Every finding on record at Medilodge of Livonia

This citation pertains to Intake 3018720 Based on interview and record review, the facility failed to accurately document the completion of bladder scans following the removal of a catheter for one resident (R901) of one reviewed for urinary retention. Findings include:A review of documentation submitted to the State Agency revealed R901 was transferred from the facility to the hospital for abdominal pain where it was alleged the resident had retained a significant amount of urine into their abdomen.A review of R901's medical record revealed they were admitted into the facility on [DATE] and discharged to the hospital on [DATE]. R901 was admitted into the facility with diagnoses which included Displaced Oblique Fracture of Shaft of Left Femur, Diabetes, and Hypertension. Further review revealed the resident was cognitively impaired and required 1-2 people for assistance with activities of daily living. Further review of the medical record revealed the following progress note:11/29/2025 11:03 (11:03am) Progress Note: Contacted [physician] . informed [them] that night nurse took out patients (name of indwelling catheter) at 6 am. Patient had (name of indwelling catheter) for urine retention and needs to schedule appointment with urologist. [Physician] ordered bladder scans. Orders placed and continue to monitor patient.A review of R901's medical record revealed the following physician order dated 11/29/25 and discontinued on 12/22/25, Order Summary: Bladder scan q (every) 6 hours. Every 6 hours for bladder retention. Further review of the resident's medical record revealed another physician order dated 11/29/25 however, it was created on 12/19/25 (9 days after the resident discharged ), Bladder scan q 6 hours. Contact provider if over 500 cc (cubic centimeters, metric unit used to measure amount of urine).Further review of the medical record revealed the December 2025 Medication Administration Record (MAR) revealing several bladder scans had not been completed:12/1/25: Missing two documented bladder scans12/2/25: No documented bladder scans12/3/25: Missing two documented bladder scans12/4/25: Missing two documented bladder scans12/5/25: Missing two documented bladder scans12/6/25: No documented bladder scans12/7/25: No documented bladder scans12/8/25: No documented bladder scans12/9/25: No documented bladder scansOn 5/27 at 12:19 PM, an interview was completed with Assistant Director of Nursing (ADON) regarding the lack of documented bladder scans. The ADON explained an audit had been completed on the resident's medical record after they had discharged , and it had been discovered the physician's order for the blader scans had been inputted into the medical record incorrectly, and as a result, the volume of urine completed during the bladder scans had not been completed. The ADON explained that nursing was measuring the resident's output however, it was acknowledged it hadn't been documented. Regarding the missing documented bladder scans, the ADON acknowledged the missing dates, and did not provide additional information regarding this. A review of the facility's Medication Orders did not address documentation and ensuring physician orders are carried out per professional standards.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 03/18/2026 at 8:21 AM an interview with Food Service Director (FSD) A regarding the frequency of use of the meat slicer found it is used periodically.On 03/18/2026 at 8:43 AM observed dried debris at the bottom of two clean equipment utensil bins.On 03/18/2026 at 9:09 AM an interview with FSD A found the cooks are responsible for cleaning and sanitizing clean utensil bins daily.On 03/18/2026 at 9:32 AM observed dried food debris accumulated on the underside of the meat slicer blade. When pointing out food debris, FSD A stated I see what you are talking about.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.On 03/18/2026 at 8:39 AM observed a 2 x 2 opening in tiled floor area near dishwashing area, filled with soiled standing water. During this observation when asked about the standing water FSD A indicated it was not an open drain and that it is where a pipe used to be and is closed off but collects water when mopping. FSD A indicated maintenance could be asked to fill it in.According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.On 03/18/2026 at 8:50 AM observed wall air ventilation cover between the 3-comp sink and hood cooking area with dust and soil build up and speckled black/brown build up on the adjacent ceiling tiles in an area approximately 2' x 2'. On 03/18/2026 at 9:10 AM an interview with FSD A regarding with soiled ceiling tiles found maintenance will come and clean as needed. When asked if it looked like it needed cleaning, FSD A replied yes.On 03/18/2026 at 9:13 AM observed Director of Maintenance (DM) E wipe ceiling with a cloth. When wiped, the buildup was removed from the ceiling.On 03/18/2026 at 12:08 PM observed the kitchen air conditioning window unit located above the three-compartment sink with an accumulation of dust and soil.According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.On 03/18/2026 at 8:45 AM observed water droplets in three stacked quarter pans located on the clean equipment rack in the kitchen.On 03/18/2026 at 9:40 AM an interview with FSD A regarding storage of wet stacked clean equipment found that staff know to air dry pans and ensure there are no droplets before storing.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried before contact with FOOD. On 03/18/2026 at 8:52 AM observation of the two-door cooler found a full pan with a facility marked label indicating it was potato salad. The pan was observed tightly wrapped in plastic wrap with condensation on the interior. An interview at this time with [NAME] B found the potato salad was cooling from room temperature and had been prepared at 8:00 AM using room temperature canned cooked diced potatoes and additional ingredients. [NAME] B indicated that sometimes they pre-chill the ingredients but hadn't today. A temperature of the potato salad was taken at this time and found to be 56-57 F.On 03/18/2026 at 1:09 PM an interview with [NAME] B found they had moved the potato salad into two shallow pans to help it cool faster. Observation of the potato salad found it separated into two pans and loosely covered with plastic wrap. A temperature of the potato salad was taken and found to be at 44 F after five hours since preparation.On 03/18/2026 at 1:10 PM an interview with FSD A found the temperature should be between 30-41 F now. FSD A indicated they would take the temperature again and discard the potato salad if it was not in range.On 03/18/2026 at 1:58 PM FSD A indicated they had discarded the potato salad.A record review of the facility provided document entitled Food Safety Requirements states, When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent , reduce, or eliminate potential hazards . Cooling- various strategies (e.g., placing foods in shallow pans, cutting roasts into smaller portions, utilizing ice water baths, and stirring periodically) shall be implemented to cool foods so that the total time for cooling does not exceed 6 hours.According to the 2022 Food Code, 3-501.14 Cooling. (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna.According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

Based on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 03/18/2026 at 9:50 AM observed black debris accumulated on the inside shelf of the cabinet located under the sink in the nourishment room. Further observation of the sink drain found multiple straws within as a possible clogging factor.On 03/18/2026 at 10:08 AM observed an assortment of discarded items layering the bottom of the clean linen transfer bin under the inside support floor (used to help bring linen near the top of the bin).An interview at this time with Housekeeping Manager (HM) C regarding expectations for frequency of cleaning bins found it should be cleaned after every load.On 03/18/2026 at 10:10 AM observed the cold-water handle missing from the handwash sink in the laundry room. An interview with HM C at this time found that the cold water shut off valve can be turned on and off to adjust the water temperature and the repair request is in the building maintenance electronic request system (TELS).On 03/18/2026 beginning at 10:12 AM an environmental tour was conducted with HM C and District Manager (DM) D.On 03/18/2026 at 10:18 AM observed wooden shelving units for clean linen storage in the B hall. Shelves were observed worn and rough to the touch.On 03/18/2026 at 10:20 AM observed wooden shelving units for clean linen storage in the A hall. Shelves were observed worn and rough to the touch.On 03/18/2026 at 10:23 AM observation of the SPA room in A hall found a pile of wet linen on the shower bed mat. Further observation found brown and white residue in the creases throughout the shower bed mat surface. Upon lifting the mat, a white residue was observed along the underside. Additional observation found a brown semi-solid substance was at the floor drain, DM D acknowledged the substance.On 03/18/2026 at 10:30 AM an interview with CNA F found the shower bed is used infrequently, but stated it does not look clean, and that they would clean it before use.On 03/18/2026 at 10:34 AM observation of SPA room B hall found black spots on the caulk along the floor wall juncture at the perimeter of the shower stall.On 03/18/2026 at 10:35 AM observation of the SPA room D hall found black spots on the caulk along the floor wall juncture at the perimeter of the shower stall. An interview with DM D found that a request was in TELS currently and indicated it had been sprayed with bleach a few days prior.On 03/18/2026 at 10:41 AM observation of the SPA room C hall found green and black buildup on the caulk along the floor wall juncture at the perimeter of the shower stall. Further observation found dripping water coming from the center crease of a shower bed mat, this area was soiled with brown residue.On 03/18/2026 at 10:43 AM observed wooden shelving units for clean linen storage in the C hall. Shelves were observed worn and rough to the touch.On 03/18/2026 at 3:22 PM observation of SPA room A hall found green and brown buildup on the caulk along the floor wall juncture at the perimeter of the shower stall.On 03/18/2026 at 3:33 PM observation of the SPA room D hall found a heating unit on the far wall with two corroded panel edges not covered creating sharp exposed surfaces. Further observation found a red/brown smear on the seat of shower chair in a shower stall.A record review of the facility provided document entitled Collection, Sorting, Handling, and Transportation of Soiled Linens states, Clean linens should be sorted, packaged, transported, and stored in a manner that prevents the risk of contamination by dust, debris, or other soiled items . Transport clean linens to patient care areas on designated linen carts or within designated containers that are regularly (e.g., daily) cleaned.

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of tube feeding poles for two residents (R1 and R4) of two resident rooms reviewed for cleanliness. Findings include: R4 On 3/17/2026 at 10:52 AM, R4 was observed in bed asleep. An observation of the resident's tube feeding pole was observed to have a buildup of dried brown tube feeding liquid. On 3/18/2026 at 9:04 AM and on 3/19/2026 at 9:36 AM, the tube feeding pole was observed in the same soiled manner. R1On 3/17/2026 at 11:00 AM, R1 was observed in bed asleep. An observation of the resident's tube feeding pole was observed to have a buildup of dried brown tube feeding liquid.On 3/19/2026 at 9:38 AM, the tube feeding pole was observed in the same soiled manner. On 3/19/2026 at 12:29 PM, Unit Manager J and surveyor observed the tube feeding pole of R1 and acknowledged the soiled manner of tube feeding pole. Unit Manager J was asked whose responsibility is it to ensure the cleanliness of the tube feeding poles, and she explained it is housekeeping's responsibility. On 3/19/2026 at 1:08 PM, the Director of Nursing was asked about the dirty tube feeding poles and explained the cleaning of the poles is housekeeping's responsibility. A review of the facility's, Resident-Patient Room Cleaning policy revealed the following, .Medical Devices. Cleaning and disinfecting medical devices and hardware is limited to noncritical devices that are at ow risk for exposure to blood, bodily fluids, secretions, or excretions .

Based on observation, interview, and record review, the facility failed to develop and implement care planned interventions for two residents (R70 and R86) of four residents reviewed for care plans. Findings include: R70 On 3/17/2026 at 11:04 AM, R70 was observed lying in bed with both hands contracted inward towards their wrist without hand splints. On 3/18/2026 at 10:00 AM and on 3/19/2026 at 10:00 AM and 12:38 PM, R70 was observed lying in bed with both hands contracted inward towards their wrist without hand splints. A review of R70's care plan did not reveal a care plan to address R70's hand contractures or extremity impairments. A review of R70's medical record noted, R70 was admitted to the facility on [DATE], transferred to the hospital on 3/10/26, and readmitted on [DATE] with diagnosis of Nontraumatic Intracerebral Hemorrhage. A review of R70's Nursing readmission Evaluation dated 3/17/2026 revealed, . Part 2 - V 6. Section VII: Musculosketetal 5. Range of motion 1. Limitations. Specify ROM limitation(s) contracted -upper and lower extremities. 6. immobilizer: a. Yes. Location of immobilizer -Lower extremities- boots support . On 3/19/2026 at 2:59 PM, the acting Director of Nursing (ADON) was asked about R70's care plan regarding the interventions for R70's hand impairments. The ADON explained R70 had not been screened by therapy since R70 had been readmitted . The ADON explained the screening by therapy start the development of R70's care plan. R86 On 3/17/2026 at 10:38 AM, R86 was observed in bed, lying on a standard facility mattress. A review of R86's medical record revealed they were admitted into the facility on [DATE] with diagnoses of Abnormal Posture, Other Lack of Coordination, and Difficulty in Walking. Further review revealed they were cognitively intact and required two-person assist with Activities of Daily Living. A review of the Incident and Accident report revealed R86 sustained an unwitnessed fall on 2/14/26. The incident description noted the following, Nurse was called to see resident in room. Nurse came to resident and nurse observed resident laying on the floor between [their] bed and the cupboard in [their] Rt (right) side of the body @ (at) 105am .Resident stated, 'My Rt leg got stocked (stuck) in the bed sheet and trying to get it off and turned loosed (lost) balance and fall.' Notes. Resident is alert and oriented x 3 (person, place and time). Has lack of perimeter awareness. Resident rolled out of bed. Corrective action to provide a perimeter mattress. A review of R86's care plan revealed the following, Focus: Resident is at risk for falls/injury related to debility and impaired vision. 2/3/2026 Considered a high fall risk per MD (medical doctor). Fall with no injury. 2/14/26 Fall with no injury. Date Initiated: 02/14/2026. Interventions: Perimeter mattress / scoop mattress. Date Initiated: 02/14/2026 . On 3/19/2026 at 12:00 PM, R86's bed was observed without a scoop/perimeter mattress in place. On 3/19/2026 at 1:08 PM, the Assistant Director of Nursing (ADON) was asked about R86 being care planned for a scoop/perimeter mattress but not having one in place. The ADON did not provide an explanation and indicated she would look further into it. On 3/19/2026 at 11:10 AM, a care plan policy was requested from the facility and not received by the end of the survey.

