Nurse (LPN) K indicated worked 2nd shift and has worked with Resident #5 often. LPN K indicated 2 staff usually care for Resident #5's needs. If more than 2 staff approached him at a time, he would become combative. LPN K indicated would never use force or hold down a resident. In an interview on 6/21/18 at 1:45, Resident #5's Family Member (FM) V indicated was notified of the bruising on Resident #5 and the investigation details. FM V indicated was aware of Resident #5's resistance to care and combativeness but 3 staff members coming at him using force him made him worse. FM V indicated if Resident #5 was cognitively intact he would have been furious with his treatment. In consideration of the reasonable person, and an interview with FM V, it is determined that Resident #5 would not want to be provided care in the manner that it was proviede and that he would have been furious if he had been able to express the feeling himself, if he had not been severely cognitively impaired. In an interview on 6/21/18 at 3:45 PM, Staff Educator E verified through transcripts CNA R, CNA S, and CNA T had all completed their Abuse and Neglect, Communicating with Older Adults with Dementia, Dementia Care: Coaching and Completing Activities of Daily Living, Dementia: Preventing Catastrophic Reaction, and Prevention, Recognizing, and Reporting Abuse trainings for every year employed at the facility and they also attended various abuse and dementia care in-services each year employed. Their last training was in (MONTH) of (YEAR). The facility submitted a request for past non-compliance that was denied due to no indication in the facility past non-compliance on when and who will periodically monitor care provided by the nursing staff, including for residents with challenging behaviors, to ensure training provided before 5/22/18 and after 5/23/18 is being followed and how the potential for caregiver burnout will being monitored.

This citation pertains to intake number MI 541. Based on interview and record review the facility failed to follow professional standards of nursing practice in 1 of 10 sampled residents (Resident #101) reviewed for code status and CPR needs, from a total sample of 13 residents resulting in an Immediate Jeopardy (IJ) when staff failed to follow physician's orders [REDACTED].#101 when she was found unresponsive and without vitals on [DATE] at approximately 6:00 a.m. Resident #101 died on [DATE] at 6:11 a.m. Findings include: According to the Code of Ethic for Nurses (American Nurses Association, 2001, pg. 14), the nurse's primary commitment is to the health, well-being, and safety of the patient. The nurse must take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team. The Code of Ethics for Nurses (pg. 17) goes on to state the nurse is accountable to the quality of nursing care give to patients and the delegation of nursing care activities of other health care workers. The nurse is responsible for monitoring the activities of these individuals and evaluating the quality of the care provided. According to the Fundamentals of Nursing (Potter and Perry, 6th ed., 2005), [MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that the client has had a [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respirations and manual external cardiac massage. Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out, according to Creighton in Law Every Nurse Should Know, 5th Edition, page 98. Per the American Red Cross First Aid and Safety Handbook (2011), A person in [MEDICAL CONDITION] is unconscious, not breathing, and has no heartbeat. The Handbook revealed that a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is: 1). Early access to the emergency medical services (EMS) system, 2). Early CPR, 3). Early defibrillation, and 4). Early advanced medical care. The Handbook also revealed that without early CPR and defibrillation, the chance for survival is greatly reduced. Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a brief interview for mental status (BIMS) score of 8 out of 15 which indicated she had moderately impaired cognition. Review of the Initial Psychological Evaluation dated [DATE] revealed Resident #101's .daily decision making is noted to be 'impaired' and 'incompetent- DPOA activated. Review of the Long Term Care Progress Note dated [DATE] revealed Resident #101 was still a full code. In an interview on [DATE] at 2:45 pm, Licensed Practical Nurse (LPN) C stated, on [DATE], I came in at 6 am. LPN C stated, I heard the call, the code blue (emergency code) to her (Resident #101) room, I ran to the room, I found (Resident #101) unresponsive. LPN C stated, said her (Resident #101) name out loud, no response, I checked pulse, didn't have pulse (indicated no heart beat) and told CNA's (certified nurse aide) get floor clear, we're going to do this. I meant we're going to get code status do CPR. LPN C stated the Assistant Director of Nursing (ADON) F came in and stated, 'It's taken care of do not do CPR'. LPN C stated, CPR was not performed per the ADON's instructions. In an interview on [DATE] at 4:30 pm, LPN D stated, During change of shift (on [DATE] at approximately 6:00 am) code was called. I stayed at the desk (nurses desk) and paged for code blue. LPN D stated, I came down there when they (ADON F, LPN C, and NHA A) were coming out of the room (Resident #101's room). LPN D stated the ADON decided not to call the code, so they didn't code her (Resident #101). LPN D stated, Nothing was communicated to me about a change in Resident #101's code status. In an interview on [DATE] at 5:41 pm, former Assistant Director of Nursing (ADON) F stated, on [DATE], she was alerted Resident #101 was without pulse and respirations. Former ADON F stated, I told all staff we are not going to pursue CPR at this time. Former ADON F stated Resident #101,Had been a full code since she had been there (in the facility). I chose to not initiate CPR on her (Resident #101). Former ADON F was asked again by the surveyor if Resident #101 was a full code, Former ADON F replied, Correct. Former ADON F was asked by the surveyor if CPR should have been performed on Resident #101 when she was found to be not breathing and without a heart beat on [DATE], Former ADON F replied, Yes. Former ADON F was asked by the surveyor if not performing CPR on a full code resident was neglect, Former ADON F replied, I don't think so, it was a process (changing Resident #101 from a full code to a DNR - do not resuscitate) wasn't yet completed. In an interview on [DATE] at 11:14 am, Registered Nurse (RN/Former Director of Nursing (DON)) E stated, I came in to the facility after the incident (of failure to perform CPR on a full code resident). Former DON E stated found out there was no DNR signed for Resident #101 and her medical records indicated she was a full code. Former DON E stated, If you don't have a written DNR then you do a full code (indicated to perform CPR). Former DON E stated, As a professional nurse, I follow orders (physician's orders [REDACTED].#101) as a full code until you get the DNR. In an interview on [DATE] at 3:20 pm, Nursing Home Administrator (NHA) A reported Resident #101 was a full code and did not receive CPR per her status. Review of the Record of Death and Mortician's Receipt dated [DATE] at 12:00 pm, revealed Resident #101's date of death was [DATE] at 0611 AM. NHA A was notified of the IJ on [DATE] at 10:14 am, that the IJ began on [DATE] at approximately 6:11 am for failure to follow physician's orders [REDACTED]. 1. As of [DATE] Resident #1 no longer resides at the facility. 2. Beginning [DATE], licensed Staff were Re-educated on the facilities . a) resuscitation policy, b) code status and c) physician/family notification practice and d) following physician orders [REDACTED]. Education was completed on [DATE]. 3. ADON F was suspended pending the investigation and resigned on [DATE]. 4. On [DATE], a face sheet book which includes code status has been placed at the nurse's station. 5. On [DATE], Review of the facility Policies and Procedure related to code status. 6. Beginning [DATE], it is the process of the facility during the morning meeting, M-F, for IDT to review the new admission charts to verify the code status order is in place. 7. On [DATE], NHA A notified the Medical Director of the audit results and discussed interventions. 8. On [DATE], an audit was conducted to verify all licensed nurses' CPR certification was completed to ensure that a nurse on all three shifts is available with current CPR certification. Although the facility removed the Immediacy on [DATE], the facility remained out of compliance at the scope of isolated and severity of actual harm that is not immediate jeopardy due to the fact the facility did not report an incident of neglect and did not educate on the requirement to report neglect.

This citation pertains to intake number MI 541. Based on interview and record review the facility failed to prevent staff to resident neglect in 1 of 10 sampled residents (Resident #101) reviewed for abuse/neglect, from a total sample of 13 residents resulting in an Immediate Jeopardy (IJ) when, on [DATE] at approximately 6:00 a.m., Assistant Director of Nursing (ADON) F informed facility staff to not perform CPR (cardio [MEDICAL CONDITION] resuscitation) for Resident #101, who was a full code (desired all life sustaining measures), and was found to be unresponsive without vital signs. Resident #101 died on [DATE] at 6:11 a.m Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a brief interview for mental status (BIMS) score of 8 out of 15 which indicated she had moderately impaired cognition. Review of the Initial Psychological Evaluation dated [DATE] revealed Resident #101's .daily decision making is noted to be 'impaired' and 'incompetent- DPOA activated. Review of the Durable Power of Attorney dated [DATE] revealed Resident #101 had executed this Durable Power of Attorney for Appointment of Patient Advocate .for the purpose of making decisions regarding my care, custody, medical, or mental health treatment. Review of the physician's orders [REDACTED].#101 was a FULL CODE. Review of the Long Term Care Progress Note dated [DATE] revealed Resident #101 was still a full code. In an interview on [DATE] at 2:45 pm, Licensed Practical Nurse (LPN) C stated, on [DATE], I came in at 6 am. LPN C stated, I heard the call, the code blue (emergency code) to her (Resident #101) room, I ran to the room, I found (Resident #101) unresponsive. LPN C stated, said her (Resident #101) name out loud, no response, I checked pulse, didn't have pulse (indicated no heart beat) and told CNA's (certified nurse aide) get floor clear, we're going to do this. I meant we're going to get code status do CPR. LPN C stated the Assistant Director of Nursing (ADON) F came in and stated, 'It's taken care of do not do CPR'. LPN C stated, CPR was not performed per the ADON's instructions. LPN C stated that Resident #101 was Still full code over the weekend because worked the weekend. In an interview on [DATE] at 4:30 pm, LPN D stated, During change of shift (on [DATE] at approximately 6:00 am) code was called. I stayed at the desk (nurses desk) and paged for code blue. LPN D stated, I came down there when they (ADON F, LPN C, and NHA A) were coming out of the room (Resident #101's room). LPN D stated the ADON decided not to call the code, so they didn't code her (Resident #101). LPN D stated, Nothing was communicated to me about a change in Resident #101's code status. In an interview on [DATE] at 5:41 pm, former Assistant Director of Nursing (ADON) F stated, on [DATE], she was alerted Resident #101 was without pulse and respirations. Former ADON F stated, I told all staff we are not going to pursue CPR at this time. Former ADON F stated Resident #101,Had been a full code since she had been there (in the facility). I chose to not initiate CPR on her (Resident #101). Former ADON F was asked again by the surveyor if Resident #101 was a full code, Former ADON F replied, Correct. Former ADON F was asked by the surveyor if CPR should have been performed on Resident #101 when she was found to be not breathing and without a heart beat on [DATE], Former ADON F replied, Yes. Former ADON F was asked by the surveyor if not performing CPR on a full code resident was neglect, Former ADON F replied, I don't think so, it was a process (changing Resident #101 from a full code to a DNR - do not resuscitate) wasn't yet completed. In an interview on [DATE] at 3:20 pm, Nursing Home Administrator (NHA) A reported Resident #101 was a full code and did not receive CPR per her status. Review of the Record of Death and Mortician's Receipt dated [DATE] at 12:00 pm, revealed Resident #101's date of death was [DATE] at 0611 AM. NHA A was notified of the IJ on [DATE] at 10:14 am, that the IJ began on [DATE] at approximately 6:11 am for failure to prevent staff to resident neglect. 1. As of [DATE] Resident #1 no longer resides at the facility. 2. Beginning [DATE], licensed Staff were Re-educated on the facilities . a) resuscitation policy, b) code status and c) physician/family notification practice and d) following physician orders [REDACTED]. Education was completed on [DATE]. 3. ADON F was suspended pending the investigation and resigned on [DATE]. 4. On [DATE], a face sheet book which includes code status has been placed at the nurse's station. 5. On [DATE], Review of the facility Policies and Procedure related to code status. 6. Beginning [DATE], it is the process of the facility during the morning meeting, M-F, for IDT to review the new admission charts to verify the code status order is in place. 7. On [DATE], NHA A notified the Medical Director of the audit results and discussed interventions. 8. On [DATE], an audit was conducted to verify all licensed nurses' CPR certification was completed to ensure that a nurse on all three shifts is available with current CPR certification. Although the facility removed the Immediacy on [DATE], the facility remained out of compliance at the scope of isolated and severity of actual harm that is not immediate jeopardy due to the fact the facility did not report an incident of neglect and did not educate on the requirement to report neglect.

This citation pertains to intake number MI 541. Based on interview and record review the facility failed to follow physician's orders and advanced directives to provide CPR (cardio [MEDICAL CONDITION] resuscitation) in 1 of 10 residents (Resident #101), reviewed for advanced directives, from a total sample of 13 residents, resulting in an Immediate Jeopardy (IJ) when staff failed to provide CPR to Resident #101, who was deemed a full code (provide CPR if a patient's heart stops beating or if the patient stops breathing), on [DATE] at approximately 6:00 am, when Licensed Practical Nurse (LPN) found Resident #101 to be unresponsive and CPR was not performed. Resident #101 died on [DATE] at 6:11 a.m. Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a brief interview for mental status (BIMS) score of 8 out of 15 which indicated she had moderately impaired cognition. Review of the Durable Power of Attorney dated [DATE] revealed Resident #101 had executed this Durable Power of Attorney for Appointment of Patient Advocate .for the purpose of making decisions regarding my care, custody, medical, or mental health treatment. Review of the Initial Psychological Evaluation dated [DATE] revealed Resident #101's .daily decision making is noted to be 'impaired' and 'incompetent- DPOA activated. Review of the Care Plan Resident has a DPOA in place, activated, son . is acting decision maker dated initiated [DATE] and revised on [DATE]. Review of the Physician's Orders dated [DATE] revealed Resident #101 was a FULL CODE. Review of the Social Service Progress Review dated [DATE] revealed Resident #101 was a Full Code. Review of the Physician's Progress Note dated [DATE] revealed Resident #101 was a Full Code. Review of the Long Term Care Progress Note dated [DATE] revealed Resident #101 was still a full code. Review of the Incident report dated [DATE] revealed the Director of Nursing (DON) called the resident MDPOA (DPOA) to discuss Resident #101's condition. In an interview on [DATE] at 2:45 pm, LPN C stated, on [DATE], I came in at 6 am. I heard the call, the code blue (emergency code for staff to respond) to her (Resident #101) room. I ran to the room. I found (Resident #101) unresponsive. LPN C stated, said her (Resident #101) name out loud, no response, I checked pulse, didn't have pulse (indicated no heart beat) and told CNA's (certified nurse aide) get floor clear, we're going to do this, I meant we're going to get code status and do CPR. LPN C reported that the Assistant Director of Nursing (ADON) F stated, it's taken care of do not do CPR. LPN C was asked by the surveyor if CPR was performed on Resident #101. LPN C stated, nope. LPN C stated Resident #101 was still full code over the weekend and knew that because I (LPN C) worked the weekend. LPN C stated, later in the day when things settled down, she reviewed the code status in the computer and it was full code and the staff should have done CPR. In an interview on [DATE] at 4:30 pm, LPN D stated, during change of shift (on [DATE] at approximately 6:00 am) a code was called. LPN D stated, I stayed at the desk (nurses desk) and paged for code blue. LPN D stated, I came down there when they (ADON F, LPN C, and NHA A) were coming out of (Resident #101's) room. LPN D stated the ADON decided not to call the code, so they didn't code (perform CPR) her. LPN D stated, I would have done CPR on Resident #101 and there was nothing communicated to me about a change in Resident #101's code status (indicated status was still Full Code). In an interview on [DATE] at 5:41 pm, former Assistant Director of Nursing (ADON) F stated, on [DATE], she was alerted Resident #101 was without pulse and respirations. Former ADON F stated to staff we are not going to pursue CPR at this time. Former ADON F stated Resident #101 had been a full code since she had been there in the facility. Former ADON F stated, I chose to not initiate CPR on her (Resident #101). Former ADON F stated, correct, (Resident #101) was a full code. Former ADON F was asked by the surveyor if CPR should have been performed on Resident #101 when she was found to be not breathing and without a heart beat on [DATE]. Former ADON F stated, Yes the full code order was in the chart. Former ADON F was asked by the surveyor if not performing CPR on a full code resident was neglect. Former ADON F stated, I don't think so, it was a process that wasn't completed. Former ADON F stated the process to change Resident #101 from a full code to a DNR (do not resuscitate) was not changed and Resident #101 was a full code. Review of the Record of Death and Mortician's Receipt dated [DATE] at 12:00 pm, revealed Resident #101's date of death was [DATE] at 0611 AM. In an interview on [DATE] at 3:20 pm, Nursing Home Administrator (NHA) A stated Resident #101 was deemed incompetent, her son was her POA (DPOA). NHA A stated, We didn't feel she could say what she wanted and the POA should be signing the Do not resuscitate (DNR) form. NHA A stated Resident #101 was a full code and did not receive CPR per her status. In an interview on [DATE] at 11:14 am, Registered Nurse (RN/ former Director of Nursing (DON)) E stated, I came into the facility after the incident. Former DON E stated found out there was not a DNR signed for Resident #101 and her medical records indicated she was a full code. Former DON E stated, If you don't have a written DNR, then you do a full code. NHA A was notified of the IJ on [DATE] at 10:14 am, that the IJ began on [DATE] at approximately 6:00 am for failure to administer CPR to a full code resident. 1. As of [DATE] Resident #1 no longer resides at the facility. 2. On [DATE], Residents residing in the facility were reviewed for code status validating Advanced Directives, and MI DNR form were completed. 3. Beginning [DATE], licensed Staff were Re-educated on the facilities . a) resuscitation policy, b) code status and c) physician/family notification practice and d) following physician orders in regards to following Full Code Status and initiating CPR and e) Code Status can be located in the hard chart, face sheet book, Kardex or physicians' orders in Point Click Care. Education was completed for all licensed staff by [DATE]. 4. On [DATE], a face sheet book which includes code status has been placed at the nurse's station. 5. On [DATE], Review of the facility Policies and Procedure related to code status. 6. Beginning [DATE], during the admission process, the licensed nurse assigned to the admission is responsible to obtain a physician's order for code status and enter into Point Click Care. 7. Beginning [DATE], it is the process of the facility during the morning meeting, M-F, for IDT to review the new admission charts to verify the code status order is in place. 8. On [DATE], NHA A notified the Medical Director of the audit results and discussed interventions. 9. On [DATE], an audit of Physicians' Orders was conducted to verify that current residents have a code status order in place. 10. On [DATE], an audit of Physicians' Orders was conducted to verify that current residents have a code status match their face sheet. 11. On [DATE], an audit was conducted to verify all licensed nurses' CPR certification was completed to ensure that a nurse on all three shifts is available with current CPR certification. Although the facility removed the Immediacy on [DATE], the facility remained out of compliance at the scope of isolated and severity of actual harm that is not immediate jeopardy due to the fact the facility did not report an incident of neglect and did not educate on the requirement to report neglect.

