Every finding on record at Medilodge of Livingston

This citation pertains to intake #3004757.Based on interview and record review, the facility failed to ensure accurate skin assessments and initiate treatments for skin impairments for one resident (R805) of two residents reviewed for skin impairments, resulting in unidentified and untreated wounds. Findings include:A complaint received by the State Agency alleged the facility did not complete accurate skin assessments and failed to initiate treatment to skin impairments. A review of R805's clinical record revealed they admitted to the facility on [DATE] and discharged to the hospital on 4/27/26. R805's diagnoses included: diabetes, falls, heart failure, heart disease, major depressive disorder, and panic disorder. A review of R805's weekly skin assessments was conducted and revealed the following: 4/23/26, no documented skin impairments. 4/26/26 MASD (moisture associated skin damage) under bilateral breasts and armpits, and redness and open areas to right and left iliac crests (curved ridge of the hip) and toes. A review of progress notes and physician's orders did not indicate the physician had been contacted, or any treatments had been initiated. On 7/14/26 at 10:05 AM, the facility's Administrator provided an investigation and past noncompliance documents regarding R805. A review of the documents provided read, .1. Description of the Quality Concern (why and how did it happen): (R805) was found to have skin issues when she was at the hospital. Facility identified skin issues 24 hours prior to send out. Not all skin issues identified in the hospital were accurately depicted in last skin assessment prior to send out. There was no intervention put into place by nursing . On 7/14/26 at 10:22 AM, an interview was conducted with the facility's Administrator regarding the identification of noncompliance. They were asked how they were made aware of the concern from the hospital and said their Hospital Liaison 'H' had reached out to the facility informing them of the condition of R805's skin. They went on to explain the facility compared the hospital documentation to the facility documentation and determined the facility skin assessments were not accurate, and staff had not initiated any treatments. On 7/14/26 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) and they were asked about how they identified and addressed the noncompliance. They said their Hospital Liaison 'H' had informed them R805 admitted to the hospital with wounds and called the facility to obtain the wound care orders for treatment they were receiving in the facility. The DON said R805 did not have any wound care orders in the facility, so they began investigating the concern. The DON said they reviewed R805's chart and saw skin impairments were identified 24 hours prior to them being sent out, but the descriptions of the impairments were not congruent with the condition of R805's skin when they admitted to the hospital. They further explained they interviewed several direct care staff (Nurses and Certified Nurse Aides) who reported R805 had several skin impairments prior to the last documented skin assessment on 4/26/26. The DON was asked if they queried staff why they did not document the impairments, inform the physician, and obtain treatment orders if they had knowledge the impairments were present prior to the assessment on 4/26/26 and said some of the staff had no answer and other staff said they, Thought someone else had already addressed it. During the onsite survey, past noncompliance was cited after the facility implemented actions to correct the noncompliance which included: identification of other residents with the potential to be affected by the deficient practice, review of the facility policy for skin management, re-education of staff, and audits of residents weekly to ensure accuracy of assessments and initiation of treatments. 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 and pantry in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents that consume food from the facility. Findings include:On 1/5/26 during an initial observation of the kitchen and pantry between 8:35 AM-9:15 AM, an observation of the main kitchen was conducted with the Certified Dietary Manager (CDM 'H') and the Corporate Registered Dietician (RD 'G'). The following items were observed:The ice machine located near the meal prep area was observed to have black vents on the right and left sides of the unit that were visibly soiled with a thick layer of dust. When asked about who maintained the ice machine, CDM 'H' reported that was the responsibility of the maintenance staff.The reach in freezer had a cardboard box that was opened and inside was a clear plastic bag with frozen beef patties. The clear plastic bag was not sealed and open with visible ice crystals on the tops of the beef patties. When asked about how the food items should be stored, CDM 'H' reported the food items should be sealed completed and proceeded to fold over the plastic bag and closed the freezer door.At 9:05 AM, CDM 'H' was asked to observe any additional food pantries and they reported there was only one on the C hall. Observations with both CDM 'H' and RD 'G' revealed:There were several refrigerators with top freezers. The first refrigerator was observed to have a package of smoked pork hocks (for a resident that was not a current resident as of this survey) and had a Use by 11/21/25. The shelving units were observed to have thick, brownish colored substance throughout the bottom inside of the freezer. There were multiple other food items stored on top of the debris.One of the refrigerators was observed to have the top freezer with a bag of small ice cubes that were not sealed and opened to air with no name or date. When asked to identify who the ice was for and if that was provided by the facility, CDM 'H' reported they weren't sure which resident that was for and confirmed the bag of ice was not provided by the facility. Additionally, the top freezer was observed to have brownish colored debris throughout the bottom of the freezer area. There were multiple other food items stored on top of the debris. This refrigerator was also observed to have several containers of greek yogurt with no resident name and had a manufacturer's expiration date of 12/14/15.One of the refrigerators was also observed to have a blue and white striped lunch box with several unidentifiable food items stored on the bottom center area. There was no resident name or date and when asked to identify who that belonged to, both CDM 'H' and RD 'G' reported they could not identify that.The vents in the storage room inside the pantry where disposable cups, lids and straws were stored were observed to be covered in thick dust and the surrounding wall had visible dust debris blown around the vent.When asked about who was responsible to maintain the refrigerators in the pantry, CDM 'H' reported they did and were not able to offer any further explanation as to the current conditions observed.According to the 2022 FDA (Food and Drug Administration) Food Code section 3-305.11 Food Storage, (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .According to the 2022 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous 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 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed 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, 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.On 1/7/26 at 12:45 PM, the Administrator was requested to provide a policy for maintenance of the ice machine and reported they did not have a specific vent cleaning policy for the ice machine and in regard to cleaning, the facility utilized the manufacturer's recommendation.On 1/7/26 at 12:55 PM, an interview was conducted with the Maintenance Director (Staff 'J'). When asked about the process for cleaning the ice machines, they reported the process was completed per manufacturer's regarding emptying and sanitizing. When asked about the external vents, Staff 'J' reported that was not a part of their process when they did the monthly routine internal cleaning.Staff 'J' was requested to observe the pantry and kitchen. Observations included:On 1/7/26 at 1:00 PM, the pantry was observed and when asked about the process for cleaning the wall vents, Staff 'J' reported anyone, housekeeping or nursing who saw the soiled vents could assist with cleaning them or place a notice in the facility's electronic reporting system. When asked if they could recall any recent notifications regarding dusty/soiled vents in the pantry or kitchen, Staff 'J' reported they had not.Upon observation of the kitchen ice machine, Staff 'J' confirmed the same soiled external vents and reported they would likely have to include that on their monthly maintenance of the ice machines and further reported they had not been notified about that via the electronic reporting system.According to the facility's policy titled, Food Receiving and Storage dated 7/1/2025: .Food Services, or other designated staff, will maintain clean food storage areas at all times .Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean .All foods stored in the refrigerator or freezer will be covered, labeled and dated (opened on and use by date) .Wrappers of frozen foods must stay intact until thawing .According to the facility's policy titled, Ice Storage dated 7/1/2025:Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions, and maintains a copy of these guidelines.According to the facility's policy titled, Use and Storage of Food Brought in by Family or Visitors dated 7/1/2025: .All food items that are already prepared by the family or visitor brought in must be labeled with content and dated .The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator .All items not maintained are subjected to being thrown away if not removed by the resident and/or resident representative .According to the manufacturer's instructions and guidelines for maintenance of the ice machine: .EXTERIOR CLEANING Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation.Sponge any dust and dirt off the outside of the ice machine with mild soap and water. Wipe dry with a clean, soft cloth.

This citation pertains to Intake 2670486.Based on observation, interview and record review the facility failed to provide proper hand hygiene procedure during medication administration for two (R112, R09) of four residents reviewed for medication administration.Findings include:On 1/6/26 at 9:38 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN) B for R112 and was observed donning clear gloves in the bathroom without washing hands prior. LPN B then placed the right gloved hand to pull the privacy curtain, then proceed to inject insulin into their left lower abdomen.LPN B was then observed at the medication cart, after using hand sanitizer, opened their blue zipper shoulder bag, retrieved a marker to date the bottle, rezipped the bag, moved items on the cart, then opened the new bottle puncturing the safety seal and prepared the medication (Miralax-laxative medication) without cleaning hands.At 9:49 AM LPN B was observed providing medication and administering a health shake to R09 with no hand hygiene.On 1/6/26 at 10:10 AM, a medication storage observation of C-Hall Cart was conducted with Licensed Practical Nurse (LPN) D and Unit Manger LPN E at which time two loose pills were observed lying in the locked narcotic drawer in between the locked box and drawer. Unable to easily retrieve the medications for disposal, LPD D was observed taking a red colored plastic knife, removed chewing gum from their mouth, placed their chewed gum on the tip of the knife and proceeded to poke into the medication drawer and pulled the pills out, while Unit Manager LPN E was commenting I know this is gross.On 1/6/26 at 12:56 PM, an interview with the Director of Nursing (DON) acknowledged hand hygiene is to be consistent and will reinforce their policy. The DON had no comment regarding the gum and pill retrieval but acknowledged that it was not sanitary,

Based on observation and interview the facility failed to ensure accurate accounting for an administered controlled medication (refers to drugs that are regulated due to their potential for abuse and dependance) for one resident (R09) of one reviewed for controlled medication administration.Findings include:On 1/6/26 at 9:38 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN) B for R09 who was to receive Ativan (a benzodiazepine classified as a controlled medication to treat anxiety, insomnia, and other related conditions) 0.5 milligram (mg) every 12 hours. Review of the controlled substance binder for the medication identified the nurse who last administered the medication identified as LPN C did not document the date or time the medication was last administered. LPN B proceeded to fill in the blank areas stating the nurse did not do it.On 1/6/26 at 9:41 AM, LPN B saw the Nursing Home Administer (NHA) in proximity and was observed telling the NHA they need to call LPN C because they did not sign out their narcotic book.On 1/6/26 at 1:10 PM, the Director of Nursing (DON) in the presence of Registered Nurse (RN) A was interviewed and acknowledged nursing must document controlled substances into the controlled substance binder and further remarked nursing performs a two-nurse reconciliation of the controlled substances every shift and should not had been missed.

Based on interview and record review, the facility failed to promote the resident's right to be treated with dignity and respect for one (R96) reviewed for dignity, resulting in facility staff searching a resident's personal possessions without giving the resident the opportunity to decline.Findings include:Clinical record review documented R96 was admitted to the facility on [DATE] requiring dialysis (medical procedure to remove waste products from the blood) because of acute kidney failure due to rhabdomyolysis (muscle breaks down and releases toxins into the blood and kidneys). R96's Skilled Medical Assessment documented on 12/25/25 confirmed R96 was orientated to person, place, date, and time.On 1/5/26 at 11:25 AM, during initial interview and introduction, R96 was observed sitting on the side of the bed, with the center of their white mustache colored yellow as if nicotine stained, had a faint odor of cigarettes and was visibly upset. When inquired, R96 revealed just prior to this interview, they went outside to have a cigarette and when they returned, their cigarettes, a lighter, an unopened shot of peanut butter whiskey (was saving for when discharged to celebrate) and their Trelegy (steroid) Inhaler were gone. R96 stated he told the Nursing Home Administrator (NHA) to return them or reimburse them ten dollars. R96 said the facility knows he smokes and they just came in here and stole my stuff.On 1/5/26 at 11:30 AM, an interview with Licensed Practical Nurse (LPN) B outside of R96's room was asked what had happened regarding the cigarettes and confirmed there was much loud commotion in their room moments earlier and replied that someone took some stuff out of their room when he was not in there.On 1/7/26 at 11:10 AM, an interview with the NHA acknowledged that staff from corporate were checking rooms, had seen the items in R96's room and confiscated without R96's knowledge or presence. The NHA admitted this was not appropriate and should have not confiscated.

Based on interview and record review, the facility failed to ensure prompt efforts to resolve a complaint/grievance regarding the disposal of fresh purchased personal food items for one resident (R29) of one reviewed for grievances.Findings include:R29 was admitted to the facility on [DATE], with end stage kidney disease, required in house hemodialysis, and was legally blind. A Brief Interview of Mental Status (BIMS) score assessed on 12/19/25 totaling 13/15 indicated R29 was cognitively intact.On 1/5/26 at approximately 11:30 AM, during initial introductions and interview, R29 voiced approximately two months ago, they had ordered a delivery for JETS Pizza. The following day when requested to have their leftovers, R29 was informed the kitchen staff had thrown the pizza into the garbage because it was not dated. R29 said he is blind and relied on the staff to label his food. R29 remarked the Nursing Home Administrator (NHA) said they would reimburse $40.00 for the cost of the meal and Certified Dietary Manager (CDM) E told them next time pizza was served as a meal at the facility, R29 they would receive extra pizza next time it was on the menu.R29 confirmed at the time of this interview, they still have not been reimbursed, nor have they received any extra pizza as promised.A record review of the grievance form filed for R29 on 10/21/25 documented .food thrown out.items never dated according to my staff.On 1/6/26 at 2:17 PM, Licensed Practical Nurse (LPN) E was interviewed who authored the initial grievance for R29 and recalled that sometimes residents or their families will date their food, and it is placed into the refrigerator. However, R29 is blind, so staff would do it on their behalf. Unfortunately, the staff did not date the food, and the kitchen threw it out.On 1/6/26 at 2:28 PM, Certified Dietary Manager (CDM) E was interviewed with Corporate Dietary (CD) I and recalled R26s pizza was thrown away because it was not dated. CDM E confirmed the facility staff are responsible for dating residents' food items when placing into the refrigerator and R29's pizza was not dated by staff. When asked if R29 was promised more pizza and or reimbursed, CDM E confirmed they were not provided extra pizza and CD I remarked any financial reimbursement would be handled by the NHA.On 1/6/25 at 2:30 PM, The NHA was interviewed and reviewed the grievance from R29 filed 10/21/25 and was informed of the above interviews. The NHA acknowledged the facility had never reconciled the grievance with R29 and commented they would address immediately.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for medication administration for two (R114, R09) of four residents reviewed for the medication administration task.Findings include:On 1/6/26 at 9:55 AM, an observation of Licensed Practical Nurse (LPN) D was at the C-Hall medication cart #1 reading aloud from the computer screen the Medication Administration Record (MAR) orders for R114's morning medications to LPN B who was observed at C-Hall medication cart #2, pulling the medications as LPN D read them off.On 1/6/26 at 12:07 PM, a record review of R09's MAR was reconciled from the earlier medication administration observation with LPN B and revealed the medications were documented as signed off by LPN D. LPN B was interviewed and when the MAR was reviewed, they had identified that it was their error, had not signed in under their log in, and charted on another nurse's credentials.On 1/6/26 at 12:07 PM, an interview with the Director of Nursing (DON) acknowledged the medications that were pulled for R114 should have been done by only one nurse. The DON confirmed having one nurse read off medications as another nurse pulls the medications was not safe and unacceptable. The DON also agreed that nursing must sign in and sign out of the computer using their own credentials and the error would be addressed.Record review of the Medication Administration Policy dated 1/2023 documented: .Medications are administered by licensed nurses.in accordance with professional standards of practice.Compare medications source of MAR to verify resident name, medication name, form, dose, route, and time of administration.

Based on observation, interview and record review, the facility failed to conduct a Safe Smoking Assessment of one resident (R96) of one reviewed for smoking.Findings include:Clinical record review documented R96 was admitted to the facility on [DATE] requiring dialysis (medical procedure to remove waste products from the blood) because of acute kidney failure due to rhabdomyolysis (muscle breaks down and releases toxins into the blood and kidneys). R96's Skilled Medical Assessment documented on 12/25/25 confirmed R96 was orientated to person, place, date, and time.On 1/5/26 at 9:22 AM, the Nursing Home Administrator (NHA) confirmed at Entrance Conference, that the facility was a non-smoking facility, no residents currently resided that smoked, and if residents are smokers, they can receive a nicotine patch.On 1/5/26 at 11:25 AM, during initial interview and introduction, R96 was observed sitting on the side of the bed, with the center of their white mustache colored yellow as if nicotine stained, had a faint odor of cigarettes and was visibly upset. When inquired, R96 revealed just prior to this interview, they went outside to have a cigarette and when they returned, their cigarettes, a lighter, an unopened shot of peanut butter whiskey (was saving for when discharged to celebrate) and their Trelegy (steroid) Inhaler were gone. R96 stated he told the NHA to return them or reimburse them ten dollars. R96 said the facility knows he smokes and they just came in here and stole my stuff.R96 said they had just started smoking again at the end of November and the cigarettes were brought in by their niece. R96 said they stored them in the top drawer of their nightstand or in their coat pocket. They do not have to have them locked up nor ask staff for them. R96 said they were asked to smoke on the far outskirts of the parking lot away from the building, which they do. R96 admits to going outside approximately 4-5 times daily to smoke and the staff was fully aware that they smoke. R96 further remarked that the NHA had asked them to wait until after 5:00 PM to go outside after you guys (State Surveyors) leave the building. No one has ever had a concern of me smoking until the State showed up.On 1/5/26 at 11:30 AM, an interview with Licensed Practical Nurse (LPN) B outside of R96's room was asked what had happened regarding the cigarettes and confirmed there was much loud commotion in their room moments earlier, and they took some stuff out of the room when they were not in there. LPN B acknowledged we know R96 smokes, they will go outside, keeps the cigarettes in their pocket and goes to an area on other side of parking lot to smoke.On 1/7/26 at 11:00 AM, an interview with Receptionist K was questioned if there were residents who smoked at this facility and admitted yes. When asked, Receptionist K confirmed they would go in and out of the main door, and smoke outside past the cars in the parking lot. When asked what residents smoke, Receptionist K replied R96 was a smoker and wondered where they had been over the past few days because they tend to go in and out frequently to smoke. Receptionist K provided the sign out book and an observation under R96 from December 2025 revealed them signing in and out. Receptionist K said sometimes they will sign out to smoke, sometimes they don't because they come right back into the building.On 1/7/26 at 11:16 AM, The NHA acknowledged that R96 was once caught before smoking and was informed by the NHA that this was a non-smoking facility. The NHA also confirmed there was no smoking policy for the facility and provided a blank document .Acknowledgment of Facility Smoking Policy which by signing the parties agree and acknowledge the facility smoking policy and will adhere to all conditions. This form was not revealed in R96's medical record. A safe smoking assessment form had not been conducted until 1/5/26 at 10:13 after the State Survey had commenced.

Based on observation, interview, and record review, the facility failed to ensure the results of the most recent recertification survey were readily accessible to residents, their family members, and their legal representatives and failed to post a notice of availability of survey reports for the past three years. This has the potential to affect all residents who reside in the facility. Findings include: On 1/6/26 at 1:00 PM, a resident council interview was conducted with seven residents who wished to remain anonymous. When queried about access to the results of previous surveys, all seven residents reported they did not know where to find the survey results. On 1/6/26 at 2:20 PM, an interview was conducted with Registered Nurse (RN) 'A' (a former Director of Nursing in the facility). When queried about where the results of the previous survey inspections were located, RN 'A' said a binder was located in the front lobby which required a code to open the door (end enter the lobby). The binders were located in a pile behind the front desk off to the side. On 1/6/26 at 2:24 PM, an interview was conducted with the Administrator. When queried about why the survey result binders were located in the lobby which was not readily accessible by the residents, the Administrator reported anyone who wanted to see the results was able to ask him and he would give them the binders. Upon further observation, there were no postings visible in the facility that noted the survey results were available for review. A review of a facility policy titled, Facility Required Postings, revised on 1/1/22, revealed, in part, the following, The facility will post required postings in an area that is accessible to all staff and residents .The facility must also post the following .Most recent survey results of the facility .

This citation pertains to intake 2647121Based on interview and record review, the facility failed to provide behavioral health services for one resident (R901) of three residents reviewed for Changes in condition. Findings include:On [DATE] a concern submitted to the State Agency was reviewed which alleged R903 did not have any support services while at the facility. On [DATE] the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnoses including Opioid dependence, depression and Dependence on renal dialysis. A Psychiatry Initial Evaluation dated [DATE] revealed the following: Chief Complaint-Depression, anxiety and insomnia-History of Present Illness- .was initially admitted to [Name of facility] on 5-9-2025 for long-term care due to requiring 24-hour assistance with ADLs (activities of daily living), skilled nursing care, and medication management. Social worker requested psychiatric evaluation regarding patient's increased symptoms of ongoing moderate depression, anxiety, and insomnia .Resident reports his mood has been down with ongoing anxiety and depression. He denies ever seeing a psychiatrist and reports starting Celexa in the hospital for depression. He reports sleeping poorly, though his appetite is very good. Resident attributes his ongoing depression to being homeless and states he will be in the facility long-term as he has no place to go Additional Notes Patient presents with increased symptoms of ongoing moderate depression, anxiety, and insomnia, which prompted the current psychiatric evaluation .Assessment and Plan- Major depressive disorder, single episode, moderate. Patient presents with ongoing moderate depression related to his current life circumstances, including homelessness. He reports his mood has been down .Plan is to increase Celexa from 20mg (milligrams) to 30mg daily for ongoing depression. Recommend psychotherapy for ongoing depression. Patient is in agreement with plan of care A Social Service evaluation dated [DATE] revealed the following: Date of most recent PHQ-9 (Patient Health Questionnaire)-[DATE]. PHQ-9 Score-15 (moderately severe depression).A Nurse Practitioner note dated [DATE] revealed the following: .He expresses concerns with his neuropathic pain that is not being treated well by existing regiment of oxycodone 10 mg twice a day and Suboxone 4 mg twice a day. I tried to find out if the patient was on Suboxone prior to his hospitalization to [local hospital] and it appears that it was initiated there. I am trying to coordinate him with the specialty clinic for addiction and withdrawal management that will do a better job with Suboxone dosage adjustment A Nurse Practitioner note dated [DATE] revealed the following: CHIEF COMPLAINT .Follow-up on the blood sugar management and other chronic issues .He agreed to my plan: referring him to the addiction specialist to titrate his Suboxone and to endocrinology if we are not able to take his blood sugars under control A Psychiatry follow up note dated [DATE] revealed the following: .He states that he had a PCP (primary care Physician) in [last state lived] and used to be on Xanax 1 mg twice daily for 2 years. He has been off Xanax for the last 6 months because his PCP did not want to prescribe it along with his OxyContin, which he has been on for at least 2 years. It is documented on a progress note of [DATE] that patient is being referred to an addiction specialist to titrate his Suboxone. He complains of chronic depression and anxiety because of his health issues and because he is homeless and does not know what the future holds for him. He admits to poor motivation and no ambition to do anything. He does not like to go to activities .He gives a history of suicide attempt 2 years ago when he injected himself with Windex cleaning solution, but it had no effect whatsoever and did not even make him ill. He states that he was depressed because his mother had died in 2020 from a fentanyl overdose .He complains of insomnia despite taking melatonin 3 mg nightly and trazodone 50 mg nightly. He is currently also on citalopram 30 mg daily. His weight was 143.6 pounds 5 days ago. He is wondering if he can go back on Xanax. I informed him that I am going to wean him off the Celexa since it has proven to be ineffective, and we will start him on Cymbalta which can help for his depression, anxiety, diabetic neuropathy, and chronic pain. He was in agreement with this plan .Assessment and Plan-Major depressive disorder, recurrent, moderate-Patient presents with chronic depression related to health issues and homelessness. Reports poor motivation and no ambition to do anything. Denies current suicidal ideation. Plan is to taper citalopram (Celexa) as it has proven ineffective: 20 mg daily for 1 week, then 10 mg daily for 1 week, then discontinue. Starting duloxetine (Cymbalta) 30 mg every morning for 1 week, then increasing to 60 mg every morning to address depression. Patient is in agreement with plan of care .Generalized anxiety disorder-Patient reports ongoing anxiety related to health issues and uncertain future. Duloxetine (Cymbalta) 30 mg every morning for 1 week, then increasing to 60 mg every morning will also address anxiety symptoms. Patient is in agreement with plan of care . Adjustment insomnia-Patient reports insomnia despite current medications. Discontinuing melatonin 3 mg nightly and increasing trazodone from 50 mg to 100 mg nightly for insomnia. Patient is in agreement with plan of care .Opioid dependence, uncomplicated *: Patient has history of OxyContin use for at least 2 years. Currently being referred to addiction specialist to titrate Suboxone per progress note of [DATE] .A Nurse Practitioner note dated [DATE] revealed the following: .Follow-up with social services regarding his scheduled addiction medicine appointments is planned On [DATE] at approximately 5:25 p.m., during a conversation with Social Work Assistant A (SWA A), SWA A was queried regarding the psychotherapy that was recommended by the psychiatry provider on [DATE] due to R903's ongoing depression and the addiction specialist follow-up per the Nurse Practitioner's notes on [DATE] and [DATE] and they indicated that they had started after [DATE] and that they were never aware that R903 had a recommendation to see psychotherapy and they were never seen by therapy because they did not know about it. SWA A was queried regarding the documentation of the addiction specialist, and they indicated they did not have any documentation that one was arranged or if R903 had gone. SWA A reported that a referral could have been made for ongoing psychotherapy to address R903's depression had known about because the psychiatric provider that the facility utilized did offer those services. At that time, SWA A was queried for any documentation that R903 had seen an ongoing psychotherapist to address their depression and anxiety, and they indicated they did not have any because R903 never saw one but that they would look in the record again to be sure. SWA A indicated they only times R903 had been seen by behavioral health was on [DATE] and [DATE]. No documentation that R903 was provided addiction specialists or psychotherapy was provided by the end of the survey. A facility document titled Behavior Management Program was reviewed and revealed the following: Each resident's drug regimen must be free from unnecessary drugs; that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. To ensure that the residents who use anti-psychotics, antidepressants, hypnotics, sedatives, and anti- anxiety drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue the drugs .Policy Explanation and Compliance Guidelines: a. Residents on an antipsychotic, resident's exhibiting behaviors negatively affecting self or other residents or with new behaviors negatively affecting self or other residents will be reviewed by the Behavior Management team which may include but not limited to (activity Director, Social services, CENA (Certified Educated Nurse Assistant), nurse manager, doctor, Contracted Behavioral Health Partner's prescriber (PA, Psychiatrist, or NP), psychologist and any other parties that the facility team members deem appropriate). The team will explore the root cause of behaviors/mood. The team will identify target behaviors and an individualized plan of care. The team will use non-pharmacological interventions, when applicable, to minimize the need for medication, permit the use of the lowest possible dose or allow medication to be discontinued

This citation pertains to Intake #2584966Based on observation, interview and record review the facility failed to ensure residents received scheduled showers for one (R801) out of one resident reviewed for ADL (activities of daily living) care. Findings include:A complaint was filed with the State Agency (SA) that alleged there were not enough staff at the facility to ensure they received their showers.On 8/27/25 at approximately 9:30 AM, R801 was observed lying in bed. The resident was alert and able to answer all questions asked. When quired as to whether they received scheduled showers, R801 replied that they finally got a shower yesterday (8/26/25) but was not regularly receiving them and often only received a bed bath. R801 noted that they need a shower to ensure cleanliness.A review of R801's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes and acute respiratory failure. A review of the resident's Minimum Data Set (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 (intact cognition).A review of review of R801's TASK record for showers noted the resident was to receive showers on Tuesday and Fridays during the day shift. A 30 day look back recorded the following: Tuesday- 7/29/25 (shower), Friday -8/1/25 (bed bath), Tuesday -8/5/25 (bed bath), Friday-8/7/25 (nothing provided), Tuesday-8/12/25 (nothing provided), Friday-8/15/25 (shower), Tuesday-8/19/25 (bed bath), Friday-8/22/25 (nothing provided) and Tuesday-8/26/25 (shower). *It should be noted that there were no notes that indicated R801 refused showers on the dates nothing was provided. In addition, there were no notes that indicated R801 preferred a bed bath on the dates noted above.On 8/27/25 at approximately 3:30 PM, an interview was conducted with Certified Nursing Assistant (CNA) F who was assigned to R801. CNA F was asked about the facility's protocol pertaining to showers. CNA F reported that showers generally are given twice per week. CNA F was asked if they provided R801 with showers and/or bed baths and they noted that they give the residents showers as that is what they prefer.A request had been made for any grievances pertaining to R801. On 8/27/25 at approximately 3:40 PM, the Administrator reported that a grievance pertaining to showers was submitted yesterday (8/26/25) and had not been fully completed.

This citation pertains to Complaint #2588818.Based on interview and record review, the facility failed to perform respiratory assessments upon admission and before and after breathing treatment administration for one (R802) of one resident reviewed for a change in condition. Findings include: A review of R802's clinical record revealed R802 was admitted into the facility on 5/23/25, readmitted on [DATE], and discharged on 8/11/25 with diagnoses that included: chronic respiratory failure with hypoxia (low oxygen level), chronic obstructive pulmonary disease (COPD), history of lung cancer, and end stage renal disease (ESRD). R802 was dependent on a mechanical ventilator for breathing, had a tracheostomy (a surgical hole in the windpipe to assist with breathing), and received renal dialysis. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had severely impaired cognition and was dependent on staff for care. Further review of R802's clinical record revealed R802 was transferred to the hospital on 6/17/25 and from there was admitted to an inpatient rehabilitation hospital until 8/5/25, at which time R802 was readmitted into the facility.A review of R802's progress notes revealed the following:On 8/5/25, a Respiratory Note documented, Resident re admitted to facility .Put on previous vent settings .A review of R802's Physician's Orders revealed from 5/30/25 until 6/19/25 the ventilator setting orders were as follows: Vent-Settings: Mode: PC (Pressure Control) RR (Respiratory Rate): 19 VT: 500 PEEP (Positive End Expiratory Pressure): +5Further review of R802's Physician's Orders revealed from 8/6/25 to 8/19/25 (after R802 returned from the hospital) the ventilator setting orders were as follows: Vent-Settings: Mode: AC (Assist Controlled) Vt: 400 RR: 16 PEEP: +5. It should be noted that the initial Respiratory progress note written when R802 returned to the facility on 8/5/25 noted R802 was put on the previous vent settings (prior to going to the hospital). However, the orders were different. A review of a Respiratory-Ventilator Resident Evaluation dated 8/5/25 revealed the settings were correct to the current physician's order, but the documentation in the progress note was not accurate. Further review of the evaluation revealed the documented vital signs on that date (8/5/25) were vital signs from 6/17/25, the day R802 was transferred to the hospital. A review of a Respiratory-Breathing Treatment assessment dated [DATE] at 11:40 PM, completed by Respiratory Therapist (RT) 'B', revealed R802 received a breathing treatment. The assessment had a section to assess the resident's breath sounds and vital signs Pre (before) and Post (after) the breathing treatment was administered. The vital signs documented for this breathing treatment were the same date and time for pre and post treatment and they were dated and timed as follows: O2 sats and Respiration: 8/10/25 at 3:06 PM (approximately eight and a half hours prior to the administration of the breathing treatment) and Pulse: 8/10/25 at 5:39 PM (six hours prior to the administration of the breathing treatment). A review of a Respiratory-Breathing Treatment assessment dated [DATE] at 4:59 AM, completed by Respiratory Therapist (RT) 'B', revealed R802 received a breathing treatment. The vital signs documented for this breathing treatment were the same date and time for pre and post treatment and they were the same vital signs documented on the previous assessment. O2 sats and Respiration: 8/10/25 at 3:06 PM (approximately 14 hours prior to the administration of the breathing treatment) and Pulse: 8/10/25 at 5:39 PM (approximately 11.5 hours prior to the administration of the breathing treatment). A review of R802's care plans revealed a care plan initiated on 8/6/25 that noted, Resident has an impaired pulmonary/respiratory status related to vent dependency and tracheostomy . Interventions included, Administer medications as ordered. Observe for effectiveness and report adverse side effects to Physician .On 8/27/25 at 1:36 PM, a telephone interview was attempted with RT 'B'. RT 'B' was not available for interview prior to the end of the survey.On 8/27/25 at 1:55 PM, an interview was conducted with Respiratory Director (RTD) 'E'. When queried about the progress notes documenting put on previous vent settings instead of documenting the vent settings, RTD 'E' said they were short of staff and probably did it to save time. When queried about the process for assessing a resident on a mechanical ventilator on admission and whether vital signs should be taken at the time of the assessment, RTD 'E' said they should. When queried about how residents on mechanical ventilators were assessed when given a breathing treatment, RTD 'E' said the RT took breath sounds and vital signs before the treatment was administered and then they would go back in after the treatment and recheck breath sounds and redo the vital signs. At that time, the breathing treatment evaluations from 8/10/25 and 8/11/25 were reviewed with RTD 'E'. RTD 'E' reported they used the previous set of vitals taken by nursing. When queried about how the RT would know if the breathing treatment was effective if they used vital signs from eight to 14 hours earlier, RTD 'E' reported they should be taken at the time of the breathing treatment.