Based on observation, interview, and record review, the facility failed to implement interventions to promote wound healing for two residents (R7, R36) of five residents reviewed for management of pressure ulcer wounds. Findings include: R36 On 03/17/2026 at 10:04 AM, R36, was observed on their back in bed. Both shoulders were flat on the bed with the head of the bed up around 30 degrees. No devices were observed at the sides of the torso to offload pressure, and a specialty or low air loss mattress was not in place. R36 did not respond verbally to the call of their name or the knock on the door. The legs of R36 were flexed at the knees so that the heels were up toward and near the buttocks (a frog legged appearance). Certified Nursing assistant (CNA) L reported the position of the legs as normal for R36, and they had not seen the legs to fully extend. At 12:55 PM and 1:38 PM, R36 was observed in bed as before. At 4:38 PM, 5:09 PM and 5:32 PM, R36 was observed in a similar position on their back in bed, legs flexed at the knees and the feet and heels toward the buttocks. The right leg was up slightly higher than the left which was in contact with the bed. R36's wheelchair had a formed fitting seat with a pommel at the front, hard side bolsters, and soiled seat cushion. On 03/18/2026 at 8:23 AM, R36 was observed on their back in bed, knees flexed as before, dressed in a hospital style gown with the call pad at their right shoulder. Both shoulders contacted the bed surface. The covers were off and no devices were observed at the sides of the torso to offload pressure from the sacrum. Staff were seen to enter the room and cover up R36. The position of R36 was unchanged. At 9:31 AM and 10:26 AM, R36 was on their back in bed as before with the covers off, no socks or pants on, and no devices were observed at the sides of the torso. At 10:36 AM, an observation of the sacral wound was completed with the wound care nurse and CNA L. The sacrum had an open wound that was bleeding. The open area was about a quarter in size wound but elongated. A picture was taken by the wound nurse. The open wound had a grapefruit size area of darkened purple and red maroon color which surrounded it. It appeared as a deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue). A secondary area of yellowish/white scar tissue was observed below the open wound. The wound nurse was asked about R36 and reported R36 does not move themself and not able to move off the wound and has to be rotated. At 12:21 PM, R36 was seated on their lower back and buttocks in a Geri-chair recliner on the right side of the bed. No devices were observed at the sides to offload pressure from the sacral area and buttocks. The head of the recliner was up around 45-60 degrees, the knees remained flexed and the feet came together at the bottom edge of the recliner seat. At 2:12 PM, R36 was observed to be in the recliner as before. CNA L entered the room and returned R36 to bed. At 3:52 PM, R36 was observed to be on their back in bed. A pillow was at the right side of the torso. The right shoulder of R36 was turned up slightly; the sacral area was observed to be on the bed surface. At 4:07 PM, CNAs O and P reported R36 as having ongoing red or purple areas to the buttocks and the knee/leg contractures since admission. They further reported R36 does not move on their own but may shake or make small movements with the torso. At 4:25 PM, R36 was on their back in bed with the head up around 30 degrees. No devices or pillows were at the sides of the torso, and the shoulders and sacral area were in contact with the bed. On 03/19/2026 at 8:38 AM, 9:29 AM, 9:58, and 10:37 AM, R36 was seated in the Geri-chair recliner with the head up around 45-60 degrees with no pillows or devices at the sides. The knees were flexed so the feet were toward the center of the body and in the top portion (well) of the footrest. At 10:43 AM, R36 had been returned to bed.A review of the record for R36 revealed R36 was admitted into the facility on [DATE]. Diagnoses included Cerebral Palsy and Contractures of the Knees and Elbows. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition and dependence on staff for all activities of daily living and rolling left and right in bed, bed to chair transfers and mobility. A review of the record for R36 revealed a note dated 03/17/26 by the Nurse Practitioner (NP) which documented a sacral (lower back/tailbone area) wound at a stage two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister. Two dietary notes dated 02/13/26 and 03/17/26 also documented the stage two sacral wound. A review of the 03/16/26 sacral wound assessment by unit manager (UM) N, documented the wound area as 5.93 (centimeters) cm long by 5.28 cm; pain with wound care, surrounding tissue as fragile. A review of the wound pictures back through 01/07/26 revealed a history of smaller open and bloody areas across the observed wound area. The area of purple and red surrounded and encompassed the wounds. The wound area measurement increased and decreased week to week. The 03/16/26 wound measurement was larger than the previous measurement from 03/09/26. A review of the active care plan revealed: Resident is at risk for impaired skin integrity related to contracture of (Left)(Right) elbow incontinence immobility recurrent (moisture associated skin damage) MASD to BIL buttocks (history) HX of contact dermatitis, moderate protein-calorie malnutrition. chronic stage ii sacrum. Date Initiated: 07/08/2025. Revision on: 02/18/2026 .Assist resident with turning and repositioning as needed . Date Initiated: 07/08/2025. Resident has an (Activities of Daily Living) ADL self-care performance deficit related to Cerebral Palsy, generalized weakness, impaired ability to make self understood, shortness of breath (SOB) Date Initiated: 07/08/2025. Revision on: 08/13/2025 .Ambulation: Resident uses a Geri chair for ambulation X1 assist Date Initiated: 07/08/2025. Revision on: 07/31/2025 . Bed Mobility: 2 person assist . Date Initiated: 07/08/2025. Resident has an impaired neurological status related to cerebral palsy, seizure disorder Date Initiated: 07/08/2025. R7 On 03/17/2026 at 12:06 PM, 12:47 PM, 1:45 PM, and 2:15 PM, R7 was seated in their wheelchair with both heels resting on the front edge of the footrest without PRAFOS boots (pressure relieving ankle foot orthoses) in place. A review of the record documented bilateral wounds to the heels. At 5:19 PM, R7 was seated in their wheelchair with left heel on the footrest and the right heel hung over the front edge of the footrest. On 03/18/2026 at 8:12 AM, R7 was observed on their backside in bed, legs extended, with the head of the bed up 30-45 degrees and the PRAFO boots on. R7's glasses were in their lap. A low air loss mattress was active. At 9:24 AM, 10:25 AM, 12:36 PM, 2:11 PM and 4:26 PM, R7 was on their backside in bed and was sitting up with the head of the bed around 45-60 degrees with their glasses on. R7 did not have a pillow or device at the sides of the torso to offload pressure. On 03/19/2026 at 8:36 AM, R7 was on their back in bed, legs extended, PRAFO boots on, a low air loss mattress was in place, and the head of the bed was up around 20-30 degrees. At 9:29 AM, R7 had been served breakfast and was on their back in bed with the head of the bed up around 45-60 degrees. At 9:58 AM the breakfast tray had been removed and R7 was supine in bed with the head of the bed up around 45-60 degrees. At 10:37 AM, 11:12 AM and 11:59 AM, R7 was on their back in bed with the head of the bed up around 45-60 degrees. At 11:12 AM, R7 had reported their tailbone was sore. On 03/19/26 at 10:43 AM, Licensed Practical Nurse (LPN) V reported R36 as not ambulatory, has to be rotated, moved their hands mostly, alert to their name and non-verbal. LPN V reported R7 to be more alert than on admission and needed assistance to change position in bed.On 03/19/2026 at 10:53 AM, CNA L confirmed the need to reposition and change R36.On 03/19/2026 at 12:48 PM, the Therapy Director, reported R36 had their knees stuck in flexion and was dependent for dressing, feeding, bed mobility and log rolling and was last on therapy in 2023 as follow up screens had noted no changes in functional ability. R7 was noted currently on therapy, had a customized footrest, lower extremity swelling to the feet and legs, the inability to fully flex the legs independently and was a max assist for (bed mobility) log rolling in bed. On 03/19/2026 at 12:15 PM, the Acting Director of Nursing (ADON) reported a low air loss mattress had been considered for R36 but not yet implemented as there was a desire to get one with bolsters to also address the history of falls but one had not been found. A review of the current mattress manufacturer's specifications and manual documented it was for basic pressure redistribution and not rated for stage three or four pressure wounds. A review of the record for R7 revealed R7 was admitted into the facility on [DATE]. Diagnoses included Dementia, Pressure Ulcer of the Right Heel, and Muscle Wasting and Atrophy. The Active care plan documented: Resident has an ADL self-care performance deficit related to pressure ulcer of right heel, extensive to total for most care. Date Initiated: 11/28/2025. Revision on: 03/05/2026 Bed Mobility extensive assist 2 person Date Initiated: 02/27/2026. Revision on: 03/05/2026. Resident has a need for indwelling catheter related to pressure ulcer(s) Date Initiated: 02/27/2026. Revision on: 03/05/2026. Resident has impaired skin integrity as evidenced by: (Right) heel (undetermined) UTD (Right) heel DTI (Left) lateral foot DTI intact blister scarring to (Bilateral) buttocks (cicatrix) intact. related to immobility underlying diagnosis incontinence . Assist resident with turning and repositioning as needed Date Initiated: 11/28/2025. Revised 03/05/26 . A review of the Rehab NP note dated 03/17/26 documented, .Mental Status: (alert and oriented) A & O X 2. (range of motion) ROM: (within functional limits bilateral upper extremities) wfl bue, (decreased bilateral lower extremities) dec ble Strength: significant weakness ble, Mobility Roll left and right = Substantial/maximal assistance Sit to lying = Substantial/maximal assistance, Sit to stand = Dependent Chair/bed-to-chair transfer = Dependent, Toilet transfer = Dependent . A review of the note dated 03/19/2026 at 12:16 PM by the wound care nurse documented: Skin Issue: .Location: Left lateral foot. Additional location information: (Left) heel Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Wound was present on admission . Right lateral foot. Laterality / Orientation: Right. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Wound was present on admission . Right medial calf. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission . Right gluteus (buttock). Laterality / Orientation: Lateral. Issue type: Moisture associated skin damage (MASD). Progress: Stalled: previously improving wound characteristics plateaued. MASD: IAD Incontinence Associated Dermatitis. Wound was present on admission . Painful: Yes . Pain description: Aching . Surrounding tissue: Dry / flaky . Scarring . Skin issue education: Turn every 2 hours . A review of the facility policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol revised 03/20/24 revealed, Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .

Based on observation, interview and record review, the facility failed to maintain a medical record which reflects the resident's current status for the use of oxygen for one resident (R86) of one reviewed for respiratory care. Findings include: On 3/17/2026 at 10:38 AM, R86 was observed in bed. The resident was not observed receiving oxygen via nasal cannula, and there was not an oxygen concentrator or tank in the room. R86 explained they had a diagnosis of Sarcoidosis and was upset they had contracted pneumonia while residing in the facility. A review of R86's medical record revealed they were admitted into the facility on [DATE] with diagnoses of Interstitial Pulmonary Disease and Sarcoidosis of Lung. Further review revealed they were cognitively intact and required two-person assist with Activities of Daily Living. Further review of the medical record revealed an active order dated 12/22/25 indicating the following, Oxygen: Run @ (at) 2[x]L/MIN (liters per minute) VIA [x] N/C (nasal cannula) Continuous every shift for Sarcoidosis of Lung Notify MD (medical doctor) of SpO2 (saturation of peripheral oxygen) less than 92%. A review of R86's February and March Medication Administration Record (MAR) was reviewed and revealed the order was documented as administered 51 times between two shifts in the month of February, and 31 times between two shifts in the month of March. On 3/18/2026 at 12:30 PM, R86 was observed sitting in their wheelchair. The resident was observed not wearing any oxygen, and there was no oxygen concentrator or tank observed in the room. On 3/19/2026 at 12:29 PM, Unit Manager J was asked about R86's lack of use of oxygen. Unit Manager J entered into the resident's room and asked them about their oxygen in which R86 explained they hadn't had any oxygen in more than six weeks. On 3/19/2026 at 1:08 PM, the Assistant Director of Nursing (ADON) was asked about R86's order for oxygen. The DON did not provide an explanation and indicated she would contact the doctor for clarification. On 3/19/2026 at 11:10 AM, a policy for Physician's Orders was requested from the facility and not received by the end of survey.

Based on observation, interview, and record review, the facility failed to administer two medication doses correctly out of 32 opportunities for one of one resident (R97) resulting in a medication error rate of 6.25 percent. Findings include: On 03/18/2026 at 8:57 AM, Licensed Practical Nurse (LPN) K was observed to prepare six medications for R97. The divalproex sodium 125 (milligrams) MG Delayed Release Oral Capsule order documented to give six capsules for a combined dosage of 750 MG capsule. One 125 MG was placed into the medication cup. The calcium carbonate 750 MG Chewable Tablet documented one tablet was to be given. One 500 MG was dispensed into a second medication cup. The medications were brought to the room and administered to R97. Upon return to the medication cart the orders for the divalproex and the calcium carbonate were reviewed with LPN K. LPN K remarked I need to give more. On 03/19/2026 at 12:15 PM, the Acting Director of Nursing (ADON) reported there was a performance improvement plan in place related to the number of new nurses hired by the facility. The ADON reported they had heard about the administration of the incorrect calcium carbonate dosage but not the divalproex. A review of the facility policy titled, Medication Administration revised 01/17/23 revealed, .Compare medication source with (medication administration record) MAR to verify resident name, medication name, form, dose, route, and time of administration. Note - If medication dispensed in a different dose/quantity per dose (example 1/2 pill or give 2 pills) a sticker will be placed on the medication packaging to denote to check the MAR for clarification . Administer medication as ordered in accordance with manufacturer specifications .

Based on observation, interview and record review, the facility failed to perform timely hand hygiene in one of one resident (R102) during medication passes. Findings include: On 03/18/2026 at 9:57 AM, Registered Nurse (RN) I was observed to move the medication cart to the opposite hall and prepare medications for R102. RN I removed three medications from the medication cart to administer to R102 via a feeding tube. RN I crushed two of the medications. The third was a liquid. RN I walked down to the room of R102. RN I set the medications down on the gown disposal bin and put on a gown and gloves. RN I picked up the medications and placed them on the tray table. RN I noted there was no water container for the administration of the medications. RN I removed the gown and gloves and exited the room. RN I walked down the hall passing hand sanitizer stations and went to the supply area and returned with a container and syringe. RN I returned to the entry of R102's room and donned a gown and pair of gloves and filled the container with some water from the sink and administered the three medications, the water and a carton of liquid nutrition to R102 via the feeding tube inserted into the abdomen. RN I rinsed the syringe and container at the sink and doffed the gloves and gown into the trash. RN I gathered the edges of the trash bag and exited the room with the trash bag in hand and went to the medication cart and pulled the keys from the rights smock pocket, unlocked the cart, returned keys to the pocket, and took trash down the hall to the soiled utility room. RN I returned to the medication cart. RN I was not observed to complete hand hygiene during the medication pass observation. When queried RN I reported they had done hand hygiene after the trip to the soiled utility room. On 03/19/2026 at 12:15 PM, the Acting Director of Nursing (ADON) recommended hand washing for twenty seconds before, during and after care that involves a feeding tube, urinary catheter or a wound. A review of the facility policy titled, Hand Hygiene revised 12/13/23 revealed, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub is the preferred method for cleaning hands in most clinical situations (*see notation for C-diff). Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom . a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves Hand Hygiene Table: Either Soap and Water or Alcohol Based Hand Rub: Hands are visibly dirty . between resident contacts . after handling contaminated objects . before applying and after removing personal protective equipment (PPE), including gloves . before preparing or handling medications . before and after handling clean or soiled dressings, linens . Before performing resident care procedures, before and after providing care to residents in isolation, after handling items potentially contaminated with blood, body fluids, secretions, or excretions, when, during resident care, moving from a contaminated body site to a clean body site

Based on observation, interview, and record review the facility failed to ensure treatment and services were provided in a dignified manner for eight residents, (R#'s 20, 70, 10, 76, 17, 13, 5, and 405) of eight residents reviewed for dignity. Findings include: R20 On 1/13/25 at 1:19 PM, R20 was observed in the Rainbow dining room in their geri-chair (reclining lounge chair). R20 was being fed their lunch meal by CNA (Certified Nurse Aide) 'B'. At the conclusion of the meal, CNA 'B' was observed to transport R20 down the hall in their geri-chair by pulling the chair in a forward motion with the chair and R20 facing rearward. On 1/13/25 at 1:22 PM, CNA 'B' was asked about pulling R20 backward in the geri-chair and said sometimes the wheels on the chair drift from side to side. They were asked if they were instructed to pull the chair with the resident facing rearward and they said no, the resident should face forward and the chair should be pushed from behind. On 1/14/25 at 4:10 PM, an interview was conducted with the Director of Nursing (DON) regarding the proper way to transport a resident in a wheelchair or geri-chair and they said the resident should be facing forward and pushed in a forward motion. R70, R10, R17, R13, R5, R405, R76 On 1/13/25 from 12:50 PM to 1:31 PM, an observation of the Rainbow dining room was conducted and eight residents were seated at six tables in the room. Certified Nurse Aide 'D' was overheard requesting bibs (clothing protectors) be brought to the dining room to be placed on residents prior to the lunch meal being served. Further observations included: At 12:59 PM, R70 was sleeping in their wheelchair at the table with their lunch meal in front of them. R10 was seated across from R70 but did not have a meal tray. At 1:05 PM, one-to-one feeding assistance was being provided to R76. R17 was seated across from R76 but was not served a meal. CNA 'E' was observed providing one-to-one feeding assistance to R13, but was observed to leave R13 in the middle of the meal to set up R5's meal tray. At 1:23 PM, R70 remained asleep in their wheelchair with their meal in front of them, R10 was seated across the table and was provided a meal tray more than twenty minutes after R70. At 1:28 PM CNA 'E' attempted to provide one-to-one assistance to R70 a half an hour after their meal had been served but R70 refused. On 1/14/25 from 12:35 PM until 1:03 PM, a second dining observation was conducted in the Rainbow dining room. Nine residents were observed seated at six tables and two CNA's were present passing the trays, setting up the meals and providing one-to-one feeding assistance. At 12:46 PM, R70 was provided a meal tray and R405 seated across the table. They had fallen asleep in their wheelchair and was not provided their meal until 12:55 PM. R70 was fidgeting with their meal ticket making no attempts to feed themselves. R17 had also been served a meal tray but was making no attempts at feeding themselves. At 12:50 PM, CNA 'F' was providing one-to-one feeding assistance to R76 and CNA 'G' was providing one-to-one assistance to R20. R70 had a meal tray in front of them but was making no attempts at feeding themselves and two residents. R405 and R5 were not provided a meal tray while the rest of the diners either received assistance or fed themselves. At 12:55 PM, CNA 'F' was observed to leave R76 in the middle of the meal to serve and set up R405's tray before returning to R76. At 12:56 PM, R5 was the only resident in the dining room who had not received a meal tray. It was overheard the meal had been delivered to the hallway and CNA 'G' left the dining room to retrieve the tray. R70 remains with a tray in front of them fidgeting with their meal ticket and staff were not observed to be available to cue them or provide one-to-one assistance. At 12:59 PM, CNA 'G' began providing one-to-one feeding assistance to R17, more than ten minutes after their meal had been served. At 1:06 PM, CNA 'F' was observed to transport R76 from the dining room. It was observed their meal tray contained an unopened ice cream and an unopened yogurt. At 1:13 PM, CNA 'F' was asked why they did not offer those meal items to R76 and said they should have. They were then asked if they had enough help in the dining room to provide the one-to-one feeding assistance and cueing and said, they did not and that was why they were, all over the place in the dining room On 1/14/24 at 4:10 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the observations in the dining room. The DON acknowledged the concerns and indicated the dining process for individuals requiring more assistance and cueing was an ongoing process. A review of a facility provided document regarding Resident rights, dignity, and respect was conducted and read, It is the policy of this facility that all residents be treated with kindness, dignity, and respect .

Based on observation, interview, and record review the facility failed to ensure bathing and hair care was completed and facial hair removed timely for six residents (R34, R57, R63, R84, R99) of six residents reviewed for activities of daily living (ADL) care. Findings include: R57 A review of the facility records for R57 revealed R57 was admitted into the facility on [DATE]. Diagnoses included Need for assistance with Personal Care, Above the knee leg amputations, and Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for partial/moderate assistance of one person for personal hygiene, substantial/maximal assistance to roll left and right and dependent to go from sitting to lying. The shower/bath self was documented as not attempted due to medical condition or safety concerns. The care plan revised 01/02/25 documented, Resident has an ADL self care performance deficit . A review of the shower task in the electronic medical record on 01/14/25 documented three showers attempted in 30 days: 01/01/25 was a bed bath; 12/25/24 was a bed bath; and 12/21/24 was documented as refused. Paper shower sheets documented bathing on 01/11/25, 01/08/25 and 12/14/24. Six of eight possible showers were documented or attempted. The task documented showers were to be given Wednesdays and Saturdays in the evenings. R63 On 01/13/25 through 01/15/25, R63 was not observed out of bed. A review of the facility record for R63 revealed R63 was admitted into the facility 10/23/24. Diagnoses included Stroke, and Bone and Muscle Disorders. The MDS dated [DATE] documented impaired cognition and the need for partial/moderate assistance of one person for personal hygiene, substantial/maximal assistance to roll left and right and dependent to go from sitting to lying. The shower/bathe self was documented as not attempted due to medical condition or safety concerns. The care plan revised 11/08/24 documented, Resident has an ADL self care performance deficit . A review of the facility records and tasks on 01/14/25 revealed five of eight showers were documented or attempted in thirty days: 12/18/24 was refused, a bed bath 12/25/24; 01/01/25 was documented not applicable; a bed bath on 01/4/25, and a bed bath on 01/09/25. Shower sheets were provided for 10/30/24, 11/27/24, 11/30/24, 12/07/24, 12/11/24 and 12/14/24. No additional shower sheets were provided to substantiate showers were given. The task documented showers were to be given Wednesdays and Saturdays in the evenings. R84 On 01/13/25 at 10:24 AM, R84 was observed to be dressed and seated in a wheelchair at the left side of the bed. R84 reported they had not always received fresh water and the cream for their buttocks wound was not applied as often as it was supposed to be. A review of the facility record for R84 revealed R84 was admitted into the facility 12/16/24. Diagnoses included Age Related Physical Debility and Myasthenia Gravis. The MDS dated [DATE] documented intact cognition, impaired range of motion of both upper extremities and the need for partial/moderate assistance of one person for personal hygiene, to roll left and right and to go from sitting to lying. The shower/bathe self was documented as not attempted due to medical condition or safety concerns. The care plan revised 01/06/25 documented, Resident has an ADL self care performance deficit . A review of the facility records and tasks on 01/14/25 indicated five of eight showers were documented in the last thirty days: 12/18/24 was a shower, 12/21/24 was refused; 12/25/24 was a bed bath; 01/01/25 was documented refused; 01/11/25 was a shower. Shower sheets were provided for 12/18/24, 12/21/25, and 12/25/24. The task documented showers were to be given Wednesdays and Saturdays in the evenings. R99 On 01/14/24 at 12:36 PM, a visitor for R99 reported concerns with R99 left in the same socks for three days; R99's feet were dependent all day which caused a dusky purple appearance. A review of the facility record for R99 revealed R99 was admitted into the facility 12/06/24. Diagnoses included Stroke with affected right dominant side and Cerebral Palsy. The MDS dated [DATE] documented impaired cognition and the need for partial/moderate assistance of one person for personal hygiene, substantial/maximal assistance to roll left and right and to go from sitting to lying. The shower/bath self section was documented as substantial/maximal assistance. The care plan initiated 01/07/25 documented, Resident has an ADL self care performance deficit . A review of the electronic shower documentation on 01/14/24 for the last thirty days revealed: showers were documented 12/16/24, 12/19/24, 12/23/24, and 12/26/24. 12/30/24, 01/06/25, 01/09/25 were documented as not applicable. Mondays and Thursdays were the indicated shower days which indicated ten opportunities since Friday 12/06/24. Four showers were documented as attempted or completed. On 01/15/25 at 12:11 PM, the Director of Nursing (DON) acknowledged a resident scheduled for a bath two times a week should be provided a bath two times a week and the completion or attempt documented. 34208 R34 On 1/13/25 at 10:28 AM, R34 was observed in their room sitting on their bed with a one-to-one sitter. R34's long, gray hair was not combed and had a greasy appearance. They were further observed to have long, thick, facial hairs covering their chin. They were asked if they would like the hair removed and said they wanted to get rid of them but nobody would help. On 1/14/25 at approximately 9:30 AM and 1:40 PM, R34 was observed in their room. Their hair remained uncombed, greasy in appearance and their face remained with thick, long facial hair on their chin. On 1/14/25 at 9:16 AM, a review of R34's clinical record revealed they admitted to the facility on [DATE] and most recently readmitted on [DATE]. R34's diagnoses included: toxic encephalopathy, cirrhosis, dementia, and anxiety disorder. The most recently completed Minimum Data Set (MDS) assessment dated [DATE] indicated R34 had severely impaired cognition, exhibited no hallucinations, delusions, behaviors, or rejection of care, and required mostly moderate assistance from staff for ADL's. A review of R34's Certified Nurse Aide (CNA) task for showers for a 30-day look-back revealed they were scheduled for showers on Tuesdays and Fridays but had only received one bed bath for the 30-day look-back period. The documentation reviewed did not indicate R34 had their hair shampooed or was assisted with the removal of facial hair. A review of R34's CNA task for behaviors for a 30-day look-back period was also conducted and did not document any behaviors. Further review of the record included progress notes, however; no progress notes dating back to November 2024 revealed any documentation to indicate R34 had been offered and refused any ADL care. On 1/14/24 at 12:15 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R34's ADL care. The DON indicated R34 frequently refused the care offered and would fight with the staff. They were asked about the lack of documentation to demonstrate the ADL care had been offered, attempted, and refused by R34 and said staff would have to do better documenting attempts at care, rejection of care, and behaviors. A review of the facility policy titled, Charting and Documentation Adopted 07/11/2018, revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting . A review of the policy title, Shaving adopted 07/11/2018 revealed, It is the policy of this facility to improve the resident's appearance. In accordance with the resident's preference.