This citation pertains to intake number MI 334. Based on observation, interview and record review, the facility failed to prevent falls in 2 of 4 residents reviewed with falls (Resident #63 & Resident #67), in a total sample of 9 residents, resulting in resident injuries (Resident #63 & #67) and a fractures (Resident #63). Findings include: Resident #63 On 8/18/16 at 10:20 AM, Resident #63 was observed sitting in a recliner chair in her room facing the window with a neck collar brace noted to be in place. Resident #63's Medication Administration Record (MAR) revealed she was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. Resident #63's Minimum Data Set (MDS) assessment dated [DATE] indicated she was not steady and was only able to stabilize with human assist in balance during transitions and walking (seated to standing, walking with her walker, turning around and facing the opposite direction while walking, and transfer between the bed and chair). The same MDS assessment revealed Resident #63's Brief Interview for Mental Status (brief screen to detect cognitive impairment, BIMS) score was 5, indicating a severe impairment. The same MDS assessment indicated Resident #63 had a history of [REDACTED]. According to the Incident Report (no title) dated 7/24/16, Resident #63 was observed sitting on the floor with her back against the bed in her room at 11:15 AM. The same report revealed Resident #63 was last seen sitting on her bed. The same report indicated Resident #63 was screened for a urinary tract infection (UTI) and was found to be negative for a UTI. Interim Director of Nursing/Assistant Director of Nursing (ADON) B was interviewed on 8/18/16 at 12:10 PM and stated no additional interventions were implemented to prevent the reoccurrence of a fall for Resident #63. During the same interview, ADON B stated that the facility does use fall alarms, but did not consider use after Resident #63's fall on 7/24/16. Resident #63's Incident Report (no title) dated 7/31/16 at 11:15 AM (same time as above fall) revealed she was found on the floor lying on her back in the doorway of her room. The same report revealed Resident #63 had suffered a laceration to the right side of her head, a skin tear to the right elbow. Resident #63 was transferred to the hospital for a trauma unit evaluation, was found to had sustained a acute left hemispheric subdural hemorrhage (pool of blood between the brain and its outermost covering) and 2 cervical vertebrae fractures (C4 & C7). ( ) Resident #67 On 8/18/16 at 10:40 AM, Resident #67 was observed lying in bed in his room. According to the Admission Record dated 7/19/16, Resident #67 was a [AGE] year old with the [DIAGNOSES REDACTED]. According to the most recent MDS, significant change assessment, dated 7/24/16, Resident #67 had a BIMS score of 6, indicating a severe impairment. The same assessment indicated Resident #67's Patient Health Questionnaire (validated interview that screens for symptoms of depression, PHQ-9) indicated a score of 9. The MDS assessment prior to the 7/24/16, dated 5/20/16 revealed Resident #67's PHQ-9 score was scored at a 3. According to the University of Michigan Health System, PHQ-9 Scoring and Interpretation Guide, retrieved from website at www.med.umich.edu/1info/FHP/ ./score.pdf; a total score of 5 to 9 would be indicative of mild depression and a score of 0-4 would be representative of minimal depression. Resident #67's depression increased from the MDS assessment dated [DATE] compared to the MDS assessment dated [DATE]. Review of an incident report (no title) dated 2/27/16, revealed Resident #67 was assisted to bed following lunch and at 2:27 PM was observed face down on the floor with his right arm behind his back, lying on his left arm and his feet under his bed. The same report indicated Resident #67 was observed with bruises on the right wrist and right knuckle; was transferred to the emergency room and returned with a [DIAGNOSES REDACTED]. Review of an incident report (no title) dated 3/27/16 at 10:15 PM revealed Resident #67 was heard moaning for help and found on the floor. The same report included a Statement of Witness statement that revealed Resident #67's low bed wasn't all the way lowered to the floor like it should have been. The same report and Resident #67's medical record were reviewed and no additional interventions were implemented following to prevent further falls. ADON B was interviewed on 8/18/16 at 12:45 PM and stated she was unable to locate an interdisciplinary team (IDT) note for Resident #67's fall on 3/27/16 and was not able to confirm that the team reviewed the fall nor implemented any interventions to prevent reoccurrence. According to the Fall Investigation Report dated 5/17/16, Resident #67 had fallen out of bed on 5/17/16 at 12:15 AM and was agitated. The same report indicated Ativan (anxiolytic medication for anxiety) was administered to Resident #67 at 2:00 AM; however, his anxiety symptoms persisted as he was assisted into his wheelchair at 4:45 AM. According to the Incident report (no title) dated 5/17/16 at 5:30 AM, Resident #67 fell out of his wheelchair near the nurses station, landing on his knees and then hit his head on the floor. The same report indicated Resident #67's fall resulted in a laceration to the left eyebrow, 3 lacerations on his left cheek, and discoloration was noted on both of his knees. The same report indicated Resident #67 asked the staff why did you hit me in the head so hard and then was transferred to the emergency room for sutures to his left eyebrow. Incident report (not title) dated 6/15/16 at 10:00 AM indicated Resident #67 was found on the floor on his right side and was last observed lying in bed. Another incident report (no title) dated on the same day, 6/15/16 at 7:00 PM revealed Resident #67 was found sitting up on floor leaning against the bed and indicated Resident #67 had stated he was attempting to straighten his bed. The same report indicated Resident #67 was incontinent at the time of the fall and a question on the incident report that queried the time Resident #67 was last toileted was left blank and unanswered in the attached investigation materials. Incident report (no title) dated 6/16/16 at 12:01 AM revealed Resident #67 rolled out of bed. ADON B was interviewed on 8/18/16 at 11:50 AM and stated all resident falls were reviewed at the beginning and end of the day, but the IDT team did not discuss Resident #67's fall that occurred on 6/16/16. ADON B stated that the IDT team does not meet to follow up on the effectiveness of fall interventions that were implemented following a residents' fall. Resident #67's Incident Report (no title), dated 7/25/16 revealed he was observed sitting on the floor mat next to his bed at 8:40 PM. The same report indicated Resident #67 was incontinent at the time of the fall. ADON B was interviewed on 8/18/16 at 11:50 AM and stated that a bladder assessment was not considered. Resident #67's incident reports and medical record reflected there had been a history of incontinence and urinary tract infections noted with more than one fall. Incident Report (no title) dated 8/2/16 at 9:20 PM indicated Resident #67 was observed on the floor mat next to his bed. The same report revealed Resident #67 was treated for [REDACTED]. ( )

This citation pertains to intake MI 451, MI 495, MI 781, MI 006. Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned and non-care-planned interventions, and 3.) ensure that those interventions were functional and in place in 1 of 5 sampled residents (Resident #105) reviewed for falls, from a total sample of 5 residents, resulting in an Immediate Jeopardy when on [DATE], Resident #105 fell supine, half in and out of the bathroom, where Resident #105 required immediate transport to the hospital, where he later died as the result of a head injury. This deficient practice placed 59 residents at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and the Minimum Data Set (MDS) revealed Resident #105 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #105 was unable to complete the Brief Interview for Mental Status, had memory problems, and his daily decision making skills score was modified independence, which indicated he had difficulty in new situations only. The MDS indicated Resident #105 required the extensive assistance of 2 staff members with bed mobility, transfers, toileting, and personal hygiene and was frequently incontinent of bladder. The MDS indicated Resident #105 was unsteady with staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off toilet and with surface to surface transfers. Review of the fall care plan, dated [DATE], revealed that Resident #105 was at risk for falls. Interventions included increased supervision, the required assistance of 1 person for ambulation, and, on [DATE], were updated to reflect Resident #105 was to be toileted every 2 hours. Review of the Incident Report, dated [DATE] at 3:30 PM, revealed Resident #105 was lowered to the floor after being found slumped over his walker after an independent transfer. Staff lowered him to the floor and there was no injury. The report indicated fall precautions implemented; the note indicated Resident #105 was reeducated on use of a call light Review of the Incident report, dated [DATE] at 12:00 AM, revealed Resident #105 had a fall out of bed onto a mat on the floor and there were no injuries. The incident report indicated that Resident #105 fell out of bed 4 more times over the course of the night on ,[DATE]-[DATE]. The report indicated gripper socks applied and implemented frequent check. The Follow Up indicated Resident #105 was to have gripper socks while out of bed, mattress to bedside while in bed, frequent checks, and continue alarms for bed and chair due to decreased safety awareness. The Root Cause was staff did not follow plan. Review of the Treatment Administration Record, dated [DATE], revealed Resident #105 had a wheelchair and bed alarm added on [DATE] on the 3rd shift. Review of the Incident Report, dated [DATE] at approximately 5:00 a.m., revealed Resident #105 had an unwitnessed fall from the wheelchair and was found lying on back half way in bathroom and half way in his room. The report indicated Resident #105 was last toileted on [DATE] at 4:30 AM. The report indicated Resident #105 was not independent for toileting and that no alarms were present at the time of the fall. The Incident report indicated there were no injuries noted. The report indicated there were no alarms at the time of the fall. Review of the Witness Statement, dated [DATE] (no time), revealed CNA C, was doing rounds about 4:40 (AM) and asked (Resident #105) if he needed anything and he said no thanks. I cleaned up the room and he was sitting his wheelchair when I walked out of the room and went next door. About 5 minutes later, I heard a crash in the bathroom and found him on the floor laying in a wet puddle. I ran to get the nurse who looked him over and found a wound on the back of his head, then she called the paramedics. In an interview on [DATE] at 11:49 AM, CNA C, who found Resident #105 on [DATE], reported she was doing rounds and noted Resident #105, was sitting in his room in his wheelchair. CNA C asked him if he needed to use the bathroom and he said no, so she went next door to answer a call light then heard a loud crash and went back to Resident #105's room and saw him on the floor on his back. CNA C noted the floor was wet with urine; he had no socks and no shoes on. CNA C flagged down the nurse (LPN D) who came to asses him. CNA C reported Resident #105 would routinely get up without using his call light. CNA C reported that the alarm was on Resident #105's wheelchair, but was not sounding at the time of the fall. In an interview on [DATE] at 11:15 AM, Licensed Practical Nurse (LPN) D stated that CNA C was sitting outside Resident #105's room due to his impulsivity and he was mentally challenged, but there was no order for 1:1 observation. LPN D stated the CNA C was across the hall at the time of the fall due to another resident needing assistance. LPN D reported she was flagged by CNA C on [DATE] about 5:00 PM and upon entry noted Resident #105 was lying supine on the floor between the doorway of the bathroom with his head facing towards the bathroom. LPN D reported Resident #105 had bleeding from the back of his head and there was blood noted on the floor. LPN D reported the bathroom floor was wet with urine. LPN D reported she completed a neurological assessment by checking his eyes and noting he could move both arms and legs. LPN D stated that Resident #105 reported his head hurt and stated ' I fall, I fall, I sorry '. LPN D reported she held pressure to the back of his head with a towel. LPN D stated she left Resident #105 with two CNA's, went to call 911, returned to the room, and monitored Resident #105 until EMS got to the facility. In a second interview on [DATE] at 10:50 AM, LPN D reported that on the night of [DATE], she had CNA C remain outside Resident #105's bedroom door to watch him (1:1 observation) due to his impulsivity, unpredictability, because he kept getting up out of bed and because of reports of recent previous falls. LPN D reported that, when she entered the room to assess Resident #105, she found approximately a 6 pool of blood under his head and a 5 laceration on the back of his head. In an interview on [DATE] at 9:30 AM, CNA F reported on [DATE], when Resident #105 fell , she was in another room providing care to another resident. CNA F reported that CNA C was sitting at Resident #105 's door that night because every time they would leave the room, he would get up independently. CNA F reported that at about 2:30 AM, CNA C took lunch and CNA F had to sit at the doorway of Resident #105's room and did toilet him at that time. Review of the Hospital Record, dated [DATE] at 6:19 AM, revealed Resident #105 was seen in the emergency room after a fall which resulted in a laceration to the back of his head. Pt (patient) has multiple bruises and abrasions in multiple states of healing. Resident #105 was noted to be positive for altered mental status, fall, laceration and required sedation to continue examination. The CT scan of the brain indicated Resident #105 had an acute left subdural hematoma. Resident #105 was placed on comfort care and discharged from the hospital on [DATE] to the funeral home. Review of the Death Certificate, dated [DATE], revealed Resident #105's Manner of death was listed as Accident and Cause of Death was complication of impact to head. On [DATE] at approximately 4:00 p.m., the Administrator was notified of the Immediate Jeopardy that began on [DATE] and was identified on [DATE], when the facility failed to implement care-planned and non-care-planned interventions for Resident #105 and ensure that those interventions were functional and in place. On /,[DATE], this surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. Resident #105 no longer resides at the facility. 