This citation pertains to intake MI00149991 and MI00150073. Based on interview, and record review, the facility failed to assess the integrity of a mechanical transfer sling for one resident (R901) reviewed of three for accidents resulting in an avoidable fall requiring emergent transfer to a higher level of care and surgery for fractures sustained to the left and right lower extremities and pain. Findings include: A review of complaint reported to the State Agency included an allegation R901 was dropped from a mechanical (Hoyer) lift and sustained a fracture because the sling was not safe for use. On 2/11/25, a clinical record reviewed revealed R901 was readmitted to the facility on [DATE] with a medical history of atrial fibrillation (abnormal heart rhythm) and required Eliquis (blood thinning medication), chronic osteomyelitis, and diabetes. R901 had an ADL (Activity of Daily Living) self-care deficit related to muscle weakness, reduced mobility, and morbid obesity. R901 required two persons assist and use of a mechanical lift for all transfers from bed to chair. Brief Interview of Mental Status (BIMS) assessed on 11/21/24 scored 15/15 indicating R901 is cognitively intact. On 2/11/25 at 9:42 AM, an interview with the Nursing Home Administrator (NHA) acknowledged on 1/30/25 after their shower, R901 was hanging from a bariatric sling and the strongest part of the sling ripped resulting in R901 falling from the lift and required to be transferred to the hospital. The NHA said no other areas of the sling appeared compromised and was weird because it ripped from its strongest support strap when asked if the manufacturer was contacted, the NHA replied they were not, and the sling was thrown in the garbage (and not available). On 2/11/25 at 10:04 AM, a telephone interview was conducted with R901. When asked about the 1/30/25 accident, R901 commented that they knew how the fall happened, stating I was in a sling that should not have been used. When asked for further clarification, R901 said the sling had a worn-out appearance and the fabric sewn to the strap look old and worn out. R901 said the two Certified Nurse Assistants (CNA) transferring them remarked that soon as they placed them (R901) back into bed, We need to throw this one out. R901 said they were about three-four feet up from the ground, the left strap supporting their left side gave out ,was ripped, tearing the loop strap from the lift and fell injuring their left leg and right ankle. During the interview, R901 said they are still hospitalized , had required surgery for a fractured left femur and broken right ankle because of the fall and had pain as a result. On 2/11/25 at 10:33 AM, a telephone interview with CNA A identified as one of the two CNA's providing the transfer to R901 confirmed they were assisting the lower portion of the sling guarding R901's position as to not hit the walls and the sling just snapped and R901 fell to the ground. CNA A was unable to verify who had the last responsibility of checking the integrity of the slings and confirmed R901 had the sling under them and could not confirm the integrity. On 2/11/25 at 12:15 PM, a telephone interview with Licensed Practical Nurse (LPN) F who authored the Progress Note dated 1/30/25 at 6:04 PM confirmed they heard a loud sound from R901's room, observed them on the ground stating they fell from the lift and had pain in their left leg. LPN F revealed that the upper left loop had ripped from the stitching, was dangling from the hook and the rest of the sling had ripped apart. When asked who is responsible for checking the integrity of the slings, LPN F was unable to answer. An interview on 2/11/25 at 12:30 PM with Laundry Services C clarified when slings are brought to be laundered, they are inspected pre and post washing. If a sling is compromised in any way, the NHA and or Maintenance Manager is notified, and the sling should be disposed of. The last recall of a sling being removed was over two months ago. When asked who has the final inspection of the slings, Laundry Services C remarked they were not sure but it should be the Nurses because they are the ones who retrieve the slings and put them on the residents. On 2/11/25 at 1:33 PM, the Director of Nursing (DON) confirmed that it is the responsibility of the CNA's or whomever is placing a resident into a sling who had the final responsibility of verifying the integrity of the sling. The DON and NHA were informed of the remarks made during the above interviews and confirmed they will reinforce the final check of integrity of the sling is done by the staff placing residents into the sling. During the review of a Past Non-Compliance Binder revealed on 1/31/25 an audit of the slings was conducted and identified a green sling labeled #809A was thrown away and not placed back into circulation (an additional sling was identified as not safe and thrown away). On 2/11/25 at 2:17 PM, LPN G returned a phone call and acknowledged the sling R901 was in was torn from the sling and strap loop and witnessed the Resident laying on the floor complaining of pain. When asked the overall condition of the sling, LPN G stated, it was not a newer sling and it had been in rotation for a while. Review of the facility's policy titled; Safe Lifting and Movement of Residents, dated 1/2022 Documented: .Mechanical lift equipment shall undergo routine checks and maintenance by the nursing and maintenance staff, respectively, to ensure that equipment remains in good working order . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education, training, reviewing current slings and removing worn slings to correct the past noncompliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review, the facility failed to consistently ensure physician approved recommendations from the pharmacist were implemented for three (R4, R10, R19, R77) of four residents reviewed for medication regimen reviews. Findings include: R4 Review of R4's monthly medication regimen review (MRR) revealed on 8/1/24 pharmacist documented Resident is on digoxin. Please consider daily apical pulse readings prior to digoxin along with 'hold' parameters if pulse less than 60, to monitor rhythm and rate. A review of the facility's MRR binder revealed that the facility physician indicated that they agreed with the pharmacist recommendation however a review of R4's digoxin order and medication administration record revealed the recommendations were not carried out. R10 Review of R10's MRR revealed on 4/1/24 pharmacist documented 1 rec (recommendation) to physician. No physician response was found in the facility's MRR binder. On 10/14/24 at approximately 2:44 PM, the DON was notified of the missing physician response to the pharmacist's recommendation for April. The DON reported they would attempt to locate the document. No response was received prior to survey exit. R77 Review of R77's MRR revealed on 9/19/24 pharmacist documented Please monitor and document placement of fentanyl patch every shift. Review of the facility's MRR binder revealed the physician agreed however a review of R77's fentanyl patch order and medication administration record revealed the recommendations were not carried out. On 10/14/24 at approximately 2:44 PM, the DON was queried on the facility's procedure for monthly medication regimen reviews. The DON reported that they receive the recommendations from the pharmacist via email each month. The email goes to the facility physicians and to the DON directly. She further reported that she will follow up with the appropriate physician if a response (to agree/disagree with the pharmacists recommendation) is not received in a timely manner and the expectation is that the physicians are making the changes/entering any new orders at the same time as they acknowledge that they agree with the recommendations. The DON reported that her double check stops at following up for recommendations that aren't received back and that she trusts when the order is signed and that the physician is entering the order at the same time. Review of the facility policy titled, Addressing Medication Regimen Review Irregularities updated 12/28/23, documented in part The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and the reports must be acted upon .The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it .If documentation of the findings is not in the active record, it will be maintained within the facility and available for review. 49083 Resident 19 A clinical record reviewed revealed R19 was admitted to the facility on [DATE] with End Stage Renal Disease (ESRD) and requires hemodialysis. R19 had diabetes, atrial fibrillation (abnormal heartbeat) schizophrenia, and major depressive order. A Brief Interview of Mental Status (BIMS) score assessed on 8/20/24 revealed a score of 15/15 indicating R19 was cognitively intact. On 10/14/24 at 1:12 PM, a record review revealed the Medication Regimen Review (MMR) from Pharmacy dated 9/3/24, Recommendation to Nursing to update Abilify (antipsychotic medication) diagnosis listed as Antianxiety and change to Major Depressive Disorder. The Medical Administration Record (MAR) was reviewed and revealed the Abilify order remained with the diagnosis of antianxiety and was not changed to Major Depressive Order. A review of the recommendation from Pharmacy to the facility documented multiple requests for blood work to include a Lipid Profile (blood test that measures cholesterol and help assess risk of heart disease) and Glycated Hemoglobin (HgA1C) (blood test to obtain the average blood sugar levels over three months) on the following dates: 2/5/24, 5/2/24, 6/21/24, 8/23/24, 10/2/24. On 10/15/24, A record review revealed no lab values for Lipid Profile or HgA1C were documented. The MMR dated 10/2/24 was provided by the Director of Nursing (DON) and Pharmacy documented .Labs recommended: fasting lipid profile and HgA1C (no results from 6-23-24 order). The DON provided documentation of laboratory results and revealed a blood draw for Lipid Profile and HgA1C were collected and reported on 8/27/24. The DON acknowledged the results were not drawn from the first recommendation dated 2/5/24, acknowledged multiple requests were missed, and results from the 8/27/24 collection were not uploaded for the Pharmacist to review.

Based on observation and interview, the facility failed to ensure appropriate medication storage and labeling in two of three carts reviewed for medication storage and labeling. Findings include: On 10/15/24 at 8:10 AM, an observation of Medication Cart C Hall #2 was conducted with Licensed Practical Nurse (LPN) H and revealed on the bottom of the second drawer, loose medications were not contained in bottles, or blister packs. Observation included: 1 white round pill, 1 orange oval pill, 1 tan oval pill, and 1/2 tablet of a purple pill and LPN H commented it was midodrine (a medication to raise blood pressure). An open albuterol inhaler (medication to relax the airways and ease breathing) was identified as not dated. LPN H acknowledged the box was opened and not dated per protocol by dating the box. On 10/15/24 at 8:40 AM, an observation of Medication Cart E 500 Hall was conducted LPN I and revealed the first drawer had a bottle of opened nitroglycerin (medication to relieve chest pain) with no resident identifiers. LPN I commented that it was for a resident who experienced chest pain the day before. When questioned how we would know which resident it belonged to, LPN I responded we don't. Drawer two revealed medications were not contained in bottles or blister packs. Observation included: 1 round white pill, 1/4 white pill, 1/2 tan pill. The narcotic box was accessed and revealed 1/2 tab of a peach colored pill on the bottom of the box and LPN I remarked looks like a Xanax (a controlled medication to treat anxiety). Three open boxes of albuterol inhalers were not dated and when questioned if they should have an open date marked on the box, LPN I commented that they believed the policy changed and no longer had to date the inhalers. On 10/15/24 at 1:27 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were questioned what was the facility's procedure for dating inhalers and the DON acknowledged nursing should be marking the date the medication was opened on the box. The DON and ADON were made aware nursing staff had not dated inhaler boxes and staff were unclear what the procedure was. The DON and ADON were also informed of numerous loose medications lying within the medication carts and acknowledged that their staff has made them aware of the observations and this was not appropriate medication storage or labeling.

Based on observation, interview, and record review the facility failed to ensure nursing staff maintained professional standards, and practices for one (R239) resident of four reviewed for medication administration. Findings include: On 10/15/24 at 7:43 AM, LPN H was observed preparing ordered Oxycodone (narcotic given for pain) 10 milligram (mg) for R239. When the narcotic log was reviewed, 17 tablets of Oxycodone 10 mg were documented, and the blister pack revealed 16 tablets. LPN H commented the medication was given to R239 at 4:30 AM, and acknowledged the medication was not documented in the narcotic log. Review of the facilities policy title; Medication Administration dated 1/2023 documented: .If medication is a controlled substance sign the narcotic book .

Based on observation, interview and record review, the facility failed to revise/implement effective interventions to prevent reoccurring falls for one resident (R22) of one residents reviewed for accidents/hazards/supervision. Findings include: On 10/13/24 at approximately 9:05 a.m., R22 was observed in the day room, wheeling around in their wheelchair. R22 was observed to have anti-tippers installed on their wheelchair indicating R22 was a high risk for falling. At that time, Nurse J was queried regarding the staffing levels on the unit and if they had enough staff to properly supervise R22 and they reported that having two CNA Certified Nursing Assistants) on the unit made it difficult to watch all the residents who were a fall risk and stated they reported that they liked to have three CNA's to ensure everyone was watched. On 10/13/24 the medical record for R22 was reviewed and revealed the following: R22 was initially admitted to the facility on [DATE] and had diagnoses including History (hx) of Falling, Traumatic brain injury (TBI) and Dementia. A review of R22's MDS (minimum data set) with an ARD (assessment reference date) of 9/21/24 revealed R22 needed assistance from facility staff with most of their activities of daily living. R22's cognition was documented as having memory impairments. A review of R22's plan of care was conducted and revealed the following: Resident is at risk for falls/injury related to TBI, dementia, prostate cancer, hx of falling Date Initiated: 09/19/2024 . A review of R22's falls since their admission on 9/19/24 revealed the following: 9/20/2024 at 22:30-Nurses' Notes-Resident found on the floor by CNA (Certified Nursing Assistant). CNA notified this RN (Registered Nurse).RN assessed resident for injury. Vitals taken. Risk management assessment completed. On call notified. No new orders. Fall mats placed on both sides of bed. Call light education provided. Bed lowered to the floor . 9/25/2024 at 13:15-Nurses' Notes-'I was going to get my car.' was informed by nursing staff that resident fell in hallway. resident assisted back into w/c (wheelchair) with multiple staff members, resident does not recall fall, neuro assessments initiated, VSS (vital sign stable), ROM (range of motion) and cognition at baseline, denied pain, no new skin abnormalities noted upon skin assessment. resident to be toileted after meals 9/26/2024 at 18:22-Nurses' Notes-Resident was observed on his knees on the floor pushing a chair in the activities room. Stated 'Im trying to get out of here'.States no pain. Skin assessment completed with nothing new noted. Vitals completed WNL (within normal limits). Neuros started. On-call, Administrator, DON (Director of Nursing) and guardian notified with no new orders . Fall Initial V.2 Form-12. What was resident doing prior to the fall? Sitting at the table eating dinner. Physical Evaluation- Describe other interventions:-Visual checks every 15 minutes. 2. Date care plan reviewed and/or updated, as indicated: 9/26/24 . 9/29/24-[Via Incident and Accident Report]-Resident was eating dinner in the TV room and writer was also in this room feeding another resident cause writer to turn and see resident on the floor on his knees and hands on the broken tray .of food was on the floor and the tray of the table was broke off the stand .Injuries at Time of incident-Bruise .Mental Status-Notes Left cheek Other info-Resident has poor self awareness and poor safety awareness . Fall Initial V.2 Form-Physical Evaluation-1a-Describe injury/suspected injury: Bruise and swelling on left cheek Describe other interventions:-Supervision while eating .G: Resident is non compliant, has poor self awareness. Does not understand his limitations and has an unreliable memory. He was incontinent at the time but the resident had been toileted an hour before and had been changed an hour before that . 10/1/2024 at 19:28-Nurses' Notes-Resident observed on the floor next to his bed. Head to toe assessment completed with nothing new noted. Vitals completed. Resident denies pain. Neuros (neurology checks) started. [Nurse Practitioner] assessed resident with no new orders . 10/8/2024 at 19:04-Nurses' Notes-Writer called by CNA to residents room at 1740. Observed resident laying on the floor next to his bed on the fall mat. Resident wearing his clothes with skid socks. Resident denied hitting his head and denies any pain. Administrator, DON, On call provider, Unit manager and guardian notified with no new orders . Fall Initial V.2 Form-12. What as resident doing prior to fall? Eating his dinner in his room on his bed.Describe other interventions:-Medication Review . On 10/15/24 at approximately 10:10 a.m., during a discussion with the Director of Nursing (DON) pertaining to R22's falls and the interventions that the facility had implemented, the DON was queried for the documentation of the 15 minute visual checks that were implemented via the Fall form for the fall on 9/26/24 and they indicated they did not have them but the visual checks intervention was not continued later on when the interdisciplinary team reviewed the fall on 9/27. The DON was queried regarding the medication review intervention that was noted on the 10/8/24 fall form and they indicated that no changes to medications were made. The DON was queired if they had implemented any other interventions after no medication changes were made and they indicated they had not. Further review of the falls for R22 indicated that a few of R22's falls were occurring during meals and that the intervention of supervision while eating was added after their fall on 9/29. The DON was informed that R22 had fallen in their room while eating on 10/8 without supervision and the DON indicated that they understood and they would have to try something else to try to prevent R22 from have reoccurring falls. On 10/15/24 a facility document pertaining to falls was reviewed and revealed the following: Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .

Based on observation, interview and record review, the facility failed to follow the Physician's order for enteral nutrition for one resident (R78) of one residents reviewed for tube feeding. Findings include: On 10/13/24 at approximately 8:54 a.m., R78 was observed in their room, laying in their bed. R78 was observed to have enteral formula infusing with Jevity 1.5 at 60ml (milliliters) per hour with 55 ml an hour on autoflush. On 10/13/24 at approximately 10:29 a.m., R78 was observed in their room, laying in their bed. R78 was still observed to have enteral formula infusing with Jevity 1.5 at 60ml per hour with 55ml an hour autoflush. The rate was not written on the bottle that was hung on the feeding pole. On 10/13/24 at approximately 10:41 a.m., R78's enteral feeing was observed with the ADON (Assistant Director of Nursing) and the enteral order was confirmed in the EMR (electronic medical record) as Osmolite 1.5 @ 70ml/hour X18 hours/day. The ADON indicated they would get the correct formula and change the rate to match the Physician's order. On 10/13/24 the medical record for R78 was reviewed and revealed the following: R78 was initially admitted to the facility on [DATE] and had diagnoses including Anoxic brain damage and Chronic respiratory failure. A review of R78's MDS (minimum data set) with an ARD (assessment reference date) of 10/2/24 revealed R78 had an enteral nutrition tube (PEG) and needed assistance from facility staff with their activities of daily living. R78 was documented as having severely impaired cognition. A Physician order with a start date of 10/11/24 revealed the following: every day and night shift Osmolite 1.5 @70ml/hour X18 hours/day to provide: 1890kcal, 1260ml, 79 gram pro/day A review of R78's comprehensive plan of care revealed the following: Focus-Resident is at risk for altered nutritional status related to diuretic use, feeding tube, risk of aspiration, swallowing problems, takes psychotropic medication. Weight loss following readmission. Date Initiated: 08/30/2024 .Interventions-Administer enteral nutrition per orders. Date Initiated: 08/30/2024 . On 10/15/24 a facility document titled Feeding Tubes was reviewed and revealed the following: Policy: Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident ' s clinical condition deems this intervention medically necessary to maintain acceptable parameters of nutrition and hydration. Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .7. Feeding tubes will be utilized according to physician orders .

Based on observation, interview and record review the facility failed to ensure sufficient staffing was provided for two residents (R10) was well as two anonymous residents who participated in the group meeting, out of a total census of 90 resulting in the potential for unmet care needs. Findings include: On 10/13/24 the payroll based journal report (a report generated from the facility reported staffing hours) was reviewed and documented that during the fiscal quarter three (April 1, 2024-June 30th, 2024) the facility had excessively low weekend staffing numbers and had a one star staffing rating (the lowest score). On 10/14/24 at approximately 2:06 p.m., during the anonymous group meeting, the residents were queried if the facility had enough Nursing staff to meeting their needs. Two residents (who wished to remain anonymous) reported the facility had recently improved but that the staffing during the night over the summer months was bad. They indicated that Nurse aides would come in and tell them they were short staffed and that was why they were late answering the call for assistance. One resident reported they had to wait a long time for call lights to be answered and when they were answered the staff would turn them off and leave the room and not come back. Another resident indicated that staff were not picking up the meals trays because they did not have enough help so the meal trays would just sit for hours in their rooms. On 10/14/24 the resident council minutes were reviewed for 2024 and revealed the following complaints: June-Nursing:beds not being made timely .May-Nursing: Not picking up trays .April-Aides grumpy when answering lights on the weekends On 10/15/24 at approximately 12:02 p.m., during a conversation with Certified Nursing Assistants E and F (CNA E and F), CNA E was queried regarding the staffing levels in the facility and they indicated that in the previous months during the summer they had been only two aides assigned to the unit on many shifts in which residents could not be supervised like they should. CNA F indicated that many residents on the unit are fall risks and they needed three Nurse Aides to appropriately be able to supervise while providing care. CNA E indicated that the staffing had been better in the more recent months. On 10/15/24 at approximately 12:30 p.m., during a conversation with the staffing coordinator A (SC A), SC A was queried regarding the PBJ report and the excessively low weekend staffing and one star staffing rating for quarter 3. SC A Indicated they had a few full time CNA's quit at the same time and that was why they were running short staffed during that period of time as they were unable to immediately fill the vacancies. SC A indicated that the Administrator and herself met and put a staffing plan into place called the Weekend CNA Premium Weekend Program or Weekend [NAME] Program which they started to implement in the middle of September to cover the low weekend staffing levels. SC A was queried regarding the staffing levels on the 200 unit and they indicated they try to staff it with three Nurse aides but sometimes cannot do due to their allotted amount of PPD hours (per patient day). On 10/15/24 a facility document pertaining to staffing was reviewed and revealed the following: Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment . 49083 Resident 10 A clinical record review revealed R10 was admitted to the facility on [DATE] with medical diagnoses that included: heart disease, renal disease, diabetes, seizure disorder, and pulmonary disease. A Brief Interview of Mental Status (BIMS) assessed on 7/13/24 revealed a score of 15/15 indicting R10 was cognitively intact. On 10/13/24, at 11:35 AM, during initial interview and introduction, R10 was observed in there room. They commented that today was different and normally there is only one Certified Nursing Assistant (CNA) for 31 patients and today there is all this extra staff. R10 stated one of the staff members commented, Why would they (State) come in on a Sunday? R10 stated they were thankful we (State) were there and mentioned the staffing is terrible and it is not fair that there are so few CNA's to help. R10 also commented it is an insult to us (residents). R10 said they were taken extra special care of today because we (SA) are here.

Based on observation, interview and record review, the facility failed to ensure non-pharmacological interventions were attempted prior to PRN (as needed) psychotropic mediation administration for one resident (R22) of six residents reviewed for unnecessary psychotropic medications. Findings include: On 10/13/24 the medical record for R22 was reviewed and revealed the following: R22 was initially admitted to the facility on [DATE] and had diagnoses including History (hx) of Falling, Traumatic brain injury (TBI) and Dementia. A review of R22's MDS (minimum data set) with an ARD (assessment reference date) of 9/21/24 revealed R22 needed assistance from facility staff with most of their activities of daily living. R22's cognition was documented as having memory impairments. A Physician's order dated 10/7/24 revealed the following: Ativan Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed (PRN) for Anxiety for 14 Days. A review of R22's comprehensive careplan revealed the following: Focus- Resident has behavior(s) such as agitation at times such as biting, hitting, kicking. Date Initiated: 10/02/2024 A review of R22's October 2024 MAR (medication administration record) revealed R22 was administered their PRN Ativan on 10/1, 10/2, 10/3, 10/4, 10/5, 10/6, 10/7, 10/8, 10/11 and 10/12. A review of R22's progress note documentation of the non-pharmacological interventions being attempted prior to PRN administration revealed no documented non-pharmacological interventions were attempted prior to PRN administration of the Ativan for any of the dates in which it was administered from 10/1 through 10/12. On 10/15/24 at approximately 10:10 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the implementation of non-pharmacological interventions prior to the administration of R22's PRN Ativan. The DON reported that the Nurses should be attempting and documenting non-pharmacological interventions before administering the PRN Ativan. The DON was informed of the lack of documentation of any non-pharmacological interventions in the progress notes and they reported that it was expected that the interventions should be in the notes. On 10/15/24 a facility document titled Medication-Psychotropic was reviewed and revealed the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident ' s response to the medication(s) .2. The indications for initiating, withdrawing, or withholding medications(s), as well as the use of nonpharmacological approaches, will be determined by: a. Assessing the resident ' s underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. b. Identification of underlying causes (when possible) .4. The indications for use of any psychotropic drug will be documented in the medical record. a. Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility. b. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. i. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. ii. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation .7. Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs .

This citation pertains to intake: MI00131841. Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one R332 of one resident reviewed for neglect, resulting in a pattern of multiple failures that contributed to the residents change of condition to have been found unresponsive, required CPR (Cardiopulmonary resuscitation) and required a transfer to the hospital for a higher level of care in less than 48 hours of admission. Findings include: Review of the medical record revealed R332 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included: acute respiratory failure with hypoxia, Guillain-Barre syndrome (rare disorder which the body's immune system attacks the nerves), type 2 diabetes mellitus, asthma, atherosclerotic heart disease, tracheostomy status, hypertensive heart and gastrostomy status. A MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 14 which indicated intact cognition and was dependent on staff for all Activities of Daily Living (ADLs). Review of the discharge paperwork titled After Visit Summary that was provided to the facility upon readmission on [DATE], documented the following medications and treatments to be implemented upon admission: The facility failed to implement the following pertinent orders upon admission: - Continuous pulse oximetry monitoring - Suction orders for secretions - Humified Oxygen Orders and Oxygen Liter orders - Ipratropium-albuterol 0XXX,d+[DATE].5 mg/3 ml nebulizer, inhale 3 ml three times a day. - Albuterol 2.5 MG / 3 ML (milliliters) 0.083% nebulizer solution. Take 3 ml (2.5 mg total) by nebulization every 6 hours as needed for wheezing or shortness of breath. - Sodium Chloride 7% nebulizer solution, take 4 ml by nebulization three times a day. - Chest Vest 3 times daily to align with nebulizer treatments - Glycopyrrolate (Robinul- used to reduce excessive drooling) 1 MG, one tablet in the morning. - Apixaban (an anticoagulant- blood thinner) 5 MG (milligram), one tablet in the morning and one tablet before bedtime. - Tracheostomy Care - PEG Care And other additional medications that were not implemented such as: - Acetaminophen 650 MG every six hours as needed for pain or Temperature over or equal to 101 F. - Buspar 5 MG, one table in the morning, one tablet at noon and one tablet at bedtime. - Atorvastatin 10 MG, take one tablet nightly. - Dextrose 40% gel, take 15 g (grams) by mouth as needed in the morning for blood sugar less than 70. - Lidocaine 4% patch, place on the skin in the morning. - Seroquel 25 MG, one tablet nightly. - Sertraline 100 MG, one tablet nightly. Further review of the After Visit Summary documentation provided to the facility upon readmission documented the following in part: - . You are being discharged on Oxygen using a trach collar at ,d+[DATE]% oxygen with humidity . Device Trach Mask . Fi02(%) 28 . Keep 02 Sat between 92%-96% . Routine Tracheostomy/Stoma Care 2 times daily . Chest Vest 3 times daily . Changed frequency to align with nebs . copious sputum production . RT (Respiratory Therapist) Eval (evaluation) and Treat . 02 Flow Rate (L- liters/min- minute) 8 - 10 L/min . - . Assessment and Plan . Patient with copious secretions, these were generally described as thin and watery; secretions were an issue apparently even prior to admission . initiated Robinul at reduced dose (1 mg daily) . this has clearly been of benefit . secretions ultimately did become somewhat thicker, and he was changed to trach mask for humidification purposes; will now plan for trach mask nocturnally to provide additional humidification; Continue to monitor for worsening of secretions, Continue DuoNeb . every 6 hours . Continue as needed use of Cough Assist device . Bilateral lower extremity DVTs (Deep Vein Thrombosis), acute. Continue apixaban 5 mg twice daily; continue to monitor . Patient appears stable, and ready to transfer to skilled nursing facility . peer to peer review with physician . per that physician he was approved to return to his previous long-term care facility . - Review of additional documentation provided to the facility from the transferring facility of a physician Internal Medicine note dated [DATE], documented in part . still requiring suctioning every ,d+[DATE] hours, and has episodic desaturations, which are not long-lasting . This statement was bolded and underlined in the report provided to the facility. The facility staff failed to administer the necessary oxygen orders/care, medications, treatments, ensure the continuous monitoring of the pulse oximetry which was required for this resident to closely monitor the episodic desaturations of the resident to ensure the resident maintained a 92 to 96 % pulse oximetry and implement the suction orders that was needed being that the resident was documented to still require every ,d+[DATE] hours suctioning. On [DATE] at 12:39 PM, the Assistant Director of Nursing (ADON) A and Regional Clinical Director (RCD) M who was present to help cover the facility in the absence of the Director of Nursing (DON) were both interviewed and asked the facility protocol for admission/readmission and medication reconciliation and the ADON A stated the facility will implement the orders from the transferring facility and the resident, orders and plan of care are then discussed at the next morning meeting with the interdisciplinary team (weekday). The ADON A then stated any changes or concerns would be discussed at that meeting with the disciplinary team and then discussed with the doctor to review. If any changes are made to the medications, treatments or plan of care it would be documented in the resident's medical chart. At this time the ADON A and RCD M was asked to review and look into the chart of R332 and explain why the resident oxygen orders, medications, and treatments were not implemented as documented by the transferring facility. The ADON A and RCD M stated they would look into it and follow back up. Review of the medical record revealed R332 admitted to the facility on [DATE] which is a Friday at 7 PM (per the nursing admission assessment) and their admission and orders was not reviewed by the interdisciplinary team at the next morning meeting due to the resident having been found unresponsive early Sunday morning on [DATE]. Further review of the medical record revealed no documentation of a physician directive to change the course of treatment for this resident. The facility staff failed to accurately reconcile and implement the resident medications and treatments upon admission. On [DATE] at 12:26 PM, the Respiratory Therapist Director (RTD) N was interviewed and asked the facility's protocol on the respiratory therapist team evaluating the admission/readmission of a resident that requires a Trach mask with humidified oxygen and RTD N stated a Respiratory Therapist would see the resident the day of admission and review the admission packet as well as the Nursing staff. RTD N then stated the Respiratory Therapist are in the building 24 hours a day and are required to complete two daily respiratory assessments however they constantly monitor the residents throughout the day, which would be documented in the residents' chart. The RTD N stated the respiratory therapists has the ability to implement any orders needed for respiratory care, but usually the nurses would implement the orders upon admission. RTD N was then asked to look into R332's chart and explain why the resident was not seen on the day of admission on [DATE] by the respiratory department and why the resident oxygen, nebulizers, suction orders and tracheostomy orders were not clarified by the respiratory therapist when the resident was first seen by the respiratory department on [DATE]. The facility Respiratory Therapist failed to assess and provide care on the day of admission and review the resident admission documents to ensure all oxygen and tracheostomy orders were implemented and administered accurately, timely and consistently as required. On [DATE] at 12:39 PM, ADON A and RTD N returned for a follow up interview. The ADON A stated they reviewed the record and could not provide an explanation on why R332 orders were not implemented correctly upon admission. RTD N stated they identified only one RT on that night and did not find any documentation of R332 to have been seen by RT on the day of admission. RTD N stated as far as the orders the nurse usually puts all of the orders in. At 3:29 PM, the ADON A returned and stated they talked to the nurse that admitted R332 on [DATE] and they could not recall what happened. No further explanation or documentation was provided by the end of survey. Review of the medical record revealed the resident pulse oximetry was not obtained continuously and was last obtained on [DATE] at 6:24 PM, which at that time was 96% via for a resident with a Tracheostomy mask who was supposed to be receiving humidified oxygen via the Tracheostomy mask. Further review of the medical record revealed the staff did not obtain any further pulse oximetry reading, ensured monitoring of the resident's pulse oximetry levels throughout the night or that suctioning was completed throughout the night being that the resident was documented to require every 3 to 4 hours of suctioning. The resident was found unresponsive on [DATE] at approximately 12:35 AM. The facility staff failed to assess and monitor the resident from [DATE] at 6:24 PM, until the resident was found unresponsive on [DATE] at approximately 12:35 AM. Review of a Nursing note dated [DATE] at 1:18 AM, documented in part . At approximately 0035 hours CNA (Certified Nursing Assistant) was making routine rounds found resident unresponsive. Nurse notified. Nurse checked for pulse and respirations. Resident was absent of both pulse and respirations. Help was called for and CPR was initiated immediately. Respiratory began bagging resident via [NAME] collar. 911 notified for emergent transfer. Upon EMS (Emergency Medical Services) arrival <sic> was placed and first round of Epi was administered. Resident was found to have a pulse at approximately 0053 hours. Resident loaded and transferred care to EMS . Review of a facility policy tilted Abuse, Neglect and Exploitation revised [DATE], documented in part . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