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during care for four residents (R82, R70, R76, and R5) of four residents reviewed for hand hygiene and infection control, resulting in the potential for the spread of infection. Findings include: R82 On 1/13/25 at 9:03 AM, Nurse 'C' was observed preparing medications at the medication cart in the hallway for R82. They were not observed to perform hand hygiene prior to beginning to prepare the medications. Nurse 'C' prepared multiple medications including an ordered 81 milligram aspirin tab. Two aspirin tabs were deposited from the bottle into the cap for transfer to the medication cup. Nurse 'C' was observed to remove the second tab from the bottle cap with their bare hands and placed it back in the aspirin bottle. When the medication preparation at the medication cart was complete, Nurse 'C' entered R82's room, and was not observed to perform hand hygiene upon entry. They administered the medications, and at that time, R82 requested a medication for pain. Nurse 'C' exited the room and returned to the medication cart to prepare the pain medication. They were not observed to perform hand hygiene upon exiting the room prior to preparing the pain medication. Nurse 'C' deposited two of the pain medication pills from the bottle into the lid of the bottle for transfer into the medication cup. R82 was only to receive one pill and Nurse 'C' was observed to grab the second pill from the bottle cap with their bare hands and place it back into the bottle. Nurse 'C' returned to R82's room to administer the medication and again was not observed to perform hand hygiene prior to administering the medication. On 1/13/25 from 12:50 PM until 1:31 PM, an observation of the Rainbow dining room was conducted and the following was observed: Certified Nurse Aide (CNA) 'D' was observed to place clothing protectors on R70, R76, and R5. They were not observed to perform hand hygiene in between contact with the different residents. They were further observed to straighten R70's hair then sit down to provide one-to-one feeding assistance to R76 without performing hand hygiene. CNA 'D' finished assisting R76 and moved to assist R17, they were not observed to perform hand hygiene after touching R76's utensils, plate, and napkins prior to assisting R17. The dining room was observed without a hand washing sink or dispenser for hand sanitizing gel/foam. On 1/14/25 at 4:10 PM, the infection control observations were discussed with the Director of Nursing. They indicated hand hygiene should be conducted in between resident contacts and pills should not be touched with bare hands. A review of a facility provided document, Subject: Hand Hygiene was reviewed and read, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a resident . Proper hand hygiene should be performed between all services to residents . After touching a resident or the resident's immediate environment .

Based on observation, interview, and record review, the facility failed to maintain the call light within resident reach for one (R22) of six residents reviewed for call light access. Findings include: Review of the facility record for R22 revealed an admitted [DATE] with diagnoses including Anorexia, Cirrhosis of the Liver, and Diabetes Mellitus. The record further indicated R22 was receiving hospice services. On 01/14/25 at 10:25 AM and12:09 PM, R22 was observed laying in bed. They were not responsive to verbal greetings. The resident's call light was observed laying on the floor under the head of the bed out of reach. On 01/14/25 at 02:28 PM and 3:18 PM, R22 was observed laying in bed and the call light remained on the floor under the head of the bed after staff had been observed in the room assisting the resident. On 01/15/25 at 08:50 AM, R22 was observed laying in bed trying to call out for help. They were interviewed at bedside and asked for help stating that their hip was hurting. The call light was observed laying on the floor under the head of the bed out of reach as it was the previous day. R22 was asked if they know how to use the call light to request assistance and they stated yeah I can use it but I don't have it. On 01/15/25 at 10:50 AM, the facility's Director of Nursing (DON) was was made aware of the concern regarding R22's call light not being accessible during multiple observations. The DON reported the expectation is resident's call lights should be kept within reach at all times. Review of the facility policy Call Lights dated 07/11/18 revealed the policy statement It is the policy of this facility to provide the resident a means of communication with nursing staff. The Procedure portion of the policy includes the entry 7. Be sure call lights are placed within reach of residents who are able to use it at all times.

Based on observation, interview and record review the facility failed to complete wound care per the physician order for one resident (R84) of one reviewed for wound care. Findings include: On 01/13/25 at 10:24 AM, R84 was observed to be dressed and seated in a wheelchair at the left side of the bed. R84 reported the cream for their buttocks wound was not applied as often as it was supposed to be. A review of the record documented a physician order dated 01/07/25 which revealed, R (right) buttock: Cleanse with NS (normal saline), apply triad, cover with border gauze. BID (two times a day) /PRN (as needed); every day and night shift for treatment. On 01/14/25 at 11:33 AM, a skin and wound observation of R84's right buttock was conducted with the wound care nurse. A dressing was not observed to be in place. A quarter size open area was observed. The wound nurse applied a dressing to the wound area. The dressing was dated for 01/14/25 and had the initals of the wound care nurse. A review of the January 14, 2025 Treatment Administration Record (TAR) revealed the dressing change had been documented as done by the night shift nurse. On 01/15/25 at 9:11 AM, the right buttocks area and dressing for R84 were observed with Registered Nurse (RN) H. The dressing was observed to be the dressing placed by the wound nurse on 01/14/25. A review of the January 15, 2025 Treatment Administration Record (TAR) revealed the dressing change had been documented as done by the night shift nurse. Review of the December 2024 TAR revealed missing documentation for completion of the right buttocks treatment. On 01/15/25 at 12:06 PM, the Director of Nursing (DON) reported the order should not have been written as two times a day and the facility had made attempts to ensure orders were not written that way unless specifically requested by the physician. The DON further noted audits of documentation were being completed. A review of the audits indicated they were checking for missing documentation. R84's wound care was documented as done but not completed and would not have been caught with only a chart review. A review of the facility record for R84 revealed R84 was admitted into the facility 10/23/24. Diagnoses included Age Related Physical Debility and Myasthenia Gravis. The MDS dated [DATE] documented intact cognition, impaired range of motion of both upper extremities and the need for partial/moderated assistance of one person for personal hygiene, to roll left and right and to go from sitting to lying. The care plan revised 01/06/25 documented, Resident has an ADL self care performance deficit . A review of the facility policy titled, Dressings, Non-Sterile adopted 07/11/2018 revealed, It is the policy of this facility to perform treatments and dressing changes per physician orders. A review of the facility policy titled, Charting and Documentation Adopted 07/11/2018, revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting .

Based on observation, interview, and record review, the facility failed to ensure application of palm protector devices for one resident (R76) of two residents reviewed for restorative services, resulting in unprotected palm of hand from contracted fingers. Findings include: On 1/13/25 at 10:05 AM, R76 was in their room in their wheelchair. An observation of the left hand revealed a contracture (shortening of mucles causing joints to stiffen) of second, third, fourth, and fifth finger. A device to protect the palm or prevent the worsening of the contracture was not observed in use, and a splint was observed on the dresser. On 1/13/25 at 10:54 AM, an interview was conducted with R76's family member and durable power of attorney. They said they were concerned about R76's left hand contracture and the potential for their fingernails to cause a wound in the palm. They said the staff were supposed to use a splint and or some device in the hand to prevent the worsening of the contracture or the development of a wound. On 1/13/25 at 11:20 AM, 12:36 PM, 4:42 PM, and 1/14/25 at 7:53 AM, R76 was observed with no splint or device in their palm. On 1/13/24 at 3:28 PM, R76 was observed in their room seated in their wheelchair. A splint or device to protect the palm was not present. With R76's Durable Power of Attorney's permission and R76's permission, an observation of their palm was conducted. R76 was able to slightly open and unclench their fingers from their palm and a reddened, small open area where the index finger nail met the palm was observed. R76's fingernails were discolored with debris under the nail bed, extended approximately a quarter of an inch beyond the nail bed, and were filed in a square fashion that gave them sharp edges. A foul odor was noted when R76's hand was opened. R76 was asked if they had any pain and made a grunting noise and nodded their head yes. On 1/14/25 at 9:59 AM, R76's fingernails remained long, discolored, with debris under the nail bed and filed with sharp edges. They were asked if their palm still hurt and nodded saying, still hurts. A review of R76's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: rectal cancer, drug induced subacute dyskinesia (uncontrollable involuntary movements), profound intellectual disabilities, autistic disorder and moderate intellectual disabilities. R76's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed they had severely impaired cognition. R76's physician orders were reviewed and an order dated 5/21/24 read, Apply foam roll in between left hand during daytime, remove at night. A review of R76's most recent Occupational Therapy Discharge Summary for service dates of 5/21/24 thru 8/1/24 was conducted and read, Patient Goals .L. digit contraction of digit 3,4,5 .continued hand splinting a must daytime foam roll and night time resting hand splint . On 1/14/25 at 10:10 AM, an observation of R76's hand was conducted with Wound Care Nurse 'I'. Nurse 'I' observed R76's fingernails and palm and confirmed the presence of odor and a new wound to the palm. A progress note entered into the record on 1/14/25 at 4:07 PM, by Wound Care Nurse 'I' was reviewed and read, .Writer completed skin observation to (L) (left) hand(contracture) with nails causing tear. Odor noted. Writer cleansed applied Bacitracin/4x4 gauze hand roll. Writer to follow with wound care. On 1/14/25 at 12:15 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R76's left hand contracture, splint, palm protector, fingernails, and development of a wound. The DON confirmed R76 was to have a splint at night and a foam roll or other device to protect the palm during the day. When made aware R76 had not been observed with any devices in place on 1/14/25 they had no explanation. They were then asked about the square nails with sharp edges and said family manicured them that way. They were asked if the family had been educated on the hazards of the nail shape and replied they should have been. They were next asked about the length of the nails and the odor in the palm and said staff should have noticed the condition of the hand and nails and addressed it. A review of a facility provided document, Subject: Restorative Care was conducted and read, It is the policy of this facility to ensure that: Restorative care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. The resident will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care .