2. On [DATE], a review of all residents was completed to ensure care plans and functional interventions have been identified and implemented. Any concerns identified were corrected and validated by the nursing management. 3. On [DATE], a review of the policies for Accidents and Incidents; Report, Investigation, Review and Analysis; Care Planning; and Fall and Injuries have been reviewed by the Director of Nursing and the Administrator. 4. Beginning [DATE], all facility staff have begun education on fall prevention, identification of interventions, and the care planning process, and on referring resident safety concerns to the Administrator and Director of Nursing. No staff will be allowed to work prior to receiving this education. 5. On [DATE], the Medical Director was notified of the survey findings, abatement plan, and agrees with the facility's actions with no further recommendations. 6. Continuing [DATE], the supervisory nurses will be responsible to ensure residents are assessed for fall risk, that fall prevention interventions are identified on the care plan, and implemented accordingly. 7. Beginning [DATE], CNA's will be responsible to conduct fall interventions review rounds at the beginning and end of shift to ensure necessary interventions are in place as per the care plan. 8. Beginning [DATE], the supervisory nurses will conduct fall intervention review rounds mid-shift daily across shifts for the next 30 days. Following the 30 day review, the auditing will be completed 3 times per week at shift change and mid-shift for another 30 days, then weekly for 30 days, then monthly for 2 months. 9. The DON or designee is responsible to review the audits and forward the information to the Quality Assurance committee. The DON is responsible to attain an sustain compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. Additional Observations In an observation on [DATE] at 2:58 p.m. Resident #107 was laying in the bed in her room with eyes closed. The alarm pad was noted under Resident #107 on the bed with the cord extended towards the foot of the bed. The alarm box was noted to be laying on the floor at the foot of the bed disconnected from the alarm cord. No alarms were sounding and they were non-functional. ( )

This citation pertains to intake MI 451, MI 495, MI 781, MI 006. Based on observation, interview and record review, the facility failed to provide sufficient nursing staffing to meet resident care needs and provide needed supervision in 1 of 5 sampled Resident (#105) reviewed for staffing, from a total sample of 6 residents, resulting in resident injury due to nursing staff members being unavailable due to care for other residents while in a room for an extended period of time the potential for resident care needs not being met. Findings include: Review of the Face Sheet and the Minimum Data Set (MDS) revealed Resident #105 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #105 was unable to complete the Brief Interview for Mental Status, had memory problems, and his daily decision making skills score was modified independence, which indicated he had difficulty in new situations only. The MDS indicated Resident #105 required the extensive assistance of 2 staff members with bed mobility, transfers, toileting, and personal hygiene and was frequently incontinent of bladder. The MDS indicated Resident #105 was unsteady with staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off toilet and with surface to surface transfers. Review of the Incident Report, dated 6/12/15 at approximately 5:00 a.m., revealed Resident #105 had an unwitnessed fall from the wheelchair and was found lying on back half way in bathroom and half way in his room. The report indicated Resident #105 was last toileted on 6/12/15 at 4:30 AM. The report indicated Resident #105 was not independent for toileting and that no alarms were present at the time of the fall. In an interview on 8/18/15 at 11:15 AM, Licensed Practical Nurse (LPN) D stated that she had Certified Nurse Aide (CNA) C remain seated outside Resident #105's room due to his impulsivity and he was mentally challenged, but there was no order for 1:1 observation. LPN D stated the CNA C was across the hall at the time of the fall due to another resident needing assistance. LPN D reported she was flagged by CNA C on 6/12/15 about 5:00 PM and upon entry noted Resident #105 was lying supine on the floor between the doorway of the bathroom with his head facing towards the bathroom. LPN D reported Resident #105 had bleeding from the back of his head and there was blood noted on the floor. In a telephone interview on 8/18/15 at 9:30 AM, Certified Nurse Aid (CNA) F reported on 6/12/15, when Resident #105 fell , she was in another room providing care to another resident. CNA F reported that CNA C was sitting at Resident #105 's door that night because every time they would leave the room, he would get up independently. CNA F reported there was another resident on the hall that required frequent staff assistance and that is where CNA C was at the time of the fall. Review of the Hospital Record, dated 6/12/15 at 6:19 AM, revealed Resident #105 was seen in the emergency room after a fall which resulted in a laceration to the back of his head. Pt (patient) has multiple bruises and abrasions in multiple states of healing. Resident #105 was noted to be positive for altered mental status, fall, laceration and required sedation to continue examination. The CT scan of the brain indicated Resident #105 had an acute left subdural hematoma. Resident #105 was placed on comfort care and discharged from the hospital on [DATE] to the funeral home. Review of the Death Certificate, dated 6/16/15, revealed Resident #105's Manner of death was listed as Accident and Cause of Death was complication of impact to head. In an interview on 8/19/15 at 10:55 a.m. LPN D reported that on the evening of 6/11/15 when Resident #105 fell there were 2 nurses on duty, 5 CNA's and 75 residents on third shift. LPN D reported she had worked a double shift that day and worked both the second and third shift. Review of the facility staffing schedule, dated 6/11/15, reflected the third shift schedule as 2 nurses, 5 CNA and 75 residents. No manager came in to assist with the staffing shortage. Review of the facility staffing schedule, dated 6/12/15, revealed 3 call-ins on first shift and 10 CNA's worked and 5 nurses and 74 residents. A note at bottom of schedule indicated 13 CNA's were called for staffing and not able to fill in. No manager came in to assist with the staffing shortage. In an telephone interview on 8/18/15 at 11:49 a.m. CNA C reported she had concerns about working short staffed. CNA C reported she believed the facility had a lot of falls because the staff worked short a lot. CNA C reported it was, Not fair to residents with increased fall risk. In an interview on 8/18/15 at 4:10 p.m. Administrator B reported there were 59 residents who required 1 to 2 person assist with activities of daily living not including the residents that required total assist at the time this surveyor entered the facility 8/12/15. In an interview on 8/19/15 at 2:37 p.m. Registered Nurse (RN) N reported that currently D hall has 2 CNA's and 1 nurse on day shift with 2 residents with tracheostomies and 3 residents with gastrointestinal tubes and most residents on the hall are a high risk for falls. RN N reported that yesterday at between 2:40 and 3:00 p.m. there were 3 residents that needed assistance quickly. RN N reported one resident fell , one resident was blind and was up independently in her room and spilled a glass vase of flowers and water on floor and the third resident was attempting to get into another residents bed. RN N reported that today around 11:15 a.m. a resident fell while both aides were at lunch and the aids that were covering D hall were doing vitals and passing water. ( )

This citation pertains to intake MI 495, MI 781. Based on observation, interview, and record review, the facility failed to provide services that met the acceptable standards of clinical practice for [MEDICAL CONDITION] care in 2 of 2 sampled Residents (#104 and #106) reviewed for [MEDICAL CONDITION] care, from a total sample of 5 resident, resulting in the potential for [MEDICAL CONDITION] and/or infection. Findings include: According to John Hopkins Medicine: Removing mucus [MEDICAL CONDITION] without suctioning. Bend forward and cough. Catch the mucus from the tube, not from the nose and mouth. Squirt sterile normal saline (approximately 5cc) into [MEDICAL CONDITION] to help clear the mucus and cough again. Remove the inner tube (cannula). Suction. Call 911 if breathing is still not normal after doing all of the above steps. Remove the [MEDICAL CONDITION] and try to place the spare tube. Continue trying to cough, instill saline, and suction until breathing is normal or help arrives. When to suction - Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. Suctioning should be considered. (1). Any time the patient feels or hears mucus rattling in the tube or airway. (2). In the morning when the patient first wakes up. (3). When there is an increased respiratory rate (working hard to breathe). (4) Before meals. (5) Before going outdoors. (6) Before going to sleep <http://m.hopkinsmedicine.org/[MEDICAL CONDITION]/living/suctioning.html> According to John's Hopkins, [MEDICAL CONDITION] Humidification, found at: http://www.hopkinsmedicine.org/[MEDICAL CONDITION]/living/humidification.html. The nose and mouth provide warmth, moisture and filtration for the air we breathe. Having a [MEDICAL CONDITION], however, by-passes these mechanisms so humidification must be provided to keep secretions thin and to avoid mucus plugs. Sterile saline drops can be instilled into [MEDICAL CONDITION] if secretions become thick and difficult to suction. Resident #104 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #104 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #104's had a BIMS (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. The MDS indicated she required two person physical assist with transfers, dressing, hygiene and bathing and one person physical assist with locomotion on the unit via wheelchair. In an interview and observation on 8/12/15 at 3:55 p.m. Resident #104 was in a wheelchair sitting in the dinning room with a portable oxygen on the back of the wheelchair that was set to deliver oxygen at 8 liters and a [MEDICAL CONDITION] mask was in place. There was no humidifier observed. Resident #104 used a pen and paper to communicate that she had two recent incidents related to her [MEDICAL CONDITION] that required her to be admitted to the hospital. Resident #104 wrote, they almost killed me. Resident #104 wrote the first incident occurred on 8/1/15 with Licensed Practical Nurse (LPN) K when her [MEDICAL CONDITION] came out. Resident #104 wrote the second incident occurred on 8/9/15 with LPN L when she began to have difficulties breathing. Resident #104 wrote that LPN L tried to suction the [MEDICAL CONDITION] but was unable to because it was clogged up and she was sent to the hospital. Resident #104 wrote she had returned from the hospital after the first incident on 8/6/15 and no one suctioned or offered to suction the [MEDICAL CONDITION] from 8/6/15 through 8/9/15 when the second incident occurred with LPN L. According to the facility Nursing Progress Notes for Resident #104, dated 8/1/15 at 3:00 a.m. revealed, pt (patient) noted to have coughed and inner cannula was dislodged.[MEDICAL CONDITION] done.[MEDICAL CONDITION] were on snug when 4x4 was placed, this occurred at 1:00 a.m. CNA came to me and said pt. needs help. Pt noted to have trach-inner and outer cannula out. Attempted to put [MEDICAL CONDITION]. Called for nurse who called 911. Used Ambu bag with oxygen at 3L (liters) to assist with breathing. PT was breathing on her own some, assisted to hyperoxygenate/assist. Ambulance arrived at 2:10 a.m. Pt. taken to hospital via stretcher. The note was signed by LPN K According to the facility Nursing Progress Notes dated 8/6/15 at 5:00 p.m. Resident #104 returned to facility from (named hospital) via wheelchair van.[MEDICAL CONDITION] place with oxygen at 8L/min and humidifier at 35%. According to the facility Nursing Progress Notes dated 8/9/15 at 4:20 p.m. revealed Resident #104 was, Sent to (named hospital) for evaluation. 48% oxygen sat. Resp. distress. (Named Physician Nurse Practitioner) ok' d. According to the facility Nursing Progress Notes for Resident #104, undated and no time noted, revealed an entry after a 8/12/15 note the reflected, late entry 8/9/15 notes patient was suctioned awaiting EMS [MEDICAL CONDITION] provided to get more oxygen. Oxygen was applied and a treatment was given by EMS. The note was singed by LPN L. According to the facility Treatment Administration Record, dated 8/6/15 through 8/9/15, Resident #104 had an order to [MEDICAL CONDITION] every shift and PRN (as needed). 