This citation pertains to intake: MI00131841. Based on interview and record review the facility failed to ensure respiratory orders were implemented accurately, ensure tracheostomy care was implemented, ensure timely and thorough respiratory therapist assessment and evaluation and ensure continuous pulse oximetry monitoring for a resident who required continuous monitoring of 02 levels for one (R332) of three residents reviewed for respiratory care. Findings include: Review of the medical record revealed R332 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included: acute respiratory failure with hypoxia, Guillain-Barre syndrome (rare disorder which the body's immune system attacks the nerves), type 2 diabetes mellitus, asthma, atherosclerotic heart disease, tracheostomy status, hypertensive heart and gastrostomy status. A MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 14 which indicated intact cognition and was dependent on staff for all Activities of Daily Living (ADLs). Review of an After Visit Summary documentation provided to the facility upon readmission on [DATE], documented in part the following medications and treatments to be implemented upon admission: Ipratropium-albuterol 0XXX,d+[DATE].5 mg/3 ml nebulizer, inhale 3 ml three times a day. Sodium Chloride 7% nebulizer solution, take 4 ml by nebulization three times a day. Pulse Oximetry . Continuous pulse oximetry monitoring should be in place at all times . Suction orders for secretions Humified Oxygen Orders and Oxygen Liter orders Albuterol 2.5 MG / 3 ML (milliliters) 0.083% nebulizer solution. Take 3 ml (2.5 mg total) by nebulization every 6 hours as needed for wheezing or shortness of breath. Chest Vest 3 times daily to align with nebulizer treatments Glycopyrrolate (Robinul- used to reduce excessive drooling) 1 MG, one tablet in the morning. Tracheostomy Care Review of the medical record revealed none of the above orders implemented upon admission and throughout the duration of the resident's inpatient care at the facility with the exception of the Ipratropium-albuterol 0XXX,d+[DATE].5 mg/3 ml nebulizer to be inhale 3 ml three times a day (nebulizer treatment), which was only implemented after the family asked the facility staff why the order was not implemented. Review of a Nursing note dated [DATE] at 2:02 PM, documented in part . Residents brother and sister at bedside. Resident's brother came up to desk and stated, My brother is supposed to be on continuous pulse ox. Latest pulse ox was 98%. (Respiratory Therapist name) from RT speaking with brother regarding the above . At this time the facility staff implemented the Ipratropium-Albuterol to start three times a day. Further review of the After Visit Summary documentation provided to the facility upon readmission documented the following in part: . You are being discharged on Oxygen using a trach collar at ,d+[DATE]% oxygen with humidity . Keep 02 Sat between 92%-96% . Routine Tracheostomy/Stoma Care 2 times daily . Chest Vest 3 times daily . Changed frequency to align with nebs . copious sputum production . RT (Respiratory Therapist) Eval (evaluation) and Treat . 02 Flow Rate (L- liters/min- minute) 8 - 10 L/min . . Assessment and Plan . Patient with copious secretions, these were generally described as thin and watery; secretions were an issue apparently even prior to admission . initiated Robinul at reduced dose (1 mg daily) . this has clearly been of benefit . secretions ultimately did become somewhat thicker, and he was changed to trach mask for humidification purposes; will now plan for trach mask nocturnally to provide additional humidification; Continue to monitor for worsening of secretions, Continue DuoNeb . every 6 hours . Continue as needed use of Cough Assist device . continue to monitor . Patient appears stable, and ready to transfer to skilled nursing facility . peer to peer review with physician . per that physician he was approved to return to his previous long-term care facility . Review of additional documentation provided to the facility from the transferring facility of a physician Internal Medicine note dated [DATE], documented in part . still requiring suctioning every ,d+[DATE] hours, and has episodic desaturations, which are not long-lasting . This statement was bolded and underlined in the report provided to the facility upon admission. Review of the medical record revealed the initial Respiratory Therapist assessment to have been completed the day after admission ([DATE]) for R332. Review of the medical record revealed the resident pulse oximetry was not obtained continuously and was last obtained on [DATE] at 6:24 PM, which at that time was 96% via for a resident with a Tracheostomy mask who was supposed to be receiving humidified oxygen via the Tracheostomy mask. Further review of the medical record revealed the staff did not obtain any further pulse oximetry reading, ensured monitoring of the resident's pulse oximetry levels throughout the night or that suctioning was completed throughout the night being that the resident was documented to require every 3 to 4 hours of suctioning. The resident was found unresponsive on [DATE] at approximately 12:35 AM. Review of a Nursing note dated [DATE] at 1:18 AM, documented in part . At approximately 0035 hours CNA (Certified Nursing Assistant) was making routine rounds found resident unresponsive. Nurse notified. Nurse checked for pulse and respirations. Resident was absent of both pulse and respirations. Help was called for and CPR was initiated immediately. Respiratory began bagging resident via [NAME] collar. 911 notified for emergent transfer. Upon EMS (Emergency Medical Services) arrival <sic> was placed and first round of Epi was administered. Resident was found to have a pulse at approximately 0053 hours. Resident loaded and transferred care to EMS . On [DATE] at 12:26 PM, the Respiratory Therapist Director (RTD) N was interviewed and asked the facility's protocol on the respiratory therapist team evaluating the admission/readmission of a resident that requires a Trach mask with humidified oxygen and RTD N stated a Respiratory Therapist would see the resident the day of admission and review the admission packet as well as the Nursing staff. RTD N then stated the Respiratory Therapist are in the building 24 hours a day and are required to complete two daily respiratory assessments however they constantly monitor the residents throughout the day, which would be documented in the residents' chart. The RTD N stated the respiratory therapists has the ability to implement any orders needed for respiratory care, but usually the nurses would implement the orders upon admission. RTD N was then asked to look into R332's chart and explain why the resident was not seen on the day of admission on [DATE] by the respiratory department and why the resident oxygen, nebulizers, suction orders and tracheostomy orders were not clarified by the respiratory therapist when the resident was first seen by the respiratory department on [DATE]. On [DATE] at 12:39 PM, the Assistant Director of Nursing (ADON) A and Regional Clinical Director (RCD) M who was present to help cover the facility in the absence of the Director of Nursing (DON) were both interviewed and asked the facility protocol for admission/readmission and medication reconciliation and the ADON A stated the facility will implement the orders from the transferring facility and the resident, orders and plan of care are then discussed at the next morning meeting with the interdisciplinary team (weekday). The ADON A then stated any changes or concerns would be discussed at that meeting with the disciplinary team and then discussed with the doctor to review. If any changes are made to the medications, treatments or plan of care it would be documented in the resident's medical chart. At this time the ADON A and RCD M was asked to review and look into the chart of R332 and explain why the resident oxygen orders, medications, and treatments were not implemented as documented by the transferring facility. The ADON A and RCD M stated they would look into it and follow back up. Review of the medical record revealed R332 admitted to the facility on [DATE] which is a Friday at 7 PM (per the nursing admission assessment) and their admission and orders was not reviewed by the interdisciplinary team at the next morning meeting due to the resident having been found unresponsive early Sunday morning on [DATE]. Further review of the medical record revealed no documentation of a physician directive to change the course of treatment for this resident. On [DATE] at 12:39 PM, ADON A and RTD N returned for a follow up interview. The ADON A stated they reviewed the record and could not provide an explanation on why R332 orders were not implemented correctly upon admission. RTD N stated they identified only one RT on that night and did not find any documentation of R332 to have been seen by RT on the day of admission. RTD N stated as far as the orders the nurse usually puts all of the orders in. At 3:29 PM, the ADON A returned and stated they talked to the nurse that admitted R332 on [DATE] and they could not recall what happened. No further explanation or documentation was provided. On [DATE] at 10:17 AM, Licensed Practical Nurse (LPN) O (the nurse that admitted R332 on [DATE] was interviewed and when asked about R332's admission on [DATE], LPN O stated they didn't remember a whole lot, but did remember the resident came at the start of their shift and it was their first time completing an admission by themselves. LPN O stated since it was their first time doing an admission, they told the nurse coming on duty that they believed they put everything in correctly. When asked if the facility has a protocol in place for another nurse to double check the orders of an admission, LPN O stated they were unsure. When asked if they administered any medications to R332, LPN O stated they could not remember. When asked if they remembered if the facility's respiratory therapist seen R332 on the day of admission, LPN O stated they could not recall. On [DATE] at 11:44 AM, a call was made to the physician that was assigned to R332 and who also serves as the facility's Medical Director (MD) P and a message was left for the physician to return the call however MD P failed to return the call.

Based on observation, interview and record review, the facility failed to avoid neglecting 13 sampled residents (#s 177, 71, 8, 65, 74, 15, 9, 54, 57, 4, 58, 41, 65) out of 22 residents observed for neglect out of a total sample of 22 residents resulting in residents not receiving showers as scheduled, ordered range of motion, assistance with getting up out of bed, grooming such as combing hair and/or shaving, long waiting times for call light response and odors in resident rooms and halls. This deficient practice had the potential to affect all 72 residents in the facility resulting in the potential for serious harm or injury and substantial psychosocial detriments and required immediate corrective action. Immediate Jeopardy was identified: 4/27/18 and the Administrator A was notified of the Immediate Jeopardy (IJ) on 4/27/18. A plan to remove the immediacy was requested. Findings Include: Resident #177 04/25/18 09:41 AM Resident 177 did not complete activities of daily living care timely and repeatedly and on Saturday he laid in a brief with bowel movement for 3 Hours. On 4/26/18 at about 1:00 PM Nurse Aide I stated Nurse Aide K works every Saturday and she just didn't want to take care of him. We have reported Nurse Aide K to License Practical Nurse (LPN) C, Nurse Manager R and RN W. On 4/26/ at 1:30 PM Nurse RN Manager R said she knew of no resident reports on K, again I asked about nurse aide (staff) complaints, she paused and said she had no complaints from staff on Nurse Aide K, Nurse RN Manager R said I would have to check my notes and see. On 4/26/17 at about 2:00 PM, Nurse W stated she had no complaints on Nurse Aide K then said do you mean today? I said no not today, RN W stated yesterday I was looking for her and Nurse Aide I said sometimes she hides in rooms, and they found her in a Resident room. I asked RN W why would she be hiding and she said she didn't know, and this was the first she heard of it. On 4/26/18 at 3:00 PM LPN C stated a nurse aide came up to him, he believed it was this past weekend, and told him she was not caring for the residents the way she was supposed to. Specifically she could not find her and she hides in empty resident rooms. Said he was too busy to talk to her but reported her to Nurse named RN E. On 4/26/18 at 3:15 PM, RN E was called and the message said her voicemail box was full. On 4/26/18 at 3:20 PM the Administrator was asked had received a report that Nurse Aide K was not caring for the residents the way she should and was hiding in empty resident rooms. Administrator stated he had not received a report regarding Nurse Aide K and did not understand why the nurses would not have reported the above information. Administrator A stated he will start his investigation today. On 5/1/18 at 10:30 AM, Administrator A was interviewed regarding the abuse policy and asked about the investigation on R177 said he was still in his 5 day window, Administrator A said the nurse aide in question worked days and the call light was only on for 1 hour during that shift, it was the afternoon shift that was a problem, Administrator A did not watch the video. As far as reporting, if it was bodily harm he would report to the State within 2 hours if not, he would investigate right away. Sometimes he investigates himself, but if it is nursing incident, nursing will investigate. Administrator A said he talked to all the nurses between 4 & 7 and they said it didn't take a long time to answer call lights (however, the videos show otherwise). On 5/1/18 at 2:05 PM Resident 177 was informed the videos on the hall outside of his door was watched, and saw he waited almost 1 hour twice between 1 and 2 and again between 6 & 7 PM. Resident 177 said he puts the call light on when ever, he needs he said he doesn't remember which shift he waited 3 hours but the midnight shift was the worse but at least you see what I go through. Nurse Aide I told LPN C, RN W and Nurse RN Manager R that Nurse Aide K did not care for the residents properly. Nurse Aide K worked Saturday on 300 hall and she does [MEDICAL TREATMENT]. Resident #54 Review of the Electronic Medical Record (EMR) on 04/25/18 at 02:23 PM reflected Resident (R) #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/25/18 at 09:33 AM R54 was observed in her room, sitting up in her bed having breakfast. R54's hair was matted on the sides and at the back of her head, with copious amounts of dried flaky dandruff about her scalp, at the perimeter of her hairline, flaky dry skin was observed on her forehead, eyebrows, and near the frontal aspect of her ears. 04/25/18 09:39 AM R54's hair appeared to be matted with dry a dry flakey scalp. With flakey scalp particles noted in and about her hair, and around her edges. Revealed she got a bed bath today, but would have preferred to have been put on clothes rather than the hospital gown. Asked she had a bath or shower and replied, No, not lately. Stated she thought her hair was washed like last Wednesday. R54's Admission Minimum Data Set (MDS: Resident Assessment Tool) dated 3/20/18 reflected R54 had a moderately impaired memory problem, required extensive assistance of 2 persons for bed mobility, dressing, toileting and total dependence of 2 persons for transfers and bathing. On 04/26/18 at 04:52 PM R54's hair was observed still matted with dry flaky dandruff about her scalp/around the perimeter of her hair line, forehead, in her eyebrows and flaky skin near the front of her ears. R54's mother was observed to be visiting. R54's Mom (DD) revealed that R54 had seborrhea and had to have special shampoo. The Medicinenet.com (YEAR) online medical reference reflected seborrhea as: A chronic [MEDICAL CONDITION] disease of the skin characterized by the accumulation of scales of greasy skin. There may be yellow crusted plaques that are itchy. Seborrhea often affects the scalp. Other sites include the face, ears, eyebrows and eyelids, umbilicus, and genitalia, Seborrhea of the scalp is commonly known as dandruff. Treatment is with frequent use of dandruff shampoos and topical steroids if necessary. Also called seborrheic [MEDICAL CONDITION]. R54's Activities of Daily Living (ADL) assistance related to: Cognitive Deficits, Deconditioning. Right side [MEDICAL CONDITION]. Date Initiated: 03/10/2018 Revision on: 04/23/2018. Interventions reflected: ·The resident prefers to bathe by (shower) Date Initiated: 03/10/2018 Revision on: 03/10/2018 - The resident prefers to bathe by (shower ) Date Initiated: 03/10/2018 ·DRESSING: The resident requires the following level of assistance (extensive) with the following number of staff (2) to dress Date Initiated: 03/10/2018 Revision on: 03/10/2018 On 04/26/18 at 11:50 AM R54's bath/shower task reflected revised 3/13/18 Bathing, shower (Wed/Sat; 1st shift) by RN Z. Task reflected R54 bed bath 3/28, 3/31, 4/4, 4/11, 4/14, 4/25 Bath 4/7, 4/18, 4/21 (n/a=hospital) On 04/26/18 at 04:52 PM first observation of having her bed low to floor. R54's Mom DD revealed R54 had seborrhea and had to have special shampoo. R54 revealed she had only had her hair wash once while being in the facility, and never refused a shower. RN T was interviewed by phone on 04/26/18 at 05:35 PM and asked if R54 received showers. RN T revealed, That I do not know. I think they were doing bed baths. RN T was asked if R54's hair appeared dirty or matted. RN T replied, Yes, we were actually waiting on special shampoo. On 04/27/18 as 02:58 PM RN Z was informed that R54's mother had revealed R54 had seborrhea. RN Z revealed she was not aware of R54's seborrhea skin condition. RN Z revealed there was shampoo for R54. RN Z reviewed R54's EMR and stated, I am unable to see a note or H&P (History and Physical) reflecting that her doctor here has seen her. On 04/27/18 at 03:15 PM R54 was observed with her hair matted in the back of her head, and flaky dry scalp primarily on the right. side of her head and abut the edges of her hair. On 5/01/18 at 08:35 AM R54 was observed sitting up in her bed eating her breakfast with her left hand. R54 was asked if her hair got washed and replied, Yes. R54 was asked how did it make her feel and replied, Good. R54 hair was noted to be without the flaky scalp/dandruff, that had been noted prior about her hair and around the perimeter of her scalp. R54 was asked how she felt before her head was washed and she replied, Itchy. An order was written the reflected, Therapeutic Shampoo 0.5 % (Coal Tar Extract). Apply to Scalp and face topically at bedtime related to SEBORRHEA CAPITIS (L21.0) for 14 Days Cleanse dry areas gently and rinse Pharmacy Active start date 4/30/2018 20:00 end date 5/14/2018 revision date 4/30/2018 Nurse Practitioner (NP N) progress notes dated 3/13/18 at 23:11 PM reflected: SKIN: no cyanosis, icterus or pallor. No documentation or treatment was listed for R54's seborrhea. HEENT (Head, Ears, Eyes, Nose, and Throat): reflected status [REDACTED]. No documentation was noted addressing [MEDICAL CONDITION] precautions. The John Hopkins Medicine undated online reference displayed on 5/11/18 reflected the following for craniotomy: A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done. Muscles: no mass or deformity, no swelling. No documentation or treatment was listed related the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. NP N's progress notes dated 3/23/18 at 20:01 PM reflected: SKIN: no cyanosis, icterus, or pallor. HEENT: status [REDACTED]. Tongue is covered with white thrush. Musculoskeletal: no mass or deformity, no swelling. No documentation or treatment was listed for R54's seborrhea. No documentation was noted specifically addressing [MEDICAL CONDITION] precautions. No documentation, treatment or precautions were listed specifically related to the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. NP N's progress notes dated 3/27/18 at 12:16 PM reflected: SKIN: no cyanosis, icterus, or pallor. HEENT: status [REDACTED]. Musculoskeletal: no mass or deformity, no swelling. No documentation or treatment was listed for R54's seborrhea. No documentation was noted specifically addressing [MEDICAL CONDITION] precautions. No documentation, treatment or precautions were listed specifically related to the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. NP N's progress notes dated 4/24/18 at 17:54 PM reflected: General appearance: pt is resting on the bed R shoulder sling, racoon eyes bilaterally, sutures on the R zigomathic area. SKIN: no cyanosis, icterus, or pallor. HEENT: status [REDACTED]. Musculoskeletal: R shoulder sling post fracture. No documentation or treatment was listed for R54's seborrhea. No documentation was noted specifically addressing [MEDICAL CONDITION] precautions. No documentation, treatment or precautions were listed specifically related to the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. NP N's progress notes dated 4/27/18 at 12:45 PM (which was the most recent note in the EMR for R54 on 5/1/18) reflected: General appearance: pt is resting on the gerychair, R shoulder sling, raccoon eyes bilaterally, sutures on the R face. SKIN: no cyanosis, icterus, or pallor. HEENT: status [REDACTED]. Musculoskeletal: no mass or deformity, no swelling. No documentation or treatment was listed for R54's seborrhea. No documentation was noted specifically addressing [MEDICAL CONDITION] precautions. No documentation, treatment or precautions were listed specifically related to the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. It was not until 5/1/18 after writer had queried facility staff related to R54's [DIAGNOSES REDACTED].CAPITIS (L21.0) for 14 Days Cleanse dry areas gently and rinse. Resident #57 On 04/26/18 at 09:16 AM Resident (R) #57 was observed in his room sitting up in his bed laying on his back in a hospital gown, with the heels of his feet making contact near the foot of the bed. His hair was about his head and had not been combed, he had a [MEDICAL CONDITION] which was covered with by a mask providing humidified oxygen, a sheet was covering him up to his waist, and his call light was in reach. On 04/27/18 at 11:00 AM R57 was in the process of being transferred via hoyer lift by 2 Certified Nursing Assistants (CNA's I and K) to a chair. CNA K revealed, R57 was a PM shower. When asked if either CNA had given R57 a shower, they both denied. R57 revealed no one had given him a shower. R57 stated, When I ask for a shower, they always cry they are too short. R57 was asked if he wanted to be shaved and replied, Yes. R57 was observed to have full facial hair. R57 was asked if he had been shaved and replied, No. CNA's asked if they had shaved R57, adn both denied, and stated that R57 received shaves with his showers. R57 was then asked if he had received a bed bath or if anyone had washed his face today (4/2718)? R57 revealed he had not gotten a bed bath or shower since he had been here. When asked if her ever refused a shower? R57 replied, You have to be offered one to refuse. R57 hair was noted to matted at the back of his head with observation . R57 stated, It's tangled. The corners of R57 eyes were observed to be crusty with dried light yellow drainage, and dry flaky like skin noted on the side of his nose. The facility on had one Bathtime Skin Anatomy Diagram sheet that was to be used by nursing staff when bathing residents, for R57 dated 3/26/18. Handwritten on the sheet reflected Refused bath/but washed up On 04/27/18 at 11:26 AM RN CCC assigned to R57 revealed that today (4/27/18) was the first time she had cared for R57. RN CCC was asked about the report she received from the preceding nurse related to R57's skin. RN CCC replied, I don't recall her telling me anything about his skin. On 04/27/18 at 11:54 AM review of R57's Electronic Medical Record (EMR) reflected R57 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. R57's Activity of Daily Activities (ADL) care plan initiated on 3/13/18 reflected: · BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 03/13/2018 · BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 03/13/2018 · BATHING/SHOWERING: The resident requires 2 person extensive assistance to bath Date Initiated: 03/13/2018 Revision on: 03/29/2018 · BED MOBILITY: The resident requires 2 person assist from staff to turn and position in bed Date Initiated: 03/13/2018 Revision on: 03/29/2018 · PERSONAL HYGIENE: The resident requires extensive by 2 staff with personal hygiene and oral care. Date Initiated: 03/13/2018 Revision on: 03/29/2018 During the survey from 4/24/18 to 5/2/18 onsite, a nursing staff employee who desired to remain anonymous called this writer. The anonymous staff persons revealed, We have a issue with staffing. One weekend we ran with 1 CNA (Certified Nursing Assistant) for every hall with every shift, last weekend. On Monday am (the previous week) because they thought the state was coming, all the managers came in at 06:00 AM. The CNA revealed he/she had between 25- 29 residents that shift. Administration said that baths were not optional, and that they have been getting a lot of complaints. We told them we understand that when we are transferring, and caring for total care people we don't have time to give people showers. They have unrealistic expectations with staffing. They said that it doesn't matter, there is no excuse the showers are to be done period. We replied, what about doing rounds. The staffperson continued, Administration will put people on the schedule who they know are on medical leave, or have the day off to make it look like we have enough people working. Then they will say (We made a mistake). The staffperson revealed what shift he/she worked, and that he/she came in and did rounds. At times when working different shifts, the staff person stated, you can't start baths on the day shift on [MEDICAL TREATMENT] people until 05:00 AM. It takes 2 hours to bathe residents, transfer resident to [MEDICAL TREATMENT], do our rounds and it is not feasible. We have talked to administration and its like talking to a wall. I have heard that if staff fill out concern forms you get wrote up. Resident's will complain that it was there shower day and they did not get one. Some resident's will ask me for showers and there are times I have to tell them I can't. If you work the B or C wing it's overwhelming with [MEDICAL TREATMENT] people. They should set us up for success, so that we are not bogged down and we can't care for residents. On E and D wing they often only have one Certified Nursing Assistant (CNA) at night. The vent unit is to run separate from the building, and their staffing is to be only related to the vent unit only. I'm telling you right now they are understaffed. All the CNA's are on C wing helping with the [MEDICAL TREATMENT] residents, and people from B wing may have there call light on and may not get a response until 05:30 AM to 06:00 AM. Recently, I was getting a resident up who was in a lot of pain and it takes a lot of time with that resident, and you have to go slow. The environment makes me feel terrible. We try to do check and changes and pass trays. Staff are leaving. I get so upset with the state my people are left in. I don't think its because the lack of care but the lack of hands. Resident #4 According to the electronic medical record, resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] which reflected a score of 10 (moderate cognitive impairment) on Brief Interview Status (BIMS), further review of the MDS reflected Resident #4 required extensive assistance from staff for toileting, personal hygiene and dressing. On 04/24/18 at 09:08 AM Resident #4 was observed resting in bed an interview was conducted at that time and resident #4 reported The service is terrible here, I had to wait so long the other day I messed in my britches. When asked about how he felt when that occurred Resident #4 replied How did I feel?, I feel like I 'd rather be at a funeral home than here. Resident #4's room had a strong urine odor. A urinal was observed hooked to the back of his wheelchair and was out of reach. On 04/26/18 at 02:46 PM during an Interview with Res #4 and his significant other S of [AGE] years, significant other S reported she visits 3 to 4 times a week, and routinely has seen the call light be on for an hour or more without any response from staff. Resident #4 was observed resting in bed, a quarter sized hole was observed on the bottom sheets. The room had an overpowering odor of urine. On 04/24/18 11:20 AM, there were no Nurse Aides (CNAs) seen in the D hall. In an interview, with Respiratory Therapist FFF, she reported, There is only one (Respiratory) Therapist a lot of the time. I don't think it is enough. I've had to do it by myself. It is not enough. One time 2 (residents) coded at the same time, but I was not by myself. I think they want to save money. I've been here 2 years. CNAs, we need help. Normally there is only one aide on this hall. Everyone on a vent is a 2 person assist. Resident #8 According to the Minimum Data Set, ((MDS) dated [DATE], Resident #8 was a [AGE] year-old, admitted to the facility on [DATE], who had no cognitive impairment, needed 2 or more staff assist with bed mobility, transfers, range of motion impairment in both lower extremities, and (during the look-back time) locomotion on or off the unit did not happen. Resident #8 had [DIAGNOSES REDACTED]. During an interview/observation, on 04/24/18 at 09:28 AM, Resident # 8 was lying in bed, and she was having difficulty speaking; she picked up a pad of paper and pen and wrote: Only one aide on a hall. Sometimes you get changed once a shift. Only one nurse, one aide, one RT a shift. I can't get up because only 1 aide. I want to get up. Today we have 2 aides, I think they should have 3. (I am transferred with) Hoyer (mechanical) lift. Had a BM (bowel movement) and wet myself just this morning because they didn't get here. I waited an hour. Resident #8 indicated she had skin breakdown and said, I'm not sure if it is getting worse . (Nurse Aide F) turned me over, leaves you on side and back long time; won't get someone to help her. She said she can do it by herself. She had attitude. In an interview regarding Resident #8, on 04/26/18 at 11:27 AM, (Nurse Aide) CNA EE, stated There is no particular reason why we didn't ask (Resident #8) if she wanted to get up. I guess we can encourage her. Second shift is shorter with staff. We almost always have 2 aids on first shift. Last week she wanted to get up, but only one person on second shift . They need 2 assist to get (Resident #8) back to bed. In an interview, on 4/27/18 at approximately at 12:30 PM, Respiratory Therapist (RT) KK stated she had worked at the facility for 2 years on a full-time basis, including every other weekend; she said, Some days we just can't keep up. They've had one of us (Respiratory Therapist) on D and one on E Halls. The way I look at it, when the acuity goes up new or sick residents need more attention, we need more staff. Our needs fluctuate. Residents are not happy. It is a weight you feel; if a resident called for you a ½ hour ago but I can't leave someone else that needs me, especially in the morning, everyone needs to be suctioned. For patient care we all help residents with things like turning, boosting, delivering trays. I have not had Nurse Aide training and I don't use a gait belt. I don't do that. If they are bogged down we (Respiratory Therapists) help so residents get attention. We all try hard. Has told (Respiratory Director LL), our boss, but she can only staff for what they let her staff. Resident #15 According to the MDS, dated [DATE], Resident #15 was a [AGE] year-old, who entered the facility on 2/10/15, had no cognitive impairment, needed 1 staff assist with bed mobility, transfers, and personal hygiene, and had [DIAGNOSES REDACTED]. During an interview/observation on 04/24/18 at 10:49 AM, Resident # 15 stated, It seems like they don't have enough staff. You have to wait up to an hour for someone to help you. I have had a couple of incontinent accidents. Only one aide and one nurse each shift comes and goes. Sometime more than one aide. Only one aide over the weekend. They were scrambling. A little upsetting. I understand if there is an emergency, but not always the case. They need more staff in here. Management does not always help. They are getting more residents on the hall, but not keeping up with getting more staff. Resident #41 According to the MDS, dated [DATE], Resident #41 was a [AGE] year-old, admitted to the facility on [DATE], who had no cognitive impairment, needed 2 or more staff assist with bed mobility, transfers, hygiene, and bathing, and had range of motion impairment in both upper extremities. The MDS indicated Resident #41 had [DIAGNOSES REDACTED]. During an observation/interview on 04/25/18 at 10:16 AM, Resident # 41 stated, Staffing is terrible; because they are understaffed, they can't get me up. I haven't been up in 3 weeks. To me, that's not gonna get me any better. They can't even get me up once a week. They are short everybody, CNAs and nurses. I ask on Thursday and Friday mornings to get up because they told me thy would get me up on Fridays. The last time I was out of bed was 3 weeks ago, Friday. It will be 4 weeks this Friday. I used to get up every day, but now I can't even walk even walk. I don't get any therapy. I can move my legs and roll over. They have not given me any exercise to do in bed. They say they are waiting to give me therapy until I get up. I have not refused to get up in the past 3 weeks. Activities has not come in to give me anything to do. I have TV, a I pad, do some reading if I can. I would like to, would like to, get out of here for a little bit and get out of bed and go outside. I get off the vent. I only need it when sleeping at night. It's still on right now because they just haven't taken it off yet. I get really frustrated that I can't get up and for the time it takes for them to come and help me. In the past 2 weeks, I've had to wait 2 hours for them to answer the call light. On Friday morning 1st shift, the (Nurse Aide) CNA was CNA EE and she had an orientee (newly hired CNA). I asked to get up. CNA EE promised she would be back at 1:00 It was my bed bath day. The light was on the whole time. No staff member came in, maybe once, but they left the light on. During an interview, on 04/26/18 at 12:00 PM, CNA EE reported, It takes (Resident # 41) an hour to get her up. Gets up once a week. I haven't gotten her up, I heard she gets up on Fridays. Staffing last Friday was my 5th day in a row working, On Thursday I had to get 8 people up and do 3 showers. There was a new aide and just me; the 2 of us on E hall. All 3 showers were on residents who are totally paralyzed. Review of Resident #41's Kardex (CNA Care Guide), dated 11/29/17, revealed Resident #41 needed the assist of 3 staff members for transfers. In an interview, on 05/02/18 11:49 AM, CNA Resident JJ reported she was assigned to Resident # 41, and said, I have not asked her today (if she wants to get out of bed). (Resident #41) is not on bed rest restrictions. We don't always have enough staff . Resident #65 According to the MDS, Resident #65 was a [AGE] year old, who entered the facility on 12/14/17, had no cognitive impairment, needed assistance of 2 or more staff for bed mobility, transfers, and personal hygiene, range of motion impairment in both upper and lower extremities, and had [DIAGNOSES REDACTED]. The MDS indicated bed rails were not in use. Resident #65 was on mechanical ventilation (vent). On 04/24/18 at 12:54, Resident # 65's family member XX reported, (Resident #65) fungal infection on his bottom. He (his adult incontinent brief) needs to be checked every 2 hours; he is a heavy wetter. I have to come 5-6 days a week because he was always soaked. He has sat wet for 6 hours. 1st shift he sits wet for 2-3 hours, second - 6 hours. 3rd shift - 3 hours. He is red on his buttocks and thigh. I have gone to Walmart and gotten cream. They don't put it on. I asked for the doctor to check (Resident #65's) pacemaker site to be checked; it looked red and irritated. I went to the desk and told the Nurse Practitioner (NP N) and she said, what do you want me to do? I said it looks like it needs to be cleaned. She said, 'ok'. I shouldn't have to tell the doctor what to do. I asked her if she had a minute and she said,'No, I don't have a minute. No I don't have 30 seconds. What do you need? Find his nurses'. Review of a complaint/Grievance Report regarding Resident #65 made by an unknown family member (family checked), (date unknown) not dated anywhere but signed by Director of Nursing (DON) B, Teeth not being brushed. No showers. Been told no time and not enough staffing for showers. During an interview, on 04/24/18 at 01:00 PM, Resident #65 was observed to be lying asleep in bed raised to a high position. There were bed rails attached to the top half of the bed and they were not raised. Review of Resident #65's most recent Fall Assessment, dated 3/22/18, revealed he was at moderate risk of falls. On 04/26/18 at 10:23 AM, Surveyor observed Resident #65 was observed lying in bed and the bed was in a high position. Surveyor observed CNAs EE and FF perform peri care on Resident #65. When they were finished, they left Resident #65's bed in the high position, then left the room. In an interview, on 4/26/18 at 11:37 AM, CNA EE reported, (Resident 365) has no mobility, he can't reach for them (bed rails). In an interview, on 04/26/18 at 12:22 PM, Nurse Aide (CNA) EE reported Resident #65 was a 2 person assist with bed mobility, but said, I have done his care by myself due to short staffing, and then put the side rail up so he wouldn't fall . (Resident #65) is not a fall risk. In an interview, on 4/26/18 at 12:46 PM, Unit Manager Z said, (Resident #65) is not a fall risk; he is paralyzed so he can't move any of his limbs. Can't turn himself. Completely immobile. When interviewed about the safety of bed mobility performed by only one staff person, she said, No, doesn't surprise me they do it by themselves . All residents on the vent unit are a 2 person assist. We can't find staff. Trying very hard to get more . Resident #71 According to the progress notes printed 5/1/18 Resident 71 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/24/18 at 4:34 PM, it was documented that Resident 71 was able to make her own choices and she was cognitively intact. On 04/24/18 11:10 AM during an interview, Resident 71 was found to be cognitively intact. Resident 71 said she waited 6 days before a shower. Resident 71 explained she was scheduled to receive her shower on Wednesdays and Saturdays, but did not receive a shower until Monday evening (4/23/18). Resident 71 stated it was 72 degrees outside yesterday (4/23/18) and she wanted to go outside but was unable to, which was upsetting for her. Resident 71 said she did not get a shower until the night shift and had to skip her 9:30 PM medications because they make her sleepy and she would be unable to take a shower because she would have been asleep. Resident 71 stated she told staff she doesn't feel well and she felt dirty. On 4/26/18 at 3:30 PM Resident said the nurse aide that works with Nurse Aide K was supposed to shower he (TRUNCATED)