Based on observation, interview, and record review, the facility failed to maintain the resident's water cup within reach for one resident (R22) of five residents reviewed for access to water. Findings include: Review of the facility record for R22 revealed an admitted [DATE] with diagnoses including Anorexia, Cirrhosis of Liver, and Diabetes Mellitus. The record further indicated R22 was receiving hospice care services. On 01/14/25 at 10:25 AM, R22 was observed laying in bed. They were not responsive to verbal greetings. A water cup was observed on the nightstand out of the resident's reach. There was a fall mat on the floor between the bed and the nightstand. On 01/14/25 at 12:09 PM, R22 was interviewed as they were laying in bed. It was observed R22's water cup was on the nightstand out of reach. R22 was asked if they would like to be able to reach their water cup without assistance and they stated yes. On 01/14/25 at 02:28 PM, R22 was observed laying in bed. The water cup was on an over-bed table at the foot of the bed out of the resident's reach after staff were observed in the room assisting the resident with their lunch. Further review of R22's record revealed the 12/03/24 care plan Focus area statement The resident has dehydration or potential fluid deficit related to Hepatitis, Diabetes Mellitus, history of Adult Failure to Thrive. This focus area included the Goal statement Resident will be free of symptoms of dehydration and maintain moist mucous membranes. The Interventions portion of the focus area included the entry Encourage the resident to drink fluids of choice. R22's record revealed no indication the resident should not have access to their water cup. On 01/14/25 at 03:18 PM, R22's water cup remained on the over-bed table out of reach near the foot of the bed. On 01/15/25 at 08:50 AM, R22 was observed laying in bed. R22's water cup was observed on the over-bed table at the foot of the bed, out of reach. There was a fall mat on the floor to the right of the bed and there was approximately 20 inches of space between the left side of the bed and the wall that would accommodate the over-bed table in order to have the water within the resident's reach. R22 was asked if they would like to have access to their water cup and they stated yes. On 01/15/25 at 10:55 AM, the facility Director of Nursing (DON) was informed of the concern regarding R22's water not being accessible while having a care plan item specific to dehydration risk and asked if they were aware of any reason that the water was not being kept within the resident's reach. The DON acknowledged that they were not aware of a care-planned or clinical reason for the water to not be accessible but indicated staff may be placing it out of reach due to a history of the resident spilling water. Review of the facility policy Hydration dated 07/11/18 revealed the policy statement It is the policy of this facility to encourage fluid intake to maintain resident's hydration in compliance with physician orders. The Procedure portion of the policy includes the entry 2. Every resident will be provided fresh ice water every shift. and 3. Fluids will offered at a minimum of every two hours for the dependent resident, unless contraindicated.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than five percent when two errors were made, from 27 opportunities resulting in a medication error rate of 7.41% for one resident, (R39) of four residents reviewed for medication administration. Findings include: On 1/14/25 at 8:20 AM, Nurse 'A' was observed preparing medications for administration to R39. Nurse 'A' prepared multiple medications including an oral folic acid supplement 400 mcg (micrograms). After preparing the medications Nurse 'A' proceeded to the room and administered the medications to R39. After R39 took the medications Nurse 'A' exited the room and signed the medications as given on the eMAR (electronic medication administration record). They were asked to confirm all medications due at that time had been administered and confirmed they were. On 1/14/25 at 8:52 AM, R39's medications observed administered were reconciled (compared) with their physician's orders. It was discovered R39's order for folic acid was for 1 mg (milligram). It was further discovered R39 had an order for cyanocobalamin (Vitamin B12) 1000 mcg due at the 9 AM medication pass, however; it was not observed the medication had been prepared and administered to R39 at that time. A review of a facility provided policy for medication administration updated 12/2019 was reviewed and read, .It is the policy of this facility that medications shall be administered as prescribed by the attending physician .

This citation pertains to Intake MI00147709. Based on observation and interview, the facility failed to ensure resident wound care treatments were documented and skin maintained intact for one resident (R901) of three whose skin management was reviewed. Findings include: A review of the record for R901 revealed: R901 was admitted into the facility on [DATE] and discharged on [DATE]. Diagnoses included Pain, Anxiety, Kidney Disease and Heart Disease. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented R901 had severely impaired cognition with a 2/15 Brief Interview for Mental Status score and the need for dependance of one or two persons for toileting hygiene, bathing, lower body dressing, rolling left or right in bed, and going from sitting to lying and back again. The MDS further documented R901 had Moisture Associated Skin Damage (MASD). A physician order updated 09/26/24 documented MASD/Buttocks: Cleanse with soap and water. Pat dry. Apply barrier cream/AD. Cover with border guaze (two times a day/as needed) BID/PRN. Every day and night shift for treatment. A review of the Treatment Administration Record (TAR) for August 2024 revealed treatment for a MASD buttocks wound began 08/29/24. A review of the Treatment Administration Record (TAR) for September 2024 revealed six missed or undocumented treatments on the day shift and eight missed or undocumented treatments on the night shift for the MASD buttocks wound. A review of the Treatment Administration Record (TAR) for October 2024 revealed two missed or undocumented treatments on the day shift and four missed or undocumented treatments on the night shift for the MASD buttocks wound. On 11/21/24 at 1:00 PM, the missing treatments and desciption of the buttocks wound were reviewed with the wound care nurse staff A. The wound care nurse acknowledged some of the treatments may have been completed but not documented by them. The wound nurse supplied a wound assessment for September which documented the MASD to the buttocks and when asked, reported the area to the buttocks as excoriation or as something from a skinned knee. The wound nurse confirmed R901 was incontinent of urine and stool and this as the likely cause of the MASD. On 11/21/24 at 4:27 PM, the missing documentation concern for R901 was reviewed with the Director of Nursing (DON). The DON reported R901 had a decline in condition and the buttocks wounds were recurring. Documentation of the the missing treatment was requested. On 11/21/24 at 5:08 PM, Certified Nursing Assistant (CNA) B was asked about the care provided to R901 on 10/22/24 and reported there was a wound to the buttock that did not have dressing on it and needed they to clean it and have the nurse put a dressing on it. The CNA was asked to describe the wound and reported it to be around the size of a quarter and was red in the middle. On 11/21/24 at 5:40 PM, the DON was asked about the missing documentation. The DON acknowledged the missing documentation and noted the treatment as an order with a dressing and confirmed an order with a dressing required documentation. No furtner documentation of the buttocks wound treatment was provided prior to survey exit. A review of the facility policy titled, Skin Monitoring and Management: Pressure Ulcer adopted 07/11/18, revealed, .Once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the Physician's order. All wound or skin treatments should be documented in the resident's clinical record at the time they are administered.