6 initialed times were noted between 8/6/15/ and 8/9/15 that indicated the care was provided. According to the hospital History and Physical/Admission Note dated 8/9/15 at 6:19 p.m. revealed Resident #104 was admitted on [DATE] with, Chief complaint: respiratory distress, pt. found at nursing home O2 sats in 40's. Pt. has trach. Under, HPI: (Resident #104) is a 53 y.o. female .While in the ED (named Physician) performed [MEDICATION NAME] removing dried occluding secretions. Please see his separate note for details. Patient was then transferred to the ICU for further management. Upon arrival (named Physicians) from the trauma [MEDICAL CONDITION] a Shiley. According to the hospital ED Provider Notes dated 8/9/15 for Resident #104, page 98, reflected continued note from the [MEDICATION NAME], MDM Patient had [MEDICAL CONDITION] with copious amounts of secretions removed. There seemed to be an obstruction past 5-6 cm past which the suction catheter could not be passed. Patient was bagged mask ventilated which improved her oxygen saturations 100%. At this point patient's mental status started to improve and she was able to explain to us that she has airway stenosis for which she was receiving surgery at (named hospital) in about a month. Her chest x-ray was also concerning for pneumonia and given her history likely aspiration. The ICU intensivist was consulted who performed a bedside [MEDICATION NAME] which showed copious amounts of secretions inside of tracheal tube. They were removed after which patient was also saturating better. It seems that this was likely due to airway obstruction from secretions as patient does still produce; bronchioles seemed fairly well preserved and it did not seem to any significant stenosis noticed either in the airway. Patient was admitted to the ICU for further management . According to the hospital Discharge Summaries-Encounter Notes, dated 8/10/15, under ICU Attending, Patient seen, examined, and discussed with (named Physician) .(Resident #104) is doing remarkably well. She is awake, alert, and breathing comfortably [MEDICAL CONDITION]. [MEDICAL CONDITION] toleting/suctioning is clearly the key to avoiding further similar episodes in the future . Under assessment/plan included to have humidified air at all times. Under Disposition, We need to reach out to patient's care facility to determine what level of care they can provide and give clear instructions at discharge on how to care for complications . In an interview on 8/13/15 at 2:05 p.m. LPN D reported she often works on D hall with Resident #104. LPN D reported she performs [MEDICAL CONDITION] care 1-2 times per shift and records in Treatment Administration Record. LPN D reported Resident #104 has a history of refusing [MEDICAL CONDITION] care and suctioning. Requested facility Incident and Accident reports with investigations on 8/14/15 at 1:35 p.m. for Resident #104. Received Incident and Accident report with no investigation on 8/17/15 at 12:00 p.m. for 8/1/15 incident. According to the facility Incident and Accident Report dated 8/1/15 at 2:00 a.m., revealed Resident #104 was found by Certified Nursing Aid (CNA) M in her room with metal [MEDICAL CONDITION] out and called for LPN K. LPN K attempted to insert emergency [MEDICAL CONDITION] and was unable to reinsert. 911 was called and Ambu bag was used with 3 liters oxygen connected to help breathing before Emergency Medical Services (EMS) arrived. In an observation on 8/17/15 at 3:50 p.m. Resident #104 was self propelling in hall with portable oxygen set at 8 liters and [MEDICAL CONDITION] oxygen mask in place with no humidifier noted. In an observation on 8/18/15 at 10:10 a.m. Resident #104 was noted to be a community room at the end of A hall in her wheelchair with the portable oxygen set at 8 liters and [MEDICAL CONDITION] oxygen mask in place with no humidifier noted. The reading on the oxygen tank was at the bottom of the red (empty) mark. Resident #104 wrote on a pad of paper that she could tell it was getting low and was returning to her room now in D hall. Resident #104 self propelled down A hall and a unnamed staff assisted her to room. Received investigation including witness statements on 8/19/15 at 9:00 a.m. from the Administrator B for Resident #104 related to the 8/1/15 incident. In a second interview on 8/19/15 at 10:10 a.m. LPN D verified her witness statement related to the 8/1/15 incident that involved Resident #104. LPN D reported she was working on A hall that evening and LPN K was working on D hall with Resident #104. LPN D reported LPN K had performed [MEDICAL CONDITION] care a few minutes prior to CNA M calling for assistance from Resident #104's room. LPN D reported she entered Resident #104's room and observed Resident #104 on the bed with the metal [MEDICAL CONDITION] out laying on the pillow on left side of Resident #104. LPN D reported LPN K attempted to insert the emergency [MEDICAL CONDITION] 2 times with no success. LPN D reported Resident #104 was anxious and loosing color in her face and lips (due to low oxygen levels). LPN D began to administer breaths via Ambu bag over her mouth and nose with 3 liters of oxygen attached with positive chest rise and she reported color started to return to Resident #104's lips and continued Ambu bag over mouth and nose until EMS arrived. LPN D denied looking inside old [MEDICAL CONDITION] after it was laying on pillow. LPN D reported receiving [MEDICAL CONDITION] training in the past, but was unsure when. LPN D reported when Resident #104 returned to the facility with a metal [MEDICAL CONDITION] LPN D did not receive training at that time because she did not care for Resident #104. LPN D reported training that was provided covered [MEDICAL CONDITION] care including how to remove inner canula and soak and clean. LPN D reported training covered how to perform suctioning including suctioning kits and to use catheter connected to suction and insert 3-4 inches. LPN D reported she does not care for Resident #104 because she does not feel comfortable caring for her [MEDICAL CONDITION]. In an interview on 8/19/15 at 2:35 p.m. Registered Nurse (RN) N reported that Resident #104 was at (named hospital) about 2 hours away for a planned doctor appointment. In an interview on 8/19/15 at 3:25 p.m. LPN L reported that on 8/9/15 Resident #104 had an episode of respiratory distress and had to be transferred to the hospital. LPN L reported he was unsure if an incident/accident report was completed. LPN L reported that Resident #104 requested at about 4:00 p.m. to be suctioned. LPN L reported Resident oxygen saturation level was 96%, he gathered the supplies needed to perform suctioning, turned on the suction machine in her room, and use the open system catheter to suction Resident #104 while she was sitting in a wheelchair. LPN L reported he inserted the suction catheter about 3 inches with no secretions removed and reported he attempted 2 addition times to pass the suction catheter with no secretions removed, but that he could see very thick secretions in the [MEDICAL CONDITION]. LPN L reported Resident #104 was having respiratory distress and reported a unnamed CNA returned to the room with a crash cart and LPN L left Resident #104's room to call 911. LPN L reported he returned to room with nebulizer supplies and performed a nebulizer treatment on Resident #104 to try to loosen secretions with the oxygen set at 8 liters and Resident #104 continued to have labored breathing with oxygen saturation at 48%. LPN L reported Emergency Medical Services arrived and transported Resident #104 to hospital. LPN L reported he last received [MEDICAL CONDITION] training in the fall of 2014 from the facility. In a second interview on 8/19/15 at 4:30 p.m. LPN L reported that when he performed [MEDICAL CONDITION] suctioning on Resident #104 on 8/9/15 prior to transfer to the hospital he did not use normal saline in the [MEDICAL CONDITION] to loosen the mucus secretions/plug. LPN L reported, the kit I grabbed didn't have it. In a observation on 8/19/15 at 4:35 p.m., LPN L opened supply closet with surveyor and noted that the suction kit included, catheter, gloves, and 100 milliliters of sterile saline. ( ) Resident #106 Review of the Face Sheet, reflected Resident #106 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In an observation on 8/19/15 at 2:05 p.m. Resident #106 was noted to be in new room laying on back with head of bed elevated. Resident #106 had a [MEDICAL CONDITION] noted with [MEDICAL CONDITION] oxygen mask over the [MEDICAL CONDITION] (trach) that was connected to a concentrator set at 4 liters of oxygen. There was no humidifier/humidification noted. In an observation on 8/20/15 during the morning tour at about 10:20 a.m. several concentrators were noted to have humidifiers normal saline bubblers attached for residents on oxygen. Resident #106 remained without humidified oxygen to her trach. In an observation and interview on 8/20/15 at 12:40 p.m., Registered Nurse (RN) O entered Resident #106's room to perform [MEDICAL CONDITION] care and suctioning. Resident #106 had oxygen via a concentrator set at 4 liter with no noted saline humidifier. RN O explained to Resident #106 what she was planning to do and setup supplies on bedside table after washing hands. RN O was observed cleaning around the [MEDICAL CONDITION] and changing 4x4 around [MEDICAL CONDITION]. RN O reported she suctions Resident #106 at least 1 time per shift. RN O disposed of the [MEDICAL CONDITION] care items, washed hands, gathered supplies for suction care. RN O opened the suction kit that included a suction catheter, gloves and 100 milliliters sterile saline. RN O opened the sterile saline and emptied content into kit basin areas. RN O explained the care to Resident #106 and donned sterile gloves and encouraged Resident #106 to take a few deep breaths while RN O tested suction with sterile saline in basin. RN O performed [MEDICAL CONDITION] suction x 3 with rest periods for Resident #106 to breath. RN O was observed placing suction catheter about 8-10 inches in [MEDICAL CONDITION] and retracting slowly with turning motion. Resident #106 was noted to have strong cough with secretions cleared. This surveyor asked RN O if she ever uses normal saline in the [MEDICAL CONDITION] to loosen thick secretions. RN O reported, No. RN O reported she never uses saline in [MEDICAL CONDITION] and if secretions are thick RN O reported she would administer a breathing treatment to the resident if ordered. In an observation and interview on 8/20/15 at 3:00 p.m. Resident #106's oxygen noted was connected to the concentrator with no noted saline humidification to [MEDICAL CONDITION]. RN/Unit Manager P reported Resident #106 does not have an order for [REDACTED]. Central Supply staff Q reported the facility does have 3-5 ml pink normal saline solutions in the supply closet [MEDICAL CONDITION]. Surveyor observed 2 boxes of 3 ml and 2 boxes of 5 ml normal saline for trach's. RN/Unit Manager P reported she was not told by the supervisors of any [MEDICAL CONDITION] issues and did not know the nurses were not using everything they need. RN P reported she would go put humidifier bubbler on Resident #106's concentrator. RN P reported she was not aware that Central Supply staff Q received clarification (from the oxygen supplier) that the oxygen equipment does need humidifier bottles to provide humidification during oxygen delivery. ( )

This citation pertains to intake MI- 868. Based on observations, interviews and records review, the facility failed to provide adequate supervision for one of five residents that were at risk for falls (Resident #101), from a total of five Sampled residents, resulting in Resident #101 falling from bed and sustaining a fractured elbow. Findings Include: Per the "Minimum Data Set", dated 12/09/12, Resident #101 was admitted to the facility on [DATE], had inattention and disorganized thinking that comes and goes and changes in severity, needed extensive assistance with toilet use, was unsteady moving on and off toilet, turning around, walking, and moving from seated to standing position, was frequently incontinent of urine, had had no falls since or prior to admission, and had [DIAGNOSES REDACTED]. Per a facility "Accident/Incident Report", dated 12/21/11 at 4:45 AM, "...(Resident #101) was on floor mat. Resident stated to have pain on her forehead and right toe. She stated that she was going to bathroom. (Resident #101) assessed ...assisted back to bed with aid of a (hydraulic) lift plus 2 assist. EMS (emergency medical services) called per Dr's order. (Resident #101) sent to (hospital) ...Immediate Action Taken To Prevent Further Incidents: (Resident #101) checked and brief changed. Encourage resident to stay in bed until help arrived. Especially use a call light..." An imaging report, dated 12/21/11 at 7:02 AM, regarding Resident #101, revealed a right elbow fracture. In an interview, on 2/07/12 at 1:44 PM, Resident #101 was observed sitting in a wheel chair in her room; her right wrist was lying on her lap and it was visibly swollen. When asked to recall what happened on 12/21/11 at the time of the fall, Resident #101 stated, " There was blood coming out of my mouth and above my eye. I hit it on the bedside table. They told me, 'Whatever you do, don't get out of bed'..." When this Surveyor asked Resident #101 why she fell , she stated, "I can't remember". In an interview, on 2/07/12 at 9:40 AM, nurse aide #1 stated she was assigned to care for Resident #101, and was the nurse aide who found Resident #101 on her floor mat on 12/21/11 at 4:45 AM. Nurse aide #1 told this Surveyor she had worked at the facility part time for the past 4-5 months and always woke Resident #101 up every two hours during the night to check to see if her adult brief was wet. Nurse aide #1 said she woke Resident #101 up at around 11:30 PM and changed her adult brief because it was wet. Nurse aide #1 stated Resident #101 ' s bed was in the lowest position, the call light and sensor alarm were in place on Resident #101's bed at that time, and that Resident #101 told her she had a doctor's appointment the next day. Nurse aide #1 stated, "(Resident #101) was upset all night because she had a doctor appointment the next day ...she stated saying she wanted to get up at about 2:00 AM ...about 15 minutes later (Resident #101) said she wanted to be changed again (but was dry) and thought she was late (for her doctor appointment). I told her I would be in about 5:00 AM to get her up for the day shift. (Resident #101) just wanted to make sure she wasn't late ...about every 15-20 minutes she'd start yelling, 'I'm going to be late"...I told the nurse at about 11:30 that (Resident #101) was restless and wanted to get up". When asked if she would do anything differently to prevent Resident #101 from falling, nurse aide #1 stated, "(Resident #101) was restless. If I had to do it over again, I would have gotten her up (in her wheel chair and placed by the nurse for observation)". In an interview, on 2/07/12 at 2:52, Unit Manager #5 told this Surveyor the Interdisciplinary Team had not done a root cause analysis of the resident of concern's fall on 12/21/11, and they did not update the resident's care plan or put interventions in place to prevent it happening again. When asked if the resident of concern's "Care Delivery Guide" had been updated since the fall to instruct nursing staff to "offer (toilet) every 2 hours during waking hours", she replied, "It's been like that since I've been here (November 2011)". Per Resident #101's "Actual/Potential for Infection Plan of Care", dated 9/12/11, "Monitor for signs/symptoms of infection: UTI (Urinary Tract Infection) ...change in behaviors ...UTI stat ordered 10/17/11". Per physician orders, dated 11/22/11, Levaquin (antibiotic) was ordered for Resident #101 because she had a UTI. Per Resident #101's "Care Delivery Guide", dated 9/13/11, "Bladder: Timed scheduled - offer every 2 hour during waking hours". In an interview, on 2/07/12 at 10:00 AM, LPN/Licensed Practical Nurse #7 stated she was assigned to care for Resident #101, said, " It was my second week working and my first nursing job", and was the nurse aide who did the assessment on Resident #101 on 12/21/11 at 4:45 AM. When asked if she recalled nurse aide #1 telling her that Resident #101 was restless earlier in the evening, LPN #7 stated she told nurse aide #1 to "make sure she is safe ...check on her, talk to her, make sure she was dry". LPN #7 stated she spoke with Resident #101 before the fall and told her, 'You can't get up ...