Based on observation, interview, and record review, the facility failed to assure there were enough adequately trained staff for supervision, transfers, and bed mobility, and safe and properly assessed assistive devices to reduce accident hazards for 6 of 7 residents reviewed for accidents (#8, #40, #41, # 65, #430 and #54), resulting in the A.) potential for falls and entrapment injuries (Residents #8, #40, #41, # 65); B.) potential shoulder injuries (R #430); and C.) a fall resulting in a facial laceration, injury to right shoulder requiring an arm sling, pain, with the potential for traumatic injury to area of the head not covered by skull (Resident #54). Findings include: During an interview, on 5/02/18 at 10:34 AM, DON (Director of Nursing) B confirmed the facility had not obtained/formulated signed informed consent, physician orders, entrapment measurements, Care Plans, and/or quarterly assessments for the use of bed rails for Residents #8, #41 or #65. DON B stated Resident #65's bed rails were connected to the bed, but were not in use, and therefore did not need to be assessed or care planned. DON B stated residents with enabler bars/grab bars (bed rails) on their beds did not need to have assessments, or care plans. On 4/27/18 at 3:06 PM, Regional Nurse UU confirmed there were 12 residents in the facility that had enabler bars attached to their beds. In an interview, on 04/24/18 at 11:20 AM, with Respiratory Therapist AAA, reported, The beds should not be in the high position (regardless of whether or not the resident is on a vent). According to Medline Plus, 11/15/2017, . Friction from rubbing can scrape or tear the person's skin. Common areas at risk for friction are the shoulders, back, buttocks, elbows, and heels . Never move patients up by grabbing them under their arms and pulling. This can injure their shoulders . <https://medlineplus.gov/ency/patientinstructions/ 9.htm> Resident 430 According to the MDS, Resident #430, entered the facility on 3/21/18, needed 2 or more staff assistance with bed mobility and transfers, and [DIAGNOSES REDACTED]. In an interview, on 04/26/18 at 11:47 AM, CNA EE reported, If we had 3 CNAs we could offer (Resident #8) to get out of bed. If she asked, we would do it, but we don't offer because if we did, we would be busy and other residents would miss out on things daily routine, give them attention because they are in their room all day. It's very fast paced and rushed. I want enough time to give them so they know that I care about them. Charting is put off until 3:30 PM - 4:00 PM. I am supposed to be out at 3:00. I work overtime every day. Last pay period I worked 85 hours. I am a single mom, so they don't mandate me. They mandate others. They were short staffed this last weekend. CNAs, we expected we will be short on the weekends; it's usually half the staffing that there is during the week. Because CNAs have to split weekends and no one wants to come in on their off weekend. Nurses help. Supposed to be 2 CNAs on E (Unit) and 2 on vent Unit); there is only one CNA on each. Always 1 nurse on E should be 2 on vent. Saturday we only had one nurse on Vent (Unit) first shift. I stayed over a couple of hours. Tammy was great help and the RT (Respiratory Therapist KK) toileted residents for me. When interviewed as to which residents RT KK transferred for her, CNA EE said, (Resident #430). According to the MDS, Resident #430, entered the facility on 3/21/18, needed 2 or more staff assistance with bed mobility and transfers, and [DIAGNOSES REDACTED]. In an interview, on 4/27/18 at approximately at 12:30 PM, Respiratory Therapist (RT) KK stated she had worked at the facility for 2 years on a full-time basis, including every other weekend; she said, Some days we just can't keep up. They've had one of us (Respiratory Therapist) on D and one on E Halls. The way I look at it, when the acuity goes up new or sick residents need more attention, we need more staff. Our needs fluctuate. Residents are not happy. It is a weight you feel; if a resident called for you a ½ hour ago but I can't leave someone else that needs me, especially in the morning, everyone needs to be suctioned. For patient care we all help residents with things like turning, boosting, delivering trays. I have not had Nurse Aide training and I don't use a gait belt. I don't do that. If they are bogged down we (Respiratory Therapists) help so residents get attention .We all try hard. Resident #8 According to the Minimum Data Set, ((MDS) dated [DATE], Resident #8 was a [AGE] year-old, admitted to the facility on [DATE], who had no cognitive impairment, needed 2 or more staff assist with bed mobility, transfers, range of motion impairment in both lower extremities, and (during the look-back time) locomotion on or off the unit did not happen. Resident #8 had [DIAGNOSES REDACTED]. The MDS indicated bed rails were not in use. During an interview/observation, on 04/24/18 at 09:28 AM, Resident # 8 was lying in bed on her back, and there were side rails rails at the head of her bed, and her bed was in a high position. During an interview/observation on 04/26/18 at 09:46 AM, Surveyor observed Resident was lying in bed on her back, and there were side rails at the head of her bed, and her bed was in a high position. Surveyor observed CNA EE and FF turn Resident # 8 side to side while performing peri care. Then, they repositioned Resident #8 back on her back and left the room, leaving Resident #8's bed in the high position. During an interview/observation on 5/24/18 at 09:43 AM, Surveyor observed Resident was lying in bed on her back, and there were side rails at the head of her bed, and her bed was in a high position. There was no perimeter mattress on the bed. When interviewed as to how she felt about having her bed in the high position, Resident #8 said, I don't like it. According to her Fall Risk Assessment, dated 7/27/2017, The resident is (Moderate) risk for falls r/t Deconditioning, Gait and balance problems. Resident #40 According to the MDS, dated [DATE], Resident #40 was admitted to the facility on [DATE], had severe cognitive impairment, and needed 2 or more staff for bed mobility and transfers, and [DIAGNOSES REDACTED]. On 04/27/18 at 02:35 PM, Tammy L, LPN was observed boosting Resident #40 up in her wheelchair by grabbing the back of her shirt and pulling up. During an interview about proper technique for wheelchair repositioning, Tammy said, I should have 2 staff and pull her up under her armpits. (Pulling under the armpits can cause injury). Resident #41 According to the MDS, dated [DATE], Resident #41 was a [AGE] year-old, admitted to the facility on [DATE], who had no cognitive impairment, needed 2 or more staff assist with bed mobility, transfers, hygiene, and bathing, and had range of motion impairment in both upper extremities. The MDS indicated Resident #41 had [DIAGNOSES REDACTED]. During an interview/observation on 05/02/18 at 10:11 AM, Surveyor observed Resident #41 had bed rails had the head of the bed and the bed was in the high position. Resident #41 reported she couldn't remember if anyone had informed her of the risks of having bed rails on her bed. Review of Resident #41's Medical Record revealed no physician order for [REDACTED].#41's Care Plans revealed her plan of care for the use of bed rails had not been reviewed since 1/30/18. Resident #65 According to the MDS, Resident #65 was a [AGE] year old, who entered the facility on 12/14/17, had no cognitive impairment, needed assistance of 2 or more staff for bed mobility, transfers, and personal hygiene, range of motion impairment in both upper and lower extremities, and had [DIAGNOSES REDACTED]. The MDS indicated bed rails were not in use. Resident #65 was on mechanical ventilation (vent). During an interview, on 04/24/18 at 01:00 PM, Resident #65 was observed to be lying asleep in bed raised to a high position. There were bed rails attached to the top half of the bed and they were not raised. Review of Resident #65's most recent Fall Assessment, dated 3/22/18, revealed he was at moderate risk of falls. On 04/26/18 at 10:23 AM, Surveyor observed Resident #65 was observed lying in bed and the bed was in a high position. Surveyor observed CNAs EE and FF perform peri care on Resident #65 each standing on opposite sides of the bed; when they rolled Resident #65 to left side, they did not raise bed rail. CNA EE reported she used the bed rail when she performed cares on Resident #65 by herself, for safety, so Resident #65 would not roll out of the bed .(Resident #65) has no mobility, he can't reach for them (bed rails). When CNAs EE and FF were finished, they left Resident #65's bed in the high position, then left the room. In an interview, on 4/26/18 at 11:37 AM, CNA EE reported, (Resident 365) has no mobility, he can't reach for them (bed rails). In an interview, on 04/26/18 at 12:22 PM, Nurse Aide (CNA) EE reported Resident #65 was a 2 person assist with bed mobility, but said, I have done his care by myself due to short staffing, and then put the side rail up so he wouldn't fall . (Resident #65) is not a fall risk. In an interview, on 4/26/18 at 12:46 PM, Unit Manager Z said, (Resident #65) is not a fall risk; he is paralyzed so he can't move any of his limbs. Can't turn himself. Completely immobile. When interviewed about the safety of bed mobility performed by only one staff person, she said, No, doesn't surprise me they do it by themselves . All residents on the vent unit are a 2 person assist. We can't find staff. Trying very hard to get more . Review of Resident #65's Care Plans revealed no current plan of care for the use of bed rails, nor to keep the bed in the high position. According to Resident #65's Activities of Daily Living (ADL) care plan, dated 12/26/17, Bed Mobility: Dependent with 2 assist . And, according to Resident #65's fall prevention care plan, dated 11/23/17, The resident will not sustain serious injury through the review date. Anticipate needs and assure safety .Bed in lowest position when not providing care . Resident #54: Review of the Electronic Medical Record (EMR) on 04/25/18 at 02:23 PM reflected Resident (R) #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R54's Admission Minimum Data Set (MDS: Resident Assessment Tool) dated 3/20/18 reflected R54 had a moderately impaired memory problem, required extensive assistance of 2 persons for bed mobility, dressing, toileting and total dependence of 2 persons for transfers. On 04/25/18 at 09:33 AM R54 was observed in her room, sitting up in her bed having breakfast. R54 was observed to have an angled shaped laceration (dark burgundy in color) to the right side of her cheek secured with multiple black colored sutures. The local hospital where R54 was treated and discharged from on 4/21/18 education materials reflected the following for a laceration: A laceration is a cut that goes through all of the layers of the skin and into the tissue that is right under the skin . The hospital's visit sheet dated 4/21/18 also reflected R54 [DIAGNOSES REDACTED]. R54's right cheek was observed to be raised with moderate swelling, and the sclera of her left eye had multiple red areas of what appeared to be broken blood vessels and/or blood clots. R54's hair was matted on the sides and at the back of her head, with copious amounts of dried flaky dandruff about her scalp, at the perimeter of her hairline, flaky dry skin was observed on her forehead, eyebrows, and near the frontal aspect of her ears. The left lateral frontal aspect of R54's head was observed to have a large raised area, approximately the size of a key lime, that appeared to move and pulsate. A black sling was noted on R54's right arm that wrapped around the left side of her neck at an angle, near her [MEDICAL CONDITION] that was capped off. R54 was observed to not move her right side while eating or talking, and appeared to have mild facial droop on the right side of her face. R54's call light was observed to be on her abdomen and in reach of her left hand. Her bed was at a standard height but not low to the ground, and bilateral floor mats were observed on the floor on each side of her bed. R54 was asked if she had any pain. None, a little, medium and extreme pain were given as options to describe pain level. R54 revealed she had medium pain at her right shoulder. The conversation was ended allowing R54 to finish her meal. R54's Admission Minimum Data Set (MDS: Resident Assessment Tool) dated 3/20/18 reflected R54 had a moderately impaired memory problem, required extensive assistance of 2 persons for bed mobility, dressing, toileting and total dependence of 2 persons for transfers. The Care Area Assessment (CAA) of the MDS for Activities of Daily Living (ADL) and Falls were triggered due to R54's history of a [MEDICAL CONDITIONS] with right side [MEDICAL CONDITIONS] disorder. The CAA continued to reflect that R54 worked with therapy, was alert, could sometimes make needs known, used communication board and hand gesturing, at risk for falls and had experienced a fall since admission without injury. Call light within reach, education on use given on admission. R54's fall care plan that was in use at the time of her fall initiated on 3/10/18 reflected R54 was at risk for falls as the focus. Be sure the resident's call light in within reach and encourage the resident to use it for assistance as needed, Bed in lowest position when not providing care, bilateral floor mate and physical/occupation therapy to evaluate and treat as ordered or as needed were listed as interventions. Record review of the facility's incident report dated 3/18/18 at 6:30 PM reflected that R54 had a fall without injury. R54 was noted to have been observed lying prone on floor between bed and window, with the bed in the lowest position, but the call light was not initiated. The facility reviewed the care plan, and added the intervention of bilateral floor mats to be in place while R54 was in bed. The only person who was investigated related to the fall was R54. There was no investigation performed by the facility of any staff related to the fall, any like residents, how the resident was positioned when last seen or the location of R54's call light prior to the her fall. No documentation was listed reflecting environmental factors. Record review of the facility's incident report dated 4/20/18 at 10:45 PM reflected that R54 had an observed fall by Certified Nursing Assistant (CNA F) resulting in a laceration to her right cheek. The brief description reflected: Resident rolled out of bed during care, causing laceration to right cheek. First aid was provided by Registered Nurse (RN T), and R54 was sent out to the hospital. The investigation of the fall reflected R54 was having her brief changed by CNA F. The Statement of Witness Continued signed by the DON and CNA F reflected: CNA described details of incident. States she rolled resident toward her during a brief change. Bed height was up to CNA's waist level. CNA supported resident with left arm while tucking 90% of linen under. CNA assisted resident to back. Resident grabbed the bed frame with her left hand. CNA moved residents right side slightly to grab linen as she pulled on linen resident rolled out of the left side of the bed to the floor. right shoulder bumped the floor/mat. CNA F was suspended pending the investigation, and staff education about turning residents towards them and not away wash implemented. The facility's Performance Improvement Form (Form #412) signed by DON B and CNA F reflected the following: Reason for Counseling/Corrective Action: Not turning resident in the proper manner, which resulted in resident falling out of bed and causing injury. Resident was turned away from CNA during care instead of towards CNA. CNA was re-educated on proper turning of resident while in bed. Always turn resident towards you (staff), not away from. The facility's summary of the incident reflected: On 4/20/18 at around 22:50 PM R54 was discharged to a local hospital related to the resulting in a laceration to her right cheek. On 4/21/18 at 01:54 AM R54 returned to the facility from the hospital with sutures to her lacerated right cheek, and sling to right arm. Computed Tomography (CT) of the head, maxillofacial, spine and an X-Ray of right shoulder were performed. Later the same day at 10:23 AM R54 was interviewed (and presented the same as 09:33 AM minus breakfast), and asked if she recalled her fall 4/20/18. R54 revealed she had lost her balance and was trying to regain it, but could not recall the fall. DON B was interviewed on 4/25/18 at around 2:50 PM, about R54's fall involving CNA F. DON B revealed that CNA F had been employed at the facility since 1990, that she was currently suspended. On 4/25/18 at 03:53 PM CNA F was called related to R54's fall. CNA F revealed she could come in and meet for a personal interview, changed her mind, ended the pone call, and when attempted to call back was not available by phone. On 04/26/18 at 10:14 AM Physical Therapist (PT Y) was interviewed, and revealed she completed the therapy recommendations sheet dated 3/20/18 that reflected R54 was a 2 person assist with maxi-lift for transfers, and a 1 person assist for bed mobility. PT Y revealed R54 could roll on her left side. Also, that it was okay for R54 to be turned by only one person. When asked if a CNA was to turn R54 on her left or right side, where should the CNA stand? PT Y stated, The CNA should be face to face of the resident. On 04/26/18 10:41 AM the Assistant Director Of Nursing (ADON Q) was interviewed, and queried about bed mobility turning of residents. ADON Q revealed CNA's received training related to bed mobility in their CNA class, upon hire, with annual skills checklist, and if issues are observed managers would do on the spot training. ADON Q was asked if a resident had a flaccid side, where should the CNA be placed when turning them? ADON Q stated, You should always roll them facing you. ADON revealed that CNA's were educated to turn residents who were flaccid towards them, CNA F's was done in (MONTH) (YEAR), although it may not be listed but was reviewed. The Certified Nursing Assistant Annual Competency Skills Checklist was signed by CNA F on 12/5/17 as completed, and co-signed by ADON Q. On 04/26/18 at 11:12 AM RN Z was asked if the raised circular area on the left side of R54's head was a result of the fall. RN Z stated, No she came in like that. RN Z was then queried if CNA staff were educated on bed mobility and how to roll residents/flaccid residents in bed. RN Z revealed that the floor staff received education on how to roll residents when they are caring for them. Also, that they were to roll the resident towards them and not away. 04/26/18 11:17 AM R54 was asked if she had any pain. R54 replied, Yes and pointed to her abdominal area. She revealed she had told the nurse and had been medicated. The sling was observed to be on her right arm, there was no change to the sclera of her right eye, the sutured lacerated area looked the same, her bed was at standard height, her call light was in reach and bilateral floor mats were noted. On 04/26/18 at 04:52 PM was the first observation of R54's bed being placed low to floor. R54's sling was observed on her right arm, the sutured laceration to her right cheek was observed to have mild swelling, and her hair was still matted with dry flaky dandruff about her scalp/around the perimeter of her hair line, forehead, in her eyebrows and flaky skin near the front of her ears. R54's mother was observed to be visiting. R54's Mom (DD) was asked if she was aware of the 2 falls R54 had had. Mom DD revealed she was aware but was very concerned about the care provided to daughter. Mom DD shared that R54 had had a craniotomy, and bone flap related to a blood clot and that she wore a helmet. Also, that part of R54's skull was removed and placed inside her abdomen to be placed at a later date. They are supposed to put a helmet on her head when she is turned, but Mom DD denied a helmet had been used since R54 had been admitted and not aware of where R54 helmet was. R54 denied the facility had used a helmet on her head, when asked. On 04/26/18 at 05:17 PM DON B provided writer with a Past None Compliance (PNC) packet related to R54's fall. DON B was queried as to what the facility had done to put them in compliance. DON replied they started education on 4/21/18, and finished most of the education for the majority of staff on 4/24/18, some staff had yet to complete the education training, that she would be starting audits next week, and that she had developed audit sheets. When asked had there been a period of compliance. DON B revealed they had did education and would start audits next week. The falls list provided by DON B reflected the facility had falls in the facility (YEAR) on (MONTH) 1, 3, 4, 5, 6, 8, 12, 14, 15, 16, 18, 20 and 21. A total of 19 falls, with 3 residents having multiple falls ranging from 2-4 in the month of (MONTH) (YEAR) alone. DON B was asked if she was aware if R54 had and/or required a helmet, related to the raised area on the left side of R54 head at what appeared to be the area where her craniotomy/bone flap was performed. DON B revealed there was no order for a helmet for R54. DON B was asked if R54's doctor had came in and performed an assessment on her, and DON B replied Yes. During the survey between 4/24/18 and 5/3/18, a CNA who desired to remain anonymous was interviewed. The CNA revealed he/she normally cared for R54, and that R54 could communicate and let you know what she needed. When asked how he/she was to turn residents the CNA replied, Towards you. Also, that he/she was educated about that way back in CNA school, and during the recent in-service at the facility. On 04/26/18 at 05:35 PM RN T was interviewed by phone, and asked about the incident involving R54 dated 4/20/18. RN T stated, I was not in the room when it happened. I heard what sounded like a trash can fall over. I went to see what was that noise as RN GG yelled (R54's name) fell . I went in her room and CNA F was there and R54 was on the floor between her bed and window laying on her right side. I took a look at her. She was awake, asked was she okay and she said yeah. CNA F said she was turning her (R54) to change her diaper, and she turned to far of the bed. She was bleeding and had a laceration. I asked her (R54) what happened. She said she rolled too far. I had RN GG call 911. Did neuro checks and vital signs. RN T was asked how were CNA's to turn residents in bed during bed mobility. RN T revealed, To my best knowledge they are to turn residents towards them. I asked her if she turned her toward her and she said she had turned her away. RN T was queried about the raised area on the left side of R54 head that had been observed to pulsate. RN T revealed R54 had part of her skull removed, and that she not aware R54 had a helmet or an order for [REDACTED].>On 05/01/18 at 08:39 AM R54 was observed in her room sitting up in her bed. R54's right eye sclera was reddened, the sling was observed on her right arm, and the sutured laceration was noted to have mild swelling. When asked if she was in pain, R54 revealed she still had some medium pain at her right should from her fall. Her bed was at standard height, her call light was in reach, but only one floor mat was noted on the left side of her bed. On 05/02/18 at 10:43 AM R54 was observed sitting up in her bed, and appeared the same as 5/1/18 at 08:39 AM, but bilateral floor mats were now located on the floor on each side of her bed. Also, R54's call light was clipped to her fitted sheet near her right shoulder (flaccid side). R54 was asked to reach call light, R54 then attempted but could not reach the call light because of its location. At 10:44 AM Medical Records Associate (MRA S) entered R54's room. MRA S was shown the location of R54's call light, and informed it was out of her reach. MRA S then moved R54's call light from out of reach and clipped it onto her blanket near her abdominal area, and in reach. R54's Fall Care Plan initiated on 3/10/18 and revised on 4/21/18 reflected the following interventions: -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 03/10/2018 -Bed in lowest position when not providing care Date Initiated: 03/10/2018 -Bilateral floor mats Date Initiated: 03/20/2018 -Educate staff (CNA's) to have resident roll towards staff during care/repositioning/turning instead of away from staff to prevent resident from falling out of bed Date Initiated: 04/21/2018 Revision on: 04/21/2018 Nurse Practitioner (NP N) progress notes dated 3/13/18 at 23:11 PM reflected: SKIN: no cyanosis, icterus or pallor. No documentation or treatment was listed for R54's seborrhea. HEENT (Head, Ears, Eyes, Nose, and Throat): reflected status [REDACTED]. No documentation was noted addressing [MEDICAL CONDITION] precautions. The John Hopkins Medicine undated online reference displayed on 5/11/18 reflected the following for craniotomy: A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done. Muscles: no mass or deformity, no swelling. No documentation or treatment was listed related the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. NP N's progress notes dated 3/23/18 at 20:01 PM reflected: SKIN: no cyanosis, icterus, or pallor. HEENT: status [REDACTED]. Tongue is covered with white thrush. Musculoskeletal: no mass or deformity, no swelling. No documentation or treatment was listed for R54's seborrhea. No documentation was noted specifically addressing [MEDICAL CONDITION] precautions. No documentation, treatment or precautions were listed specifically related to the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. The [MEDICAL CONDITION] Consult note documented by Doctor (DR) EEE on 3/14/18 at 09:19 PM reflected R54 had an intracrainial hemorrhage and craniotomy. NP N's progress notes dated 3/27/18 at 12:16 PM reflected: SKIN: no cyanosis, icterus, or pallor. HEENT: status [REDACTED]. Musculoskeletal: no mass or deformity, no swelling. No documentation or treatment was listed for R54's seborrhea. No documentation was noted specifically addressing [MEDICAL CONDITION] precautions. No documentation, treatment or precautions were listed specifically related to the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. NP N's progress notes dated 4/24/18 at 17:54 PM reflected: General appearance: pt is resting on the bed R shoulder sling, racoon eyes bilaterally, sutures on the R zigomathic area. SKIN: no cyanosis, icterus, or pallor. HEENT: status [REDACTED]. Musculoskeletal: R shoulder sling post fracture. No documentation or treatment was listed for R54's seborrhea. No documentation was noted specifically addressing [MEDICAL CONDITION] precautions. No documentation, treatment or precautions were listed specifically related to the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. NP N's progress notes dated 4/27/18 at 12:45 PM (which was the most recent note in the EMR for R54 on 5/1/18) reflected: General appearance: pt is resting on the gerychair, R shoulder sling, raccoon eyes bilaterally, sutures on the R face. SKIN: no cyanosis, icterus, or pallor. HEENT: status [REDACTED]. Musculoskeletal: no mass or deformity, no swelling. No documentation or treatment was listed for R54's seborrhea. No documentation was noted specifically addressing [MEDICAL CONDITION] precautions. No documentation, treatment or precautions were listed specifically related to the raised area located on the left side of R54's head where the documented craniotomy/bone flap appeared to have been performed. It was not until 5/1/18 after writer had queried nursing management/nursing staff about R54's abnormal raised area over what appeared to be the area where R54's craniotomy/bone flap was performed, that an order was obtained and/or written reflecting: Resident to wear protective helmet during transfers. Likewise, it was not until writer queried facility staff related to R54's [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to prevent an avoidable fall which resulted in injury for one sampled Resident (#504) out of one resident observed for falls out of a total sample of 4 residents resulting in a fractured ankle. Findings include: Resident #504 was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. On 9/13/17 at 9:30 AM, a record review of Resident #504's Minimum Data Set indicated a brief interview for mental status score of 15 out of 15 points indicating no concerns with mental cognition. Resident #504 was a 2 person assist with toileting, dressing and transfers. A record review of ADL (activities of daily living) care plan indicated Resident #504 requires 2 person assist, dated 1/15/14 and revised on 8/24/17. The care plan indicated Resident #504 had a self-care deficit r/t (related to) stroke with R (right) hemiparesis (weakness on one side of the body). Transfer status, initiated on 1/15/14 and revised on 8/24/17, indicated the resident was dependent with hoyer and 2 staff. Additionally, the care plan revealed Resident #504 had Dycem (a non-slip material) to w/c (wheelchair) to prevent sliding. On 9/13/17 at 11:00 AM, Resident #504 was observed in her room, sitting upright in her bed. Her right foot/ankle area was in a cast. Resident #504 was smiling and nodding her head. On 9/13/17 at 1:00 PM, Registered Nurse (RN) A was interviewed. RN A was the unit manager on Resident #504's unit. When RN A was asked about Resident #504's fall, she stated the CNA who transferred her (CNA B) did not check the CNA care guide to see how many staff were needed to transfer the resident. On 9/14/17 at 8:00 AM, an interview was done with certified nursing assistant (CNA) B. CNA B stated she was stilll on orientation when she assisted Resident #504 to the bathroom. CNA B said, on 8/20/17 at approximately 9:30 PM, she saw Resident #504 had her call light on and went to see what Resident #504 needed. Resident #504 told her she needed to go to the bathroom. Initially, CNA B left the room and looked for other CNAs to assist with transferring Resident #504 from her wheelchair to the bathroom. Both CNAs were assisting other residents. Resident #504 was very impatient and kept telling CNA B that she had to use the restroom. CNA B decided to transfer Resident #504 by herself. CNA B placed a gait belt around Resident #504 and wheeled her into the bathroom. CNA B transferred Resident #504 to the toilet without difficulty. According to CNA B, when she transferred Resident #504 back to the wheelchair, Resident #504 ended up sitting on the edge of the wheelchair and leaning forward. CNA B moved to the back of the wheelchair with the intent of pulling Resident #504 back into the wheelchair using the gait belt but Resident #504 was stuck on the edge of the wheelchair so CNA B assisted her to the floor where Resident #504's foot hit the wall. On 9/14/17 at 8:15 AM, an observation of a re-enactment of Resident #504's fall was done with CNA B and the Director of Nursing (DON). CNA B used a gait belt to transfer the DON from the wheelchair to the toilet. CNA indicated Resident #504 had to stand up using the grab bar in the bathroom twice - once to have her perineal area cleaned and once to have her brief pulled up and adjusted - before CNA B attempted to assist Resident #504 back into the wheelchair. Because Resident #504 had limited use of her right arm and leg, Resident #504 had to pull herself up with her her left arm. CNA B then attempted to pivot transfer Resident #504 to the wheelchair using the gait belt but Resident #504 landed on the edge of the wheelchair and was leaning forward. CNA B moved from the front of the wheelchair to the back of the wheelchair and attempted to pull Resident #504 backwards but was unable to do so. CNA B then assisted Resident #504 down to the floor where Resident #504 hit the wall with her right foot. CNA B said I guess I should have paid attention to her bad(right) leg. On 9/14/17 at 9:00 AM, a record review of Resident #504's progress note, dated 8/21/17, confirmed that Resident #504 had a fractured right fibula. On 9/14/17 at 10:00 AM, a record review of the Falls - Clinical Record policy and procedure, undated, was reviewed. Under Item 6 stated The care plan and CNA care guide should be updates as interventions change.