This citation pertains to Intake: MI00147554 Based on interview and record review, the facility failed to provide ongoing monitoring and treatment for a change in condition for one resident (R901) of four residents reviewed for change of condition resulting in the initiation of Cardiopulmonary Resuscitation (CPR). Findings include: A review of Intake: MI00147554 revealed the following, Complainant states the resident was exhibiting an altered mental status and the nurse on duty called EMS (emergency medical services) to have the resident sent to the hospital. The complainant states EMS arrived at the residents bedside and the administrator made them leave and told the Nurse Practitioner to treat the resident in house. The complainant states the resident was found dead the next day. The complainant states they don't know the residents cause of death but appeared fine prior to showing signs of altered mental status. A review of R901's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Diabetes, and Heart Failure. Further review revealed the resident was cognitively intact, oxygen dependent, and required ,d+[DATE]-person assistance for transfers, toileting and dressing. Further review of R901's medical record revealed the following progress note: [DATE] 17:35 (5:35pm). General Progress Note Patients left, and right hand noticeably shaking, unable to grasp things without it falling. MD (medical doctor) notified via Doctors book. Will continue to monitor patient duration of this shift. [DATE] 17:19 (5:19pm) Change of Condition Note Text: pt (patient) hypotensive (low blood pressure) in am (morning), bs (blood sugar) wnl (within normal limits), general weakness, lethargy difficulty speaking, [insurance company] NP (nurse practitioner) present, straight cath (catheter) for possible u/a, (urinalysis) STAT CXR ( immediate xray) ordered, lasix (diuretic) on hold, parameters added,02 (oxygen) tank replaced .continue to monitor and notify oncoming shift. On [DATE] at 12:33 PM, an interview was completed with Licensed Practical Nurse (LPN) A regarding R901 on [DATE], and they explained they were inside the resident's room when staff were attempting to get the resident up in the sit to stand lift (used to help transfer patients from a seated to a standing position) however, the resident was exhibiting decreased strength with the inability to grasp the bars to the sit to stand, as each time they attempted to hold on to the bar, they would become too weak and let go. LPN A explained R901 kept stating they didn't feel good. LPN A explained the following morning, [DATE], they observed the resident with an altered mental status, with the inability to feed themselves due to their decreased strength with attempting to hold their spoon. LPN A confirmed R901's assigned nurse attempted to send the resident out via EMS on [DATE] however, it they were directed the resident could be treated in the facility. On [DATE] at 12:40 PM, Registered Nurse (RN) B was asked about the incidents leading up to [DATE] when CPR was initiated on R901. RN B explained the resident's assigned nurse called 911 on [DATE] due to R901 exhibiting a change of condition however, there was a directive for EMS to leave without the resident as they could be treated at the bedside. RN B explained they observed R901, and they looked like they needed to be sent out, as their mental status had declined. They explained R901 normally was alert and oriented to person, place and things with the ability to express their needs, however, R901 was observed as alert, but lethargic and not able to get out of bed. RN B explained the resident's assigned Nurse Practitioner (NP E) who is familiar with the resident was not in the building during this time, and the Nurse Practitioner covering for her (NP J) was not familiar with the resident. RN B confirmed the covering Nurse Practitioner ordered labs, a chest x-ray, and a urinalysis. RN B further explained on [DATE] between 9:,d+[DATE]:00am a code blue (need for immediate medical intervention) was called for R901 who later died . On [DATE] at 12:51 PM, Certified Nursing Assistant (CNA C) who was assigned to R901 on [DATE] and [DATE] was asked about the resident's baseline on those dates. CNA C explained the resident was shaky and in pain for those two days, explaining they had to assist the resident with eating the morning of [DATE] due to their inability to hold their spoon, and consumed, a little (name of gelatin). CNA C explained on [DATE], R901's assigned nurse called EMS for the resident due to a change of condition however, they left without R901. On [DATE] at 2:30 PM, the Director of Nursing (DON) was interviewed regarding R901's change of condition, and she explained she was not in the building however, in interviewing facility staff, she learned R901 showed a decline and attempts to send the resident to a higher level of care was unsuccessful. The DON explained she relies on her nurses to assess the residents, and they did what was expected of them. The DON explained she would have liked for the resident's physician to have been contacted regarding the resident so they could assess the timing of when their results (labs, Xray, urinalysis) would have been received. The DON explained there was also discussion among facility staff regarding the Nursing Home Administrator (NHA) becoming involved in the decision for the resident to be treated at beside and EMS's directive to leave, and indicated that if this was the case, she (the Administrator) should have stayed in her lane. A review of R901's progress notes revealed the following: [DATE] 02:39 (2:39am) General Progress Note. Note Text: chest Xray result was faxed in and result shows Heaviness in the lower chest, with blunting of the costophrenic angle (pleural effusion), and Loculated pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest) on the L (left) Side appears to be present. I tried calling the Dr (doctor) but no response, so I sent a text message to him and notified the morning shift nurse for follow up. On [DATE] at 3:09 PM, Physician D was interviewed regarding R901 and their change of condition, and acknowledged the resident experienced a change of condition, and that the nurse texted them at 2:00am, which he didn't receive until 9:00am, and upon review attempted to reach someone at the facility for the resident to be sent out. At that time, Physician D was informed that CPR had already been initiated on the resident. Physician D acknowledged the resident should have been sent out to the hospital upon their change of condition as they were hypoxic, had chronic kidney disease, high potassium levels, and the hospital is approximately 1 mile away. On [DATE] at 3:30 PM, Nurse Practitioner (NP) E was interviewed via phone regarding R901's change of condition. NP E explained she saw R901 regularly with the last time being [DATE], as there were other Nurse Practitioners assigned to the building while she was off. NP E explained that upon returning to the building on [DATE], and going to see R901, she located the resident with blueish lips, and called a code blue. NP E explained she was informed that leading up to [DATE], R901 showed a change of condition resulting in EMS arriving to the building and although appearing ill looking and sick, EMS was directed to leave as the resident would be treated at the bedside. NP E explained the staff at the nursing facility know her very well, and explained that if she would have seen the resident, she would have sent them out (to the hospital). NP E explained if treatment would have occurred at bedside, she would have expected for IV (intravenous) fluids to have been provided if the resident was arousable however, continued monitoring would also have been appropriate. NP E further explained, an altered mental status and lethargy in R901 warranted them sending the resident out. On [DATE] at 4:07 PM, an interview was completed the with the Nursing Home Administrator (NHA) regarding R901's change of condition, and she explained the ambulance arrived, and the nurse practitioners from R901's health plan indicated they could treat the resident at the bedside, and would contact the physician. On [DATE] at 9:19 AM, an interview was completed with LPN F, assigned nurse to R901 on [DATE]. LPN F was asked about R901's change of condition, and they explained the resident was not their normal self. They explained the resident is usually talkative, but was sparingly using their words and was in and out of it and was also weak and lethargic. LPN F explained he checked the resident's vitals in which at that time the resident's blood pressure was ,d+[DATE]. He explained he left the room to allow the resident to rest, and returned approximately a half hour later hoping the resident's blood pressure would have improved but upon assessing the resident, there was no improvement, so he called EMS to take the resident to the hospital. LPN F further explained they had everything ready for the resident to be transferred and was providing EMS with everything needed for the transfer when the NHA, Unit Manager, and Nurse Practitioner approached the room. LPN F confirmed the Nurse Practitioner advised they would take over, asked him to retrieve supplies to obtain urine for a urinalysis, and a suppository. LPN F explained EMS left, and he continued to monitor the resident for the duration of their shift which when until 7:00pm, noting no improvement in R901's mental status or condition. On [DATE] at 11:10 AM, an interview was completed with LPN G regarding the change of condition of R901, and explained the morning of [DATE], she was approached by CNA C who asked she assess R901 as their assigned nurse had taken a break and she had concerns about the resident. LPN G explained she assessed R901 and observed them to be unable sit up, appeared in and out of consciousness to the point they had to be held up to obtain their vitals. LPN G explained in R901's state of unconsciousness, they said, Please help me. LPN G explained she informed the resident's assigned nurse upon their return from break, and reports approximately 10 minutes later, EMS arrived and later left without R901. LPN G explained the Nurse Practitioner asked them if she had a suppository in her medication cart because they wanted to clean [R901] out. On [DATE] at 11:45 AM, an interview was completed with Central Supply Staff H (CS H) regarding observations of R901 on [DATE], and she explained on that date she entered R901's room regarding supplies for their oxygen, and while in the room, she observed R901 crying and stating, Help me. CS H explained upon exiting the room, she witnessed the CNA talking to the assigned nurse about R901, and later witnesses EMS enter the building for R901. CS H further explained later that day, after EMS exited the facility, she continued to witness R901 crying, which was unlike R901, as they were an active resident who was usually up daily participating in activities. On [DATE] at 2:48 PM, Nurse Practitioner (NP J), the covering NP on [DATE] for R901 was interviewed via phone. NP J explained upon assessing R901, she observed them lethargic appearing weak and was asking for their oxygen as their concentrator was malfunctioning. NP J explained this was her first time seeing the resident, and orders were placed for the resident following her assessment, and any continued monitoring would be done by nursing staff. NP J was asked if she contacted R901's physician, in which she explained she did not. NP J was asked what treatments were provided to R901and why the condition didn't warrant a transfer to the hospital, NP J stated, My progress note speaks for itself. A review of R901's progress note written by NP J revealed the following: [DATE] 13:00 (1:00pm) Late Entry: Note Text .New Patient Encounter ([DATE]) .History of Present Illness Resident seen today for acute change in condition or left and right hand tremors reported by NH (nursing home) staff yesterday evening. Upon arrival to the resident's room, EMS was present due to NH staff's concerns regarding the resident's lethargy, and weakness, which the nurse observed while administering medications that morning. It was noted that the resident's oxygen concentrator was malfunctioning, with an unclear duration of time without oxygen, SPO2 85%. The resident is oxygen-dependent at baseline, requiring 2L (liters) continuous NC (nasal cannula). Resident was transitioned to a portable oxygen tank set at 4L NC and administered a DuoNeb breathing treatment while EMS assessed the resident at the bedside. The resident responded well to the breathing treatment, with SPO2 improving to 96%. It was agreed upon by the writer and paramedics that the resident's condition was likely r/t (related to) hypoxia and it was appropriate to treat in place in which resident consented to .Upon further exam, the resident appeared lethargic but conversational and orientedx4. Afebrile . resident requested oral fluids and expressed a desire for lunch. Able to make her needs known . On [DATE] at 12:55 PM, an interview was completed with the resident's representative, Family Member I regarding R901. Family member I explained they visited R901 on [DATE] between 2:00pm-5:30pm. Family Member I was unaware EMS had arrived earlier and was advised to leave the facility after being called by LPN F. They explained that upon arriving to the facility, they had no idea the resident hadn't been feeling well all day, and upon observing R901 in bed, explained they did not seem like themselves as they were lethargic, not speaking clearly, stated they felt dizzy and tired. Family Member I said R901 seemed out of it as they would say something and then float off. Family Member I said they stopped by the office where the Nurse Practitioner (NP J) was located after visiting with R901, and explained to them they wanted her to check out R901 again because they seemed out of it, and NP J confirmed they would. Family Member I explained there was no way that she thought her family would have died the following morning, as they hadn't been ill, hadn't been hospitalized , and was going to outside appointments regularly. Further review of R901's medical record revealed that following, NP J's initial assessment of the resident, there was no further documentation of any treatment and/or monitoring provided to the resident after a noted change of condition. A review of the facility's Change in a Resident's Condition or Status policy did not address ongoing monitoring and/or treatment related to a resident showing a change of condition.

This citation pertains to Intake: MI00147554. Based on interview and record review, the facility failed to notify the resident representative of a change of condition for one resident (R901) of three residents reviewed for notification. Findings include: A review of R901's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Diabetes, and Heart Failure. Further review revealed that the resident was cognitively intact, oxygen dependent, and required 1-2-person assistance for transfers, toileting and dressing. Further review of R901's medical record revealed the following progress note: 10/6/2024 17:35 (5:35pm). General Progress Note Patients left, and right hand noticeably shaking, unable to grasp things without it falling. MD (medical doctor) notified via Doctors book. Will continue to monitor patient duration of this shift. 10/7/2024 17:19 (5:19pm) Change of Condition Note Text: pt (patient) hypotensive in am (morning), bs (blood sugar) wnl (within normal limits), general weakness, lethargy difficulty speaking, [insurance company] NP (nurse practitioner) present, straight cath (catheter) for possible u/a, (urinalysis) STAT CXR ( immediate xray) ordered, lasix (diuretic) on hold, parameters added,02 (oxygen) tank replaced .continue to monitor and notify oncoming shift. On 10/23/24 at 9:19 AM, an interview was completed with LPN F, assigned nurse to R901 on the morning shift on 10/7/24. LPN F was asked about R901's change of condition, and they explained that the resident was not their normal self. They explained that the resident is usually talkative, but was sparingly using their words and was in and out of it. They explained that the resident was also weak and lethargic. LPN F explained that he checked the resident's vitals in which at that time the resident's blood pressure was 80/50. He explained that he left the room to allow the resident to rest, and returned approximately a half hour later hoping that the resident's blood pressure would have improved but upon assessing the resident, there was no improvement, so he called EMS to take the resident to the hospital. LPN F further explained that they had everything ready for the resident to be transferred and was providing EMS with everything needed for the transfer when the NHA (Nursing Home Administrator), Unit Manager, and Nurse Practitioner approached the room. LPN F explained that the Nurse Practitioner advised that they would take over, asked him to retrieve supplies to obtain urine for a urinalysis, and a suppository. LPN F explained that EMS left, and he continued to monitor the resident for the duration of their shift which was until 7:00pm, noting no improvement in R901's mental status or condition. On 10/23/24 at 12:55 PM, an interview was completed with the resident's representative, Family Member I regarding R901. Family member I explained they visited R901 on 10/7/24 between 2:00pm-5:30pm and someone mentioned to them upon arrival to the facility that R901 wasn't feeling well that day, as R901 could usually be located in the activity room. Family Member I explained when they arrived to R901's room, they found the Nurse Practitioner in the room who explained they would be conducting a urinalysis of R901. Family Member I explained they were unaware R901 had been assessed by their assigned nurse who determined the resident needed to be trasnferred to a higher level of care, and that EMS had been called, and left withthout R901. Family Member I explained they observed R901 in bed, and they did not seem like themselves as they were lethargic, not speaking clearly, stated that they felt dizzy and tired. Family Member I explained R901 seemed out of it as they would say something and then float off. Family Member I explained they stopped by the office where the Nurse Practitioner was located after visiting with R901, and explained to them she wanted them to check out R901 again because they seemed out of it, and the nurse practitioner confirmed that they would. A review of the facility's Change in a Resident's Condition or Status policy revealed the following, The facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .

Based on observation, interview and record review, the facility failed to ensure safety measures were followed per the plan of care and prevent a fall from bed during incontinence care for two sampled residents (R41 and R64) from a sample of three residents reviewed for accidents, resulting in fall with head injury and a transfer to the hospital. Findings include: R41 On 10/30/23 at 10:12 AM, R41 was observed sitting in their wheelchair eating breakfast. R41 was observed to have a healed scar to the left side of their forehead. They were asked about their stay in the facility, and they reported that they were hospitalized a few months prior as a result of a fall from their bed while being provided care. R41 reports that they were lying on their side while their assigned Certified Nursing Assistant (CNA D) was providing incontinence care. R41 explained that they were facing away from the CNA when they started to roll out bed. R41 explained that they ultimately fell on to the floor, hitting their head, and requiring a transfer to the hospital where they obtained stitches to their forehead. A review of R41's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Hypertension, BI-Polar Disorder, and Epilepsy. Further review of R41's medical record revealed a quarterly Minimum Data Set assessment dated [DATE] indicating that R41 had a Brief Interview for Mental Status score of 13/15 indicating an intact cognition, and required extensive assistance of two people for bed mobility, transfers and toilet use. A review of R41's progress notes revealed the following: 10/4/2023 06:52 (6:52am) General Progress Note Note Text: Aide notified writer that resident had rolled out of bed as she was cleaning [them] up, on going to resident's room resident observed laying on the floor besides [their] bed on [their] left hand side bleeding from [their] head, resident was noted to still be conscious, able to identify [themselves] and situation at hand transferred back to [their] bed, bleeding noted to be coming from the top of [their] left eye open area noted, pressure dressing applied to stop the bleeding . guardian notified [contact information] about incident and that resident was being sent out to hospital to rule out a concussion .c/o (complain of) pain 8/10 -headache. 10/4/2023 11:39 (11:39am) General Progress Note Note Text: Patient returned from ER (emergency room ) via stretcher at approximately 11:18 am. Resident is alert. Writer noted 5 stitches on left forehead laceration. new order for cyclobenzaprine (muscle relaxant) 5 mg (milligrams) 3 times daily PRN (as needed). Provider notified of Resident Return and new Med . 10/4/2023 14:59 (2:59pm) Medical Practitioner Progress Note .New Patient Encounter. Reason: Fall on 10/04/2023. History of Present Illness (HPI) (10/04/2023). The patient`s recent experience or cause of the new problem: Per staff member had fall from bed during repositioning. [R41] was transferred to [local] hospital ED [emergency department] visit only treated for laceration to lateral forehead. Member was examined today upright in bed. Noted to have five intact sutures to left lateral temporal forehead area no, negative signs and symptoms of infection. Post Fall Evaluation (10/04/2023) 1.Date of fall: 2023-10-04 2.Time of fall: 4:01 am - 8:00 am 3.Witnessed fall?: Yes 4.Location of fall: Patient Room 5.Injuries of fall: Major (fracture, head injury) 6.Is the resident on a Toileting Program? Yes 7.Please list any other factors that impacted this fall: CNA repositioning on bed. 8.Disposition: Emergency Department Only . Plan Facial laceration, initial encounter 1. [R41] is seen upright on bed, baseline cognition and non-illness appearing. Monitor changes neurological status and notify MD (medical doctor)/Telehealth; Keep suture site clean and dry every shift and monitor s/s (signs and symptoms) infection; 2. Continue Tylenol Tablet 325 MG , Ibuprofen Tablet 400 MG; consider antibiotic ointment ->Neosporin or bacitracin as indicated; Sutures removal 5-7 days if wound edges well approximate . 10/5/2023 08:49 (8:49am) General Progress Note Note Text: Resident indicated to writer that [their] left knee was in pain and signs of swelling. These symptoms are related to a fall the resident said [they] had. Writer asses the clients left knee; swelling visual to eye. Writer administered PRN Acetaminophen for pain. Left Knee X-ray Ordered. Physician notified. Neuro checks in place. Writer will continue to monitor resident for pain, discomfort or alt (alteration) in neuro for duration of shift. Further review of R41's medical record revealed a physician progress note dated for 10/5/23 revealing the following, .seen in follow-up regarding a fall for which [they were] sent to the hospital for head laceration and knee pain .Patient also complains of left knee pain .[R41] indicates that so much attention was paid to the laceration in the emergency department, that no imaging was conducted of the left knee. We will order an x-ray. [R41] does have pain and swelling . On 11/1/23 at 11:41 AM, an interview was completed with CNA D via phone, and asked about R41's fall during care. CNA D explained that they were attempting to get R41's brief from underneath them when they rolled over onto the floor. CNA D explained that R41 was turned toward her but as she turned R41 a little bit they rolled over and fell . CNA D was asked if R41 required one or two people for repositioning, and she explained that R41 is usually a one person, but that they try to utilize two. She reports that on this date, there was no one available to assist her. A review if R41's care plan revealed the following: Focus: [R41] is at risk for falls due to potential medication side effects, weakness, impaired balance, use of psych (psychotropic) meds, DX (diagnosis) of Vertigo, and a HX (history) falls. [R41] is mobile via wheelchair. [R41] also requires assistance with bed mobility, transfers, and toileting needs 2 persons assist with positioning PRN Date Initiated: 12/25/2018. Created on: 05/26/2017 . R64 On 10/30/23 at 11:07 AM, R64 was observed lying in bed. Due to their cognition, they were unable to respond to surveyor's questions. A review of R64's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Cerebral Edema. Aphasia, Depression, and Gastrostomy Status. Further review revealed a quarterly Minimum Data Set assessment dated [DATE] indicating that R64 was severely cognitively impaired, and was Total Dependent on two staff for Activities of Daily Living, including toileting, bed mobility and transfers. Further review of the R64's medical record revealed the following progress note: 9/18/2023 19:46 (7:46pm) General Progress Note Note Text: Writer was called about resident falling off from the bed during care. Caregiver stated [R64] fell on [their] back and butt and did not hit [their] head On 10/31/23 at 11:08 AM, an interview was completed with Nurse E regarding R64's fall, and she reported that the CNA was providing care by themselves, and the resident fell to the floor. Nurse E was asked if the resident was supposed to have one or two people providing care at that time, and explained, [R64] required two people. On 10/31/23 at 2:12 PM, CNA F was interviewed via phone and asked about R64's fall. CNA F explained that he was providing care by himself when he attempted to view what was underneath R64. CNA F explained that he pushed the resident away from him and thought that the perimeter mattress would prevent the resident from falling however, it gave away and the resident started to roll. CNA F explained that he attempted to grab the resident but was unable to do so. CNA F denied that the resident was injured or hit their head. On 11/1/23 at 12:23 PM, the Director of Nursing (DON) was interviewed regarding R41's fall, and did not provide an explanation, rather interventions implemented following the fall. Regarding R64's fall, she did indicate that CNA F was provided with education on ensuring that the plan of care is checked, and ensuring that you're turning residents toward you, and not away when providing care. A review of CNA F's education was provided and dated for 9/18/23. It revealed the following, Always turn the resident toward you, not away from you. Check the Kardex care plan, ask your nurse or fell ow aides for assistance as needed. On 11/1/23 at 2:02 PM, the Nursing Home Administrator (NHA) was asked if falls have been addressed in Quality Assurance, and she explained that falls have been identified as a concern, and that the root cause was staff needing additional education and needing to check the plan of care. She further explained that they have implemented audits as a result. A review of the facility's Fall Prevention policy revealed the following, POLICY: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN (registered nurse/licensed practical nurse) to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department and if appropriate, a fall prevention protocol will be initiated. PURPOSE: 1. To identify residents at risk in a timely manner. 2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. 3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls. 4. To evaluate outcomes .

This citation pertains to intake # MI 303. Based on interview and record review, the facility failed to initiate treatments, follow doctor recommendations, complete and/or document the completion of wound care for one resident (Resident #701) of two residents reviewed for pressure ulcers (PU: a wound formed over a bony prominence as a result of prolonged pressure to the skin) care, resulting in the development of new pressure ulcers, the worsening of wounds, and delayed wound healing. Findings include: A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #701 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition. Resident #701 needed extensive two person assistance with bed mobility and transfers. The MDS revealed no pressure ulcer or wounds present. Resident #701 was diagnosed with [CONDITION(S)] (MS), [CONDITION(S)], Bladder Cancer and [CONDITION(S)]. A review of the initial skin assessment on the Nursing Evaluation dated 01/21/2022 revealed the following wounds present: Sacrum (lower buttocks region)-pressure ulcer. L (left) butt-pressure (ulcer). L toe-scab. L ankle-scab. R (right) iliac (hip region)-blister. L iliac-scar/wound. A review of the Progress Notes for Resident #701 revealed the following: 1/22/2022 00:38 (12:38 AM) General Progress Note .admitting to us s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Multiple medical, including MS .pancreatic CA (cancer), hx (history) of bladder CA .and sacral and L (left) ankle PUs. 3/1/2022 02:29 (PM) General Progress Note .when I went to do wound care on this patient .wound was a lot worse than I seen it last time it is much deeper and .skin is breaking down even more. A review of the Skin Observation Tool for Resident #701 revealed the following: 02/08/ , 02/11/2022, 02/19/2022-no new new wounds documented. 02/24/2022-blank 02/26/2022-new sacrum wound, stage 3 (wounds staged according to depth of layers of skin involved, stage 3 indicates the wound extended into the subcutaneous tissue into the muscle). A review of the Skin Integrity Care Plan for Resident #701 revealed the following: Focus-Resident has potential/actual impairment to skin integrity r/t (related to) incontinence Date Initiated: 01/22/2022. Goal-Resident's skin integrity breaks will exhibit healing by next review date. Date Initiated: 01/22/2022. Interventions-Elevate heels off bed surface while at rest in bed. Date Initiated: 01/22/2022. Follow physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Provide pain management with treatments as needed. Date Initiated: 01/22/2022. Use a draw sheet or lifting device to move resident. Date Initiated: 01/22/2022. Focus-Resident has actual impairment to skin integrity r/t Chronic disease processes 2/8/2022- DTI left bunion 2/8/2022- DTI left heel Date Initiated: 02/09/2022. Interventions-Elevate heels off bed surface while at rest in bed. Date Initiated: 02/09/2022. Encourage and assist resident to participate in mobility activities per additional plan of care. Date Initiated: 02/09/2022. Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 02/09/2022. Follow physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Provide pain management with treatments as needed. Date Initiated: 02/09/2022. Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD (Medical Doctor). Date Initiated: 02/09/2022. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated: 02/09/2022. A review of the Wound Doctor's notes for Resident #701 revealed the following: 02/08/2022-Wound #1 .Left Heel DTI (deep tissue injury) .Measurement: Length 6.0 Width 9.2 .Drainage: Dry .Wound #2 .Lt (left) bunion DTI .Measurement: Length 0.8 Width 0.9 .Preventative Care: Float heels/Foam Boots .Rotate every 2 hours . 02/22/2022-Wound #1 .Left Heel DTI .Measurement: Length 6.0 Width 9.0 .Drainage: Light .Wound #2 .Left Bunion DTI .Measurement: Length 0.8 Width 0.9 .Preventative Care: Float heels/Foam Boots .Rotate every 2 hours . On this note, the left heel and left bunion wounds had treatment changes by the Wound Doctor which stated, [MEDICATION(S)] Dry Dressing Change QODay (every other day). A review of Resident #701's Physician Orders revealed the following: Dry Dressing to left heel and left bunion initiated 02/09/2022. Cleanse L iliac crest with wound cleaner, pat dry, and cover with dry dressing every night shift initiated 01/22/2022. L ankle PU-cleanse with NS (normal saline), apply wet to dry dsg (dressing), cover with DD (dry dressing) Q (every) day and PRN (as needed). Initiated 01/22/2022. Sacral PU-cleanse with NS, apply wet to dry drsg (dressing) (NS soaked 4x4) cover with DD Q day and PRN until wound care assesses and writes order. Initiated 01/22/2022. There was no change of treatments ([MEDICATION(S)]) and/or foam boots ordered as indicated by the Wound Care Doctor notes on 02/22/2022. A review of the Treatment Administration Records (TARS) for Resident #701 revealed the following: January 2022-Left iliac crest wound, sacral wound and left ankle wound care were not documented as being completed on 01/22/2022-01/23/2022, 01/25/2022-01/27/2022, 01/30/2022-01/31/2022. February 2022-Left iliac crest wound, Left ankle wound and sacral wound revealed no wound care completed on 02/01/2022, 02/03/2022-02/04/2022, 02/06/2022, 02/10/2022-02/12/2022, 02/14/2022, 02/16/2022-02/17/2022, 02/20/2022-02/22/2022 and 02/24/2022-02/25/2022. March 2022-03/01/2022 and 03/02/2022, no wound care documented as being completed. Resident was discharged from the facility on 03/02/2022. There were no change of treatments ([MEDICATION(S)]) and/or foam boots ordered as indicated by the Wound Care Doctor notes on 02/22/2022. On 04/05/2021 at 01:40 PM, the Director of Nursing (DON) was interviewed in regard to the several areas of missing documentation of wound care during Resident #701's stay at the facility. The DON explained that they hired a wound nurse that had previously worked at a hospital who did not understand long term care and wrote orders that weren't normally done in a nursing home. The DON stated, We ended up letting him go, he left violently. We got a wound team in here now who gave us recommendations and hired a new wound nurse. A wound doctor and nurse practitioner come in weekly. The DON further explained that once they let the original wound nurse go, they went and did a complete skin sweep of the building to assess the skin condition of the residents and addressed any concerns that they found. The DON was asked about the lack of documentation in the TAR by any nurse. The DON stated, The nurses thought that he (the previous wound nurse) was doing the wound care. The DON was asked about the indication that the Wound Care Doctor had changed the treatment to the Left Heel and Bunion and recommended foam boots on the wound notes not being carried out. The DON stated that she would look into it. On 04/05/2022 at 02:03 PM, the Nursing Home Administrator (NHA) was questioned in regard to the lack of completed wound documentation and missed recommendations, but did not provide an explanation. A review of the facility policy titled Best Practice Skin and Wound Management revised 01/20/2020 revealed the following: .IDT (interdisciplinary team) will complete documentation weekly on each patient with skin impairment utilizing information above and additional known information, such as labs, compliance with treatment(s), nutritional status, etc. within a progress note in medical record under type - Skin .