(she wanted to go to the bathroom) ...We made sure you are dry'...We do check her and change her about 1 ?-2 hours". LPN #7 stated, "You know some mistakes were made by me. If a resident complains of pain after a fall we can't get the resident off the floor. I'm supposed to call the ambulance to come". When asked if she did range of motion on Resident #101's extremities, LPN #7 stated, "I did nothing because she was moving her hands. I did not do the full range of motion. I didn't know at that time, I know now about resident safety ...if a resident is confused and want to get up, make sure they get up. If they fall, call for help and avoid bigger problems". In an interview, on 2/07/12 at 3:25 PM, when asked what measures had been put in place to prevent Resident #101 from falling again, Unit Manager #5 told this Surveyor, "No, I don't...We went into fracture mode and forgot to finish our process". Per the facility "Falls and Injuries" Procedure, "Fall/Injury Management-Post Fall or Injury", ...proper action following a fall includes: Ascertaining if there were injuries and providing treatment as necessary, Determining what may have caused or contributed to the fall, Addressing the contributing factors for the fall, Revising the residents plan of care and/or center practices to reduce the likelihood of another fall (Causal factors leading to a resident fall is necessary to provide consistent interventions to help prevent future occurrences) ...Provide staff training as needed ...Verify completion of the accident/incident process..." ( )

THIS CITATION PERTAINS TO INTAKE MI 508. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED PROVIDE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS IN 3 (#104, #105, AND #106) OF 6 SAMPLED RESIDENTS, FROM A TOTAL SAMPLE OF 6 RESIDENTS, WHEN: 1) RESIDENT #104'S SENSOR ALARM IN HER WHEELCHAIR DID NOT SOUND AND ALERT STAFF, 2) RESIDENT #105'S SENSOR ALARM IN HER WHEELCHAIR WAS NOT PLUGGED IN TO AN ALARM BOX WHEN SHE WAS SITTING IN HER CHAIR, AND 3), RESIDENT #106'S SENSOR ALARM IN HER WHEELCHAIR WAS NOT PLUGGED IN TO AN ALARM BOX WHEN SHE WAS SITTING IN HER CHAIR, RESULTING IN RESIDENT #104 SUSTAINING A FALL WITH A FRACTURED RIGHT HIP, REQUIRING SURGICAL REPAIR AND THE POTENTIAL FOR A FALL WITH INJURY FOR RESIDENT #105 AND RESIDENT #106. FINDINGS INCLUDE: RESIDENT #104: REVIEW OF RESIDENT #104'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO PHYSICIAN ORDERS, RESIDENT #104 WAS SENT TO THE hospital on [DATE] FOR EVALUATION AND treatment of [REDACTED]. RESIDENT #104'S MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT SHE WAS SEVERELY IMPAIRED WITH COGNITIVE FUNCTION, REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR TRANSFERS AND DRESSING, AND REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON FOR LOCOMOTION, WITH NO DECREASE IN HER RANGE OF MOTION ABILITY TO ANY OF HER 4 EXTREMITIES (ARMS AND LEGS). RESIDENT #104'S FALLS PLAN OF CARE DOCUMENTED HER TO BE AT RISK FOR FALLS RELATED TO DIZZINESS, HISTORY OF SEIZURES, PAIN AND OSTEOPOROSIS (WEAKENING OF THE BONES), WITH INTERVENTIONS LISTED TO INCLUDE A CHAIR ALARM AND A BED ALARM. FACILITY INCIDENT REPORT DATED 10/22/11 AT 1:30 PM, DOCUMENTED THAT RESIDENT #104 WAS FOUND ON THE FLOOR ON HER RIGHT SIDE AND THAT RESIDENT #104 STATED SHE fell WHILE REACHING FOR SOME CANDY. THE INCIDENT REPORT ALSO DOCUMENTED THAT RESIDENT #104 COMPLAINED OF PAIN IN THE RIGHT HIP, BUT HAD NO APPARENT INJURIES. NURSING NOTES FOR RESIDENT #104 DATED 10/22/11 AT 1:30 PM, DOCUMENTED THAT RESIDENT #104 WAS OBSERVED LAYING ON THE FLOOR AND THAT SHE HAD LANDED ON HER RIGHT SIDE, AND POINTED TO AREA JUST ABOVE HER RIGHT HIP AS PAINFUL, BUT WAS INCONSISTENT AND THAT RESIDENT #104'S PHYSICIAN AND DAUGHTER WERE NOTIFIED OF THE FALL WITH NO NEW PHYSICIAN ORDERS. FACILITY INCIDENT REPORT DATED 10/22/11 AT 4:45 PM, DOCUMENTED THAT RESIDENT #104 WAS HEARD YELLING OUT AND WAS FOUND ON THE FLOOR. THE INCIDENT REPORT ALSO DOCUMENTED THAT RESIDENT #104 COMPLAINED OF HER RIGHT HIP REALLY HURTING AND YELLED OUT WHENEVER HER RIGHT LEG IS MOVED, AND WAS PLACED BACK IN BED THERE WERE NO FURTHER NURSING NOTES FOR RESIDENT #104 UNTIL 10/23/11 AT 5:00 PM, WHICH DOCUMENTED COMMUNICATION WITH RESIDENT #104'S DAUGHTER. THERE IS NO DOCUMENTATION IN THE NURSING NOTES FOR RESIDENT #104 OF A FALL AT 4:45 PM ON 10/22/11. NURSING NOTES FOR RESIDENT #104 DATED 10/24/11 AT 2:00 PM, TWO DAYS AFTER THE FALL AND DISCHARGE TO THE HOSPITAL OF RESIDENT #104, REGISTERED NURSE (RN) #11 DOCUMENTED THAT FOLLOWING RESIDENT #104'S FALL AT 4:45 PM ON 10/22/11, RESIDENT #104 WAS ASSESSED WHILE ON FLOOR, AND EXHIBITED THE PRESENCE OF CHRONIC PAIN OF HER BACK, AND NO NEW COMPLAINTS OF PAIN WERE NOTED. RN #11 ALSO DOCUMENTED ON 10/24/11 THAT ON 10/22/11 SHE ASSESSED LENGTH AND ROTATION OF RESIDENT #104'S LEGS AND THEN INSTRUCTED CNA'S (CERTIFIED NURSE AIDES) TO MOVE RESIDENT #104, AND WHEN RESIDENT #104 WAS LIFTED IN THE SLING OF THE LIFT, SHE COMPLAINED OF INCREASED PAIN IN THE RIGHT GROIN. RN #11 DOCUMENTED ON 10/24/11 THAT ON 10/22/11 ONCE RESIDENT #104 WAS IN HER BED, FOLLOWING HER FALL AT 4:45 PM, IT WAS EVIDENT THAT RESIDENT #104'S RIGHT FOOT WAS EXTERNALLY ROTATED APPROXIMATELY 45 DEGREES (TURNED OUTWARD) AND HER RIGHT LEG WAS APPROXIMATELY 1 TO 2 INCHES SHORTER THAN HER LEFT LEG. RADIOLOGY REPORT FOR RESIDENT #104 DATED 10/22/11 DOCUMENTED FINDINGS AS RIGHT HIP: ACUTE INTERTROCHANTERIC FEMORAL FRACTURE WITH MILD DISPLACEMENT WITH VARUS ANGULATION. HOSPITAL TRANSFER RECORD FOR RESIDENT #104, DATED 10/26/11 DOCUMENTED DISCHARGE [DIAGNOSES REDACTED]. IN AN INTERVIEW ON 11/1/11 AT 9:00 AM, CNA #5 STATED ON 10/22/11 AROUND 4:30 PM, SHE WAS WALKING DOWN THE HALL WHEN SHE HEARD RESIDENT #104 SCREAM. CNA #5 STATED A DRIVER FOR A TRANSPORT VAN HAD JUST DROPPED OFF A RESIDENT, WAS IN THE HALL AND ALSO RESPONDED TO RESIDENT #104'S SCREAM, AND ENTERED THE ROOM AT THE SAME TIME. CNA #5 STATED SHE OBSERVED RESIDENT #104 LAYING ON THE FLOOR, TWISTED, SORT OF ON HER SIDE. CNA #5 STATED THAT RN #11 CAME IN THE ROOM AND RESIDENT #104 ASKED RN #11 TO CALL HER DAUGHTER. CNA #5 STATED SHE DID NOT SEE RN #11 ASSESS RESIDENT #104 BEFORE GETTING HER INTO THE LIFT. CNA #5 STATED SHE DID NOT SEE RN #11 TOUCH RESIDENT #104 BEFORE SHE WAS PLACED IN THE LIFT. CNA #5 STATED THAT RN #11 ASKED RESIDENT #104 IF SHE WAS OKAY AND TOLD RESIDENT #104 THAT SHE HAD TO STOP THROWING HERSELF ON THE FLOOR. CNA #5 STATED CNA # 8 ARRIVED IN THE ROOM OF RESIDENT #104 AND SHE (CNA #5) LEFT FOR A MINUTE. CNA #5 STATED WHEN SHE RETURNED TO THE ROOM, RESIDENT #104 WAS UP IN THE SLING LIFT AND SHE (CNA #5) HELPED CNA #8 TRANSFER RESIDENT #104. CNA #5 STATED WHEN THE SLING WAS TURNED OVER THE BED, RESIDENT #104 YELLED OUT "OUCH" AND "DON'T TOUCH THAT LEG". CNA #5 STATED SHE ASKED CNA #8 IF RN #11 WAS AWARE OF RESIDENT #104'S PAIN AND THAT CNA #8 STATED YES, RESIDENT #104 HAD BEEN COMPLAINING OF PAIN IN HER RIGHT LEG, SINCE SHE WAS ON THE FLOOR. CNA #5 STATED SHE REPORTED RESIDENT #104'S COMPLAINT OF PAIN IN HER RIGHT LEG TO RN #11 AND THAT RN #11 STATED SHE (RN #11) THOUGHT IS WAS JUST HER (RESIDENT #104) BACK. IN AN INTERVIEW ON 11/4/11 AT 10:20 AM, CNA #5 STATED THE MONDAY AFTER RESIDENT #104 fell AND BROKE HER HIP, THE FACILITY DIRECTOR OF NURSING CALLED HER INTO THE OFFICE AND STATED THAT THEY (CNA #5, CNA #8 AND RN #11) WEREN'T SUPPOSED TO MOVE RESIDENT #104 AFTER SHE fell . CNA #5 REPEATED TO THE SURVEYOR THAT SHE DID NOT OBSERVE RN #11 ASSESS RESIDENT #104 AFTER THE FALL, WHILE THE RESIDENT WAS ON THE FLOOR, PRIOR TO BEING LIFTED IN A SLING AND PLACED IN A BED. IN AN INTERVIEW ON 11/1/11 AT 1:10 PM, CNA #8 STATED ON 10/22/11 BETWEEN 4:30 PM AND 5:00 PM, SHE HEARD A RESIDENT SCREAMING, SO SHE RESPONDED TO RESIDENT #104'S ROOM AND OBSERVED RESIDENT #104 LAYING ON THE FLOOR. CNA #8 STATED CNA #5 AND RN #11 WERE IN THE ROOM WITH HER (CNA #8), AND THAT RN #11 DID NOT DO AN ASSESSMENT ON RESIDENT #104. CNA #8 STATED THAT RESIDENT #104 TOLD RN #11 TO CALL HER DAUGHTER. CNA #8 STATED SHE AND RN #11 PUT THE LIFT SLING UNDER RESIDENT #104 AND RESIDENT #104 YELLED, "OH IT HURTS". CNA #8 STATED SHE (CNA #8) AND RN #11 THEN LIFTED RESIDENT #104 UP ON THE LIFT, THEN CNA #5 HELPED GET RESIDENT #104 INTO HER BED, AND RN #11 LEFT THE ROOM. IN AN INTERVIEW ON 11/4/11 AT 10:35 AM, CNA #8 STATED RN #11 TOLD RESIDENT #104 SHE HAD TO STOP THROWING HERSELF ON THE FLOOR. THE SURVEYOR ASKED CNA #8 IF SHE OBSERVED RN #11 STRAIGHTEN RESIDENT #104'S LEGS, OR TOUCH RESIDENT #104 IN ANY WAY. CNA #8 STATED NO, THAT RN #11 TOLD HER TO GET RESIDENT #104 OFF THE FLOOR. IN AN INTERVIEW ON 11/2/11 AT 11:50 AM, RN #11 STATED ON 10/22/11, RESIDENT #104 HAD FALLEN EARLIER IN THE DAY, AND HAD BEEN PLACED BACK IN HER WHEELCHAIR. RN #11 STATED SHE WAS IN THE HALL A FEW ROOMS DOWN FROM RESIDENT #104'S ROOM, PASSING MEDICATIONS WHEN SHE HEARD A YELL AND RAN TO RESIDENT #104'S ROOM. RN #11 STATED SHE OBSERVED RESIDENT #104 ON THE FLOOR WITH HER RIGHT LEG TUCKED UNDER HER LEFT LEG. RN #11 STATED SHE STRAIGHTENED RESIDENT #104'S RIGHT LEG OUT AND RESIDENT #104 STATED OUCH AND THAT HER BACK HURT. RN #11 STATED SHE DID NOT NOTICE ANY ROTATION OR SHORTENING SO SHE HAD CNA #8 HELP GET RESIDENT #104 INTO THE LIFT SLING AND ONCE RESIDENT #104 WAS LIFTED INTO THE AIR, SHE YELLED OUT IN MORE PAIN, AND ONCE RESIDENT #104 WAS IN BED, RN #11 STATED SHE NOTICED RESIDENT #104 HAD ROTATION OF HER RIGHT LEG OF 45 DEGREES (TURNED) AND SHORTENING OF RIGHT LEG BY 1 TO 2 INCHES. RN #11 STATED RESIDENT #104'S YELLING CAUSED HER (RN #11) TO GO TO RESIDENT #104'S ROOM, AND THAT THE CHAIR ALARM WAS NOT SOUNDING BECAUSE IT WAS UNDER TOO MANY LAYERS WHICH INCLUDED TWO CHAIR PADS, SO IT DIDN'T GO OFF. RN #11 STATED, "THERE'S ONLY SUPPOSED TO BE ONE PAD IN THE CHAIR". A REVIEW OF THE FACILITY RESIDENT TRANSFER FORM FOR RESIDENT #104, DATED 10/22/11, REVEALED THAT RN #11 DOCUMENTED THE REASON FOR TRANSFER TO THE HOSPITAL AS RIGHT FEMUR FRACTURE MILD DISPLACEMENT WITH VARUS ANGULATION. IN THE "BEHAVIORAL OR SOCIAL ISSUES" SECTION OF THE TRANSFER FORM, RN #11 DOCUMENTED "ATTENTION SEEKING". RESIDENT #105: REVIEW OF RESIDENT #105'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO PHYSICIAN ORDERS FOR 11/11, RESIDENT #105 WAS TO HAVE A FLOOR MAT TO THE LEFT SIDE OF THE BED RELATED TO FALLS, AND A WHEELCHAIR AND BED ALARM WITH PLACEMENT AND FUNCTION TO BE CHECKED EVERY SHIFT. RESIDENT #105'S MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT SHE WAS SEVERELY IMPAIRED WITH COGNITIVE FUNCTION, REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR TRANSFERS, DRESSING, AND LOCOMOTION. RESIDENT #105'S PLAN OF CARE DOCUMENTED HER TO BE AT RISK FOR FALLS RELATED TO BEING UNSTEADY, WEAKNESS, LEGALLY BLIND, AND OSTEOPOROSIS (WEAKENING OF THE BONES), WITH INTERVENTIONS LISTED TO INCLUDE A CHAIR ALARM AND A BED ALARM. DURING AN OBSERVATION ON 11/1/11 AT 10:45 AM, RESIDENT #105 WAS OBSERVED BY THE SURVEYOR TO BE SITTING IN A WHEELCHAIR, IN HER ROOM, ALONE, FACING AWAY FROM THE DOOR TO THE HALL, AND REACHING FOR A CUP OF ICE CREAM ON HER BEDSIDE TABLE. THE SURVEYOR OBSERVED A WHITE CORD HANGING OVER THE BACK OF RESIDENT #105'S WHEELCHAIR, WHICH WAS NOT ATTACHED TO ANYTHING. THE SURVEYOR THEN ASKED CNA #6 TO EXPLAIN WHAT THE WHITE CORD WAS FOR. CNA #6 STATED THE WHITE CORD SHOULD BE PLUGGED INTO A BOX THAT ALARMS IF THE RESIDENT ATTEMPTS TO STAND, BUT THERE WAS NOT A BOX. CNA #6 LEFT RESIDENT #105'S ROOM AND STATED HE WAS GOING TO GET A BOX. CNA #6 RETURNED APPROXIMATELY 2 MINUTES LATER WITH A BOX, WHICH HE PLUGGED INTO THE WHITE CORD AND PLACED IN A BAG ON THE BACK OF RESIDENT #105'S WHEELCHAIR. RESIDENT #106: REVIEW OF RESIDENT #106'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO PHYSICIAN ORDERS FOR 11/1/11 THROUGH 11/30/11, RESIDENT #106 WAS TO HAVE A GEL CUSHION WITH CHAIR ALARM ON HER WHEELCHAIR AND A PERIMETER MATTRESS WITH A BED ALARM. THERE WAS NO PHYSICIAN ORDER LOCATED IN RESIDENT #106'S MEDICAL RECORD BY THE SURVEYOR, TO DISCONTINUE THE BED OR CHAIR ALARM. RESIDENT #106'S MINIMUM DATA SET (MD'S) DATED 7/10/11 DOCUMENTED THAT SHE WAS SEVERELY IMPAIRED WITH COGNITIVE FUNCTION, REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON FOR TRANSFERS, DRESSING, AND LOCOMOTION. RESIDENT #105'S PLAN OF CARE DOCUMENTED HER TO BE AT RISK FOR FALLS RELATED TO PAIN, OSTEOPOROSIS (WEAKENING OF THE BONES), HIGH AND LOW BLOOD SUGAR, WEAKNESS, AND DEMENTIA, WITH INTERVENTIONS LISTED TO INCLUDE A BED ALARM AND A PERIMETER MATTRESS DATED 10/31/11. DURING AN CHECK OF RESIDENT OF ALARMS DONE WITH THE FACILITY DIRECTOR OF NURSING ON 11/1/11 AT 111:50 AM, RESIDENT #106 WAS OBSERVED BY THE SURVEYOR AND THE DIRECTOR OF NURSING TO BE SITTING IN A WHEELCHAIR, IN THE DINING ROOM. THE SURVEYOR OBSERVED A WHITE CORD HANGING OVER THE BACK OF RESIDENT #106'S WHEELCHAIR, WHICH WENT INTO A BAG ON THE BACK OF THE RESIDENT'S WHEELCHAIR. THE SURVEYOR THEN ASKED THE DIRECTOR OF NURSING TO OPEN THE BAG. THE DIRECTOR OF NURSING OPENED THE BAG ON THE BACK OF THE WHEELCHAIR. THE SURVEYOR AND DIRECTOR OF NURSING THEN OBSERVED THE WHITE CORD TO BE HANGING INTO THE BAG, NOT PLUGGED INTO ANYTHING, AND THE ALARM BOX WAS LOCATED IN THE BOTTOM OF THE BAG BY THE DIRECTOR OF NURSING. THE SURVEYOR OBSERVED THE ALARM CORD FROM THE SENSOR PAD IN RESIDENT #106'S WHEELCHAIR TO BE UNPLUGGED FROM THE ALARM BOX. THE DIRECTOR OF NURSING STATED THAT THE ALARM WAS NOT PLUGGED IN. THE SURVEYOR OBSERVED THE FACILITY DIRECTOR OF NURSING REVIEW THE MEDICAL RECORD FOR RESIDENT #106 AND A PHYSICIAN'S ORDER DATED 11/1/11 THROUGH 11/30/11 FOR A CHAIR ALARM WAS LOCATED.