Based on observation, interview and record review, the facility failed to protect three cognitively impaired Residents from sexual abuse (#'s 904, 907 and 915) of nine residents reviewed for abuse from a total sample of 18 and one supplemental sampled resident (#45), when Residents #'s 911 and 914, who had a long standing history of inappropriate sexual behavior, were witnessed by staff to be fondling, licking, and making sexually inappropriate remarks, resulting in an immediate jeopardy when the facility did not investigate, report all incidents to the state agency, or implement timely interventions to protect residents from further abuse. This deficient practice had the potential to affect all 72 residents in the facility resulting in the potential for serious harm and/or injury or death and required immediate corrective action. The Administrator was notified of the Immediate Jeopardy (IJ) on 4/19/17. A plan to remove the immediacy was requested. The immediacy was removed on 4/20/17 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained at a pattern with potential harm that is not immediate jeopardy. Findings include: Resident #904 On 4/18/17 at 9:15 A.M., Resident #904 was observed in bed eating breakfast. Resident #904 did not respond verbally when spoken to. On 4/18/17 at 1:30 P.M., Resident #904's clinical record was reviewed and revealed the following: Resident #904 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #904 had severely impaired cognition and required extensive to total physical assistance with bed mobility, transfers, and all activities of daily living except for eating. A MDS assessment dated [DATE] documented Resident #904 had moderately impaired cognition. A review of progress notes from 9/2016 through 4/2017 revealed the following: A nursing progress note dated 9/28/16 at 2:30 P.M. that documented, Resident observed in female resident's room standing at bedside of female with his pants down, female resident stroking resident's penis. Resident redirected to his room .Nurse manager, DON (Director of Nursing), Dr., and responsible party notified. See incident report for more information. A nursing progress note dated 9/29/16 at 9:00 A.M. documented, Resident was observed in (room number) standing in front of female resident, female resident had resident's penis in hand .Administrator was immediately reported to . A nursing progress note dated 10/4/16 documented, Resident went to doorway of (room number) and she began to yell at him and he left. Incident and Accident reports (I&As) and any investigations for Resident #904 were requested from the Administrator on 4/18/17 at 2:45 P.M. The Administrator reported that the only investigation for Resident #904 was already provided (it pertained to another unrelated incident). I&As for Resident #904 were reviewed on 4/18/17 at 4:00 P.M. and revealed the following: An I&A dated 9/28/16 at 2:30 P.M. documented, Resident observed in female resident's (room number - identified by Staff M as Resident #914) standing at bedside of female resident with his pants down, female resident stroking residents' penis. The incident was witnessed by Nurse A. The I&A was signed by the DON and Administrator (who is the abuse coordinator for the facility) on 9/28/16. There was no name documented in the section for notification of the resident's responsible party. An attached Quality Assessment & Assurance (QA&A) Investigation Report (a seven page report) was blank except for #8 which documented, Inappropriate Behavior (sexual). A Statement of Witness form documented, Nurse (A) observed resident in wheelchair outside Residents (#914's room number). Female resident (Resident #914) waving male resident into her room. Male resident advised not to go into female resident's room. Male resident was returning to his room. Nurse (A) observed male resident standing in female resident's room with his pants down, female resident observed stroking male resident's penis. The witness statement did not document who conducted the interview or when the interview took place. No interventions, interviews of residents or staff, or additional information was included in the attached investigation. An I&A dated 9/28/16 at 3:15 P.M. (30 minutes after the incident mentioned above) documented, Resident was observed in female resident's room with his penis exposed. Resident was standing next to female resident. It was documented that the incident was witnessed by Certified Nursing Assistant (CNA) B. The section for notifying the resident's responsible party was left blank. The I&A was signed by the DON and the Administrator on 9/29/16. The attached QA&A Investigation Report documented that Resident #904's clinical record was reviewed on 9/29/16 and there were no concerns. The Results of Investigation documented, Resident was redirected and the nurse escorted resident back to his room. An undated Statement of Witness form was completed and signed by CNA B and documented, On the 28th of September I came into work on my shift and was told to look after (Resident #904) and (Resident #914). CNA on 1st (shift) said some sexual stuff happen(ed) between them (two). When I was doing my waters I saw them doing what the CNA told me and tried to break them up and look like (Resident #914) was giving (Resident #904) head and other sexual thing(s). Time was 3:15 P.M. on second shift. Told the nurse and she broke them up. The witness statement did not document who conducted the interview or when the interview took place. No interventions, additional interviews of residents or staff, or additional information was included in the attached investigation. An I&A dated 9/29/16 at 9:00 A.M. documented, Resident observed standing in front of female resident (Resident #914's room number) while sitting in her w/c (wheelchair), female resident had resident's penis in hand. It was documented that the incident was witnessed by Nurse F. The administrator signed the I&A on 9/29/16. The attached QA&A Investigation Report documented, Sexual resident to resident. It was documented that Resident #904's clinical record was reviewed on 9/29/16 by Nurse F and there were no concerns. The Results of the Investigation documented, Resident observed in (Resident #914's room number). Resident (#904) was removed from room and asked to go back to his room . The investigation report was signed on 10/3/16 (five days after the incident). A statement of witness form documented the date and place of the interview as 9/28/16 (the day before the incident) and the date and time of the incident as 9/29/16. The name of the witness was documented as Nurse F and the name and title of the person conducting the interview was also documented as Nurse F. The witness statement documented, Resident was observed standing in front of resident (#914) while she was sitting in her w/c. His penis was in resident's hand, asked resident to return to his room, he stated (expletive), but returned without any issue. No interventions, additional interviews of residents or staff, or additional information was included in the attached investigation. Resident #914 On 4/19/17 at 12:12 P.M., Resident #914's clinical record was reviewed and revealed the following: Resident #914 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] documented that Resident #914 had moderately impaired cognition, wandering behaviors, and could ambulate independently with supervision. A quarterly MDS assessment dated [DATE] documented Resident #914 had severely impaired cognition, daily wandering, and hallucinations and delusions. A review of Resident #914's progress notes revealed in part the following: 9/28/16 - At (2:30 P.M.) a nurse observed a male resident standing by her bed with his pants down and she was touching his private area . 9/29/16 - (9:00 A.M.): Resident was sitting in her wheelchair with male resident standing in front of her room .resident had male's penis in hand . 9/29/16 at 9:36 P.M. .Continuously going in other Residents rooms .Confused and disoriented . 10/11/16, .Res. was observed in (identified as Resident #45's) room holding onto other resident's hand and kissing him on the cheek . 10/16/16 at 10:40 A.M. .Alert, unable to determine level of orientation, pt does not often speak . 10/19/16 at 2:04 P.M., a behavior note documented, .Wanders into other resident's rooms, sexual promiscuity .Interventions attempted: Redirection, activities . 11/1/16 at 9:08 P.M., .Often wanders into other residents' rooms. Must monitor frequently . 11/3/16 - .Continues to wander . 11/4/16 at 8:35 A.M. a behavior note documented, .Continues to wander halls .Interventions attempted: Will offer private time for self pleasure .Interventions successful/unsuccessful: Interventions successful at times . 11/13/16 at 9:19 P.M., Resident walks around the unit, entering into different rooms. Was found in the (room number) trying to help (resident name) with toilet transfer . 11/28/16 - Resident found in another resident's room attempting to cover her up. Resident was overheard saying You better shut up now .Resident found in the same room [ROOM NUMBER] minutes later . 11/30/16 - Resident found in bed in another resident's room . 12/5/16 at 5:30 A.M., .Found Resident (#914) in (room number) bed. The brief she had on was not what CNA had put on .Resident #914 pulled on (other resident's room number) and tried to wrap her leg around her to keep her in the bed . 12/5/16 at 6:24 P.M., Resident #914 attempted to toilet another resident. 12/10/16, Resident was trying to attack staff when they redirected her from going into another resident's room. 12/31/16 at 11:36 A.M., Resident was in the doorway of (another room) dancing and beginning to lift up shirt . 1/2/17 at 4:22 P.M., Following different people around - hugging a male visitor for another patient . 1/2/17 at 5:00 P.M., Resident found in bed with roommate . 1/13/17 at 1:10 P.M., Pt observed standing over a pt male seated in his w/c in the hallway, rubbing her hands up and down on his groin area, over his gown and brief .Pt moved to (another facility) after incident . I&As for Resident #914 were requested and reviewed on 4/19/17 at 1:24 P.M. The I&As revealed the following: An I&A dated 9/28/16 at 2:30 P.M. that documented Nurse A witnessed Resident #914 touching Resident #904's penis. The I&A was signed by the Administrator on 9/28/16. A QA&A Investigation Report and witness statement was attached and documented the same as the above mentioned I&A for Resident #904 on that date. A progress note written by the contracted behavioral services company was attached and dated 9/30/16 which documented, .seen for session today as requested by social services after reports of being sexual w/ male peers at the facility. Pt alert w/ confusion .limited ability to respond to questions, some word finding difficulty noted .Discussed safety concerns and need to not have men in her room .Insight and judgment are grossly impaired. Monitor patient for safety. She is impulsive and episodes of behavior will occur again without monitoring . An I&A dated 9/28/16 at 3:00 P.M. documented, Resident was observed with male resident standing next to her. Male resident's penis was exposed and resident was fondling the penis. The Administrator signed the I&A on 9/29/16. It was documented in the QA&A Investigation Report that Resident #914's clinical record was reviewed and there were no concerns. The results of the investigation documented, Male resident redirected to go to his room. Nurse escorted male resident to his room. There were no witness statements attached to the I&A for Resident #914 on that date. An I&A dated 9/29/16 at 9:00 A.M. documented that Nurse FF Walked into room, resident had male resident's penis in hand, told male resident to return to his room. The I&A was signed by the Administrator on 9/29/16. It was documented in a QA&A Investigation Report that Resident #914's clinical record was reviewed by Nurse FFand there were no concerns. The results of the investigation documented that a room change was immediately implemented. There was one witness statement completed by Nurse FF. No other interviews were attached to the investigation. An I&A dated 10/11/16 at 4:30 P.M. documented, Resident (#914) entered (Resident #45)'s room and kissed him on the cheek. Resident has a hx (history) of sexual behavior toward the opposite sex. It was documented that this incident was witnessed by staff. The administrator signed the I&A on 11/9/16 (a month after the incident occurred). Actions taken were care plan update, staff re-education, and re-direction of resident. It was witnessed by Resident #45's roommate. The results of the investigation as documented in a QA&A investigation report documented, Res. was observed going into (Resident #45's room), holding resident and kissing him on the cheek. Res. was redirected and separated .Res. CP (careplan) reviewed, was a CNA and does have hx of care giving. Resident does easily redirect and was not observed going into res. (room) again. Continue with CP interventions. The report was signed by the DON on 10/11/16. An I&A dated 1/13/17 at 10:45 A.M. documented, This pt (patient - Resident #914) observed standing over a pt in his w/c rubbing, pulling up on pt's groin/penis over his gown. Pt redirected and removed from situation .The Administrator signed the I&A on 1/17/17 (four days after the incident occurred). A QA&A Investigation Report documented that Housekeeping and Laundry Director (Staff C) witnessed Resident #914 Stroking the genitalia of a male resident and reported it to the Administrator (no time documented). It was documented that Resident #914 had a history of [REDACTED].with a BIMS (Brief Interview of Mental Status) score of 6.0 (a score of 0 to 7 indicates severe cognitive impairment) was observed stroking the genitalia of a male resident at the nurse's station. Residents were separated and 1:1 supervision initiated. Resident on wait list for locked unit at sister facility, bed available, move occurred 1/13/17 at approximately 4:00 P.M . A witness statement from Staff C documented, I went to the D Wing nurse's station and witnessed resident (#914) with her hand on (Resident #915 who no longer resided in the facility at the time of the survey)'s groin area. Resident was wearing a gown. (Resident #914) was making an up and down motion on (Resident #915)'s genitals; on top of gown. (Resident #915) said, Stop. I said stop. and pushed himself away .I reported incident to the Administrator. The statement was signed by Staff C on 1/16/17 (three days after the incident occurred). There was no additional information or interviews in the investigation. On 4/19/17 at 11:25 A.M., Nurse A (who witnessed the first sexual incident between Resident #904 and Resident #914) was interviewed about the incident on 9/28/16 at 2:30 P.M. Nurse A reported that she glanced in Resident #914's room and saw Resident #904 standing beside her bed. She was stroking his penis, pants down, penis hanging out. Nurse A reported that she called for help, redirected the resident back to his room, and reported the incident to the DON, Administrator, and physician. When queried about any interventions that were put in place after the sexual incident was observed, Nurse A stated, We just kept a close eye on them. (Resident #904) would try to wheel toward (Resident #914's) room and (Resident #914 would try to provoke him and wave him into the room. It was reported to the next shift to keep an eye on them. Nurse A was asked about Resident #904 and Resident #914's cognitive status. Nurse A reported that Resident #914 was cognitively impaired, but Resident #904's cognition was not. Nurse A reported that she did not think either resident would be able to consent to sexual activity with one another. On 4/19/17 at 11:45 A.M., CNA B (who witnessed the second incident between Resident #904 and Resident #914 on 9/28/16) was interviewed. CNA B reported that 1st shift explained that Resident #904 kept going into Resident #914's room and that she kept waving Resident #904 into the room and they were found doing sexual things. CNA B stated, I went to go check on them right away when I started my shift. I walked into (Resident #914)'s room, the roommate was in there, and (Resident #904) was standing next to the bed, Resident #914 was laying down on the bed, Resident #904's pants were pulled down and it looked like he was getting (oral sex) from Resident #914. I tried to break it up, but they wouldn't listen so I got the nurse. When queried about Resident #904 and Resident #914 and whether or not they were able to consent to sexual activity, CNA B stated, Not (Resident #914), but I think (Resident #904) knew better not to do it but did it anyway. When queried about any other known sexual incidents with Resident #914, CNA B stated, She had a history. She left now. There were a couple other times where she did inappropriate things. I think she was touching another resident under the table in the activities room once and there might have been other things, I don't remember, but I've always reported them right away. On 4/19/17, Staff C was interviewed (who witnessed the sexual activity between Resident #914 and Resident #915 on 1/13/17). Staff C stated, It was on the D Wing Hall. I noticed Resident #915 yelling 'Get away! Stop it! Resident #914 had her hand between Resident #915's legs and was holding his genital area moving up and down. Staff C reported that she had a housekeeper take Resident #914 back to her room and told the Administrator and DON. On 4/19/17 at 1:55 P.M., the Administrator (abuse coordinator) was interviewed. When asked to explain the facility's process for investigating and reporting resident to resident abuse, the Administrator stated, We make a trigger call to determine if something is reportable. If the resident's BIMS score is zero then there is no intent, it's just impulse control. The Administrator reported that a trigger call was a discussion between the Administrator, DON, Regional staff, and the company attorney. When queried about why the sexual encounters between Resident #914 and #904 were not reported to the state agency, the Administrator stated, At that time, (Resident #904) and (Resident #914) were consensual. They liked it and they were happy. When queried about why the sexual incident between Resident #914 and Resident #915 was not reported the state agency, the Administrator stated, I would have to look at the trigger call to see the decision we made. The I&A for the incident between Resident #914 and #915 was handed to the Administrator to review. The Administrator handed the I&A back without reviewing it and stated, That's useless. I have to look at the trigger call. The information regarding the trigger call was requested at that time, but was not received prior to the end of the survey. The Administrator was asked if Resident #914 and Resident #904 were cognitively able to make their own decisions. The Administrator stated, (Resident #914) was, (Resident #904) was not but his brother is his legal guardian and he knew about the situation and was okay with it. When queried about why Resident #914 was moved to another facility on the day of the incident with Resident #915, the Administrator stated, She was an elopement risk. She moved to a locked unit. When asked why she needed a locked unit if Resident #914 was able to make her own decisions, the Administrator did not offer a response. On 4/19/17 at 4:30 P.M., Resident #914 and Resident #904's clinical record was further reviewed and revealed the following: #914 A Decision Making Determination Form for Resident #914 dated 10/19/16 documented Incapable of making decisions regarding medical treatment. A Petition for Appointment of Guardian of Incapacitated Individual dated 12/8/16 for Resident #914 and an Order Appointing Guardian Ad Litem . dated 12/12/16. Review of Resident #914's care plans revealed a care plan initiated 9/28/16 that documented, The resident exhibits behaviors such as sexual promiscuity r/t cognitive deficits and hx of mental illness. A care plan initiated 9/23/16 documented, .has impaired cognitive function/dementia or impaired thought processes r/t dementia, difficulty making decisions, impaired decision making . #904 A Decision Making Determination Form for Resident #904 dated 11/30/16 documented Incapable of making decisions regarding medical treatment. On 4/20/17 at 11:00 A.M., Resident #915's clinical record was reviewed and revealed that Resident #915 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment documented that Resident #915 had severely impaired cognition and required physical assistance from two staff members for transfers and activities of daily living. Resident #907 On 4-19-2016 at 9:30 am, record review of Resident #907's electronic medical record revealed [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] reflected long and short term memory impairment and moderately impaired decision making skills. A court appointed legal guardian was in place. All incident and accident reports that pertained to Resident #907 were requested on 4-18-2017, none involving abuse were received on 4-18-2017. Review of Nurses notes dated 4-16-2017 at 02:51, authored by Licensed Practical Nurse (LPN) BB, reflected resident was in sexual contact with another resident the other male resident came into resident bed and was licking residents stomach and saying to resident to come on baby let's do this resident was redirected immediately sent to his room with 1 on 1 assistance I check on resident ask him if he was alright he nodded head yes check on him 5 minutes later resident was asleep Attempts to interview LPN BB were made via phone on 4-19 and 4-20-2017 were unsuccessful. Review of Nurses notes dated 04-16-2017 at 04:01, authored by Unit Manager Registered Nurse (RN) I, revealed, This Nurse was notified of incident involving another resident where sexual contact was made by resident A (Resident #911) but not consented to by this resident (resident B - Resident #907). The LPN immediately redirected resident A to his own room, and returned to check on this resident. The resident when asked what had happened stated to the LPN, 'that man tried to squish me.' This resident denies pain, and responds he is not afraid. This nurse went to provide follow up assessment at approx 0300 and resident was asleep. Will closely monitor q shift for 72 hrs. Message left for MD requesting a call back. SW notified. Administrator notified. Review of Nurse notes dated 04-16-2017 at 22:16 Resident had no recollection of last night. Resident had a good day. Review of Nurses Notes dated 4-17-2017 at 22:59 Resident does not remember so had a good day. Review of Nurse notes dated 4-18-2017 at 10:30 No ill effects from incident. Confused does not appear to recall what happened. On 4-19-2017 at 9:42 am, during an interview with RN I, she reported she was at the facility and notified of the incident by LPN BB, RN I further reported that she had reported the incident to the State Agency early that morning and that Resident #911 had a history of [REDACTED]. RN I stated I think they are still working on it. Resident #911 On 4-19-2017 at approximately 11:00 am, a review of Resident #911 medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE] reflected a brief interview status of 4, indicating severe cognitive impairment, and that he was physically abusive. The clinical record further reflected a legal guardian was in place. Resident #911 was observed throughout the survey days of 4-19 and 4-20-2017 to have facility staff with him. Review of nurses notes dated 1-09-2017 documented, Resident found in a couple all female rooms sitting in his wheelchair believes one of the female residents is his wife. 1-12-2017 Threatening behavior, wandering, throwing things, sexually inappropriate. Behavior notes dated 1-16-2017 He tries to get other residents (women) to go to bed with him. Behavior notes dated 1-21-2017 Resident observed in female residents room and I asked him to leave and he told me to leave him the hell alone and to get lost. I waited until resident left the room. Behavior notes dated 1-24-2017 Resident approaches women thinking they are his wife and he or the female resident is removed from the area. He also goes into other resident rooms thinking that is his room and gets mad when he sees another resident in the room. Behavior notes dated 2-05-2017 Resident entered female room, was observed kissing female resident on the lips, also seen rubbing female residents arm and leg. Behavior note dated 02-09-2017 meeting held for occurrence on 2-05-2017 where resident was observed kissing another sleeping female resident and touch arm and leg over clothes blankets. Res thought it was his wife. Nurses notes dated 2-21-2017 reflected 03:39 up and down restless had to remind him to use wheelchair which makes him mad had to redirect as he was going in womans (sic) bedroom Behavior note 3-02-2017 Resident is confused, tried to enter other residents rooms. Was reoriented several times. Behavior note 3-08-2017 resident entered into females resident room .3-05-2017 Behavior note 3 am resident is confused has physical need looking for someone to have sex with. Nurses note dated 3-10-2017 Resident tried to come in to room through bathroom of resident in (room number) while she was on bathing bed. She was completely covered. Resident was ushered out and redirected. Resident (room number) could not let this go she was worried about her safety. No amount reassurance was helping. So called social worker notified residents family notified and resident moved to E wing. Nurses notes dated 3-17-2017 15:42 Resident had a female resident in his bed in his room with the door shut. Female resident was fully clothed and no touching was observed. . Nurses noted dated 3-17-2017 15:42 Incident report did not need to be filled out per management. Behavior note dated 3-24-2017 reflected Resident exhibits verbal sexual behavior, physical aggression, and verbal aggression. Nurses notes dated 4-16-2017 resident observed in another resident's bed rubbing abdomen and licking abdomen saying baby let's do this redirected resident to his own bedroom resident went to another resident room starting augment call assign cena to 1 on 1 with resident.A review of the incident report dated 4-16-2017 included a witness statement which reflected when resident #911 was asked what he was doing he replied I wanted to know if it was good with a man. The care plan for Resident #911 dated 1-11-2017 with a revision date of 4-18-2017 identified resident #911 as having physical sexual behaviors-sexual behaviors women staff/residents come to bed with me the interventions included redirection, document behaviors, attend activities, and continue to be followed by psychiatric services and the interdisciplinary team to follow. On 4-19-2017 at approximately 10:00 a.m., during an interview with the Director of Nursing (DON), she reported being employed at the facility for one month and was unable to provide any specific information on Resident #911 except that he now has 1 on 1 staff with him at all times since the incident with Resident #907 occurred on 4-16-2017. On 4-19-2017 at 1:55 PM, during an interview with the Administrator, she reported resident #911 needs another setting When queried about her knowledge of all preceding behaviors that Resident #911 had leading up to the event that occurred on 4-16-2017, the Administrator stated behaviors were discussed in the morning meetings that she attends. When queried why Resident #911 did not have 1 on 1 supervision prior to the incident on 4-16-2017 she offered no explanation. On 4-20-2017 at 9:35 a.m., during an interview with Social Worker AA, she reported she was a new employee at the facility and was looking at alternate placement for Resident #911, when queried what was in place to address resident #911's behaviors she stated 1 on 1 supervision now. When queried what was in place prior to 4-16-2017 she stated he was followed by the psychiatric group and staff tried to redirect him. According to the facility's policy titled Abuse Prevention Program, with a revision date of 11-28-2016, reflected Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs systems, etc, to assist in preventing resident abuse. 1. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: K. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. .When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, DON, or individuals designated will immediately (not to exceed 24 hours if the suspicion does not result in serious bodily injury. No later than 2 hours if the events that cause the sispicion result in serious bodily injury) notify the following persons or agencies .1. The State licensing/certification agency responsible for surveying/licensing the facility . The facility submitted the following acceptable plan to remove the immediacy on 4/20/17: Removal plan for IJ of Abuse for Medilodge of Livingston 4/19/2017 As a result of the finding of immediate jeopardy by the survey team on 4/19/2017 related to resident #911 the facility has reviewed the below to determine causation. Findings include: Resident #911 was admitted to the facility with dx including [MEDICAL CONDITIONS], Mood disorder, [MEDICAL CONDITION] with delusions, generalized muscle weakness, GERD, [MEDICAL CONDITIONS], and dementia. Prior to admission resident was found at home, self-neglect, unable to care for self. Behaviors were followed by standards of care and physician with care plan interventions deemed appropriate. However, d/t the states findings that the facility should have acted upon the first encounter of the resident touching/rubbing a female's arm the facility is re-educating staff to include any contact between residents that is not accidental or unwanted as possible abuse. Resident #911 remains in the facility and remains on 1:1 supervision as of the date of the event on 4/16/17. No further inappropriate sexual behavior noted. Resident #914 no longer resides in the facility Resident #915 no longer resides in the facility Resident #904 has been assessed by social services for s/s abuse and no concerns have been noted. Resident # 907 remains in the facility and has no memory of the event per social service assessment on 4/19/ 2017 Total of 72 residents, The 45 residents that are capable of

This citation refers to Intake Number (s) M#I 646 Based on interview and record review, the Facility failed to ensure resident care was provided in a safe manner for one Resident (#802) of three residents reviewed for falls/injuries, from a total sample of five, resulting in Resident #802 falling out of bed and sustaining a laceration over the right eyebrow resulting in the Resident being sent to the hospital emergency room for evaluation and treatment that required seven sutures. Findings include: The Facility reported to the State Agency that Resident #802 had sustained a fall out of bed at the Facility on 11/15/16 resulting in a laceration to the right eyebrow requiring seven sutures. On 1/24/17 at 11:00 a.m., Resident #802 was observed lying in a Broda (a deep tilt reclining chair) chair in the activity room. The Resident had a red scar approximately one inch long on his right eyebrow. Resident #802 was alert, but unable to answer questions regarding the life in the Facility and the injury to his right eyebrow. On 1/24/17 at 11:20 a.m., Resident #802's clinical record was reviewed and revealed the following: Resident #802 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 10/27/16 documented that Resident #802 had severely impaired cognition and required total physical dependence of two staff members for assistance with transfers and bed mobility. A Care Plan for Activities of Daily Living (ADL) dated 5/27/14 documented the following: Bed mobility: The Resident requires max assist. Two staff to turn and reposition every two hours and as necessary .Personal Hygiene requires two person for care. Transfer two person Hoyer lift uses Broda chair. A review of the Facility's Incident and Accident report dated 11/15/16 and authored by Nurse C was reviewed and documented the following: Date of Incident: 11/15/16 Witness: Certified Nursing Assistant (CNA) D Description: Observed Resident face down on floor of Resident's room. Deep Laceration above right eyebrow. Result of Investigation: CNA in Resident's room providing care she noted draw sheet was wet due to feeding tube leaking. CNA pulled Resident towards her then on to his side away from her. Resident's bottom was towards her. CNA stated he then jerked and went to the other side of the bed. He fell hitting the IV (intravenous) pole located on the side of the bed causing the laceration . On 1/24/17 at 10:50 a.m., an interview was conducted with Nurse C regarding the incident. Nurse C stated that she remembered the incident and investigation and stated, Resident #802 was a two person assist for mobility and transfers. I remember talking to CNA D about the incident and whether she new how to use the Kardex (electronic medical information system) to determine a Resident's transfer status. We knew she was a new hire and had training during orientation. We ended up suspending her and then terminated her. On 1/24/17 at 1:40 p.m., an interview was conducted with the Director of Nursing (DON) and the Administrator regarding the incident and injury pertaining to Resident #802. The DON and Administrator both agreed that CNA D did not follow the Resident's care plan and Kardex information (two person assist) to properly care for Resident #802. The DON stated, We in-serviced our CNAs about using the Kardex. We checked to see if the our resident's care plans matched the Kardex. On 1/24/17 at 3:45 p.m., review of the facility's policy titled, Falls - Clinical Protocol, revised 2/2013, revealed the following documentation: Based on the assessment an initial plan of care (IPOC) will be developed and implemented to address identified risk. The Minimum Data Set (MDS) will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls. Interventions should be developed and implemented per the assessed needs. ( )

Based on observation, interview and record review, the facility failed to asses for hot beverage for one (# 701) of three sampled residents from a total sample of three, resulting in the resident spilling hot coffee which caused extensive second degree burns to the back of the left thigh, scrotum and right thigh and extreme pain. Findings include: On 6/2/16 at 9:00 AM, record review revealed that Resident #701 was an eighty-one year old resident who was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum data set (MDS), dated [DATE], indicated a Brief interview for mental status (BIMS) score of 9 of a possible 15 points indicating some deficits with thinking. In addition, the resident needed extensive assistance with transferring, dressing, hygiene and bathing. A review of the progress notes dated 5/16/16 indicated Resident #701 was burned with hot coffee at 8:40 am and the pain level was 10 out of a possible 10. Thirteen blisters were documented at that time. At noon on 5/16/16, the pain level was 7 of 10 and the blisters had merged into seven areas. Six areas were on the right thigh area and one 5 centimeter (cm) by 3 cm blister was located on the scrotum. Documentation on 5/24/2016 noted the following: left posterior thigh 2 cm X 1 cm X 1 cm granular wound, improving. Right posterior thigh 12 cm X 12 cm X .1 cm wound granular and improving. Wound to the scrotum was resolved. On 6/2/16 at 9:20 am, an observation of a dressing change to Resident #701's burns was done. When Resident #701 was turned to his left side, a large (approximately 6 inches) area of burnt skin was noted on the right posterior thigh. Resident #701 moaned with pain throughout the dressing change although he had been medicated for pain before the dressing change. On 6/2/16 at 10 am, a re-enactment of the incident which caused Resident #701's burns was done with Unit Manager (UM) G , Certified Nursing Assistant (CNA) B and CNA D. After Resident #701 received his breakfast tray, he requested a cup of coffee which was brought to him and left on his bedside table. CNA D indicated she was passing a breakfast tray across the hall from Resident #701's room when she heard Resident #701 yell Help me. CNA D ran across the hall and, after she entered Resident #701's room, asked the resident what happened. Resident #701 stated I spilled my coffee. CNA D noted a coffee cup on Resident #701's lap and on top of a sheet. CNA D lifted the cup and the sheet and asked the Resident Did you get burned? Resident #701 indicated he wasn't sure if he was burned. CNA D yelled to CNA B to get UM G.Who was down the hall at the nurse's station. CNA B stated she walked quickly to get UM G, told him about the spilled coffee and indicated she would get some linens to change Resident #701's sheets. When UM G entered Resident #701's room, CNA B and CNA D were in the process of changing this resident's sheets and wiping the spilt coffee off his legs with a wet wash cloth. The wash cloth contained tepid water. When Resident #701 was turned on his left side, both CNAs and UM G observed red areas to the back of the right thigh. UM G noted the reddened areas were blistering slightly and went to get cold wash cloths to put on the reddened areas. UM G stated he placed cold wash cloths on the posterior thigh area, called the Nurse Practitioner for orders to treat the burn and then went to the 9 am morning meeting to inform the management team of the occurrence. On 6/2/16 at 11:30 am, a review of the coffee brewing and serving temperatures indicated, on 5/16/16, the brewing temperature of coffee for breakfast was 166 degrees and the serving temperature was 145 degrees. On 6/2/16 at 10:45 am, the Administrator was interviewed and noted that there was no hot beverage assessment completed for Resident #701 prior to the burns. A review of the Hot Liquid Safety Evaluation form, dated 5/16/16 at 9:08 AM indicated Resident #701 was at risk for burns due to decreased cognition levels, decreased strength in his upper extremities and reduced mobility in his upper extremities. On 6/2/16 at 11:10 AM, a review of the undated First Aid Treatment policy, indicated, Residents . who experience minor injuries shall be treated at the facility. All direct care staff will receive training on current first aid skills. Basic first aid interventions include interventions for (b) Burns (chemical, heat, electrical). Additional information, dated 5/16/16, defined a major second degree burn as one on the groin and/or buttocks. Treatment if the skin was unbroken was to run cool water over the area of the burn or soak it in a cool water bath. Keep the area under water for at least five minutes. On 6/2/16 at 1:00 PM, an interview was conducted with CNA B who indicated she was not aware of the treatment for [REDACTED].#701 was burned. On 6/2/16 at 1:30 PM, an interview was conducted with CNA D. She stated there was an education done immediately after Resident #701 was burned regarding the treatment for [REDACTED]. On 6/2/16 at 2:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. She stated she attended the burn prevention inservice and knew to pour cold water over the burned area if she witnessed a hot coffee spill. On 6/2/16 at 4 PM, an interview was conducted with LPN F. She stated she attended the burn inservice and was aware now to immediately pour cold water over the potential burn area if she witnessed a hot coffee spill. The facility submitted a Plan of Correction for the following Past Non-Compliance. What corrective actions will be done for residents found to have been effected by the deficient practice? Resident #1 was re-assessed for safety r/t handling of hot liquids and pain assessment on 5/16/16. The physician and family were notified of the incident on 5/16/16. The physician has given orders and nursing is providing care. On 5/16/16. Resident #1 care plan was updated to have lids on hot beverages, cool hot liquids with ice prior to serving and to be encouraged to eat at a table not in bed. How facility will identify other residents having potential to be affected by practice AND what corrective action will be taken. Residents were re-assessed by the nurse managers and care plans were updated for any resident found to be at risk for hot liquid spills. All hot liquid assessments will be initiated upon new admissions, significant changes, and quarterly thereafter. All residents that were identified to be at risk were care planned to utilize lids and cool hot liquids with ice prior to serving by nurse managers on 5/16/16. Dietary manager has initiated daily hot liquid temperatures and updating tray tickets with Hot Risks in red. What measures will be put in place or what system changes will you make to ensure that the deficient practice will not recur? All facility staff members were re-educated by the Staff Development Nurse on burn assessments and first aid process on 5/16/16. Dietary has been re-educated on hot liquid temperatures and serving temperatures which was completed on 5/16/16. How the corrective action(s) will be monitored to ensure the deficient practice will not recur. i.e. what quality assurance program will be put in place. Daily dining room audits will be conducted for the next three weeks Monday-Friday and then weekly thereafter for 3 months by the Director of Nursing/Designee to ensure safety measures are in place for the residents that are at risk for hot liquid spills. Review will be conducted during the morning clinical meeting and follow up during the weekly SOC meeting. Results will be presented to the QAPI committee for further recommendations. ( )