THIS CITATION PERTAINS TO INTAKE MI 508 AND MI 195. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL BEING FOR 1 (#104) OF 6 SAMPLED RESIDENTS, FROM A TOTAL SAMPLE OF 6 RESIDENTS, WHEN REGISTERED NURSE (RN) #11 MOVED RESIDENT #104 AFTER SHE SUSTAINED A FALL, PRIOR TO DOING A COMPLETE ASSESSMENT, RESULTING IN A POSSIBLE INCREASED INJURY, AND PAIN FOR RESIDENT #104. FINDINGS INCLUDE: REVIEW OF RESIDENT #104'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO PHYSICIAN ORDERS, RESIDENT #104 WAS SENT TO THE hospital on [DATE] FOR EVALUATION AND treatment of [REDACTED]. RESIDENT #104'S MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT SHE WAS SEVERELY IMPAIRED WITH COGNITIVE FUNCTION, REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR TRANSFERS AND DRESSING, AND REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON FOR LOCOMOTION, WITH NO DECREASE IN HER RANGE OF MOTION ABILITY TO ANY OF HER 4 EXTREMITIES (ARMS AND LEGS). RESIDENT #104'S FALLS PLAN OF CARE DOCUMENTED HER TO BE AT RISK FOR FALLS RELATED TO DIZZINESS, HISTORY OF [MEDICAL CONDITION], PAIN AND [MEDICAL CONDITION] (WEAKENING OF THE BONES), WITH INTERVENTIONS LISTED TO INCLUDE A CHAIR ALARM AND A BED ALARM. FACILITY INCIDENT REPORT DATED 10/22/11 AT 1:30 PM, DOCUMENTED THAT RESIDENT #104 WAS FOUND ON THE FLOOR ON HER RIGHT SIDE AND THAT RESIDENT #104 STATED SHE fell WHILE REACHING FOR SOME CANDY. THE INCIDENT REPORT ALSO DOCUMENTED THAT RESIDENT #104 COMPLAINED OF PAIN IN THE RIGHT HIP, BUT HAD NO APPARENT INJURIES. NURSING NOTES FOR RESIDENT #104 DATED 10/22/11 AT 1:30 PM, DOCUMENTED THAT RESIDENT #104 WAS OBSERVED LAYING ON THE FLOOR AND THAT SHE HAD LANDED ON HER RIGHT SIDE, AND POINTED TO AREA JUST ABOVE HER RIGHT HIP AS PAINFUL, BUT WAS INCONSISTENT AND THAT RESIDENT #104'S PHYSICIAN AND DAUGHTER WERE NOTIFIED OF THE FALL WITH NO NEW PHYSICIAN ORDERS. FACILITY INCIDENT REPORT DATED 10/22/11 AT 4:45 PM, DOCUMENTED THAT RESIDENT #104 WAS HEARD YELLING OUT AND WAS FOUND ON THE FLOOR. THE INCIDENT REPORT ALSO DOCUMENTED THAT RESIDENT #104 COMPLAINED OF HER RIGHT HIP REALLY HURTING AND YELLED OUT WHENEVER HER RIGHT LEG IS MOVED, AND WAS PLACED BACK IN BED THERE WERE NO FURTHER NURSING NOTES FOR RESIDENT #104 UNTIL 10/23/11 AT 5:00 PM, WHICH DOCUMENTED COMMUNICATION WITH RESIDENT #104'S DAUGHTER. THERE IS NO DOCUMENTATION IN THE NURSING NOTES FOR RESIDENT #104 OF A FALL AT 4:45 PM ON 10/22/11. NURSING NOTES FOR RESIDENT #104 DATED 10/24/11 AT 2:00 PM, TWO DAYS AFTER THE FALL AND DISCHARGE TO THE HOSPITAL OF RESIDENT #104, REGISTERED NURSE (RN) #11 DOCUMENTED THAT FOLLOWING RESIDENT #104'S FALL AT 4:45 PM ON 10/22/11, RESIDENT #104 WAS ASSESSED WHILE ON FLOOR, AND EXHIBITED THE PRESENCE OF CHRONIC PAIN OF HER BACK, AND NO NEW COMPLAINTS OF PAIN WERE NOTED. RN #11 ALSO DOCUMENTED ON 10/24/11 THAT ON 10/22/11 SHE ASSESSED LENGTH AND ROTATION OF RESIDENT #104'S LEGS AND THEN INSTRUCTED CNA'S (CERTIFIED NURSE AIDES) TO MOVE RESIDENT #104, AND WHEN RESIDENT #104 WAS LIFTED IN THE SLING OF THE LIFT, SHE COMPLAINED OF INCREASED PAIN IN THE RIGHT GROIN. RN #11 DOCUMENTED ON 10/24/11 THAT ON 10/22/11 ONCE RESIDENT #104 WAS IN HER BED, FOLLOWING HER FALL AT 4:45 PM, IT WAS EVIDENT THAT RESIDENT #104'S RIGHT FOOT WAS EXTERNALLY ROTATED APPROXIMATELY 45 DEGREES (TURNED OUTWARD) AND HER RIGHT LEG WAS APPROXIMATELY 1 TO 2 INCHES SHORTER THAN HER LEFT LEG. RADIOLOGY REPORT FOR RESIDENT #104 DATED 10/22/11 DOCUMENTED FINDINGS AS RIGHT HIP: ACUTE INTERTROCHANTERIC FEMORAL FRACTURE WITH MILD DISPLACEMENT WITH VARUS ANGULATION. HOSPITAL TRANSFER RECORD FOR RESIDENT #104, DATED 10/26/11 DOCUMENTED DISCHARGE [DIAGNOSES REDACTED]. IN AN INTERVIEW ON 11/1/11 AT 9:00 AM, CNA #5 STATED ON 10/22/11 AROUND 4:30 PM, SHE WAS WALKING DOWN THE HALL WHEN SHE HEARD RESIDENT #104 SCREAM. CNA #5 STATED A DRIVER FOR A TRANSPORT VAN HAD JUST DROPPED OFF A RESIDENT, WAS IN THE HALL AND ALSO RESPONDED TO RESIDENT #104'S SCREAM, AND ENTERED THE ROOM AT THE SAME TIME. CNA #5 STATED SHE OBSERVED RESIDENT #104 LAYING ON THE FLOOR, TWISTED, SORT OF ON HER SIDE. CNA #5 STATED THAT RN #11 CAME IN THE ROOM AND RESIDENT #104 ASKED RN #11 TO CALL HER DAUGHTER. CNA #5 STATED SHE DID NOT SEE RN #11 ASSESS RESIDENT #104 BEFORE GETTING HER INTO THE LIFT. CNA #5 STATED SHE DID NOT SEE RN #11 TOUCH RESIDENT #104 BEFORE SHE WAS PLACED IN THE LIFT. CNA #5 STATED THAT RN #11 ASKED RESIDENT #104 IF SHE WAS OKAY AND TOLD RESIDENT #104 THAT SHE HAD TO STOP THROWING HERSELF ON THE FLOOR. CNA #5 STATED CNA # 8 ARRIVED IN THE ROOM OF RESIDENT #104 AND SHE (CNA #5) LEFT FOR A MINUTE. CNA #5 STATED WHEN SHE RETURNED TO THE ROOM, RESIDENT #104 WAS UP IN THE SLING LIFT AND SHE (CNA #5) HELPED CNA #8 TRANSFER RESIDENT #104. CNA #5 STATED WHEN THE SLING WAS TURNED OVER THE BED, RESIDENT #104 YELLED OUT "OUCH" AND "DON'T TOUCH THAT LEG". CNA #5 STATED SHE ASKED CNA #8 IF RN #11 WAS AWARE OF RESIDENT #104'S PAIN AND THAT CNA #8 STATED YES, RESIDENT #104 HAD BEEN COMPLAINING OF PAIN IN HER RIGHT LEG, SINCE SHE WAS ON THE FLOOR. CNA #5 STATED SHE REPORTED RESIDENT #104'S COMPLAINT OF PAIN IN HER RIGHT LEG TO RN #11 AND THAT RN #11 STATED SHE (RN #11) THOUGHT IS WAS JUST HER (RESIDENT #104) BACK. IN AN INTERVIEW ON 11/4/11 AT 10:20 AM, CNA #5 STATED THE MONDAY AFTER RESIDENT #104 fell AND BROKE HER HIP, THE FACILITY DIRECTOR OF NURSING CALLED HER INTO THE OFFICE AND STATED THAT THEY (CNA #5, CNA #8 AND RN #11) WEREN'T SUPPOSED TO MOVE RESIDENT #104 AFTER SHE fell . CNA #5 REPEATED TO THE SURVEYOR THAT SHE DID NOT OBSERVE RN #11 ASSESS RESIDENT #104 AFTER THE FALL, WHILE THE RESIDENT WAS ON THE FLOOR, PRIOR TO BEING LIFTED IN A SLING AND PLACED IN A BED. IN AN INTERVIEW ON 11/1/11 AT 1:10 PM, CNA #8 STATED ON 10/22/11 BETWEEN 4:30 PM AND 5:00 PM, SHE HEARD A RESIDENT SCREAMING, SO SHE RESPONDED TO RESIDENT #104'S ROOM AND OBSERVED RESIDENT #104 LAYING ON THE FLOOR. CNA #8 STATED CNA #5 AND RN #11 WERE IN THE ROOM WITH HER (CNA #8), AND THAT RN #11 DID NOT DO AN ASSESSMENT ON RESIDENT #104. CNA #8 STATED THAT RESIDENT #104 TOLD RN #11 TO CALL HER DAUGHTER. CNA #8 STATED SHE AND RN #11 PUT THE LIFT SLING UNDER RESIDENT #104 AND RESIDENT #104 YELLED, "OH IT HURTS". CNA #8 STATED SHE (CNA #8) AND RN #11 THEN LIFTED RESIDENT #104 UP ON THE LIFT, THEN CNA #5 HELPED GET RESIDENT #104 INTO HER BED, AND RN #11 LEFT THE ROOM. IN AN INTERVIEW ON 11/4/11 AT 10:35 AM, CNA #8 STATED RN #11 TOLD RESIDENT #104 SHE HAD TO STOP THROWING HERSELF ON THE FLOOR. THE SURVEYOR ASKED CNA #8 IF SHE OBSERVED RN #11 STRAIGHTEN RESIDENT #104'S LEGS, OR TOUCH RESIDENT #104 IN ANY WAY. CNA #8 STATED NO, THAT RN #11 TOLD HER TO GET RESIDENT #104 OFF THE FLOOR. IN AN INTERVIEW ON 11/2/11 AT 11:50 AM, RN #11 STATED ON 10/22/11, RESIDENT #104 HAD FALLEN EARLIER IN THE DAY, AND HAD BEEN PLACED BACK IN HER WHEELCHAIR. RN #11 STATED SHE WAS IN THE HALL A FEW ROOMS DOWN FROM RESIDENT #104'S ROOM, PASSING MEDICATIONS WHEN SHE HEARD A YELL AND RAN TO RESIDENT #104'S ROOM. RN #11 STATED SHE OBSERVED RESIDENT #104 ON THE FLOOR WITH HER RIGHT LEG TUCKED UNDER HER LEFT LEG. RN #11 STATED SHE STRAIGHTENED RESIDENT #104'S RIGHT LEG OUT AND RESIDENT #104 STATED OUCH AND THAT HER BACK HURT. RN #11 STATED SHE DID NOT NOTICE ANY ROTATION OR SHORTENING SO SHE HAD CNA #8 HELP GET RESIDENT #104 INTO THE LIFT SLING AND ONCE RESIDENT #104 WAS LIFTED INTO THE AIR, SHE YELLED OUT IN MORE PAIN, AND ONCE RESIDENT #104 WAS IN BED, RN #11 STATED SHE NOTICED RESIDENT #104 HAD ROTATION OF HER RIGHT LEG OF 45 DEGREES (TURNED) AND SHORTENING OF RIGHT LEG BY 1 TO 2 INCHES. A REVIEW OF THE FACILITY RESIDENT TRANSFER FORM FOR RESIDENT #104, DATED 10/22/11, REVEALED THAT RN #11 DOCUMENTED THE REASON FOR TRANSFER TO THE HOSPITAL AS RIGHT FEMUR FRACTURE MILD DISPLACEMENT WITH VARUS ANGULATION. IN THE "BEHAVIORAL OR SOCIAL ISSUES" SECTION OF THE TRANSFER FORM, RN #11 DOCUMENTED "ATTENTION SEEKING". REVIEW OF CONSULTATION NOTES FOR RESIDENT #104 BY BEHAVIORAL CARE SOLUTIONS FOR 10/7/11 DOCUMENTED RESIDENT #104'S ANXIETY AND DEPRESSION AS STABLE WITH A DECREASE IN ANTI-ANXIETY MEDICATION.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO RESPOND TIMELY TO A RESPIRATORY EMERGENCY AND FAILED TO HAVE AVAILABLE THE MEDICAL SUPPLIES AND EQUIPMENT NECESSARY TO MANAGE A RESPIRATORY EMERGENCY FOR THE ONLY RESIDENT (#1) WHO HAD A [MEDICAL CONDITION] (AN ARTIFICIAL AIRWAY IN THE NECK) IN A TOTAL SAMPLE OF 20 RESIDENTS REVIEWED, AND FAILED TO ASSURE THAT AN AGENCY NURSE COULD LOCATE THE EMERGENCY CART, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #1 WITH THE LIKELIHOOD FOR SERIOUS HARM, INJURY, IMPAIRMENT OR DEATH DUE TO AIRWAY BLOCKAGE AND LOSS OF OXYGEN. THE IMMEDIATE JEOPARDY BEGAN AT 5:45 AM ON 4/5/2011 WHEN RESIDENT #1 EXPERIENCED RESPIRATORY DISTRESS AND WAS IDENTIFIED ON 4/5/2011 AT 12:15 PM WHEN RESIDENT #1 REPORTED THE INCIDENT TO SURVEYORS AND THE NURSE ON DUTY "M" CONFIRMED THAT RESIDENT #1 HAD EXPERIENCED AN EPISODE OF THE [MEDICAL CONDITION] TIES BEING LOOSE AND THE INNER CANNULA BEING HALFWAY OUT. THE FACILITY ADMINISTRATOR WAS INFORMED OF THE SURVEY TEAM'S FINDING OF IMMEDIATE JEOPARDY ON 4/6/2011 AT 4:55 PM. THE IMMEDIATE JEOPARDY WAS REMOVED BUT NOT CORRECTED ON APRIL 5, 2011 AT 3:30 PM WHEN ALL EMERGENCY EQUIPMENT WAS AVAILABLE AT THE BEDSIDE OF RESIDENT #1. THE FACILITY ADMINISTRATOR PRESENTED A WRITTEN CORRECTIVE ACTION PLAN ACCEPTED ON 4/7/2011 AT 1:10 PM THAT INCLUDED PHYSICAL ASSESSMENT OF RESIDENT #1'S RESPIRATORY STATUS, REVIEW OF POLICIES FOR [MEDICAL CONDITION] CARE AND MANAGEMENT, EDUCATION OF LICENSED NURSES REGARDING [MEDICAL CONDITION] CARE AND LOCATION OF OXYGEN AND EMERGENCY EQUIPMENT, AUDIT TOOLS TO EVALUATE COMPLIANCE OF THE CORRECTIVE PLAN, AND INITIATION OF THE FACILITY'S QUALITY ASSURANCE PROCESS. NO OTHER RESIDENTS WITH [MEDICAL CONDITION] RESIDED AT THE FACILITY AT THE TIME OF THE IMMEDIATE JEOPARDY. EVEN THOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, NON-COMPLIANCE WITH REGULATORY REQUIREMENTS REMAINED ISOLATED AT A POTENTIAL FOR MORE THAN MINIMAL HARM FOR RESIDENT #1 DUE TO ADDITIONAL TRAINING YET TO BE PROVIDED TO LICENSED NURSES REGARDING THE EMERGENCY MEDICAL SUPPLIES AND EQUIPMENT AT THE BEDSIDE, [MEDICAL CONDITION] CARE, AND THE LOCATION OF OXYGEN AND EMERGENCY EQUIPMENT. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET, DATED 1/25/2011, RESIDENT #1 WAS A [AGE] year-old MALE ORIGINALLY admitted to the facility on [DATE]. ACCORDING TO THE [DIAGNOSES REDACTED]. THE CARDIOPULMONARY RESUSCITATION FORM, SIGNED BY RESIDENT #1 ON 12/22/2010, REFLECTED THAT RESIDENT #1 WISHED TO HAVE CARDIOPULMONARY RESUSCITATION INITIATED IF HIS BREATHING OR HEART FUNCTION CEASED. DURING AN INTERVIEW ON 4/5/2011 AT ABOUT 12:15 PM, RESIDENT #1 REPORTED THAT HE HAD DEVELOPED AN INCREASING AMOUNT OF SECRETIONS OVER THE PAST FEW DAYS AND THAT MORNING HIS [MEDICAL CONDITION] BECAME "PLUGGED" AND HE HAD DIFFICULTY BREATHING. RESIDENT #1 WENT ON TO STATE THAT HE HAD REMOVED THE INNER CANNULA FROM HIS [MEDICAL CONDITION] AT THAT TIME, EVEN THOUGH HE HAD NO TRAINING TO DO SO, BECAUSE HE COULD NOT BREATHE AND NO ONE WAS PRESENT TO ASSIST HIM. DURING THE INTERVIEW, RESIDENT #1 WAS OBSERVED TO HAVE A FREQUENT COUGH AND EXPECTORATE MODERATE AMOUNTS OF TANNISH COLORED MUCOUS FROM HIS [MEDICAL CONDITION]. A PHYSICIAN ORDER [REDACTED]. DURING THE INTERVIEW ON 4/5/2011 AT ABOUT 12:15 PM, A SUCTION MACHINE WAS OBSERVED ON THE BEDSIDE DRESSER OF RESIDENT #1'S ROOM. HOWEVER, NO SUCTION CATHETERS, NECESSARY EQUIPMENT TO OPERATE THE MACHINE, WERE LOCATED AT THE BEDSIDE. NO AMBU BAG (USED DURING AN EMERGENCY TO MANUALLY FORCE AIR INTO THE LUNGS), HEMOSTATS OR FORCEPS (USED TO AIDE IN KEEPING THE STOMA OPEN IN CASE OF ACCIDENTAL REMOVAL OF THE [MEDICAL CONDITION]), SPARE [MEDICAL CONDITION], OR OBTURATOR (USED TO EASE INSERTION OF A [MEDICAL CONDITION]), WERE LOCATED AT THE BEDSIDE. WHEN ASKED WHAT WOULD HAPPEN IF RESIDENT #1 NEEDED EMERGENCY EQUIPMENT, STAFF "G" STATED "I GUESS WE SHOULD GET IT". STAFF "G" STATED THAT RESIDENT #1 HAD BEEN TRANSFERRED FROM ANOTHER ROOM, AND SHE THOUGHT THE EMERGENCY SUPPLIES MIGHT HAVE BEEN IN THE OTHER ROOM. HOWEVER, A NURSES NOTE DATED 4/5/2011 REFLECTED THAT A SPARE [MEDICAL CONDITION] WAS ORDERED ON THAT DATE FROM A MEDICAL SUPPLY COMPANY. THE RESPIRATORY PLAN OF CARE FOR RESIDENT #1, DATED 1/25/2011, REFLECTED THAT EMERGENCY EQUIPMENT WAS TO BE AT THE BEDSIDE BUT DID NOT SPECIFY WHAT THAT EMERGENCY EQUIPMENT MIGHT BE. AN ADDITION TO THE RESPIRATORY CARE PLAN FOR RESIDENT #1, DATED 4/7/2011, HAD A LIST OF EMERGENCY EQUIPMENT THAT INCLUDED A [MEDICAL CONDITION], HEMOSTATS, SUCTION MACHINE AND SUCTION CATHETER, AND AN AMBU BAG. AN ENTRY IN THE PROGRESS NOTES, DATED 4/5/2011, REFLECTED THAT NURSE "G" HAD NOTIFIED THE NURSE PRACTITIONER OF THE RESIDENT'S CONDITION BY PHONE ON 4/5/2011 AT 3:30 PM. THE NURSE PRACTITIONER HAD INSTRUCTED THAT A CHEST RADIOGRAPH AND A THROAT CULTURE WERE TO BE PERFORMED. THE NURSE PRACTITIONER LEFT INSTRUCTIONS TO NOTIFY HER IF THE RESIDENT HAD A TEMPERATURE OR A POSITIVE CHEST RADIOGRAPH. A TELEPHONE ORDER REVEALED THAT AN ANTIBIOTIC HAD BEEN ORDERED FOR RESIDENT #1 ON 4/5/2011. THE NURSE PRACTITIONER EVALUATED RESIDENT #1 ON 4/6/2011 AND NOTED THAT THE CHEST RADIOGRAPH HAD BEEN ABNORMAL. THE NURSE PRACTITIONER ALSO ORDERED RESPIRATORY NEBULIZER TREATMENTS TO BE ADMINISTERED FOUR TIMES A DAY FOR THE NEXT 7 DAYS. STAFF "M" , AN AGENCY NURSE, WAS INTERVIEWED ON 4/5/2011 AT ABOUT 1:30 PM. STAFF "M" STATED THAT THIS WAS THE FIRST DAY SHE HAD WORKED AT THIS FACILITY AND SHE HAD BEEN GIVEN ABOUT A TWO HOUR ORIENTATION TO THE FACILITY. STAFF "M" STATED THAT AT ABOUT 5:45 AM ON 4/5/2011, SHE AND THE NURSE WHO HAD WORKED THE NIGHT SHIFT WERE CALLED TO RESIDENT #1'S ROOM. STAFF "M" STATED THAT RESIDENT #1 WAS COUGHING, THE SECURES TO THE [MEDICAL CONDITION] WERE LOOSE, AND THE INNER CANNULA OF THE [MEDICAL CONDITION] WAS ABOUT HALF WAY OUT. STAFF "M" STATED THAT SHE BELIEVED THAT THE WASH CLOTHS RESIDENT #1 WAS USING TO WIPE AWAY SECRETIONS HAD BECOME TANGLED IN THE [MEDICAL CONDITION]. STAFF "M" FURTHER STATED THAT SINCE SUPPLIES FOR EMERGENCY RESPIRATORY CARE WERE NOT AT THE BEDSIDE, SHE WOULD HAVE TO OBTAIN THEM FROM THE SUPPLY CLOSET, LOCATED AT THE OPPOSITE END OF THE HALLWAY, TO TREAT RESIDENT #1 IN THE EVENT OF AN ACCIDENTAL REMOVAL OF THE [MEDICAL CONDITION], OR IF SHE HAD NEEDED TO USE THE SUCTION MACHINE TO REMOVE SECRETIONS THAT OBSTRUCTED THE AIRWAY. A REVIEW OF THE PROGRESS NOTES FOR RESIDENT #1 ON 4/5/2011 AT ABOUT 4:00 PM, REVEALED NO NURSING NOTE FOR THE RESPIRATORY EVENT THAT, ACCORDING TO STATEMENTS BY RESIDENT #1 AND STAFF NURSE "M", HAD OCCURRED ON 4/5/2011 AT ABOUT 5:45 AM. THE RESPIRATORY STATUS LOG FOR RESIDENT #1 HAD NO ENTRIES FOR 4/5/2011. THE ONLY ENTRIES ON THE RESPIRATORY STATUS LOG AS OF 4/8/2011 AT 9:00 AM WERE DATED 4/4/2011, 4/6/2011, AND 4/7/2011. THE RESPIRATORY TREATMENT [MEDICAL CONDITION] RECORD, REVIEWED ON 4/6/2011 AT ABOUT 10:00 AM, LOCATED IN A BINDER AT THE NURSES STATION, REFLECTED NO RESPIRATORY CARE PROGRESS NOTES HAD BEEN ENTERED. ON 4/5/2011 AT ABOUT 4:00 PM, AGENCY NURSE "N", WHO WAS TO CARE FOR RESIDENT #1 FOR THE NEXT SHIFT, WAS ASKED TO SHOW THIS SURVEYOR WHERE THE EMERGENCY CRASH CART WAS LOCATED. NURSE "N" WALKED TO THE "D" WING HALLWAY AND STARTED LOOKING AROUND AT THE VARIOUS DOORS SAYING, I THINK IT IS HERE SOMEWHERE. THEN STAFF "N" STATED, "OH, NO, IT IS OVER THERE" AND INDICATED THE "A" WING HALLWAY. NURSE "N" THEN WALKED OVER TO THE "A" WING AND LOCATED THE EMERGENCY CRASH CART IN AN ALCOVE. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TREATMENT AS ORDERED BY THE PHYSICIAN FOR TWO RESIDENTS (#2 AND #4) AND FAILED TO MAKE REFERRALS TO THERAPY AS RECOMMENDED BY THE WOUND CLINIC FOR ONE RESIDENT (#4) OF 7 RESIDENTS REVIEWED WITH PRESSURE SORES FROM A TOTAL SAMPLE OF 20 RESIDENTS, RESULTING IN THE POTENTIAL FOR DELAYED HEALING AND INFECTION IN A WOUND. FINDINGS INCLUDE: THE FACE SHEET FOR RESIDENT #4, DATED 9/28/2010 REFLECTED THAT RESIDENT #4 WAS ORIGINALLY admitted to the facility on [DATE]. THE [DIAGNOSES REDACTED]. THE FORM TITLED "SKIN GRID" REFLECTED THAT AN INITIAL IDENTIFICATION WAS MADE OF A STAGE 2 BLISTER ON RESIDENT #4'S LEFT HEEL ON 11/15/2010. THE SKIN GRID FORM ALSO REFLECTED THAT THE LOCAL WOUND CLINIC WAS CALLED FOR AN APPOINTMENT FOR RESIDENT #4 ON 11/24/2010. DURING AN INTERVIEW WITH STAFF "H" ON 4/8/2011 AT ABOUT 9:20 AM, STAFF "H" STATED THAT SHE HAD CALLED THE CLINIC FOR A REFERRAL WHEN THE WOUND WAS FIRST IDENTIFIED. THE REPORT OF CONSULTATION FROM THE LOCAL WOUND CLINIC ON 2/3/2011 REFLECTED THAT RESIDENT #4 HAD BEEN SEEN AT THE CLINIC ON THAT DATE. THE NOTE FROM THE CLINIC READ, "PT.(PATIENT) HAD OLD DRSG (DRESSING) ON SINCE 1/31/11. PT. ORDERS ARE DAILY. WOUND WAS FOUL, BLACK & PT FEVERISH. CARE LOOKS NEGLECTFUL & CLINIC HAS CONCERNS RE (REGARDING): WOUND CARE & PT. CARE...". ON THE REPORT OF CONSULTATION DATED 3/10/2011, A NOTATION READ, "PRESENTED WITH DRESSING DATED 3/8/11- TODAY 3/10/11- NOT DOING DAILY CHANGES". A CHANGE OF THE WOUND DRESSING WAS OBSERVED ON 4/6/2011 AT ABOUT 7:50 AM. AT THAT TIME STAFF "H" REMARKED THAT RESIDENT #4 WAS TO HAVE ON TWO [MEDICATION NAME] TO PROTECT THE WOUND. WHEN THE DRESSING HAD BEEN REMOVED, ONLY ONE [MEDICATION NAME] HAD BEEN IN PLACE. THE TREATMENT RECORD, DATED APRIL 2011, FOR RESIDENT #4 REFLECTED THAT THE PHYSICIAN HAD ORDERED DAILY DRESSING CHANGES FOR THE LEFT HEEL. FOR THE TIME PERIOD OF APRIL 1 TO APRIL 6, 2011, THERE WAS NO INITIAL FOR A DRESSING CHANGE ON APRIL 4, 2011. AN UNDATED TREATMENT RECORD FOR RESIDENT #4 REFLECTED A PHYSICIANS ORDER FOR A DAILY DRESSING CHANGE TO HIS LEFT HEEL WOUND. THE DATES 9, 16, & 27 HAD NO INITIAL FOR A DRESSING CHANGE. A TREATMENT RECORD FOR RESIDENT #4 WITH A DATE OF 2/8/2011 UNDER THE HAND WRITTEN DRESSING CHANGE ORDER, HAD ANOTHER ENTRY FOR A DAILY CALL TO THE WOUND CLINIC ON FIRST SHIFT. A LINE INDICATED THE DAILY CALL WAS TO BEGIN ON THE FOURTH. INITIALS WERE CIRCLED ON THE FOURTH AND FIFTH AND NO ENTRY WAS MADE ON THE 6TH. ON THIS SAME TREATMENT RECORD WAS AN ORDER TO FAX OVER A REPORT ON THE HEEL ON MONDAY 2/14 TO THE WOUND CLINIC. THERE WAS NO INITIAL ON THAT DATE TO INDICATE THE FAX REPORT WAS SENT. THE BACK SIDE OF THIS SHEET HAD NO NOTATIONS AS TO WHY ENTRIES THAT SHOULD HAVE BEEN THERE WERE BLANK, OR WHY SOME INITIALS WERE CIRCLED ON SOME DATES. THE REPORT OF CONSULTATION FROM THE WOUND CLINIC ON 3/24/2011 REFLECTED THAT THERE WAS AN EXTENDED AREA OF NECROSIS ON THE WOUND AND THE WRITER SUSPECTED THAT THIS WAS FROM RESIDENT #4'S OFF-LOADING HEEL BOOT. THE WRITER ADDED, "IF NOT APPLIED CORRECTLY IT WILL CAUSE PRESSURE - PLEASE EVAL & CHANGE". THE REPORT WRITER RECOMMENDED THAT PHYSICAL THERAPY SHOULD INSTRUCT ON THE PROPER APPLICATION OF THE BOOT. DURING AN INTERVIEW WITH STAFF "J", A PHYSICAL THERAPIST, ON 4/8/2011 AT ABOUT 1:30 PM, STAFF "J" STATED THAT SHE WAS NOTIFIED OF THE ORDER FOR A REFERRAL ON 4/5/2011, 12 DAYS AFTER IT WAS WRITTEN. THE FORM TITLED "SKIN GRID" HAD INSTRUCTIONS THAT IT WAS TO BE COMPLETED WEEKLY. THERE WERE NO ENTRIES FROM 1/10/2011 UNTIL 2/9/2011. AN ENTRY AFTER THAT NOTATION READ "3 WEEKS OFF WOUNDS - DT (DUE TO) NEEDING STAFFING ON HALLS". DURING AN INTERVIEW WITH STAFF "H" ON 4/8/2011 AT ABOUT 9:20 AM, STAFF "H" STATED THAT SHE HAD WORKED AS A FLOOR NURSE FOR SEVERAL WEEKS AND HAD NOT BEEN ABLE TO PERFORM THE DUTIES OF THE WOUND CARE NURSE. THE NEXT WEEKLY NOTATION AFTER 2/9/11 WAS DATED 3/7/11. ( ) DURING THE INITIAL TOUR, ON 4/5/11, AT APPROXIMATELY 12:30 PM, WITH THE DIRECTOR OF NURSING (DON), RESIDENT #2 WAS OBSERVED SLEEPING IN HER BED. SHE WAS POSITIONED ON HER BACK, THE HEAD OF HER BED WAS ELEVATED SLIGHTLY (APPROXIMATELY 30 DEGREES), HER [MEDICAL CONDITION] FEEDING TUBE WAS NOT CONNECTED OR RUNNING. THE DON INDICATED THAT RESIDENT #2 HAD A PRESSURE ULCER ON ONE OF HER HEELS (SHE COULD NOT REMEMBER WHICH ONE), THAT IT HAD DEVELOPED IN HOUSE, AND THAT THEY WOULD HEAL IT BUT THAT IT KEPT OPENING UP. A REVIEW OF THE FACE SHEET DATED 12/31/09, AND CLINICAL RECORD FOR RESIDENT #2 REFLECTED THAT SHE WAS ORIGINALLY admitted TO THE FACILITY 6/25/07 AND WAS RE-admitted on [DATE]. HER [DIAGNOSES REDACTED]. FROM HER MOST CURRENT CUMULATIVE physician's orders [REDACTED]. A REVIEW OF HER CARE PLANS ON 4/5/ AND 6/11 REFLECTED ON HER SKIN INTEGRITY ASSESSMENT INDICATED THAT SHE WAS TO BE TURNED AND REPOSITIONED EVERY 2 HOURS. THE ENTRY WAS HAND WRITTEN AND DATED 4/5/11. A REVIEW OF THE "CARE DELIVERY GUIDE," UPDATED 4/5/11, FOR USE BY THE NURSING ASSISTANTS (C.N.A.S), DID NOT DIRECT THEM TO TURN AND REPOSITION THE RESIDENT EVERY 2 HOURS. HOWEVER, THERE WAS A TURN SCHEDULE STICKER ON THE BOTTOM OF THE FORM FOR RESIDENTS TO BE TURNED EVERY EVEN HOUR, AROUND THE CLOCK. RESIDENT #2 WAS OBSERVED ON HER BACK AT THE FOLLOWING TIMES: ON 4/5/11, AT 2:55 PM. THE SCHEDULE INDICATED THAT SHE SHOULD BE ON HER LEFT SIDE; ON 4/5/11, AT 5:40 PM. THE SCHEDULE INDICATED THAT SHE SHOULD HAVE BEEN ON HER RIGHT SIDE; ON 4/6/11, AT 11:25 AM. THE SCHEDULE INDICATED THAT SHE SHOULD BE ON HER RIGHT SIDE; THAT POSITION WAS ALSO OBSERVED ON 4/8/11, AT 11:55 AM; ON 4/6/11, AT 5:15 PM. THE SCHEDULE AGAIN INDICATED SHE SHOULD HAVE BEEN ON HER RIGHT SIDE; AND ON 4/7/11, AT 9:30 AM SHE WAS TURNED SLIGHTLY ON HER RIGHT SIDE. THE SCHEDULE INDICATED THAT SHE SHOULD HAVE BEEN ON HER BACK (FROM 8 AM TO 10 AM); THAT POSITION (ON HER BACK) WAS ALSO OBSERVED AT 9:15 AM, ON 4/8/11. IN ADDITION, RESIDENT #2 HAD A REOCCURRING, RE-OPENING OF A PRESSURE ULCER ON HER LEFT HEEL. SHE WAS OBSERVED ON 4/5/11 AT APPROXIMATELY 2:55 PM TO HAVE TWO DIFFERENT KINDS OF BLUE COLORED BOOTS ON BOTH FEET. IN ALL OF THE OBSERVATIONS RECORDED ABOVE WHEN SHE WAS IDENTIFIED FLAT ON HER BACK WHEN SHE SHOULD HAVE BEEN POSITIONED, THE RESIDENT'S FEET WERE FLAT ON THE BED WITH BOOTIES ON. ADDITIONAL OBSERVATIONS ON 4/6/11 AT 9:20 AM AND AGAIN AT 12:10 PM SHOWED HER FEET WITH BOOTIES ON WERE FLAT ON BED. THE BOOTIE ON HER LEFT HEEL WAS A SOFT, NYLON, QUILTED FABRIC THAT WHILE THE HEEL RESTED IN THE BOOT, IT WAS NOT SUPPORTED OR FLOATED. RESIDENT #2'S HEELS IN THEIR BOOTIES WERE OBSERVED ON 4/6/11, AT 12:10 PM, WITH REGISTERED NURSE "O". SHE INDICATED THAT THE LEFT HEEL ULCER HAD HEALED BUT THAT THEY WERE USING A PROTECTIVE HEEL PAD, "ALLEVYN HEEL PAD" AND THEN WRAPPING IT WITH GUAZE. A SHORT TIME LATER, AT 12:30 PM, RESIDENT #2'S ASSIGNED C.N.A., STAFF "W" WAS QUERIED ABOUT HER BOOTS AND REPOSITIONING. SHE INDICATED THAT THE BOOTIES WERE TO ALWAYS BE ON EXCEPT FOR BATHING. A REVIEW OF "CARE DELIVERY GUIDE" KEPT IN THE ROOM DID NOT MENTION ANYTHING ABOUT SUPPORTING HER CALVES OR FLOATING HER HEELS. WHEN SHE LOOKED IN RESIDENT #2'S ROOM, SHE THEN POSITIONED THE RESIDENT'S CALVES TO FLOAT HER HEELS. SHE INDICATED THAT SHE DID NOT DO RANGE OF MOTION AND SHE DID NOT DO THE POSITIONING SCHEDULE. ON 4/6/11, AT APPROXIMATELY 5:15 PM, IT WAS MENTIONED TO REGISTERED NURSE "O" THAT RESIDENT #2 HAD NOT BEEN OBSERVED UP IN HER GERI-CHAIR AND ALSO THAT SHE HAD NOT BEEN OBSERVED TURNED AS STATED IN HER CARE PLAN. HER SKIN INTEGRITY CARE PLAN ALSO HAD A SPACE FOR A CHECK MARK FOR THE STAFF TO POSITION CALVES ON PILLOWS TO ELEVATE OFF THE BED. HOWEVER, IT WAS NOT CHECKED ON THE FORM NOR WAS IT LISTED ON THE "CARE DELIVERY GUIDE" FOR THE C.N.A.S. SHE had a history of [REDACTED]. AND, ALTHOUGH VENOUS INSUFFIENCEY WAS NOT LISTED ON HER [DIAGNOSES REDACTED]. ON 4/8/11, AT 9:15 AM RESIDENT #2 WAS OBSERVED IN HER ROOM POSITIONED PARTIALLY ON HER RIGHT SIDE., THE FIRST TIME OBSERVED OFF HER BACK IN HER BED. A SHORT TIME LATER, ALSO ON 4/8/11, AT 11:55 AM, RESIDENT #2'S DRESSING CHANGE TO HER LEFT HEEL WAS OBSERVED WITH THE LICENSED TREATMENT NURSE "H". DISCUSSION WITH NURSE "H" REVEALED THAT THE BOOTIES HAVE BEEN USED FOR A LONG TIME, (YET HER HEEL OPENS AND CLOSES). SHE INDICATED SHE WAS NOT AWARE IF THERE HAD BEEN ANY THOUGHT TO INVESTIGATING ANOTHER SUPPORT. SHE SAID IN THE PAST, EXTRA PILLOWS AND WEDGES HAD BEEN TRIED TO SUPPORT HER FEET, HOWEVER, THEY OFTEN CAME UP MISSING FROM THE RESIDENT'S ROOM, WHEREAS, THE BOOTIES REMAIN ON HER FEET AT ALL TIMES. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR AND IMPLEMENT THE FACILITY'S [DIAGNOSES REDACTED] GUIDELINES FOR ONE OF ONE DIABETIC RESIDENT (#3) FROM A TOTAL SAMPLE OF 20 RESIDENTS, RESULTING IN THE ADVERSE EFFECTS OF LOW BLOOD SUGAR AND hospitalization . FINDINGS INCLUDE: RESIDENT REVIEW ON 4/7/11 AT 10:00 AM NOTED RESIDENT #3 WAS A [AGE] year OLD, COGNITIVELY IMPAIRED, MALE WHO WAS ORIGINALLY admitted to the facility on [DATE]. ACCORDING TO THE APRIL PHYSICIANS ORDERS HE HAD [DIAGNOSES REDACTED]. REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ON THE 4/4/11 MIDNIGHT, THE BLOOD SUGAR CHECK WAS 101. NORMAL BLOOD SUGAR IS FROM 60 TO 120 MG/L. ACCORDING TO THE MAR, AND A PHONE INTERVIEW WITH STAFF NURSE "C" ON 4/8/11 AT 12:15 PM, THE 4/5/11 MORNING BLOOD SUGAR WAS DONE AT 7:30 AM. AND [MEDICATION NAME] 10 UNITS SUBCUTANEOUS WAS GIVEN. PARAMETERS WERE IN PLACE TO HOLD THE INSULIN IF THE BLOOD SUGAR WAS LESS THAN 100. THE BLOOD SUGAR ON 4/5/11 AT 7:30 AM WAS 107. INTERVIEW WITH STAFF MEMBER "D" ON 4/8/11 AT 11:15 AM REPORTED THAT THE RESIDENT DID NOT EAT BREAKFAST UNTIL 8:30 AM THAT DAY. FURTHER INTERVIEW WITH STAFF MEMBER "D" ON 4/8/11 AT 11:20 AM, REVEALED THAT THE RESIDENT "...KEEPS SPITTING OUT HIS FOOD... AND THAT HE USUALLY EATS IN THE DINING ROOM, BUT ON 4/5/11 STAFF MEMBER "D" WAS RUNNING BEHIND AND DECIDED TO FEED THE RESIDENT IN HIS ROOM ". BREAKFAST WAS SCHEDULED TO BE SERVED AROUND 7:30 AM TO 8:00 AM IN THE DINING ROOM. ADDITIONAL INTERVIEW REVEALED, "THE RESIDENT WAS VERY SWEATY WHEN SHE GOT HIM UP FOR BREAKFAST. ALSO HE WOULD NOT EAT OR DRINK ANYTHING". STAFF MEMBER "D" FURTHER STATED, "THE NURSE WAS TOLD BY TWO CERTIFIED NURSING ASSISTANTS (CNA) THAT HE DIDN'T EAT ANY BREAKFAST". STAFF NURSE "C" STATED DURING HER INTERVIEW ON 4/8/11 AT 12:15 PM, THAT THE RESIDENT STATED, " I FEEL LIKE I'M GOING TO PASS OUT". SHE FURTHER STATED, " I WAITED 15 MINUTES AND STAYED WITH THE RESIDENT THE ENTIRE TIME". HOWEVER, AFTER THAT, STATED, "APPROXIMATELY 20 MINUTES LATER HIS BLOOD SUGAR WAS 79, HE WAS RESTING COMFORTABLY AND BLOOD PRESSURE WAS GOOD". ACCORDING TO STAFF MEMBER "E", STAFF NURSE "C" REQUESTED SOME ORANGE JUICE BUT DECIDED NOT TO GIVE IT. FURTHERMORE, STAFF NURSE "C" STATED, "STAFF NURSE "Z" KEPT WATCHING WHILE I PASSED MY MEDS". STAFF MEMBER "E" STATED, ON 4/8/11 AT 11:50 AM , THAT SHE WAS IN RESIDENT #3'S ROOM ON 4/5/11 AT 9:15 AM AND OBSERVED HIM TO BE LEANING TO THE RIGHT IN HIS WHEELCHAIR, SWEATING PROFUSELY AND STATED, "I'M DIZZY". STAFF MEMBER "E" STATED SHE NOTIFIED STAFF NURSE "C" RIGHT AWAY AND SHE CAME AND CHECKED HIS BLOOD SUGAR. ACCORDING TO THE PROGRESS NOTES FOR 4/5/11 AT 10:00 AM "...RES UNRESPONSIVE WITH CBG = 26, 1 ML [MEDICATION NAME] GIVEN IM (INTRAMUSCULAR) PER NP (NURSE PRACTITIONER) ORDER". HOWEVER, THE 4/5/11 ENTRY, ON THE MAR, FOR THE [MEDICATION NAME] STATED "...CBG=26 AND SEMI-CONSCIOUS". NO FURTHER DOCUMENTATION, OR INTERVENTIONS, COULD BE FOUND IN THE PROGRESS NOTES TO INDICATE HOW THE RESIDENT WAS MONITORED AFTER 10:00 AM. ACCORDING TO THE FACILITY "[DIAGNOSES REDACTED] GUIDELINES", FOR A BLOOD SUGAR LESS THAN "...50 AND UNCONSCIOUS, NO IV PRESENT: ADMINISTER 1 MG (1 UNIT) [MEDICATION NAME] SUBQ (SUBCUTANEOUS) OR IM (INTRAMUSCULAR) ...". ADDITIONALLY, THE "[DIAGNOSES REDACTED] GUIDELINES" STATED THAT THE "...RESIDENT IS MONITORED ONE TO ONE, NOTIFY THE PHYSICIAN AND AFTER 15 MINUTES RECHECK BLOOD SUGAR AND FOLLOW THE LEVELS ACCORDING TO THE BLOOD SUGAR...". AT 11:10 AM THE PROGRESS NOTES STATED "...CBG = 71." ACCORDING TO THE "[DIAGNOSES REDACTED] GUIDELINES", WHEN THE "...BLOOD SUGAR IS GREATER THAN 70 PROVIDE ONE SELECTION IF MEAL IS NOT TO BE SERVED WITHIN ONE HOUR: 1/2 SANDWICH, OR 1 CUP MILK OR CARTON OF YOGURT, OR 1 OUNCE CHEESE AND 6 SQUARE CRACKERS, OR 1 TABLESPOON PEANUT BUTTER AND 6 SQUARE CRACKERS, 3 GRAHAM CRACKER SQUARES OR 6 VANILLA WAFERS." NO FURTHER INTERVENTIONS OR MONITORING NOTES WERE NOTED AFTER THE 11:10 AM CBG CHECK. STAFF MEMBER "E" FURTHER STATED ON 4/8/11 AT 11:50 AM, " I GOT THE RESIDENT UP AT 11:30 AM ON 4/5/11, AND HE WAS SWEATY AND CLAMMY. I TOOK THE RESIDENT TO THE DINING ROOM FOR LUNCH". SHE FURTHER STATED, " APPROXIMATELY 15 - 20 MINUTES LATER I CAME BACK TO THE DINING ROOM AND OTHER STAFF WERE TAKING THE RESIDENT OUT OF THE DINING ROOM. THEY WERE HOLDING HIM UP AS THEY WHEELED HIM OUT". STAFF NURSE "C" STATED, "ON 4/5/11, CLOSER TO LUNCH HIS BLOOD SUGAR DROPPED BELOW 20 AND HE WAS PALE, SWEATY, GRAY AND LETHARGIC". ACCORDING TO THE 4/5/11 ENTRY FOR THE SCHEDULED 11:30 AM BLOOD SUGAR, STAFF NURSE "C" CHARTED "20" BUT, THE 4/5/11 PROGRESS NOTE AT 12:15 STATED, "CBG = 21, 1 ML [MEDICATION NAME] GIVEN IM. OK TO TRANSPORT TO (HOSPITAL) ER FOR EXAM AND TREAT PER NP". YET IT WAS FURTHER NOTED ON THE MAR FOR 4/5/11, " THE [MEDICATION NAME] WAS GIVEN AT 12:30 PM FOR CBG OF 21 AND SEMI-CONSCIOUS". NO FURTHER DOCUMENTATION COULD BE FOUND IN THE PROGRESS NOTES THAT DETAILED THE 11:30 AM BLOOD SUGAR OR ADDITIONAL INTERVENTIONS THAT WERE USED BEFORE THE RESIDENT WAS TRANSPORTED TO THE HOSPITAL. STAFF NURSE "C" WAS INTERVIEWED, BY PHONE, ON 4/8/11 AT 12:15 PM. DURING THE INTERVIEW SHE STATED SHE WAS AN AGENCY NURSE AND THIS WAS THE FIRST TIME SHE WORKED IN THE BUILDING". SHE FURTHER STATED THAT ON 4/4/11 SHE HAD HAD A TWO HOUR ORIENTATION TO THE FACILITY AND WAS SHOWN WHERE THE SUPPLIES WERE KEPT AND WHERE THE BACK-UP BOX WAS". WHEN ASKED IF SHE WAS AWARE OF THE FACILITY "[DIAGNOSES REDACTED] GUIDELINES" USED FOR ALL DIABETIC RESIDENTS, SHE STATED, "YES, AND I AND ANOTHER FACILITY NURSE HAD REVIEWED IT". HOWEVER, SHE FURTHER STATED THAT SHE WAS NOT SURE WHAT THE EMERGENCY PROCEDURE FOR DIABETICS WAS". IN ADDITION, STAFF NURSE "C" STATED DURING HER INTERVIEW THAT STAFF NURSE "EZ" STATED TO HER , " I'M SURE YOU AREN'T AWARE OF WHAT PAPERWORK YOU NEED TO FILL OUT FOR A TRANSFER". ACCORDING TO STAFF NURSE "C", STAFF NURSE "EZ" COMPLETED THE TRANSFER PAPERWORK WHILE SHE CONTINUED TO PASS MEDICATIONS. SHE FURTHER STATED THAT STAFF NURSE "EZ" TOLD HER THAT STAFF NURSE "EZ" AND STAFF NURSE "EM" WOULD TAKE CARE OF ALL THE CHARTING AND SHE WAS TO FINISH HER MEDICATION PASS. THERE WAS NO DOCUMENTATION FROM STAFF NURSE "C" IN THE PROGRESS NOTES. RESIDENT #3 WAS TRANSFERRED TO THE emergency roiagnom on [DATE], EXACT TIME UNKNOWN, WAS admitted TO THE HOSPITAL AND HAD NOT RETURNED BY THE END OF THE SURVEY PERIOD OF 4/8/11. ( )