This citation pertains to intake MI 274 Based on interview and record review, the facility failed to develop and implement fall precautions for one (#701) of three residents reviewed for falls, out of a total of four, resulting in an actual fall that caused a disconnection from the ventilator (vent; mechanical life support), extreme respiratory distress that resulted in bagging (manually providing air for a person who is not breathing) for 45 minutes, unconsciousness, a transfer to acute care, and mental anguish. Findings include: On 5/18/16 at 9:30 a.m. review of Resident #701 face sheet revealed an admission into the facility on [DATE] and a re-admission on 4/27/16 with [DIAGNOSES REDACTED]. Diff). The Nursing Admission Assessment indicated that Resident #701 alert and was oriented to person, place, and time. She displayed some confused at times. Resident #701 was dependent upon others for all activities of daily living (ADLs). On 5/18/16 at 9:50 a.m., Resident #701 was observed lying in bed alert, resting on an alternating specialty air mattress and was connected to a ventilator. She was receiving liquid nutrition by way of a feeding tube. Her indwelling urinary catheter was intact and draining clear yellow urine. Isolation/Contact precautions were in place for a highly transmittal intestinal infection (C. Diff; Clostridium Difficile). Resident #701 was queried regarding an incident where she had fallen out of bed at the facility. Resident #701 was able to mouth words and write only due her being connected to the ventilator. She reported that she fell at the facility and pointed towards the left side of the bed (indicated where she had the fall). When asked how she had fallen, she shrugged her shoulders. She communicated needing help at the time. When asked if she was hurt, she became tearful. When asked what was the matter, Resident #701 mouthed, This place. On 5/18/16 at 3:30 p.m., review of Resident #701's Incident and Accident Report, dated 5/6/16 at 5:40 a.m., revealed the following documentation: Resident #701's Resident found by CNA (Certified Nursing Assistant) at 0540 (5:40 a.m.) on floor by bed. Foley and tube feed tubing stretched across bed still intact. Resident un-attached to vent (w/no alarm) without alarm. Resident unresponsive and cyanotic (blue). Resident turned over, Ambu-bagged. Doctor and EMS called. Sent to hospital for evaluation. SPO2 at 56% (oxygen level). The Incident and Accident Report also indicated that Resident #701's bed level was up at a regular height, not down. The Incident and Accident Report indicated that Resident #701 was alert prior to the incident. Witness statements from the staff who were on duty at the time were reviewed and revealed the following: The Registered Nurse's (RN B) written statement, dated 5/6/16, read: Resident found face down on floor next to bed on the door side. Face was on base of IV pole. Vent tubing was disconnected at trach (tracheostomy site) .Resident's left arm was up and hand was behind head .Quarter size bruise noted on inside of left knee. Resident was bagged for 45 minutes before becoming responsive. The Respiratory Therapist's (RT A) written statement, dated 5/6/16, read: RT in another resident room doing care and was alerted by RN (Registered Nurse) to come to room 411 B. I observed resident (#701) lying on her back on the floor unresponsive This RT immediately asked for pulse oximetry (measure of oxygen in blood) and measured SpO2 at 53% (critical low value of oxygen). I grabbed the emergency E tank turned it to flush and RN manually ventilated resident. After about 45 minutes of bagging SpO2 (oxygen level) returned to 96% and resident put back on the ventilator again. On 5/18/16 at 3:50 p.m., review of the Emergency Department (ED) physician's notes, dated 5/7/16 at 6:11 a.m., revealed the following documentation: The patient (#701) presents following it was reported by EMS the patient had a fall sometime this morning. She was found unresponsive but when EMS arrived they explained that she was back on her vent and alert and at her baseline. The patient (#701) was unsure of what transpired this morning but did know that she did fall .Although she has a history of being vent dependent she is able to provide some history and is reliable historian with respect to her current review of systems. Review of the hospital's (acute care) History and Physical, dated 5/7/16 at 8:37 a.m., revealed the following documentation: Reason for Admission; Chief Complaint: Hypoxia (too low oxygen) off of her chronic ventilator at the care facility .The patient is a [AGE] year-old female with a history of chronic respiratory failure ventilator dependent, morbid obesity, hypoventilation, diabetes mellitus type 2, COPD (Chronic Obstructive Pulmonary Disease), previously on 4 liters of oxygen (at home), [DIAGNOSES REDACTED](irregular heart rate), Congestive Heart Failure, Hepatitis C who has been a resident of medical Lodge of (name of current facility) for the past 3 weeks who was found out of her bed unhooked from her tracheostomy and ventilator with oxygen saturation of 70% (extremely low, normal 90-100%). She states that she became unhooked from her tracheostomy and ventilator tube fell on the floor. She was not getting the assistance that she needed therefore she tried to lean over to grab the ventilator tubing and then fell on to the floor. Unclear as to how long she was on the floor. She believes about a half hour. She is able to tolerate some time off the ventilator however she was found to have an oxygen saturation of 70% and brought into the emergency department for further evaluation. She (resident #701) states it was simply related to her becoming disconnected from the ventilator. On 5/18/16 at 4:10 p.m., the Director of Nurses (DON) and the Administrator were queried regarding Resident #701's fall risk at the time of the fall. They were asked if Resident #701 was identified for being at risk for falls and if so where was the plan care and/or interventions that were in place to prevent the fall that occurred on 5/6/16. Review of Resident #701's clinical records, with the DON and Administrator, revealed that there was no Fall Prevention care plan and no documented fall prevention interventions in place at the time of the fall, despite a Fall Risk Evaluation (dated 4/20/16) identified her as being at risk for falls. Per the DON, the Fall Risk Evaluation score was a 14. When queried what a 14 meant. The DON stated, She (#701) was at a moderated risk for falls. On 5/18/16 at 5:45 p.m., review of the facility's policy titled, Falls - Clinical Protocol, revised 2/2013, revealed the following documentation: Based on the assessment an initial plan of care (IPOC) will be developed and implemented to address identified risk. The Minimum Data Set (MDS) will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls. Interventions should be developed and implemented per the assessed needs. ( )

This citation pertains to MI 219 Based on observation, interview and record review, the facility failed to obtain and administer pain medication as ordered by the physician for 1 (#905) of 3 sampled residents that were reviewed for pain medication administration from a total sample of 5 residents, resulting in unnecessary and avoidable pain. Findings include: According to the electronic medical record (emr) review that was reviewed on 5-10-2016. Resident #905 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set had not yet been completed, but the brief interview status was done on 05-06-2016 and reflected a 13 which indicated Resident #905 was cognitively intact. A review of the Medication Administration Record [REDACTED]. Further review of the April 2016 MAR indicated [REDACTED]. A review of the nurses notes dated 4-30-2016 at 13:56 revealed No [MEDICATION NAME] came in the med's (sic) for patient today. The nurses note further reflected the pharmacy, the physician, and the nurse supervisor were all notified.supervisor on call said she would be later to handle it. The Nurse Practitioner (NP) on call asked that an incident report be written up since this women has been here for over 24 hours and not received it. The nurses note on 05-01-2016 11:45 Started to attempt to get patient her [MEDICATION NAME] on 4/30/2016 at 1000 as charted previously. Came in and 20 hours later there was still no [MEDICATION NAME] for the patient. Requested that RN on night shift follow up on this which she did and got orders for the med's faxed . Obtained auth (sic) for the [MEDICATION NAME] ER and administered at 1000 then additional auth (sic) for liquid [MEDICATION NAME] at 1100 which was administered at that time as well. Pain rating went from a 10 to a 2 by 1200. Review of the May 2016 MAR indicated [REDACTED]. The Nurses notes dated May 5 2016 reflected unavailable. notified pharmacy The nurses note dated May 8 2016 read med unavailable Resident # 905 was observed and interviewed in her room on 5-10-2016 at 1:00 p.m. During the interview, resident # 905 was observed to reposition herself in bed and had facial grimacing. When queried about pain she reported the [MEDICATION NAME] usually controls her pain when she receives it. When further queried about receiving her pain medications she reported she could not specifically recall dates of missing doses but it would be very bad if she did not get her pain medicine as prescribed. On May 10 2016 at 3:45 p.m. during an interview with Director of Nursing (DON) C reported this was her second day at the facility and could not speak on the specifics of resident #905 and the [MEDICATION NAME] but her expectation was that all residents receive all scheduled medications as ordered by the physician. On May 10 2016 at 4:00 p.m. during an interview with the Interim DON B she reported that she was not sure why the first dose of [MEDICATION NAME] was not given or available until 4-30-2016 but the May 5 th and May 8 th omitted doses of [MEDICATION NAME] Could just be a hole in the mar. When clarification was asked about The Nurses notes dated May 5 2016 reflected unavailable. notified pharmacy The nurses note dated May 8 2016 read med unavailable Interim DON B stated she was not sure what that meant. On May 10, 2016 at 4:45 p.m. during an interview with the Interim Administrator A she reported she was aware of other issues pertaining to the pharmacy and had recently taken steps end their contract ( )

This citation has two deficient practices. Deficient Practice #1: Based on observation, interview, and record review, the facility failed to implement safety interventions for three (#'s 705, 713 and 717) of five sampled Residents reviewed for accidents out of a total sample of 21, resulting in falls, emergency medical attention, lacerations, a dislodged tracheostomy tube, bruising, and the potential for further accidents/injuries. Findings include: On 2/10/15 at 10:00 A.M., during the initial tour of the facility, Resident #717 was observed lying in bed. When the Resident was asked how she was doing, the Resident said, while raising her right bandaged thumb into the air, "I got my thumb sutured. I got ahold of the toilet paper holder and it was sharp. I got a high toilet seat now. I'm so happy! Lots of us (the Resident and staff) were talking before I fell , about the higher seat. I just kept telling them and telling them (about a raised toilet seat). They (staff) said they had them. I said, 'Why don't you use them?' I needed one and that's why I fell ." A raised seat was observed at this time attached to the resident's toilet. No safety devices were observed installed or attached to the Resident's bed. On 2/10/15 at 10:45 A.M., Nurse Unit Manager "B" was interviewed in regards to Resident #717's raised toilet seat. Nurse "B" said, "She (Resident #717) was in the bathroom, went to stand up, lost her balance, grabbed the toilet paper holder, didn't fall, but cut her hand real bad. Her son was here. Steri-strips wouldn't stop the bleeding, so the son and doctor decided it was best to go to the hospital, and she's on antibiotics for that." When nurse "B" was queried as to if the Resident had requested a raised toilet seat prior to her injury, nurse "B" said, "She talked to us about it afterwards." On 2/12/15 at 9:38 A.M., Resident #717's clinical record was reviewed. According to the admission face sheet, the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #717's Admission Minimum Data Set Assessment (MDS), dated [DATE], the Resident's cognition was intact, required minimal assistance with transfers, mobility, dressing, and hygiene, and was continent of bowel and bladder. Incident Report and Nursing Notes for Resident #717 revealed the following: On 2/7/15 at 3:27 P.M., "Resident transferred self to BR (bathroom) and lost her balance and attempted to catch herself and caught herself on the toilet paper dispenser causing a laceration on her right inner thumb. Resident Description: 'I lost my balance and caught myself on the metal thing'. Ordered Steri-strip to area and if unable to abate bleeding send her to the ER (hospital emergency room )." A Nursing Note dated 2/10/15 documented, "Resident states she needs a boost (raised) seat for her toilet as it is very hard to get up off toilet." On 2/13/15 at 2:00 P.M., Therapy Manager "S" was interviewed. Manager "S" said, "We (therapy staff) put in (Resident's) transfer recommendations (i.e. from toilet to standing) for the team. Therapists write doctors orders for transfer status." Manager "S" was queried if Resident #717 was assessed as needing a raised toilet seat. Manager "S" said, "Oh wait. We do have a work order for that." A "Maintenance Work Order" dated 1/30/15 was reviewed at this time with Manager "S" which read the following: "(Resident #717's room/bed number) needs raised toilet seat for bathroom (by) window per Resident request. Location: (Resident #717's room/bed number). Corrective Action: Referral to PT (Physical Therapy)/OT (Occupational Therapy)." On 2/13/15 at 2:45 P.M., the facility's Director of Nursing (DON) was interviewed in regards to the injury Resident #717 sustained on 2/7/15. The DON when queried as to how the facility's Maintenance Work Orders were processed. The DON said, "There is a work order book at each nurses station and any time maintenance is needed, it's filled out and maintenance checks it daily. I think this Resident switched rooms. Oh no, wait a minute, this (incident) was recent. (Resident #717) hasn't switched rooms since then. Well, obviously therapy was aware. They are the ones that gave you a copy of the work order. I'll have to follow up." On 2/13/15 at 2:50 P.M., Resident #717's bed was observed with Nurse "T". At this time Resident #717 was lying in her bed and said, "I use my wheelchair to help me get up." The Resident then demonstrated by pulling at her wheelchair parked next to her bed and raising herself from a lying to sitting position. On 2/13/15 at 4:10 P.M., Resident #717's Emergency Medical Documents were reviewed, which noted: The Resident received emergency medical care for "Laceration of the finger. A Laceration is a cut or lesion that goes through all layers of the skin and into the tissue just beneath the skin." During an interview with the Administrator on 2/13/15 at 4:13 P.M., the Administrator stated that, per Resident #717's online Emergency Medical Record, the Resident received six sutures to the right thumb. The Administrator did not respond why the 1/30/15 work order for the raised toilet seat was not promptly honored. ( ) On 2/10/15 at 9:40 a.m. during the initial tour, Resident #705 was observed lying in a low bed, with three twin size mattresses on the floor, two on the right side of the bed and one on the left side. The bed frame and mattress Resident #705 was lying on was observed to be 6 to 8 inches above the mattresses on the floor. A tracheostomy cannula (a tube placed into the trachea through an opening in the neck for exchange of air into the lungs) was observed in place at the base of Resident #705's neck. Two large, approximately 2 centimeter (cm) by 2 cm, circular, yellowish/gray bruises were observed on her left lateral forearm. When Resident #705 was queried as to whether she knew how she got the bruises, she looked at both arms rubbed the bruises and nodded "no". Additional observations of Resident #705 during the survey were as follows: On 2/10/15 at 2:20 p.m., observed up in a geri-chair with footrest raised in the hall outside her room awake; On 2/12/15 at 10:45 a.m., observed in bed with mattresses on the floor; On 2/12/15 at 2:35 p.m., observed sitting up at bedside with legs on mattress on the floor to the right side of the bed, crying, with Unit Manager Staff "G" in room. On 2/12/15 at 3:15 p.m., Resident #705 was observed on the mattress on the floor to the right side of her bed, crying, with Social Worker staff "E" in the room. Per Staff "E", Resident (#705) crawled to the mattress on floor from bed. On 2/13/15 at 9:45 a.m. through 11:30 a.m., observed with bed frame removed from room and Resident #705 asleep on the middle of three mattresses pushed together on the floor. On 2/11/15 at 11:30 a.m., a review of Resident #705's electronic medical record (EMR) revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the admission Minimum Data Set Assessment ((MDS) dated [DATE], Resident #705 was severely cognitively impaired and usually able to make herself understood and understand others. The EMR revealed a falls Care Plan dated 1/6/15 that documented: "The resident is High risk for falls related to unaware of safety needs, confusion, poor communication/comprehension, deconditioning and incontinence." Goals included, "The resident will be free of minor injury....the resident will not sustain serious injury...." Interventions included, 1/6/15-"Anticipate and meet the resident's needs. Be sure the resident's call light is within reach. Follow facility fall protocol. 1/9/15- Mattresses bed side at all times when in bed, family in agreement of mattresses bedside for safety purpose...." A Care Plan focus noted: "The resident has potential/actual impairment to skin integrity. Resident is high risk for skin integrity issues has been observed crawling out of bed onto floor and flails arms bumping into bed frame and things within reach. When in chair in hall, has been observed swinging arms and bumping into siderails." Goals included, "The resident will maintain or develop clean and intact skin...." Interventions included, "....Identify/document potential causative factors and eliminate/resolve where possible...." On 2/12/15 at approximately 11:00 a.m., incident and accident (I&A) reports for Resident #705 were reviewed and revealed the following: 1.) 1/8/15 at 9:05 p.m.-Staff was called to Resident #705's room and found "the respiratory therapist (RT) yelling that she could not put the vent (Ventilator-a machine designed to mechanically move breathable air into and out of the lungs) back on patient (#705) as she was lying face first on the floor. The RT and (Nurse) were able to roll patient on her side and re-attach the vent....An assessment was done....no signs of injury....RT explained she was in the room at the time of the fall and heard patient cough and then a loud 'thud'." The family and Physician were notified. On 1/9/15, the corrective action to prevent reoccurrence: "Bolsters were applied to bed." 2.) 1/14/15 at 10:57 p.m.-"CNA (Certified Nurse Assistant) notified nursing that patient (#705) had fallen from geri chair....patient was observed on the floor at the foot of the chair....Resident sent to hospital and immediately sent back....with no action taken and airway intact." The corrective action: Therapy staff "were educated on informing nursing and CNA staff when returning a resident to a room. Resident (#705) not to be left up in chair while unattended." The Physician was notified. A Nursing note documented family was notified. 3). 1/25/14 at 3:29 p.m.-Resident #705 was found sitting on ground with her buttocks on floor, mattress was pushed to side from fall, feet and legs on mattress, family member holding (Resident #705's) head until help arrived." No injuries were noted. The corrective action: Hourly monitoring. Physician and family were notified. 4.) 2/4/15 at 12:00 noon-"found by nurse kneeling next to chair (in hall)....continue to monitor hourly. Resident evaluated by MD (Medical Doctor) several times for anxiety and pain management, and medication reviews done. Resident to be in common area when up in chair. Resident had multiple diagnostic tests run....with negative results." On 2/12/15 at 9:45 a.m., unit Nurse Manager "G" was queried regarding the I&A's for Resident #705. Nurse "G" stated, (Resident #705) has had numerous falls with no injuries. On 1/8/15, she rolled from bed while RT was in the room and bolsters were added, but she was able to climb over them, so they were removed and mattresses were placed on the floor. Then on 1/14/15, returned from therapy and was left unattended in chair in the room. On 1/25/15, slid from bed and 2/4/15, was found kneeling next to her chair in the hall. There were no injuries with any of her falls. Nurse "G" said, "We keep her in view and in activities when possible. We moved her (room) closer to the center where there is more traffic at the hall intersection. Monitoring her closely and psych (mental health services) is involved." On 2/12/15 at 12:02 p.m., Resident #705's brother was interviewed by phone. He said, "Our family's concern is with her falls. She constantly rolls out of bed. At least 10 to 15 times, they have called us to say she fell out of bed....she has rolled out of bed several times. She fell yesterday and pulled out her trach. She has pulled out her trach two times." On 2/12/15 at 2:25 p.m., the Director of Nursing (DON) was queried regarding the falls for Resident #705. The DON said, "(Resident #705) crawls in and out of bed to the mattress on the floor....if the bed and mattress is the same height, we don't do an incident report unless there is an injury. I don't know if it (bed and mattress on floor) was level or not." The facility's fall and I&A policies were requested from the DON at this time. On 2/12/15 at 2:35 p.m., Staff Nurse "D" was queried about a fall for Resident #705 on 2/11/15 as described by her brother. Nurse "D" said, "(Resident #705) was found on the mattress on the floor on the right side of her bed two times yesterday. The second time she de-cannulated (accidentally dislodged the trach tube from the neck opening). It was replaced without concerns. I did do an assessment and progress note related to it. I was told we don't do an incident report if she crawls or rolls to the the lower mattress on the floor." Nurse "D" was unable to say who told him an I&A wasn't required. On 2/12/15 at 3:15 p.m., Social Worker Staff "E" was observed in Resident #705's room. When queried as to what the bed height should be, Staff "E" then proceeded to place the bed to its lowest position. The bed was observed to be 6 to 8 inches above the mattresses on the floor. Further review of the EMR for Resident #705 revealed the following 12 incidents in progress notes with no documented corresponding I&A reports provided: 1.) 1/11/15 at 10:28 p.m.-"Resident (#705) fell out of bed...RT replaced inner (tracheostomy) cannula...." (No documentation of new fall interventions or notification of Physician or family.) 2.) 1/25/15 at 11:32 a.m.-"contacted (name of doctor) related to fall reported to on coming nurse." (No other documentation related to the fall circumstances, time of fall, witness to fall, assessments or injuries that may have been sustained, or notification of family). 1/26/15 "order for mattresses both sides of bed, bolsters removed, continue to monitor hourly." 3.) 1/29/15 at 1:08 p.m.-"....rolled out of bed onto mattresses for 3rd time this shift...." (No documentation of notification of Physician or family. No new fall interventions). 4.) 2/2/15 at 12:41 p.m.-"out of bed onto mattress, placed in chair in hall for safety." (No documentation of assessments for injuries, or of notification of Physician or family. No new fall interventions). 5.) 2/2/15 at 2:20 p.m.-"....Out of bed onto mattress, place patient in chair in hall for safety." (No documentation of notification of Physician or family. No new fall interventions). 6.) 2/7/15 at 7:46 p.m.-"....trying to crawl out of bed." 7.) 2/8/15 at 7:49 a.m.-"....attempting to roll out of bed. Mattress to floor on bilateral sides of the bed." 8.) 2/8/15 10:57 a.m.-"out of bed onto mattress, crying, no pain, bruise, purple, purple/yellow anterior side of left hand 2.5 cm x 2.5 cm, 2 bruises purple/yellow anterior side of left forearm, 2.5 cm x 2.5 cm." (No documentation of notification of family or Physician. No new fall interventions documented). 9.) 2/9/15 at 8:09 a.m.-"Resident anxious and trying to exit bed all night." Resident noted as positive for urinary tract infection." 10.) 2/9/15 at 3:36 p.m.-"....out of bed onto mattress, crying, no pain, bruise (documented the same as on 2/8/15)." (No documentation of notification of family or Physician. No new fall interventions documented). 11.) 2/10/15 at 5:39 a.m.-"....when awake trying to roll out of bed. Resident rolled onto knees at bedside twice. No injuries noted or reported." (No documentation of notification of family or Physician. No new fall interventions documented). 12). 2/11/15 at 3:53 p.m.-"(Resident #705) found in room onto mattress de-cannulated, RT was called into room by CNA, replaced trach....minimal bleeding." Family notified. (No documentation Physician was notified). On 2/13/15 at 10:45 a.m., the DON was queried related to the progress notes about Resident #705 falling or found out of her bed. The DON said, "I reviewed the notes yesterday and saw that there were no I&A's. Yes, they are falls by definition. I'm not sure why or what the confusion was that staff did not think they were falls, but they were. There was a definite change in level between the bed and the floor mattress." When questioned about notification of the family and physician, and new preventive interventions, the DON said, "I understand, they didn't do the I&A reports, so it was not documented that they were notified....Why it was assumed that the lower mattress was not considered a fall, I don't know. Yes, those incidents should have been documented on I&A's....The I&A's would have documented notifications and new interventions. I'm not sure why the I&A's weren't done." ( ) On 2/10/15 at 10:00 a.m., Resident #713 was observed lying in a low bed asleep. The left side of the bed was pushed against the wall. The right side of the bed a bed bolster (soft cushion that is elongated and restricts movement while in bed) attached parallel along with Resident #713's body and mattress. On 2/11/15 at 9:10 a.m., Resident #713 was observed again in bed asleep with the left side of her bed pushed against against the wall and the bed bolster attached to the right side of her bed. Resident #713 was observed in bed throughout the entire survey in this manner at the following times: 2/12/15 at 11:00 a.m., and 2/13/15 at 9:45 a.m. On 2/12/15 at 2:25 p.m., Resident #713's fall incident was reviewed with the Unit Manager (Nurse "B"). The fall of concern revealed the following: The fall of concern occurred on 3/28/14 at 2:00 p.m., per the "Fall" Report provided by the facility. The "Fall Report revealed the following documentation: "Resident found on her bathroom on her right side." Per this report, Resident #713 was oriented to person only; confused to situation, place, time and had an impaired memory. Review of the nurses' notes with Nurse "B" revealed no documentation of the fall incident on 3/28/14. Nurse "B" was queried regarding Resident 713's ambulatory status. Nurse "B" reported that she was not working at the facility at the time of the incident. On 2/13/15 at 1:45 p.m., the Director of Nurses (DON) was queried regarding Resident #713's ambulatory status during the time of the incident on 3/28/14 at 2:00 p.m. She was asked how and why Resident #713 was found lying on the bathroom floor. At this point, Resident #713's occupational and physical therapy notes were reviewed (for the time period of the fall) with the DON. The DON stated, "Someone must have put her there (in the bathroom). She required maximum to moderate assistance with the assistance of two people for transfers." On 2/13/15 at 1:40 p.m., the facility's Licensed Physical Therapy Assistant (LPTA "U") and the Director of Therapy (Therapist "S") were interviewed regarding Resident #713's transfer/mobility status. LPTA "U" stated, "On 3/28/14, Resident #713 was only able to ambulate with a front wheel walker with the support of 75 to 100% assistance. She required 80% support with the assistance of two people. She had poor trunk control." The Director of Therapy ("S") stated, "She required maximum assistance for toileting." Review of the Occupational Therapy notes, dated 3/28/14, indicated that Resident #713 was a fall risk. Also, she required 75% assistance with standing balance. On 2/13/15 at 1:55 p.m., review of Resident #713's Admission Minimum Data Set (MDS) assessment, dated 2/4/14, indicated a mildly impaired cognition, did not walk independently in her room nor in the corridor, required the assistance of two people for locomotion on the unit, and extensive assistance was required for bed mobility with the assistance of two plus people. On 2/13/15 at 4:15 P.M., the facility's policy entitled, "Falls Prevention Program", dated 9/14/14, revealed: "(Facility name) has adopted the RITUAL concept for its fall prevention program. R: Review self-assessment, I: Identify risk factors, T: Test gait and balance, U: Undertake multi-factorial assessment, L: Later, follow-up. The fall prevention program includes all of the following components: Identification of Residents at high risk for falling, Evaluating and analyzing hazards and risks, Implementing appropriate interventions, Monitoring and Modifying. Section 2. Residents are encouraged to participate in their own falls assessment when possible." The "Nursing Policy and Procedure-Fall Prevention" dated 9/14 revealed the following: The facility will identify each resident who is at risk for falls and will plan care and implement procedures to prevent falls. The facility will prevent falls by providing an environment that is free from potential hazards. . .Definition "Fall is defined as or refers to unintentionally coming to rest on the ground floor or other lower level. . .A fall without injury is still a fall.. . .Upon determination that the resident is at risk, the qualified staff initiates immediate fall prevention measures. The fall prevention program assists in identifying the appropriate preventative interventions, which must be recorded on the resident's care plan. If a fall occurs, the qualified staff assess for injury from the fall, immediately investigates the root cause and determines immediate intervention to prevent future falls. The physician and family are notified and an incident and accident report are initiated within 24 hours. . ." The facility policy titled "Accident/Incident Reporting" dated 10/2013 was reviewed and revealed the following: "It is the policy of the facility to actively investigate any accident/incident, witnessed and unwitnessed, and to put a plan of care in place that will assist in preventing further accidents/incidents. Procedure; 1. Staff members who witness accidents/incidents incurred by a resident, or who note that a resident has an injury of unknown origin, shall immediately report the accident/incident to the Charge Nurse on duty.. . .2. The Nurse will complete an assessment of the resident, initiate any necessary medical treatment, take and document the resident's vital signs, and complete an Accident/Incident Report form. 3. One medical treatment has been administered and the resident is stable, the Nurse will contact the resident's attending physician. The date, time, and person contacting the physician must be appropriately documented. 4. The Nurse will also contact the resident's representative or a family member. The name of the representative/family member, date, time and person contacting the family must be appropriately documented. 5. Accident/Incident Report, which is located under Risk management (name computer program) must be completed by the end of the shift.. . .7. The Director of Nursing will submit copies of the Accident/Incident Reports to the Administrator and Medical Director for review. A thorough review of the Accident/Incident report may prompt further investigation. . .Based upon the results of the investigation(s), corrective action will be initiated. . . All accidents and injuries will be logged and tracked. The data will be analyzed monthly to determine possible causal factors and positive or negative trends. . ." ( ) Deficient practice #2: Based on observation, interview, and record review, the facilty failed to secure one of six medication carts, resulting in the potential for accidental ingestion, abuse or diversion of medications. Findings include: On 2-13-15 at 10:12 a.m., an unlocked medication cart was observed in the hallway near room 413. Nine people (staff and visitors) walked by the cart while it was unlocked. Nurse "N" returned to the cart at 10:20 a.m. and locked the cart. When queried about the unlocked cart, Nurse "N" said, "The med cart is to be locked when (I'm) not present." On 2-13-15 at 2:50 p.m., the Director of Nursing was interviewed and queried as to her expectation regarding securing medication carts. She said, "If a nurse is not at the med cart, the cart should be locked." Review of the facility's policy titled, "5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles" revision date 1-1-13, documented: "#3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors." ( )

This citation pertains to intake #MI 754 Based on observation, interview and record review, the facility failed to ensure an in place fall alarm was properly functioning, failed to adjust implemented safety measures, for one cognitively impaired Resident (#901), who was hard of hearing, frequently removed the fall alarm, and who had a known history of falls, out of three Residents reviewed for falls, from a total sample of three, resulting in the Resident experiencing a fall, sustaining a broken humerus (arm), black eye, and requiring emergency medical care. Findings include: On 8/22/14 at 10:25 A.M., Resident #901 was observed sleeping in her bedroom in a low bed. The Resident wore a sling on her left arm and was observed with a black and yellowed circle surrounding her left eye. On 8/22/14 at 12:20 P.M., a telephone interview was conducted with Nurse "B" regarding the fall Resident #901 sustained on 8/15/14. Nurse "B" was the nurse assigned to the Resident on the evening of 8/15/14. Nurse "B" stated, "I know (Resident #901) very well. I've known her for years. She wanders, and is very confused. She looks for her dead husband and is difficult to redirect. We had (fall) alarms on her bed and chair and she has a history of taking them all off, making it difficult to keep her safe. We watch her more than most, because she (Resident #901) is a known safety risk. We were all aware of that. She (Resident #901) was in bed sleeping and got up for dinner. (After the fall) Her wheelchair was there, but she hadn't gotten in it. The closet door was open. She's been repeatedly instructed to use the call light, she never used it. The alarm wasn't going off (after the fall). I don't know if it (the alarm) was broken or what." Nurse "B" continued, "It's on my TAR (Treatment Administration Record, the checking of Resident #901's fall alarm) at 5 (P.M.)." When Nurse "B" when queried as to how she checks fall alarms and if the alarm was ever checked for proper function, Nurse "B" stated, "I do a visual check. I have 40 patients. No, the alarm was never reassessed for function. The only way to check an alarm is to have her (Resident #901) get up, and she was sleeping. I do a visual check to make sure it's (the alarm) in place, but you can't tell if its going to ring." When Nurse "B" was queried as to if she had been told Resident #901 needed to be closely watched because she had been attempting to ambulate unassisted over the past 24 hours prior to the fall, Nurse "B" stated, "We (staff) knew she needed to be watched, but never was told she had been self-transferring (or ambulating) in the past 24 hours (prior to the fall on 8/15/14)." On 8/22/14 at 12:30 P.M., a telephone interview was conducted with CNA "A" (Certified Nursing Assistant "A") regarding the fall Resident #901 sustained on 8/15/14. CNA "A" was the CNA assigned to the Resident on the evening of 8/15/14. CNA "A" stated, "She (Resident #901) was sleeping. I have her (Resident #901) tray. Got her up. She sat up on the side of the bed and I went to go help others. I left the floor (Resident Care Area) to take trays down. She (Resident #901) prefers to eat in her bedroom. It was normal to give her her tray and do other tasks." When CNA "A" was queried as to if it was her responsibility to check the Resident's fall alarm for proper function, CNA "A" responded, "I'm totally unsure about that. I don't remember the last time (Resident #901's) alarm was checked." CNA "A" continued, "When I came back on the floor, everything was chaos (after Resident #901 fell ). She (Resident #901) was crying, waiting on the ambulance." When CNA "A" was queried as to if Resident #901 had ever tried to ambulate in her bedroom unassisted during meal times, CNA "A" responded, "Yes, she (Resident #901) does try and self-transfer a lot. Yes, she had been given a tray before and (Resident #901) would try to walk." When CNA "A" was queried as to if she had reported Resident #901's self transfer and ambulation attempts to a nurse, CNA "A" responded, "No, I didn't tell a nurse. I don't remember when or how often, but it had happened (self transfer/ambulation attempts by Resident #901)." CNA "A" was then queried as to if she had been told that Resident #901 needed to be closely watched because she had been attempting to ambulate unassisted over the past 24 hours prior to the fall. CNA "A" responded, "It's been known to watch her close because she has a history of trying to get up." On 8/22/14 at 12:50 P.M., the facility's Assistant Director of Nursing (ADON) was queried as to why Resident #901 did not eat her dinner in the dining room on 8/15/14 per the Resident's Care Plan. The ADON stated, she (Resident #901) normally did go to the Dining Room, I don't know why she didn't that day. Let me call the DON to find out." On 8/22/14 at 1:15 P.M., Unit Manager, Nurse "D", was interviewed in regards to the fall Resident #901 experienced on 8/15/14. Nurse "D" stated, "The CNA (CNA "A") told me the Resident (Resident #901) asked to eat dinner in her room that day. It wasn't unusual, she was pretty non-compliant. She had a tab alarm and would take it off." When Nurse "D" was queried as to if Resident #901 tried to self-transfer or ambulate unassisted, Nurse "D" stated, "It's often she attempts to do that." When Nurse "D" was queried as to how she balanced a Resident with impaired cognition's request to eat in her room alone with maintaining safety, considering she disarms the fall alarm and self ambulates. Nurse "D" stated, "I started asking the CNA's to take her to the Dining Room anyway (after the fall with injury) against her wish, unless a CNA has time to sit with her, which is not often. She has to go to the Dining Room for safety. Once the Resident is in the Dining Room she is ok." When Nurse "D" was queried as to her expectation in regards to checking fall alarms for placement and function as the Unit Manager, Nurse "D" stated, "The nurses are required to check alarms. CNA's usually check them and report problems to the nurse. It's an actual function check. If Resident is laying on them, move the Resident (alarm sounds when Resident moves, if alarm is properly functioning). There is no indicator light on these (fall alarms). Visual assessment (of a fall alarm) is definitely not adequate." On 8/22/14 at 1:30 P.M., the "Fall" Occurrence Report, Fall "Incident Investigation Tool", staff's written "Investigation Statements", and emergency room Report, each regarding the fall Resident #901 sustained on 8/15/14, were reviewed. A Review of the "Fall" Occurrence Report revealed the following: On 8/15/14, "Resident found sitting on floor between end of bed and closet door at 7 P.M., c/o (complains of) left arm and shoulder pain at rest with increase in pain with movement. One centimeter laceration above left eye with one centimeter raised bruise to left of eyebrow. '(Resident stated) I fell and broke my arm (crying) it really hurts. I can't move it'. Predisposing Physiological Factors: Confused, Gait Imbalance, Impaired Memory. Non-complaint with instructions to use call light and not to ambulate without assistance. Confused at times and has a history of shutting off sensor alarms. Sensor alarms were not sounding." A review of the Fall "Incident Investigation Tool", dated 8/15/14, revealed, "Factors that may have attributed to fall: High risk for falls, confusion, hx (history of) getting up unassisted, non-compliant with alarms and call light." A review of an unsigned "Investigation Statement", dated 8/16/14, by CNA "A" (Certified Nursing Assistant "A"), revealed, "Dnner trays came up around 5:30 to 6:00 P.M., I assisted her onto the side of the bed and put her tray in front of her to eat. She started eating and this is normally where she eats her dinner. I picked up her tray at about 6:55 P.M. She was still eating her fruit and drinking her tea so I left those two items at her table. Her call light was within reach and she had gripper socks on. She did not need anything at this time and I left the room." A review of an unsigned "Investigation Statement", dated 8/16/14, by Nurse "B", revealed, "At 7:00 P.M., on 8/15/14 Resident (#901) was observed sitting on the floor in room in between end of bed and closet. Closet doors were open. At time of the fall, the bed alarm was not sounding." A review of Resident #901's emergency room "History and Physical" (emergency room Medical Report) with a noted admitted [DATE], revealed, "(Resident #901) apparently had a trip and fall, landing on her left shoulder and afterwards having severe pain. The patient had told the ER (Emergency Medical Room) at that time she was having 9/10 (9 out of 10, with 10 being most severe) pain. The patient (Resident #901) is unsure during her fall whether or not she hit her head, although she does have ecchymotic (bruise as a result of when blood escapes from veins when there is a sudden blow to a certain area) area just above the left eye. Pertinent past medical history of [REDACTED]. Imaging: Xray of left shoulder and humerus (arm) with the following impression: left humeral fracture involving the surgical neck with shortening and angulation." On 8/22/14 at 1:45 P.M., the Rehab (Therapy) Director was interviewed in regards to Resident #901's physical abilities prior to the fall the Resident experienced on 8/15/14. The Therapy Director indicated that Resident #901 was receiving both Occupational Therapy and Physical Therapy from 5/12/14 up until the time of her fall on 8/15/14. The Rehab Director indicated, and provided a physician's orders [REDACTED].#901's transfer status, which was set and unchanged since 5/12/14, was a 2 Person (physical assist) with gait belt. A review of therapy notes with the Rehab Director revealed that, as recent as 8/7/14, the Resident required supervision for walking. On 8/22/14 at 2:00 P.M., Physical Therapist "C" (PT "C") was interviewed in regards to Resident #901's physical abilities prior to the fall the Resident experienced on 8/15/14. PT "C" stated, "She (Resident #901) has bilateral OA (Osteoarthritis). She has pain and drags her right toes because of the pain. She is not fully weight bearing in the right leg due to the pain. She needs a lot of cueing (verbal reminders for safety) and is hard of hearing. In her room she goes to the bathroom by herself -- I caught her doing that and go and assist her. It is dangerous." When PT "C" was queried as to if the Resident was wobbly during ambulation, PT "C" indicated that the Resident was "unstable due to the pain, not due to muscle weakness." On 8/22/14 at 2:05 P.M., a review of additional "Fall" Occurrence Reports for Resident #901 revealed the following history of falls for the Resident: 1) On 5/5/14 at 11:22 A.M., "Resident fof (found on floor) on right side, next to bed. Bed in lowest position. Resident has bruise on right forehead, with bump. Resident had been restless, but unable to sit up in w/c (wheelchair). Ambulance here to transport to hospital for mental status changes. Prior to leaving, Resident was non verbal, eyes open, restless, not able to hold herself up in sitting position. Predisposing Physiological Factors: Weakness/Fainted." 2) On 5/13/14, "Nurse was walking by Resident's (Resident #901's) room on 5/13/14 at 0230 (2:30 A.M.) and found Resident standing by the bathroom door. Resident was very weak and unable to walk. The nurse tried to get Resident to sit in her w/c, Resident unable. Nurse lowered her (Resident) to ground. Resident was carrying her tab alarm (alarm not sounding as Resident had removed alarm). Tab alarm was placed again on Resident. Predisposing Physiological Factors: Confused, Drowsy, Incontinent, Recent Illness, Weakness/Fainted, Gait Imbalance." On 8/22/14 at 2:30 P.M., a review of Resident #901's Nursing Notes revealed the following regarding the Resident's gait patterns and/or unassisted ambulation attempts: 1) On 5/5/14 at 11:09 A.M., "Resident fof (fell on floor) prior to going to hospital. Resident not talking to staff, but eyes open. Unable to sit up/falls over. (Physician) orders to transfer to hospital for evaluation/mental status change." 2) On 7/1/14 at 4:39 A.M., "No change in behavior tonight from the Resident's "usual" normal behavior. The staff assisted the Resident back to bed after she ambulated to the bed with one assist. Her gait and balance is unsteady and requires assist of one to two (staff) at times." 3) On 7/26/14 at 6:48 A.M., "Resident turned her bed alarm off so we did not hear her get out of bed to use the toilet." 4) On 7/27/14 at 1:10 P.M., "Remains not compliant with asking for assist with using the restroom. She turns bed pad (fall) alarm off." 5) On 8/14/14 at 7:00 A.M. (one day before Resident #901 fell and sustained broken arm and black eye), "The Resident was transferring self throughout the noc (night) without assist and was seen turning her bed/chair alarm off. I explained multiple times to the Resident not to turn her alarm off, but she continued to say "what what" as if she couldn't hear me. The Resident was caught ambulating in the room, also without assist and was also instructed not to do that and to call for assist. The Resident continued to act as if she couldn't hear. The staff was informed of the Resident's behavior and activities and to monitor her closely." On 8/22/14 at 2:55 P.M., Resident #901's clinical record and Care Plans were reviewed. A review of Resident #901's facesheet revealed the Resident was admitted into the facility on [DATE] and readmitted on [DATE] and 8/17/14 (after receiving hospital emergency medical care after the fall sustained in the facility). The facility's admitting [DIAGNOSES REDACTED]. A review of Resident #901's "Fall Risk Assessment", dated 5/13/14, revealed, "Score: 14. Category: Moderate Risk (to experience a fall in the facility). Reason for Assessment Request: New Admission. History of falls within last 6 months: No History. Memory and Recall Ability: Sometimes. Continence: Occasional incontinent. Gait Analysis: Exhibits loss of balance while standing, Requires hands-on assistance to move from place to place, Has lurching, swaying or slapping gait." The "Fall Risk Assessment" did not reflect the falls Resident #901 sustained on 5/5/14 or 5/13/14 at 2:30 A.M. A review of Resident #901's most recent Comprehensive Minimum Data Set Assessment (MDS), dated [DATE], revealed the Resident had severely impaired cognition, exhibited fluctuating inattention, and disorganized thinking. The MDS indicated the Resident required extensive assistance of one staff person physical assist for transfers (i.e. from bed to wheelchair), and limited assistance of "one staff person physical assist" for eating and for walking around in the Resident's bedroom. According to the MDS the Resident was frequently incontinent of bladder, occasionally incontinent of bowel and was "not steady, only able to stabilize with staff assistance" during walking and moving from seated to standing position. The MDS also revealed that at that time, the Resident had experienced two falls without injury since admission into the facility. A review of the physician's orders [REDACTED].#901, revealed, "Pressure alarms to bed and chair. Fall Prevention." A review of Resident #901's Meal Care Plan, the Plan of Care which was in place at the time of the fall on 8/15/14, revealed, "Focus: Requires assistance to maintain function for self-sufficiency for eating related to cognitive deficit, poor dentition. Supervision required. Interventions: Eat meals in unit dining room. Date initiated: 1/17/14." A review of Resident #901's Mood/Behavior Care Plan, the Plan of Care which was in place at the time of the fall on 8/15/14, revealed, "Focus: Potential for alteration in mood/behavior aeb (as evidenced by) Resident is at risk secondary to use psych meds. Interventions: Speak up as she is HOH (hard of hearing) and repeat as needed to assure needs are met. Dx ([DIAGNOSES REDACTED]." A review of Resident #901's Fall Care Plan, the Plan of Care which was in place at the time of the fall on 8/15/14, revealed, "Focus: Risk for falls characterized by multiple risk factors related to: unsteady gait, pain, non-compliance with mobility aide use, visual and hearing deficit. Goals: No injury from falls, decreasing number of falls. Interventions: Reinforce need to call for assistance. Pressure pad alarm to bed and chair. Date Initiated 5/14/14." The Fall Care Plan made no mention of Resident #901's history of "turning of sensor alarms" until 8/16/14, the day after the resident sustained [REDACTED]. On 8/22/14 at 4:55 P.M., the facility's Administrator, Assistant Director of Nursing (ADON), and Unit Manager Nurse "D", were interviewed in regards to the fall Resident #901 experienced on 8/15/14. When queried as to why witness statements regarding the incident were not signed by the actual witness, the Administrator stated, "Interviews were done on the phone because it (Resident #901's fall) happened on the weekend. I guess we could've had them (the witnesses) sign them (witness statements) later." When queried as to how a Resident's fall alarm should be checked, the ADON responded, "Q (every) shift, you (staff) should unplug it and make sure it goes off. Check for placement and function." The Administrator, ADON, and Nurse "D" agreed the functionality of a Resident's fall alarm should still be assessed if the Resident is sleeping." The facility's policies on falls, fall prevention and fall alarms (checking placement and function) were requested. On 8/22/14 at 6:00 P.M., the facility's policies regarding falls and fall alarms were reviewed. A review of the facility's policy entitled, "Fall Interventions - Alarm Audit", undated, revealed, "1. Each facility should audit the number of alarms that they have and their trend in falls. Alarms will be checked on every shift and documented on the TAR." The policy as provided did not indicate the manner in which fall alarms should be "checked" to ensure proper function while in place nor did it indicate whose responsibility it was to ensure proper function of the alarms (nurse or Certified Nursing Assistant). A review of the facility's policy entitled, "Fall Risk Assessments", Revised 10/2013, revealed, "Policy: The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each Resident to prevent avoidable accidents. Procedure: 1. As part of the admission process, a Licensed Nurse will conduct a Fall Risk Assessment to determine the Resident's risk for falling. 2. If, through evaluation of the findings entered onto the assessment form, the Resident is determined to be at-risk for an accident: a. the Resident's physician shall be notified, b. orders shall be obtained for the necessary referrals and/or safety devices, c. Physical and/or Occupational Therapy shall be notified to conduct screens and make recommendations, d. A care plan shall be initiated that addresses the Resident's risk." A review of the "Fall Reduction Program", undated, revealed, "Practice Guidelines: 1. The qualified staff assesses all Residents for fall risk. 2. Upon determination that the Resident is at risk, the qualified staff initiates the fall prevention measures. 5. If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls. Identification of a Fall Risk: Fall risk is identified through the Nursing Assessment form completed upon admission. If a Resident scores 10 or more then the Resident is identified as a fall risk and the Fall Prevention Program should be implemented on that Resident. Fall Triggers Parameters: Level of consciousness, History of falls past 3 months, Ambulation/elimination status, gait/balance, medications, predisposing disease." ( )

This citation pertains to intakes MI 672 and MI 673. Based on interview and record review, the facility failed to complete a clinical assessment and failed to provide emergency medical treatment for [REDACTED].#101) of four sampled Residents, from a total sample of four, resulting in a transfer to the hospital for emergency life support treatment and an Immediate Jeopardy (IJ) to the health and safety of the resident and the potential for serious harm/and or death. The IJ was identified on [DATE] at 3:00 p.m. The Administrator was notified of the IJ on [DATE] at 9:00 a.m., and a plan of correction was requested to remove the IJ. The IJ was removed on [DATE] at 4:45 p.m., based on the facility's implementation of corrective action, and verified on [DATE] during the on-site extended survey. Although the IJ was removed, the facility's deficient practice remained isolated with the potential for more than minimal harm that was not immediate jeopardy. Findings include: A review of the closed medical record on [DATE] at 11:00 a.m., revealed that Resident #101 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #101 was identified to be alert with confusion, scoring a ,[DATE] on her BIMS (brief interview for mental status), and required total assistance for all activities of daily living. During an interview on [DATE] at 2:40 p.m., Resident #101's daughter said that on [DATE] at approximately 5:00 p.m., she walked into her Mother's room and knew immediately that something was wrong with her (Resident #101) because she could not move her arms, her eyes, or respond verbally to the family. Resident #101's daughter said that she asked the nurse (Licensed Practical Nurse 'C') what was wrong, or if something had happened to the Resident, and Licensed Practical Nurse 'C' said nothing was wrong with Resident #101, and that she (Resident #101) just, "didn't feel like talking". Resident #101's daughter said that she called '911' because the nurse would not even look at, or assess the Resident to see what was going on. According to the EMS (Emergency Medical Services) run sheet date [DATE] at 5:18 p.m., reviewed on [DATE] at 2:45 p.m., Resident #101 was observed to have unreactive pupils that deviated to the left, could not respond to painful stimuli, and was short of breath. Resident # 101 was immediately taken to the nearest emergency room . During an interview on [DATE] at 2:45 p.m., the EMS first responder said that on [DATE] at approximately 5:15 p.m., he saw Resident #101 from the doorway and immediately knew the Resident had a stroke. The EMS first responder said that Resident #101 was slumped to the left, her eyes and mouth were also deviated to the left, and she did not respond to any painful stimuli. There was no nursing staff at Resident #101's bedside during their (EMS)arrival, only the Resident's family. The EMS first responder said when the nurse arrived in the Resident's room, she (the nurse) could not answer any of his questions regarding the Resident's vital signs, medications, or even what her [DIAGNOSES REDACTED]. According to the emergency room records dated [DATE] at 5:54 p.m., Resident #101 was completely unresponsive to painful stimuli and had a fixed gazed with unreactive pupils that deviated to the left. Resident #101 was immediately placed on life support and had a CT scan of the head. On [DATE] at 6:45 p.m., Resident #101 was diagnosed with [REDACTED]. Due to poor prognosis and a very minimal chance of recovery, the Resident's family decided on a terminal wean. On [DATE] at 4:38 p.m., Resident #101 expired and was pronounced dead at the hospital. A review of the nursing notes by Registered Nurse (RN) 'E', dated [DATE] at 3:13 p.m., revealed that Resident #101 was tearful and anxious earlier in the shift, and was given a [MEDICATION NAME] ( anti-anxiety). Nursing notes dated [DATE] at 6:25 p.m., documented by Licensed Practical Nurse (LPN) 'C' reported that during shift change, RN 'E' reported that Resident #101 had not been responding verbally to her. There is no further nursing notes, or documentation to support any assessments were completed by either RN 'E', or LPN 'C'. During an interview with RN 'E' on [DATE] at 9:25 a.m., she said that Resident #101 was very anxious and tearful in the morning, but could not say what was wrong. RN 'E' said she gave Resident #101 a [MEDICATION NAME] because the Resident was displaying signs of anxiety, and that the Resident seemed fine after that. RN 'E' said that she did not complete any assessments of the Resident because she seemed to be sleeping the rest of the day. During an interview with Certified Nursing Assistant (CNA) 'F' on [DATE] at 9:45 a.m., she said that she repositioned Resident #101 a couple times throughout the day on [DATE], and noticed that Resident #101 did not say anything to her. CNA 'F' said that Resident #101 usually said "Don't", "No", or "Ouch", during repositioning, and she reported it to the nurse (RN 'E') that Resident #101 had not said anything all day. During an interview with LPN 'C' on [DATE] at 12:45 p.m., she said that the day shift nurse reported to her that Resident #101 had not verbalized anything all day, even during care. LPN 'C' said that she did not complete any assessments because the Resident looked "O. K". LPN 'C' could not explain why she did not complete any neurological assessments, or any other types of assessments when Resident #101 was displaying a change in condition. LPN 'C' said she did notify the physician that Resident #101 was being transferred to the hospital per the family's request. During an interview with the Physician 'G', on [DATE] at 10:20 a.m., he said that LPN 'C' called him to say that Resident #101 was being sent out to the hospital because the family insisted upon it. The Physician said that LPN 'C' could not answer any of his questions regarding the status or condition of Resident #101,and that she (LPN 'C') kept saying, "I don't know". According to the facility's 'Concurrent Review' policy, and the 'Notification of Physicians regarding changes in Resident's condition' policy, both revised on ,[DATE]; the licensed staff will document any change in Resident's mood, behavior, level of consciousness, or motor skills on the clinical record and immediately report these findings to the physician. According to the facility's 'Neurological Assessment' policy (undated), when a Resident presents with a change in condition the licensed nursing personnel is to complete the following; 1) determine state of consciousness, 2) observe speech pattern, 3) check pupil reaction, 4) determine motor ability, (strength of extremities) 5) have Resident smile. These assessments and findings are to be documented in the Resident's clinical record and the Physician and the Nursing supervision notified of any changes or abnormalities of the assessment. The facility submitted a plan of correction (POC) dated [DATE] that indicated the following; Corrective Actions for Residents Affected: Resident #101 no longer resides in the facility Identification of Others with Potential to be Affected: Residents who reside in the facility are at risk for a similar occurrence. Clinical rounds were made on the residents who reside in the facility to ensure that there were no similar occurrences. The rounding did not identify any other residents that were in need of immediate intervention. Resident conditions were updated accurately during " Grand Round " and the 24 hour reports. Measures to Prevent Recurrence: The Afternoon nurse involved in this occurrence is no longer employed at the facility, the day shift nurse for resident #101 was counseled as a result of this occurrence. All nurses on all shifts were in-serviced on the following policies: " Resident Examination and Assessment " , " Neurological Assessment " " Concurrent Review " , Transcription of Physician order [REDACTED]. Residents who reside in the facility who are not at-risk will be observed/assessed once (1) at each shift change and again in once (1) the middle of the shift by the nurse or nurse designee and more often if needed. Clinical observations will take place at 7am, approx. 11am, 3pm, approx. 7pm, 11pm and at approx. 3am. Residents who are at-risk will also be observed/assessed by the nurses at 7am, approx. 11am, 3pm, approx. 7pm, 11pm and at approx. 3am or more frequently which will be determined by condition after review with a nurse manager. CNAs will continue their rounds and report any condition changes to the nurse. Resident condition changes that do not need immediate intervention are reported to the nurse manager for further assessment, the physician will be called and informed of the change and any changes in treatment. Residents with a more significant change in condition will be assessed immediately, the physician will be notified and EMS will be called if necessary. Additional follow-up of patient condition changes that are discussed in " Grand Rounds " and clinical stand-up will occur in the Afternoon Clinical Stand-down. Monitoring of Corrective Actions: Communication of resident condition changes will be reviewed during " Grand Rounds " , Clinical Stand-up and at the Afternoon Clinical Stand-down to ensure that nurse manager communication, proper assessment, physician notification and appropriate action takes place. The DON and ADON will be responsible for ensuring compliance. A report will be made monthly to QA for review. Compliance date [DATE] ( )

This citation refers to intake number MI 282 Based on observations, interviews and record review, the facility failed to provide safe mechanical ventilator services to a ventilator dependent Resident, by using a Heat Moisture, Exchanger (HME) device that is contraindicated for Residents with copious amounts of secretions, which caused multiple episodes of respiratory distress for one (#504) of three sampled Residents reviewed for ventilator services from a total sample of six, resulting in an Immediate Jeopardy when Resident #504 experienced multiple episodes of respiratory distress, loss of responsiveness, hospitalization , and the potential for serious injury, harm or death. The Immediate Jeopardy (IJ) was identified on [DATE] at 9:10 A.M. The Director of Nursing representing the Administrator was notified of the IJ on [DATE] at 1:00 P.M. A Plan of Correction was requested to remove the IJ. The Immediate Jeopardy was removed on [DATE] based on the provider's implementation of corrective actions on [DATE] as verified on site and per documentation on [DATE], during the completion of the extended survey. Although the IJ was removed, the Facility's deficient practice was not corrected and remained as isolated, actual harm that is not immediate jeopardy. Findings include: According to a Clinical Record review on [DATE] at 11:00 A.M., Resident #504, was originally admitted to the facility in 2010 and had multiple readmission's following hospitalization s with the latest readmission on [DATE]. According to the face sheet and physician history and physical sheets, Resident #504's [DIAGNOSES REDACTED]. According to the Minimum data Set Assessment ((MDS) dated [DATE], Resident #504 was severely cognitively impaired and required staff assistance of two persons for all activities of daily living. Observations of Resident #504 on [DATE] were made at approximately 10:20 A.M. and 1:25 P.M., on [DATE] at 9:15 A.M. and on [DATE] at 9:15 A.M., Resident #504 was in his room in bed connected to a ventilator (a machine designed to mechanically move breathable air into and out of the lungs). Resident #504 had tubing attached to his [MEDICAL CONDITION] (tube surgically placed into the windpipe to provide an airway and remove secretions), with an inline suction device, an HME (Heat Moisture Exchanger/artificial nose), and a peep (positive end-expiratory pressure) valve, which then attached to the ventilator. The HME was a small oval shape device and was in place during all aforementioned observations. The HME was later identified by the facility Director of Respiratory Therapy(DRT) as being the new smaller lighter type HME. In interviews on [DATE] at 9:30 A.M. and 3:15 P.M., the (DRT), said the facility changed to a new type of (HME) which are smaller, lighter and produce more humidity for residents on Mechanical Ventilators. She said all residents including (Resident #504) had the new HME in place except one. The DRT was not able to say when the new HME's began to be used on residents but she thought it was May or [DATE]. When queried, The DRT said facility staff nurses and Respiratory Therapists had spoken to her about concerns with (Resident #504) having increased hospitalization s and having been found unresponsive requiring "bagging" (use of an Ambu bag and oxygen to provide respirations) and requiring 911 (Emergency Medial Services) to be called with subsequent transfer to the hospital. On [DATE] at 11:12 A.M., the DRT said she follows the AARC guidelines and bases all her policies and procedures on their Clinical Practice Guidelines. The DRT was queried regarding the "American Association for Respiratory Care (AARC) Clinical Practice Guidelines for Humidification during invasive and noninvasive Mechanical Ventilation: 2012" that states; "1.0 Description-When the upper airway is bypassed during invasive mechanical ventilation, humidification is necessary to prevent hypothermia, disruption of the airway epithelium, [MEDICATION NAME], atelectasis, and airway obstruction . . . two systems , active humidification through a heated humidifier (HH) and passive humidification through a heat and moisture exchanger (HME), are available . . . " When queried regarding the AARC's 2012 contraindication for use of HME's, "4.1 use of an HME is contraindicated for patients with frank bloody or thick, copious secretions." The DRT said "we have always used HME's for everyone. . . (Resident #504) has always had large amounts of secretions and required a lot of suctioning. We have a PRN (whenever necessary) clause that the (HME) can be changed more often as needed. The DRT said "we do not have a policy on humidification for vent patients." The DRT said there was no documentation of what type HME a resident is using. She said "we are going to trial (Resident #504) on a HMEF (an HME with a filter), which doesn't have the contraindication the (currently used) HME had . . . if it works we may change everyone to it. If not, for (Resident #504) we may have to go back to (name of previous HME used) if staff thought it was better or a heated wire." A clinical record review on [DATE] at 11:00 A.M., of a Physician order [REDACTED].#504) to an acute care hospital for evaluation and treatment, [DIAGNOSES REDACTED]. Review of a Nurse's note dated [DATE] at 6:00 A.M. and signed by Staff Nurse ("J"), documented Resident (#504's) unit (Ventilator) beeping, staff found resident "white as a sheet with a very weak pulse. Cardiopulmonary Resuscitation (CPR) started and 911 called. RT's (Respiratory Therapists) bagging resident. 6:10 A.M. EMT's (Emergency Medical Technicians) arrived and stabilized resident. Resident sent to (name of hospital)." Review of a Respiratory Therapy (RT) flow sheet dated [DATE] to [DATE], documented Resident #504 had large/copious/frothy amounts of sputum on [DATE] at 1:00 P.M. and 6:05 P.M. The RT flow sheet documented an assessment note dated [DATE] at 6:15 A.M., signed by RT (employee "F"), which documented Respiratory Therapist's ("F") and ("M") were called into the room by a Certified Nursing Assistant (CNA). "Upon entering (the) room patient (Resident #504) not breathing, HME and flex tube completely clogged, patient had no pulse and was gray/blue in color and unresponsive. (We) began bagging patient and CPR (Cardiopulmonary Resuscitation). Patient HR (heart rate) came back after sternal rub and compressions. Pt. began breathing while bagging with o2 (oxygen). EMS (Emergency Medical Staff) and Nurse notified and present. Patient sent to hospital. Patient off vent (bagging only) until EMS arrived 6:40 A.M. On [DATE] at 12:00 noon, staff nurse (employee "J") said that on [DATE], she was in another room and "heard (Resident #504's) alarm sounding a lot. . . I went in and he (Resident #504) had a lot of mucus in his tubing, it is not unusual for him. The RT's were suctioning him and preforming CPR and brought him back. . . They give him [MEDICATION NAME] and he has been on [MEDICATION NAME]es (drugs used to decrease excessive pharyngeal, tracheal, and [MEDICATION NAME] secretions). Staff Nurse ("J") said "some of the RT's say that for some of the residents with increased secretions the (new) HME's can't handle it." On [DATE] at 11:20 A.M., RT (employee "F") said the new HME's let secretions go through and can fill the tube because they have no filter. RT ("F") said "for residents who have increased secretions it can fill the HME, expiration valve and possibly the peep valve (circuit) . . . At times (Resident #504) can have a lot of secretions like with a sudden cough. It is a problem. You can suction him and a few minutes later it's (circuit) filled and we have to bag (use Ambu bag and Oxygen for respirations) and change out the (circuit). He (Resident #504) kind of explodes and fills everything. Previously with the old equipment (HME) that never happened . . . The (new HME) seem to work well, except for residents with a lot of frothy secretion . . . (the new HME's ) don't set off the high pressure alarm as soon. The secretions can fill more of the tubing before it alarms and we may need to bag the resident to change everything (circuit). I think it can be a concern for residents with increased secretions like (Resident #504)." When queried regarding the contraindication on the manufactures packaging for the new HME, RT ("F") said he had read it and it described (Resident #504). On [DATE] at 11:25 A.M., RT (employee "M"), said that on [DATE], "I could see his (Resident #504) color was off just walking into the room." RT ("M") said he and another RT ("F") entered the room. "I (RT "M" ) checked . . . and did not get a pulse, and no oxygen sat (measurement of oxygen available in blood). I grabbed the Ambu bag and RT ("F") disconnected the vent. . .set oxygen on 100% per oxygen tank. I ("M") did breaths and RT ("F") did compressions, maybe 5 or 6, then I checked his (Resident #504) pulse and he had a sudden bounding pulse, we stopped CPR, and his (#504)'s HR came back to 120 and his (oxygen) sat was in the 90's. EMS arrived and put him on their vent. . . I (RT "M") know there was a lot of secretions in the flex tube and into the HME . . . " When queried if this was the first time he (RT "M") had treated Resident #504 for respiratory distress, RT ("M") said "no, but that was by far the worst. . . Once he was cyanotic, well into respiratory distress, the tubing was all clogged with secretions. . . Three times in 1 month he clogged his circuit and was sent to the hospital in August. I can't recall any other resident that has had to be sent to (the) hospital for increased secretions that clogged the system to that point. He (#504) has always had periodic increased secretions. I think it's related to this HME (new), with the old type it was larger and could handle more secretions and had a filter. I never saw secretions go through the HME and into the circuit before. I (RT "M") can't think of any other residents who have had respiratory distress related to filling the system. The (new HME) is the only packaging I'm aware of with that contraindication (not to be used in patients producing fulminating, frothy secretions). I would say it's related to the (smaller)size . . . I believe I did speak to (DRT) about the HME getting filled up with secretions and that it had contraindications. It didn't seem like it was good to use it for him (Resident #504). A handful of residents here would benefit from the larger HME. Further review of the Clinical Record on [DATE] at 11:00 A.M. revealed a physician progress notes [REDACTED].#504) incurred a cardiopulmonary arrest on [DATE] secondary to mucus plugging. Review of a Nurse's note dated [DATE] at 8:30 A.M. signed by Staff Nurse ("D"), document she "found resident (#504) high pressuring (alarming). Resident was diaphoretic (excessive sweating, commonly associated with medical emergency) and cyanotic (blue or purple coloration of skin or mucous membranes). The HME was completely blocked with secretions. . . Resident's oxygen saturation decreased (to) 50's, (normal level 97%-99% for healthy individual) pulse ,[DATE] (normal 60- 100 for healthy individual), respirations 8 (normal 12 to 20 for healthy individual). Unable to get a response . . . to tactile stimulation or chest rub. . . RT's in and changed HME, suctioned resident for 10 minutes. Resident was bagged until (oxygen) saturation increased to 98 %. . . Resident unresponsive. Resident's skin color started to improve after 15 minutes . . . opened eyes. . . " Review of a Respiratory Therapy flow sheet dated [DATE] to [DATE], documented an assessment dated [DATE] at 9:20 P.M., "Resident (#504) having difficulty with large amount of white frothy sec's (secretions) coming out [MEDICAL CONDITION] and orally. [MEDICAL CONDITION] mouth of continuous large amount of secretions Sats 98% (oxygen saturation levels), HR (heart rate) increased to ,[DATE] secondary to secretions. Notified Nursing. 10:30 P.M., Resident (#504) continues to have difficulty with large amount of white frothy secretions coming out [MEDICAL CONDITION] mouth. Sat's 98%, HR 128 at this time. Reported to nursing of continuous difficultly maintaining airway with copious large amounts of secretions. 11:40 P.M., Resident (#504) sats 98%, increased HR 126 at this time. Resident continues to have difficulty with large amounts of white frothy secretions. BS (breath sounds) diminished bilateral throughout lung fields. Nursing notified." The flow sheet documented Resident #504 was suctioned at 9:20 P.M., 10:15 P.M., 11:35 P.M., 12:15 A.M., 3:40 A.M., 4:10 A.M., and 9:30 A.M.. The Respiratory flow sheet dated [DATE] to [DATE], documented on [DATE] at 8:20 A.M. Resident #504 had large amount of sputum and was unresponsive, o2 sat 97%, HR 120. In a phone interview on [DATE] at 10:00 A.M. staff nurse (employee "D") said on [DATE] in the morning she was told by a facility aide (CNA), (employee "E" ) to come to (Resident #504) now. Nurse ("D") said (Resident #504) was cyanotic and his HME was completely clogged up with secretions . . . We were able to get him back, the RT's bagged him for a few minutes and he came around. Nurse ("D") said she talked with Respiratory Therapist (employee "F" ) who found the older type of HME that is larger and replaced it (the new HME). . . It (respiratory distress related to secretions filling tubing and HME) had happened to him (Resident #504) once before . . . a few weeks earlier." In a phone interview on [DATE] at 11:40 A.M., CNA (employee "E") said in August (not able to recall date) she and (Staff Nurse "K") "went in the room and I thought he (Resident #504) was dead." CNA "E" got another Nurse (employee "D" ) and said, "When we ("E" and "D") got there the RT was in the room already, he increased the oxygen and bagged him (Resident #504) and his color improved. . .(Resident #504) has a lot of secretions at times, it comes and goes fast, it is not unusual for him. The staff complains that the (new) HME's fill up often and the tubes pop off. I see the tubing often getting more secretions in them. On [DATE] at 2:10 P.M., Staff Nurse (employee "K") said in August (Resident #504) had two episodes of distress (unable to recall date). One day about 6:30 A.M., She observed the crash cart outside Resident #504's room and two RT's (employees "F" & "M") and a Nurse (employee "J") were "bagging and suctioning him (Resident #504) and got a pulse back. . . The second time I (Nurse "K") was in the room . . . and looked over at (Resident #504) and he . . . had no alarms sounding, was pale and unresponsive, the tubing and HME was completely filled with secretions, clear white. I was suctioning him and RT ("M") was bagging him and had him on 100 % oxygen. His color came back . . . his Nurse (employee "D") got a sat (oxygen level) . . . he was sent to the hospital. I don't think the new tubing and HME is effective for him because of his secretions, he has so much. (Resident #504) is the only one who has the concerns that I'm aware of." In an interview on [DATE] at 11:15 A.M., staff nurse (employee "I") said, "we did get a new HME and they clog faster . . . they are smaller and do get clogged easier for residents who have a lot of secretions, otherwise they work fine. . . (the) RT's complaint is they sometimes change (them/HME) more often. . . (Resident #504) does have periods of increased frothy secretions, which come out of his mouth and nose too. . . (Resident #504) can cough and fill his circuit (tubing and HME) all at one time, the machine high pressure alarms and we change it (tubing and HME)." In a phone interview on [DATE] at 12:25 P.M., RT (employee "H") said "we have more concerns with the new HME's and for (Resident #504), he has a lot of white frothy secretions and clogs it (HME) often . . . I have seen his entire tubing get clogged . . . It happens on and off, usually a few days of the week. It (the tubing) will be filled with white frothy secretions (which come) out his (Resident #504's) nose and mouth everywhere. He (Resident #504) is the only one with white frothy secretions, but all the residents tubing gets more moisture in them and we change them more often (since the new HME)." In a phone interview on [DATE] at 2:30 P.M., RT (employee "L") said she cares for (Resident #504) a lot. "I think the new HME's are too small. (Resident #504) has a lot of secretions and it fills up the HME and tubing so quickly he is in immediate distress. I have had that happen twice on my shift. I heard the alarm sounding went in and had to change the HME and tubing and his color gets better immediately. His lips are cyanotic and his eyes look wide open, surprised or fearful. As long as you can get to him quickly he's ok. . . When we first got the new HME's in June, I spoke with the DRT about them, that for (Resident #504) and some others who have more secretions and fill up the tubing completely, it was dangerous. . . I explained it was a potential risk for the residents. She originally said she would get different ones for those residents, but never did. . . I feel (Resident #504) is at risk because he plugs it so quickly." A record review on [DATE] at 11:00 A.M. revealed, A Physician extender progress note dated [DATE], that documented (Resident #504) was transferred to the emergency department on [DATE] secondary to respiratory distress and [MEDICAL CONDITION] (The clinical record did not contain any information related to an event of respiratory distress or hospital transfer on [DATE], it contained this information dated [DATE]). At [DATE] at 3:15 P.M. the DRT read the contradiction warning on the manufactures packaging 2007, for the new HME being used at the facility and in place for Resident #504. The Manufactures packaging read, "Contraindicated in patients producing fulminating frothy secretions within their airways and lungs." When queried the DRT denied Respiratory Therapy staff had informed her that since the use of the new HME (Resident #504) was having increased secretions which filled his vent tubing past the new HME, and was causing him respiratory distress. On [DATE] at 3:35 P.M., the Director of Nursing (DON), read the contraindications on the manufactures packaging for the HME currently being used in the facility. The DON said (Resident #504) has always had increased secretions and has been on medication for it. When queried regarding the resent episodes of being found in respiratory distress and requiring transfer to hospital emergency room s. The DON said she was not aware of any changes for him (Resident #504). On [DATE] at 11:00 A.M. Resident #504's Care Plans dated [DATE] were reviewed and included the following; ventilator dependence, [MEDICAL CONDITION] care, ineffective cough, supplemental oxygen and risk of respiratory distress. The Care Plans did not address humidification or identify what type of HME was in use for Resident #504. Further review of Resident #504's clinical record revealed a Physician's note dated [DATE], that documented Resident #504 had stable vital signs with excessive oral white frothy secretions, lungs clear to auscultation. He has a history of excessive oral secretions secondary to dysphagia (difficulty swallowing). Further review of Respiratory flow sheets for ,[DATE] and ,[DATE] documented Resident #504 had copious white frothy secretions on [DATE], moderate white secretions on [DATE], pale yellow copious frothy secretions on [DATE], white copious frothy secretions on [DATE], white, large foamy secretions on [DATE] and pale yellow frothy secretions on [DATE]. The facility Policy and Procedure manual for "Respiratory Care, Ventilator/[MEDICAL CONDITION] Residents" was reviewed on [DATE] at 12:20 P.M. No Policy related to Humidification for Ventilator dependent residents was found within the manual. The manual did not contain any policy or reference within a policy to humidification or use of an HME for Ventilator residents. References to the HME were only found on the "equipment change schedule form" and the "Respiratory specific abbreviation form." On [DATE] at 3:20 P.M. facility staff provided a copy of an article titled "Humidification for Patients with Artificial Airways" (Respiratory Care-[DATE] VOL 44 N0 6), they said they followed as a guide line. The article included a section titled "Artificial Noses" on page 633, paragraph 7, that documented, "By definition, an artificial nose is a passively acting humidifier that collects the patient's expired heat and moisture and returns it during the following inspiration." A section of the article titled "Use of Humidification Devices During Mechanical Ventilation," page 637, paragraph 2, included "Artificial noses are attractive alternatives to heated humidifiers . . . but not all patients can use an artificial nose. Patients with preexisting [MEDICAL CONDITION] disease characterized by thick, copious, or bloody secretions should receive heated humidification . . . if secretions appear thick on 2 consecutive suctioning procedures, the patient should be switched to a heated humidifier." On [DATE], at 1:22 P.M., the facility Director of Nursing, representing the Administrator was notified of the Immediate Jeopardy that began on [DATE]. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following plan of correction: 1. Resident #504 is stable, in house and having no current Respiratory issues. Resident #504 was assessed by RT, Director of Respiratory Therapy (DRT) at 10:50 A.M. and found to be stable with no excessive secretions, lungs clear. Director of Nursing (DON) assessed resident in A.M., full body assessment, with focus on respiratory, cardiac and abdomen-no issues noted, vital signs within normal range, no signs and symptoms of respiratory distress. Nurse Practitioner saw resident [DATE] and signs issues noted with respiratory status, no new orders indicated Primary attending was notified [DATE] of Immediate Jeopardy (IJ) regarding Resident #504. No new orders received. Medical Director was notified of (IJ) situation Care Plan and current MD orders were reviewed, no revision or recommendations made. On [DATE] at 10:50 A.M. Resident #504, was changed from a Kimberly-Clark Kim Vent 1500 Heat Moisture Exchanger to a Kimberly-Clark Kim Vent 1000 Heat and Moisture Exchanger Filter. At this time, resident was assessed again and resident was not having excessive secretions. 2. On [DATE] an audit was conducted to identify those residents with an HME. Of those residents, 24 of 24 (100% of current ventilator residents) were assessed for respiratory function, including noted excessive secretions and functioning of HME by Respiratory Director and Director of Nurses. None of the current 24 ventilator dependent residents were identified as having any current respiratory issues or current concerns with their HME that would be contraindicated for an HME use. Care Plans and orders were reviewed for the 24 ventilator residents and no changes were needed. 3. Ventilator System Checks by Respiratory Therapy every 6 hours and PRN, to evaluate resident status and system check. Ventilator System Check policy date original ,[DATE], revised ,[DATE] was reviewed with team no changes made at this time. Respiratory Therapist documents their assessments every 6 hours and PRN as indicated. Nursing round routinely to ensure resident is stable and not I respiratory distress. Kimberly Clark representative contacted [DATE], and there are no clinical contraindications at this time for using either HME 1500 or HME 1000 on Mechanically Ventilated Residents. 4. Facility QA team met [DATE] to review the above plan, no recommendations were made at this time. Respiratory Therapy will evaluate residents ' respiratory status every 6 hours and PRN. Nursing will evaluate resident routinely to ensure resident is stable. Director of Respiratory Therapy/designee will review Respiratory Therapy documentation weekly and sign the Respiratory Therapy note. Director of Nurses/Designee will during daily rounds validate residents are in no acute distress and ensure needs are being met. Director of Respiratory Therapy and Director of Nurses will bring any concerns to the facility QA meeting as indicated. All above Elements have been addressed and plans currently in place as of [DATE]. ( ) ( )( )