This citation pertains to intake #MI 916. Based on interviews and record review, the Facility failed to provide the necessary services to maintain the highest practicable physical well-being (assess and monitor and provide emergency cardiopulmonary resuscitation (CPR)) for 1 of 6 sampled residents (#201), whose advance directive indicated she wanted to receive CPR in the event of respiratory or cardiac failure, resulting in immediate jeopardy (IJ) and death when resident #201 was found not breathing and without a heartbeat and no CPR was started and placing 38 residents who were identified as full code (requesting CPR) at high risk for serious harm or death due to the potential for them not to receive CPR if/when needed. Findings Include: Review of the clinical record for resident #201 revealed that she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the physician-signed durable power of attorney (DPOA) document dated [DATE] revealed resident #201 checked "YES" after the statement "CPR is to be administered per facility policy." The document indicated the advanced directives which were declared by resident #201 were to be honored as the expression of her legal rights. Review of the nurse's notes dated [DATE] at 3:30 PM revealed resident #201 fell in her bathroom and hit her head. She sustained a ",[DATE] inch long cut to the left of her forehead and then vomited. Resident #201 was transferred to a hospital, treated for [REDACTED]. Review of the facility's incident report dated [DATE] at 5:45 PM revealed resident #201 fell again in her room. A pulse oximetry of the percentage of oxygen saturation in the blood revealed a reading of 77% (normal is ,[DATE] %). She was placed on oxygen, and the reading increased to 91%. Review of the nurse's notes dated [DATE] at 4:00 am revealed resident #201's heart rate was recorded as ,[DATE] (normal is ,[DATE] beats per minute) and irregular with a shallow respiration of 24 breaths per minute (normal is ,[DATE] breaths per minute). In an interview on [DATE] at 9:40 AM, CNA "H" said she was assigned to care for in resident #201 on [DATE] from 6:00 AM until 2:00 PM, but CNA "I" took care of her most of the time because they traded residents. CNA "H" said she asked resident #201 if she wanted breakfast. Resident #201 said she didn't feel good and did not want to eat because she felt nauseated. When asked if she reported to the charge nurse that resident #201 felt nauseated, CNA "H" said, "no I didn't tell the nurse." When asked if she took resident #201's vital signs that day, CNA "H" said, "no I didn't take vitals." CNA "H" said the last time she saw resident #201 was at 12:00 PM in her room in her bed. Resident #201 took her covers off, because she complained she was "hot." CNA "H" said resident #201 also took her oxygen off. CNA "H" put the oxygen back on resident #201. CNA "H" said, "The next thing I heard was she was gone." CNA "H" said she then headed back to "D" hall and saw licensed practical nurse (LPN) "G" upset and crying. LPN "G" said resident #201 is gone. CNA "H" said she went to resident #201's room, but the door was closed. She said she did not go in. In an interview on [DATE] at 10:00 AM, CNA "I" said the last time she saw resident #201 on [DATE] was at about 12:00 PM. CNA "I" said resident #201 was in her bed in her room (located in the middle of D hall halfway down the hall from the nurse's station). CNA "I" said resident #201 was "OK." CNA "I" said the next time she saw resident #201 was about 45 minutes later, and she was "dead." CNA "I" said she checked the "neck pulse" on resident #201 and "felt nothing." CNA "I" said she was not blue, not purple, not yellow, and not cold. CNA "I" said there was nothing different about resident #201's color or temperature than when she saw her earlier. CNA "I" said she left to get LPN "G," who was at the nurse's station. CNA "I" said LPN "G" went to resident #201's room and checked her and then left the room. CNA "I" said she left resident #201's room with LPN "G" who "called a code over the intercom, from the phone at the nurse's station, and then everyone came, all the nurses." CNA "I" said she left and took care of other residents then. When asked if she took resident #201's vital signs, CNA "I" said, "no." In an interview on [DATE] at 3:55 PM, LPN "G" said she noticed "a little change in (resident #201) when I went to give her pills." LPN "G" said, "she was more lethargic, really tired, and she didn't eat at all that day." LPN "G" said she did not obtain her vital signs. LPN "G" said she attempted to contact resident #201's guardian to have her code status changed from a full code to a "do not resuscitate" (DNR), but she could not reach resident #201's guardian. LPN "G" said, "the next thing I know, (CNA "I") mouthed (resident #201) is dead." LPN "G" said it was around 1:00 PM, and she was at the nurse's station. LPN "G" said she ran down to resident #201's room with all the other nurses. LPN "G" said resident #201 was "cold," and she did not initiate CPR. She asked if she could call a code and "they said yes." When asked who she had asked or which other nurses were there, LPN "G" said she could not recall, and she did not write "those things" down. LPN "G" said she went back to the nurse's station and called "code blue to room D 7" on the intercom. LPN "G" said she then asked if she should call 911 and "they said yes." When asked if anyone did CPR, LPN,"G" said, "I didn't see anyone do CPR." In an interview on [DATE] at 3:25 PM, the Director of Nursing (DON) said someone told her on [DATE] after lunch that resident #201 looked like she was gone. The DON said she went down to the room and resident #201's pupils were fixed and dilated and she was pale. The DON said she ran back to the nurse's station and called a code. When asked why she didn't stay in resident #201's room and call the code, the DON said because there is no intercom. The DON said they knew resident #201 was a full code because they were trying to work with the guardian on a code change but were not able to contact the guardian. The DON said they could not change the code so they brought the crash cart and the automatic external defibrillator (AED) machine. When asked if she started CPR, the DON said, "We didn't initiate CPR because she had no signs of life." In an interview on [DATE] at 2:40 PM, LPN "D" said she worked on [DATE] and was at the nurse's station between 1:00 PM and 1:15 PM when she heard "code blue to room D7." LPN "D" said she got up and went to resident #201's room, but she did not initiate CPR. LPN "D" said she did not document at all regarding the emergency crisis situation with Resident #201. In an interview on [DATE] at 3:00 PM, RN "E" said she was at the nurse's station on [DATE] in the afternoon and heard nurses whispering "(resident #201) isn't breathing" as they headed down the hall. RN "E" joined the DON. RN "E" said she went to resident #201's room. RN "E" said she did not see resident #201's chest rise (breathing). RN "E" said she tried to get a radial pulse at the wrist, and there was none. RN "E" said resident #201 was cold. RN "E" said she did not do CPR. Then RN "E" said the AED machine arrived. RN "E" applied the pads, turned the machine on, and let it cycle. RN "E" said the machine said no action was required. RN "E" said EMS arrived minutes later. RN "E" said she did not write anything down regarding the incident with resident #201. In an interview on [DATE] at 3:15 PM, RN "A" said she was in her office when she heard a page for all nurses to go to resident #201's room. RN "A" said she went to resident #201's room right away. RN "A" said she observed resident #201, but she did not do CPR or write anything down regarding the incident. RN "A" said the EMS came, and she left the room. In an interview on [DATE] at 1:20 PM, RN "J" (D hall unit manager) said she was in a meeting in the Administrator's office on [DATE] at about 1:00 PM when she heard a page. She said she could not understand the page. So she walked to the nurse's station. The DON was at the nurse's station and told her that she had a code blue in room D7 bed 1 (resident #201). RN "J" said she went to the room, and the crash cart was already in the room. When asked who did CPR, RN "J" said, "nobody." The EMS came and applied an electrocardiogram which showed a flat line (meaning no heart beat). The EMS called the police to find out if the medical examiner was necessary, and they said no. So they did post mortem care on resident #201. Review of the facility's policy/procedure titled "Cardiopulmonary Resuscitation (CPR) - Basic Life Support (BLS)" effective [DATE] and revised in [DATE] and again in [DATE] revealed, "Unless a decision not to initiate CPR has previously been made by the resident and State guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the facility." The facility's CPR procedure stated, "Assign the responsibility of notifying the following persons simultaneous with the initiation of CPR. ? Emergency Medical Services (911 where applicable) ? Physician ? Family/legal representative" The facility's CPR procedure stated, "(applied to all facilities) Cardiopulmonary Resuscitation (hereafter "CPR"), is initiated when a resident's breathing and/or heart function has ceased. CPR is the provision of assistance with breathing and heart function provided by facility staff by blowing air into the resident's lungs to stimulate breathing and by pressing on the chest to stimulate heart function." In an interview on [DATE] at 10:55 AM, the DON said licensed nurses at the facility were responsible to perform CPR on residents who are a full code. The Administrator was notified on [DATE] at 3:05 PM of the immediate jeopardy that began on [DATE] as a result of the failure to provide provide emergency CPR per the advance directive for resident #201 when she was found without a heart beat or respirations and the failure to ensure that assessments were done such as listening to lung sounds and obtaining complete vital signs. On [DATE], the surveyor confirmed that the facility completed the following to remove the immediate jeopardy: 1. On [DATE], records for for code status were reviewed for all 93 residents, and 38 residents had full code status indicated. The advance directives for all 93 residents were reviewed for accuracy on [DATE], and 1 of the 93 records was corrected on [DATE]. 2. On [DATE], in-service training for 31 licensed nurses began. The training included: Emergency Management, Advance Medical Directives, Do Not Resuscitate (DNR) Orders, Incident Report Completion Post-Code, Cardiopulmonary Resuscitation (CPR) Basic Life Support, Post Acute Change of Condition Monitoring, including Vital Signs, Lung Sounds, and Oxygen Saturation Monitoring, Automated External Defibrillator (AED), Episodic Documentation, and The Abuse/Neglect Policy. Any licensed nurses who did not receive the in-service will not be allowed to work until the in-service has been completed. 28 licensed nurses completed the in-service, 3 had not completed the in-service, 2 of whom were on a Leave of Absence (LOA). 3. On [DATE], 18 of 31 licensed nurses had current certification and training on CPR cards on file. Recertification began and will continue until all licensed nurses have current CPR cards. Any licensed nurse who has not received the training and recertification will not be allowed to work. All newly hired licensed nurses must provide verification of current CPR training and certification prior to working. 4. On or before [DATE] 59, 62 CNA's received in-service training that included Emergency Management, Resident Assessment and When to Report Changes, Daily Assessments, Notification of the Licensed Nurse and Pulse Oximetry. CNA's who have not completed the training will not be allowed to work until they have received the training. 5. On [DATE], the facility's Corporate Quality Assurance Process was initiated. Mock code exercises were begun on [DATE] to determine competency of licensed nurses and CNAs. The facility began competency audits on [DATE] Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at the scope of pattern and severity of no actual harm but potential for more than minimal harm but not immediate jeopardy due to all of the staff had not been in-serviced on the emergency training and CPR and sustained compliance had not been verified by the State agency. #