This Citation pertains to intake numbers MI 687, MI 748 and MI 433 and contains multiple deficient practice statements. A) Based on observation, interview and record review, the facility failed to supervise, follow physician dietary orders, and prevent the oral ingestion of food and/or beverages in 1 of 6 sampled residents (Resident #101), from a total of 6 sampled residents, resulting in an Immediate Jeopardy when Resident #101 who had a Percutaneous Endoscopy Gastrostomy (PEG) tube and was NPO (nothing by mouth), drank a chocolate beverage on or about 5/15/13, developed respiratory distress and was admitted to the hospital on [DATE]. Resident #101 remained ventilator dependent for aspiration pneumonia and respiratory failure. This deficient practice placed 70 additional residents, identified as having difficulty with eating or required therapeutic, physician ordered diets, at risk for serious harm, injury, and or death. Findings include: Review of the hospital History and Physical, dated 5/3/2013, revealed Resident #101 had a history of [REDACTED]. Review of the medical record revealed Resident #101 was a [AGE] year-old male admitted to the facility on [DATE] and resided in the C-Wing. Review of the physician progress notes [REDACTED]. Review of the Eating/Nutrition Plan of Care dated 5/8/2013, revealed Resident #101 was to be "NPO" (nothing to eat or drink by mouth). Review of the "Nutritional Assessment" dated 5/13/13, revealed Resident #101 had a diet order of NPO. The assessment revealed Resident #101 was alert, able to make his needs known, had a history of [REDACTED]. Review of Resident #101's "Evaluation and Plan of Care for Speech Language Pathology", dated 5/15/2013, revealed Resident #101 was referred to speech therapy by nursing secondary to coughing and vomiting. Resident #101 has a history of dysphagia (difficulty swallowing), was NPO for approximately 1 year with PEG tube for nutrition, has a history of cognitive issues and is alert and oriented. Review of "24 Hour Report", dated 5/12/2013, revealed Resident #101 was "trying to eat reg. (regular) food". There was no documentation of what facility staffs did to prevent this from reoccurring. Review of "24 Hour Report", dated 5/15/2013, revealed Resident #101 "spit up chocolate with mucous" and that a chest x-ray was ordered and Speech Therapy was to treat. Review of the "Medicare Daily Skilled Nursing Note", dated 5/15/2013, revealed at 11:30 AM, Resident #101's physician was notified that he had spit up a chocolate light-colored mucous and an order for [REDACTED]. Review of the "Medicare Daily Skilled Nursing Note", dated 5/16/2013, revealed at 8:10 AM, Resident #101 was alert but lethargic, oxygenation SATS (saturation - percent of blood carrying oxygen, normal is greater than 92%) was 66%. Resident #101 was transferred via ambulance in the company of two Emergency Medical Technicians (EMT's) at 8:30 AM and was "very lethargic, not easily arousable". In an interview on 5/22/13 at 1:10 PM, Registered Nurse (RN) #17 (Community Mental Health Nurse) stated that she went to the facility to check on Resident #101 and was told by a facility staff member (unknown name) that Resident #101 had been transferred to the hospital for respiratory issues and that he may have aspirated hot cocoa. Review of the Hospital Physician Notes, dated 5/16/13 at 11:48 AM, revealed Resident #101 had a bronchoscopy performed and was found to have "dark purulent material in the right lower lobe--this was aspirated and sent to the lab...". In a telephone interview on 5/22/2013 at 11:20 AM, RN #10 stated that on 5/16/2013, she had told the EMT that, according to the shift report, Resident #101 was caught drinking cocoa yesterday. In a telephone interview on 5/22/2013 at 2:10 PM, EMT #19 stated that facility staff informed him that Resident #101 was caught drinking yesterday, and they were concerned that he may have aspirated. In a telephone interview on 5/22/2013 at 3:20 PM, EMT #20 stated that Resident #101's nurse reported to him that the day before 5/16/13 (on 5/15/13), Resident #101 was caught drinking some cocoa and that Resident #101 was supposed to be NPO. EMT #20 stated he was told by a nurse that after they caught Resident #101 drinking, and an x-ray was ordered. In an interview on 5/21/2013 at 3:05 PM, Certified Nursing Assistant (CNA) #8 stated that Resident #101 was very mobile in his wheelchair and that it was normal for Resident #101 to propel throughout the facility. CNA #8 stated that on 5/15/2013, Resident #101 was found in his room, spitting up brown-colored mucus. When asked, CNA #8 stated it was darker than what was in his feeding tube. In an interview on 5/21/2013 at 4:08 PM, Director of Nursing (DON) #2 reported that Resident #101 sought food and drink all the time. DON #2 stated Resident #101 has mental issues and can't remember that he is to not eat or drink. On 5/22/2013 at 11:41 AM and 11:54 AM, an unsupervised beverage cart was observed in the E-Wing hallway and the C-Cubby hallway. In an interview on 5/22/2013 at 10:00 AM, CNA #14 stated, "I always seen (sic) (Resident #101) cruising down the hall in his wheelchair." CNA #14 stated on 5/16/2013 at 11:30 that she entered Resident #101's room to help CNA #8 clean up Resident #101. CNA #14 stated that CNA #8 told her that Resident #101 was throwing up. CNA #14 stated there was about 200 cc's of vomit on the floor that had the appearance of chocolate milk. In a telephone interview on 5/31/13 at 3:37 PM, RN #41 (Hospital Emergency Department nurse) stated that she received report from Resident #101's nurse at the facility prior to Resident #101 arriving the emergency room , and was told Resident #101 had been seen drinking cocoa, and staff at the facility were concerned Resident #101 possibly aspirated. During an observation made on 5/21/2013 at 11:15 AM, a resident in a wheelchair propelled herself to an unsupervised beverage cart in the E-Wing hallway and poured herself a cup of what appeared to be coffee. On 5/24/13 at 9:40 AM, the Administrator was notified of the Immediate Jeopardy that began on 5/15/13, as a result of the facility's failure to supervise, follow physician dietary orders, and prevent the oral ingestion of food and/or beverages for Resident #101 who had a Percutaneous Endoscopy Gastrostomy (PEG) tube and was NPO (nothing by mouth), drank a chocolate beverage on or about 5/15/13, developed respiratory distress and was admitted to the hospital on [DATE] and remained ventilator dependent for aspiration pneumonia and respiratory failure. On 5/28/13, this Surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1. On 5/24/13, the nurse managers completed a facility wide audit to identify resident with tube feedings, dysphagia diagnoses, thickened liquid orders, and NPO status, and residents with behaviors to seek out and obtain food and liquid. The audit showed 13 residents on thickened liquid, 15 residents identified as NPO, 28 residents with tube feedings, and 14 residents with dysphagia. 2. On 5/24/13, the development educator along with nursing, dietary, activities, and social services staff completed and in-service on policy and procedures for resident safety with food intake that included how to identify residents at risk and proper supervision. 72 of 166 facility staffs were in-serviced on 5/24/13. No facility staff will be allowed to work prior to receiving the education. 3. Beginning 5/24/13, residents identified as at risk will be supervised during meal times by nursing staff through direct observation to ensure there is no access to food or liquid. 4. On 5/24/13, vending machines were unplugged and the room they were located in was locked until they can be relocated to a non-resident location. 5. Beginning 5/24/13, beverage carts will no longer be used. Beverages will be placed, covered, and delivered via closed food carts. Doors to the food carts will be kept against the wall for no resident access. Facility staffs will maintain food carts in sight to ensure no resident access. 6. Beginning 5/24/13, the Director of Nursing or designee will complete random audits of nursing units and dining rooms to ensure residents who are at risk for aspiration do not have access to food or liquid. 7. Beginning 5/24/13, Unit managers will monitor food carts on assigned units daily to ensure food cart doors are positioned against the wall. 8. Beginning 5/24/13, assigned nursing staffs will monitor dining rooms to ensure proper supervision of residents at risk for aspiration. Although the Immediate Jeopardy was removed on 5/24/13, the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due the fact that all facility staffs had not yet been educated and sustained compliance had not yet been verified by the State Agency. ( ) B) Based on observation and interview, the facility failed to ensure the resident environment remains free of potential hazards (loading dock door failing to completely close and hand rails, facility wide, being in disrepair) resulting in the potential for injury to all 102 residents residing in the facility. Findings include: During observations made from 5/21/13 thru 5/30/13 the following were found: The handrail corner outside of the "Daisy Dining Room" had multiple cracks exposing sharp edges, was falling off, and was being held together by tape. The handrail end piece outside of the "Vent Unit Nurses Station" was not the proper size, did not properly seal the handrail and exposed sharp edges. The handrail end cap outside of the "Occupational Therapy/Speech Therapy" room and "Nursing Home Administrator's" office did not seal with the handrail properly, exposing sharp edges. The handrail end caps outside of Resident Rooms 315, 320, 321, 323 and 504 did not seal with the handrail properly, exposing sharp edges. Two handrail corners outside of Room 402 were loose, cracked, and exposed sharp edges. The handrail end piece outside of Room 419 was cracked, did not form a tight seal and exposed sharp edges. The handrail end piece outside of Room 508 was loose, cracked, exposed sharp edges and was being held together by tape. Multiple areas throughout the facility had handrail seams that were not covered properly, and exposed sharp edges. During an observation on 5/30/13 at 9:53 AM, the loading dock door was not completely shut. Dietary Aide (DA) #42 attempted to close the door, but was unable to completely shut the door. DA #42 stated, "I guess it (loading dock door) doesn't shut". In an interview on 5/30/13 at 10:05 AM, Maintenance Supervisor #31 stated he was aware of the handrail issues, and was working on a purchase order for repairs. Maintenance Supervisor #31 stated he was aware of the loading dock door not closing properly, and had put in a work request with a contracted company to repair the door. No information was provided as to when the work was to be completed. ( )

BASED ON INTERVIEW, THE FACILITY FAILED TO TOILET 1 RESIDENT (#10) OF 19 OBSERVED SAMPLED RESIDENTS IN A DIGNIFIED MANNER, RESULTING IN BEING DEMEANED AND MADE TO FEEL WORTHLESS WHILE LYING IN WET BRIEFS. FINDINGS INCLUDE: RESIDENT #10 WAS INTERVIEWED ON 1/11/12 AT 11:45 A.M. IN HER ROOM. SHE WAS LYING IN BED. DURING THE CONVERSATION SHE WAS CLUTCHING HER CROTCH AND FIDGETING. WHEN ASKED IF SHE NEEDED TO GO TO THE BATHROOM, SHE STATED "YES, BUT THEY DON'T WANT TO". THE CALL LIGHT WAS ACTIVATED. A FRIEND OF RESIDENT #10 WAS ALSO AT THE BEDSIDE. THE FRIEND INDICATED 2 STAFF AND A LIFT WERE REQUIRED TO TAKE RESIDENT #10 TO THE BATHROOM. THE FRIEND ALSO STATED "SOMETIMES THEY TELL HER TO WAIT UNTIL AFTER LUNCH". THE RESIDENT WAS ASKED IF SHE HAD WETTING ACCIDENTS. SHE STATED THAT SHE DID AND "SOMETIMES THEY TELL ME TO JUST PEE IN THE DEPENDS". APPLYING THE REASONABLE PERSON CONCEPT, THE STATEMENT TO "JUST PEE IN THE DEPENDS" IS DEMEANING AND DEHUMANIZING TO RESIDENT #10 RESULTING IN PSYCHOSOCIAL HARM. RESIDENT #10 CLEARLY RECALLED THE STATEMENT. ON 1/12/12, THE DIRECTOR OF NURSING (STAFF "B") WAS INTERVIEWED IN HER OFFICE AT ABOUT 3:00 P.M. ABOUT THIS ISSUE. SHE STATED SHE WAS UNAWARE OF THE PROBLEM. ( )

This citation pertains to Intake #MI 262. Based on observation, interview, and record review, the facility failed to assure that 1of 7 sample residents (#100) was fully informed of her total health status, including her medical condition, resulting in feelings of isolation and dehumanization, leading to anxiety, depression, and anger as Resident #100 did not understand that the physical challenges of her medical condition impeded achievement of her goals and, therefore, felt that her goals were not supported by facility staff members. Findings Include: According to the admission record, Resident #100 was a [AGE] year old woman, who was admitted to the facility in 2005 for care related to her ventilator dependent [MEDICAL CONDITION] (inability to breathe without the assistance of a mechanical respirator). Other [DIAGNOSES REDACTED]. Although Resident #100's was a full code, meaning she would receive full cardiopulmonary resuscitation in the event that her breathing and/or heartbeat stopped. Resident #100 was hospitalized multiple times during 2010 for stabilization of her [MEDICAL CONDITION]. Her most recent re-admission to the facility was on 12/23/10. According to her most recent Minimum Data Set (MDS), dated [DATE], Resident #100 was very short of breath and became fatigued easily. According to the MDS, she needed maximum physical assistance from two people to move while in bed and to transfer into or out of bed. She needed maximum physical assistance from one person to bathe, for personal hygiene, and to dress. On 2/8/11 at 1:30 PM, an interview was held with staff nurse #14 and staff nurse #23 in the D-wing nurses' station. Nurse #23 said Resident #100 "looked much better than she did two months ago, but she does not get out of bed". Nurse #14 said Resident #100 rode in an electric wheelchair and went "all around the facility", but the wheelchair is in storage now, because Resident #100 "gets very short of breath and anxious when she gets out of bed". Nurse #14 added, "It's scary". At 1:45 on 2/8/11, an obeservation and interview was held with Resident #100 in her room. Resident #100 was in bed with the head of the bed elevated approximately 45 degrees. She was watching television. Resident #100 said she has not been out of bed since her return to the facility on [DATE]. According to Resident #100, she had been able to get out of bed and use a bedside commode beside her bed prior to her 12/22/10 hospitalization . Resident #100 said she has been using a bedpan since her return to the facility on [DATE]. She said she did not like to use a bedpan, because it was "difficult and embarrassing". She said, " Using (the bedside commode) was the last dignity I had left!" Resident #100 said she wanted to get up in her wheelchair, but staff would not help her to get out of bed. She said, "They don't want me to get up because I am woozy. But, I know I have to get up or I will not be able to (get up)". On 2/8/11 at 2:05 PM, an interview was held with the facility's manager for respiratory therapy, RT #33 and nurse manager #6, who was in charge of the D-wing ventilator unit, in the D-wing nurses' station. Nurse manager #6 said Resident #100's oxygen saturation level drops when she gets up to use the bedside commode. RT #33 said Resident #100's oxygen saturation level dropped as far as the low 70% range (normal is above 90%). RT #33 said it was often "difficult to bring her back", saying that she has needed to use oxygen from a tank, (as it has a higher concentration of pure oxygen than "oxygen" created by an oxygen concentrator), as well as an Ambu bag (a device with a tightly fitting mask and an inflated balloon that is used in emergency situations to mechanically force air into a person's airway) to revive Resident #100. Neither nurse manager #6 nor RT #33 was able to state individual performance parameters established by Resident #100's attending physician to guide professional staff caring for Resident #100. An interview was held with physician assistant (PA) #31 on 2/10/11 at 9:55 AM, as she was exiting Resident #100's room. PA #31 said that she has been rounding at the facility for the past three years. In that time, PA #31 said she never saw Resident #100 when she was out of bed. PA #31 also said that Resident #100 has never shared her goals using a bedside commode chair and getting up in her wheelchair. PA #31 said that she was not Resident #100's regular PA and, therefore, she was not able to make a determination of the amount of activity Resident #100 could tolerate. On 2/10/11 at 11:30 AM, an interview was held with Resident #100 in her room. She was lying in bed on her right side, with the head of the bed elevated about 35 degrees. Resident #100 said she felt "okay". Again, Resident #100 stated her goals to use a bedside commode and to get up in her wheelchair. When asked how she felt when she was standing up, Resident # 100 said, she felt "woozy" and her "legs went out from under (her)". When asked if she remembered the RT using an Ambu bag to assist her breathing, Resident #100 said, "Yes, and (I) felt better afterward". Resident #100 gave no indication that she understood the connection between her difficulty breathing and her "woozy" feeling or her collapse. At 12:15 PM on 2/10/11, an interview was held in the social work office with the D-wing social worker (SW) #37 and RT #33. RT #33 said that Resident #100 may be assisted by using an oxygen tank instead of an oxygen concentrator, but it was also necessary to balance Resident #100's blood oxygen-to-carbon [MEDICATION NAME] levels as well as her oxygen saturation. RT #33 said excessive use of an oxygen tank would place Resident #100 at risk for increased levels of carbon [MEDICATION NAME], which would inhibit her respiratory response rate. RT #33 said she did not think the physician has explained this to Resident #100. SW #37 said neither Resident #100 nor her son have attended an interdisciplinary team meeting for quite some time, at least since her most recent re-admission on 12/23/10. Upon questioning, SW #37 said she did not believe anyone had discussed specific risk factors with Resident #100 or her son in regard to using a bedside commode or getting up into a wheelchair with the current state of her respiratory status. ( )

This citation pertains to Intake MI 262. Based on observation, interview, and record review, the facility failed to assure that 1 of 7 sample residents (#100) participated in care planning and treatment, resulting in feeling of humiliation and dehumanization, leading to anxiety, anger and depression, as Resident #100 felt her goals were not understood or valued by facility staff members. Findings include: According to the admission record, Resident #100 was a [AGE] year old woman, who was admitted to the facility in 2005 for care related to her ventilator dependent [MEDICAL CONDITION] (inability to breathe without the assistance of a mechanical respirator). Other [DIAGNOSES REDACTED]. Resident #100 was hospitalized multiple times during 2010 for stabilization of her [MEDICAL CONDITION], her most recent re-admission was on 12/23/10. According to a Minimum Data Set (MDS), dated [DATE], Resident #100 was very short of breath and became fatigued easily. She needed maximum physical assistance from two people to move about in bed and to transfer into or out of bed. She needed maximum physical assistance from one person to bathe, for personal hygiene, and to dress. Resident #100's plan of care, dated 12/23/10, directed staff members to encourage her to re-position in bed every 2 hours as needed, and to change positions every hour and shift her weight every 15 minutes when in her wheelchair. There were no goals or interventions for assistance with moving about in bed, despite the MDS finding, dated 11/8/10, that Resident #100 needed maximum physical assistance from two people to move about in bed. There were no goals or interventions for transferring Resident #100 into or out of bed, although the MDS, dated [DATE], clearly stated that she needed maximum physical assistance of two people to transfer in and out of bed. Document review of Resident #100's "Personal Care Card", for the month of February, showed that she had not been out of bed during the month of February. The "Positioning Log", for the month of February, revealed that Resident #100 had independently positioned herself. D-Wing's 24-Hour Nursing Report, dated 2/8/11, showed that Resident #100 had a mucous plug in her trachea (windpipe) and needed assistance from a Respiratory Therapist to remove it using suction (a negative pressure device to assist in removing respiratory secretions) and lavage (irrigate or rinse with fluid). Resident #100 was interviewed in her room on 2/4/11 at 1:40 PM. Resident #100 was in bed in high Fowler's position (head of the bed very high mimicking a sitting position). The bed was rumpled and there was a bath basin on her lap. Resident #100's [MEDICAL CONDITION] was connected to a ventilator that rested on top of a bedside cabinet. She was able to speak audibly when she placed one finger over the opening of her [MEDICAL CONDITION], but the sound faded as she ran out of breath at the end of each phrase. Resident # 100 said that she had been nauseated for several days and she was afraid that she may vomit. During another interview, conducted on 2/8/11 at 1:45 PM, Resident #100 said she had not been out of bed since she returned to the facility from a hospital stay on 12/23/10. Resident #100 said she had been able to use a bedside commode prior to her hospitalization , but she had been using a bedpan since she had returned to the facility. She said she did not like to use a bedpan, because it was "difficult and embarrassing". She said, "Using (the bedside toilet) was the last dignity I had left!". Resident #100 said her son wanted her to move to another facility, where the oxygen was piped in through the walls, instead of using an oxygen concentrator. She said she did not really want to move, but that her son "may have a point" about the "strength" of piped in oxygen compared with oxygen from a concentrator. Resident #100 again said she wanted to get up into her wheelchair. She said she was "concerned that (she was) losing ground". Resident #100 demonstrated that she can move her feet through full range of motion. She said, "They don't want me to get up because I am woozy. But, I know I have to get up or I will not be able to (get up)". On 2/8/11 at 1:20 PM an interview was held with nurse #23, who was assigned to care for Resident #100 on that day. Nurse #23 spoke about Resident #100's mucous plug being removed and said that she then had a headache. During a subsequent conversation in the nurses' station, nurse #14 joined the conversation. Nurse #23 said that Resident #100 "does not get out of bed". Nurse #14 said, "She gets very short of breath and very anxious when she gets out of bed". She said "It's scary". A review of Resident # 100's "CENA Care Card", used by nurse aides to identify the care needs of each resident, showed that there were no actions listed to direct the aides caring for Resident #100 in regard to bed mobility and moving about the facility. The Care Card had a section for "transfers" and a section for "mobility". The options listed under "transfers" were: 1 or 2 person assistance; 1 or 2 person pivot transfer; independent; and (mechanical) lift with a space to designate the size of the sling to be used. None of these choices were selected. There was a notation that read, "supervision prn (as needed)". There was no indication of the number of persons or the type of supervision that may be required. The section of the Care Card for "mobility" listed these choices: independent; uses walker; walks with assistance-with a space to designate 1 or 2 to assist; wheelchair; special chair; self propels; no weight bearing-with space to designate left or right; and gait belt-with a space to designate 1 or 2 to assist. None of these choices was selected. There was no notation at all for this portion of the Care Card. On 2/8/11 at 2:05 PM, an interview was held with the facility's manager for respiratory therapy, RT #33 and nurse manager #6, who was in charge of the D-wing ventilator unit, in the D-wing nurses' station. Nurse manager #6 said Resident #100's oxygen saturation level drops when she gets up to use the bedside commode. RT #33 said Resident #100's oxygen saturation level dropped as far as the low 70% range (normal is above 90%). RT #33 said it was often "difficult to bring her back", saying that she has needed to use oxygen from a tank, (as it has a higher concentration of pure oxygen than "oxygen" created by an oxygen concentrator), as well as an Ambu bag (a device with a tightly fitting mask and an inflated balloon that is used in emergency situations to mechanically force air into a person's airway) to revive Resident #100. Neither nurse manager #6 nor RT #33 was able to state individual performance parameters established by Resident #100's attending physician to guide professional staff caring for Resident #100. An interview was held with physician assistant (PA) #31 on 2/19/11 at 9:55 AM, as she was exiting Resident #100's room. PA #31 said that she has been rounding at the facility for the past three years. In that time, PA #31 said she had never seen Resident 100 out of bed. PA #31 also said that Resident #100 has never shared her goal of getting out of bed. At 11:30 AM on 2/10/11, an interview was held with Resident 100. She was in her bed, lying on her right side, with the head of the bed elevated about 35 degrees. Resident #100 said she felt "okay" and that she had no nausea. Resident #100 again said that her goal is to get up into her wheelchair. When asked how she felt when she is standing up, Resident #100 said she felt "woozy" and her "legs to out from under (her)". Resident #100 did not give any information about the clinical basis for her physical sensations or the risk factors involved in achieving her goal. At 12:15 PM on 2/10/11, an interview was held in the social work office with the D-wing social worker (SW) #37 and RT #33. RT #33 said that Resident #100 may be assisted by using an oxygen tank instead of an oxygen concentrator, but it was also necessary to balance Resident #100 ' s blood oxygen-to-carbon [MEDICATION NAME] levels as well as her oxygen saturation. RT #33 said excessive use of an oxygen tank would place Resident #100 at risk for increased levels of carbon [MEDICATION NAME], which would inhibit her respiratory response rate. RT #33 said she did not think the physician has explained this to Resident #100. SW #37 said neither Resident #100 nor her son have attended an interdisciplinary team meeting for quite some time, at least since her most recent re-admission on 12/23/10. Upon questioning, SW #37 said she did not believe anyone had discussed specific risk factors with Resident #100 or her son in regard to using a bedside commode or getting up into a wheelchair with the current state of her respiratory status. The facility failed to include Resident #100 in the development of her plan of care. Resident #100's goal may be unrealistic considering her physical limitations. Facility staff did not discussed with Resident #100 the relationship between her symptoms and activities required to achieve her goal. The facility assessed that Resident #100 needed maximum physical assistance from two staff members to move about in bed and to transfer into and out of bed. However, the facility did not addressed these restrictions in Resident #100's active plan of care. The facility did not directed nurse aides to assist Resident #100 to move about in bed, or to get her out of bed. The facility did not provide any mechanism for Resident #100's to state her goals, which were, therefore, not addressed. ( )