This citation pertains to Intake: MI 962 Based on interview and record review, the facility failed to identify a dislocated shoulder and obtain an X-ray in a timely manner for one sampled Resident (R913) reviewed for a delay in treatment resulting in, R913 being in unnecessary prolonged pain, feelings of loss of independence, and frustration. Findings include: A review of Intake MI 962 revealed the following, On February 16, 2022, patient complained of pain to left shoulder. The physician ordered an x-ray which indicated a dislocation of the shoulder of indeterminate age. Physician ordered the resident to be sent to ER (emergency room ) for evaluation and treatment as indicated. Patient was transported to ED (Emergency Department) . Resident relayed to the hospital that 2 to 3 months ago (Approx. time frame of Thanksgiving thru December 15, 2021) [R913] was reaching over [their] head and noticed sudden onset left shoulder with pain and decreased range of motion . On 3/22/2022 at 10:34 AM, R913 was interviewed in their room about their dislocated shoulder. R913 explained that they started to experience pain in their left shoulder before Thanksgiving 2021 after using the trapeze to assist the Certified Nursing Assistants (CNA) with providing care. R913 reported that after using the trapeze, they instantly felt pain to their shoulder and complained because it hurt so bad. R913 explained that they couldn't move their left arm the way they had been able to previously, and it didn't move like their right shoulder did. R913 explained that when the excruciating pain was expressed to the physician, they stated that it was a result of arthritis, and prescribed an ointment to be rubbed on the shoulder, which R913 stated did not work. R913 explained that the shoulder hurt so bad that when the nurses rubbed the ointment on the shoulder, it hurt. R913 explained that no one performed an X-ray on the shoulder until February 2022. R913 was asked who they told about the pain, and revealed the nurse, CNAs, and the physician. R913 explained that they continued to assist the CNAs by using the trapeze even though they were in pain. R913 explained that the CNAs would lift their arm and place it on the trapeze because they were unable to do it themselves, and it was excruciating. R913 was asked if they received any pain medication during that time and explained that they would take over the counter medications such as Tylenol, but did not like taking any other strong pain medications as a personal preference. R913 also indicated that they don't like to get out of bed because the Hoyer hurts them due to chronic [CONDITION(S)] in their legs. R913 explained that they kept complaining of the shoulder pain and feel that they have lost their independence to turn and reposition or reach for items out of their side table drawer. R913 became tearful and stated, It's not fair. I can barely lift my arm for them to wash underneath it. When I sit up, it hurts so bad .It took my independence away . A review of R913's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a Minimum Data Set assessment dated [DATE] indicating that R913 had a Brief Interview for Mental Status score of 14/15 indicating an intact cognition and required extensive to dependence for Activities of Daily Living. Further review of R913's medical record revealed the following progress notes: 11/15/2021 00:00 (12:00 am) Encounter Date of Service: 11/15/2021 Visit Type: Acute Presenting Problem: Left shoulder pain .History Of Present Illness: Resident is evaluated per [their] request with multiple medical issues today. Reports that [R913] has left arm pain originating from shoulder, no recent trauma, does have hx (history) of fracture in the arm. per resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . DW (discussed with) with resident will add [MEDICATION(S)] gel (arthritis pain gel) to left shoulder for 7 days then monitor . 11/18/2021 00:00 (12:00 am) Encounter Date of Service: 11/18/2021 Visit Type: 120-day Follow Up .The patient's greatest complaint is of pain in the left shoulder which is now being treated with [MEDICATION(S)] .Pain Management Level: Complains of left shoulder pain and right ear pain. Pain Med Changes: Patient is just started on [MEDICATION(S)] gel Left shoulder pain: Likely due to arthritis from old trauma . 12/10/2021 00:00 (12:00 am) Encounter Date of Service: 12/10/2021 Chief Complaint / Nature of Presenting Problem: Left shoulder pain History Of Present Illness: Resident is requesting evaluation secondary to ongoing pain to left shoulder. Resident is morbidly obese and is sedentary [R913] does not get out of bed. Request PM&R (physical medicine and rehabilitation) consult and add [MEDICATION(S)] gel twice daily to affected shoulder . 2/16/2022 00:00 (12:00 am) Encounter Date of Service: 02/16/2022 Visit Type: Acute Chief Complaint/ Nature of Presenting Problem: Multiple medical issues History Of Present Illness: Resident is requesting evaluation due to multiple medical issues. [R913] is with c/o (complain of) of pain to right (left) shoulder, admits to having remote hx of fracture in the LUE (lower upper extremity). DW with resident will order x-ray for evaluation . 2/18/2022 00:00 (12:00 am) Encounter Date of Service: 02/18/2022 Visit Type: Acute Chief Complaint / Nature of Presenting Problem: Left shoulder pain/[CONDITION(S)] History Of Present Illness: Resident is being monitored secondary to multiple issues. [R913] has had OA ([CONDITION(S)]) of shoulder and is with c/o of pain. DW with nursing staff today, X-ray was ordered, however no results. Nurse to reorder . 2/21/2022 00:00 (12:00 am) Encounter Date of Service: 02/21/2022 Visit Type: Acute Transition of Care: Chief Complaint / Nature of Presenting Problem: Abnormal left shoulder x-ray. History Of Present Illness: Resident is evaluated secondary to abnormal left shoulder, x-ray, there is no available comparative x-ray, with evidence of complete inferior and slightly medial dislocation of the left humeral head in relation to the glenoid rim. No fracture. May be related to recent or old injury. DW with resident, due to uncertainty of age of injury, recommendation is for [them] to be evaluated at [local hospital], where [R913] last saw orthopedic for the arm for evaluation and treatment if feasible . 2/22/2022 00:26 (12:26 am) General Progress Note Note Text: [R913] was transferred to [local hospital] by rapid response staff at 2141 (9:41 pm) for repair of dislocated left humeral head of [their] arm . 2/22/2022 21:13 (9:13 pm) General Progress Note Note Text: writer received pt. (patient) at above time. Resident AOX3 (alert and oriented to person place and time), not in any distress, resident came back with lower arm sling . 2/23/2022 00:00 (12:00 am) Encounter Date of Service: 02/23/2022 Visit Type: Acute Chief Complaint/ Nature of Presenting Problem: S/p left shoulder reduction for dislocation History Of Present Illness .[R913] was evaluated for left shoulder dislocation in ER and dislocation was manually reduced in ER. [R913] has sling in place. [R913] is to fu (follow-up) with ortho (orthopedic) again in 2 weeks .[R913] reports improvement in pain at this time. 2/24/2022 00:00 (12:00 am) Encounter Date of Service: 02/24/2022 Visit Type: Follow Up Chief Complaint / Nature of Presenting Problem: Return from hospital with left shoulder subluxation (dislocation). Seen in follow-up regarding return to the hospital after left shoulder subluxation. Upon exam, the patient is resting comfortably in bed. Patient is wearing a sling on the left upper extremity. The patient is doing relatively well. [R913] indicates that the pain is improving. No surgical intervention was required. Patient indicates that [they] caused a subluxation by repositioning [themselves] using left upper extremity and pulling on the trapeze . A review of R913's medical records from the hospital dated 2/22/2022 revealed the following, Presenting to our ED via EMS (emergency medical services) from [R913's] ECF (extended care facility) with chief complaint of left shoulder dislocation [R913] states around Thanksgiving 2021 while attempting to move in bed with a trapeze [they] felt pain and a pop in [their] left shoulder. Patient was seen by a provider at the nursing facility who did not obtain imaging. [Their] left shoulder pain has persisted since Thanksgiving; A radiograph was taken last Friday demonstrating an anterior inferior left shoulder dislocation. Pt.(patient) denies numbness and tingling to the LUE. [R913] endorses left shoulder pain only .Physical examination: LUE: Swelling about the left shoulder .tenderness to palpation about the shoulder. Range of Motion (ROM) of shoulder minimal, full ROM of elbow and wrist .Imaging AP left shoulder demonstrating an interior inferior left shoulder dislocation without fracture . On 3/23/2022 at 3:17 PM, the Director of Nursing (DON) was interviewed regarding R913's dislocated shoulder, and the delay in obtaining an X-ray. The DON explained that R913's pain was generalized and that they initially thought it was because of the COVID vaccination, and them being sedentary and refusals to get out of bed. The DON further explained that while R913 was participating in therapy, they didn't complain of the pain and that when they became more specific about where the pain was located, an X-ray was obtained. A review of the facility's Pain Management policy outlined the following, PURPOSE: The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: Screening to determine if the resident has been or is experiencing pain, Comprehensively assessing the pain Identifying circumstances when pain can be anticipated, Developing, and implementing a plan, using pharmacologic and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals . A review of the facility's Change of Condition-Monitoring policy was reviewed but did not address obtaining x-rays in a timely manner.

This citation pertains to Intake MI 5809. Based on observation, interview and record review, the facility failed to prevent one resident (R901) from exiting through a shower room window on 11/6/2020 at an unknown time. The window lock was loose, and the resident was able to bypass the lock and push out the window screen. The resident is severely cognitively impaired with a diagnosis of Paranoid [CONDITION(S)]. The resident was located by the police approximately 1 mile from the facility panhandling at an ice cream shop and taken to the hospital. This deficient practice resulted in an Immediate Jeopardy and the likelihood for serious injury, harm, and/or death. The Nursing Home Administrator was notified of the Immediate Jeopardy on 11/12/2020 at 1:54 PM and was asked for a plan to remove the immediacy. The Immediate Jeopardy (IJ) started on 11/6/2020 and was identified on 11/12/2020 The IJ was removed on 11/6/2020, based on the facility's implementation of the removal plan as verified onsite on 11/12/2020. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings include: A review of Intake MI 5809 revealed the following, Date of alleged incident: 11/6/2020. Incident Summary: Resident was unable to be located at the facility by staff. Resident was located and returned to the facility. Staff completed skin and pain (assessment) without any findings. Wander assessment was also completed. Physician and Legal Guardian were notified. Resident placed on one on one supervision. Psych (psychiatric) services to evaluate. Resident does not recall the incident. On 11/12/2020 at 8:57 AM, R901 was observed in bed asleep. The resident was observed to have 1:1 supervision in the room at that time. The 1:1 staff member was asked how long they had been providing supervision for R901, and indicated, three days. A review of R901's medical record revealed that the resident was admitted into the facility on [DATE] with diagnoses that included [CONDITION(S)], Dementia, and a Cognitive Communication Deficit. R901's Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 6/15 indicating a severely impaired cognition and required Supervision for Activities of Daily Living. Further review of the medical record also revealed that the resident's Wandering Risk assessment completed upon admission on 8/4/2020 indicated that the resident scored an 11 indicating, High Risk to Wander. Further review of the medical record revealed the following progress notes: 8/6/2020 19:44 (7:44pm) Admit/Readmit Note Text: Admission Assessment. Resident admitted to the facility after being hospitalized at (local hospital) 7/18/2020 to 8/4/2020. Resident is alert with confusion at times. [R901] presents with difficulty recalling recent and remote events and is a poor historian .Resident was admitted to the facility receiving [MEDICATION(S)] and [MEDICATION(S)] (psychotropic medications) for DX (diagnosis): [CONDITION(S)] .Resident noted with intermittent behaviors such as wandering and exit seeking at times . 8/14/2020 12:48 (12:48pm) Social Services Note Text: Behavioral Management: Resident is a new admit to the facility with h/o (history of) behaviors including refusing medications and care at times, attempting to walk unassisted, wandering, and delusional behaviors. (Psychiatric Services) in on 8/14 for follow up to review medications as [R901] is currently receiving [MEDICATION(S)] Sprinkles and [MEDICATION(S)] for [CONDITION(S)]. No medication changes noted at this time. [Psychological Services] will continue to follow while resident is in the facility . 8/16/2020 06:27 (6:27am) General Progress Note Text: Resident had a quite (quiet) night without any distress, still refusing all treatments and care. At 0600 (6:00am), resident walked from [their] room 1A and met staff on the hallway door room 6A. started (stated) that they will want staff to call (family member), to take them home. Still refused all treatment, care and food. calmly walked back to [R901's] room. 11/2/2020 11:58 (11:58am) Social Services Note Text: Writer spoke with resident in the SW (social work) office to discuss current placement. Resident wishes to return to the community and at this time [R901] requires 24/7 care and supervision r/t (related to) mental health and cognitive status. LG (legal guardian) expressed that there are no active/pending discharge plans as resident has a significant hx (history) of substance abuse; elopement; pan handling; and prostitution. LG stated resident will remain in the facility for LTC (long-term care) and is not open to group home placement d/t (due to) previous elopement attempts from prior ALF (adult living facility) . On 11/12/2020 at 10:40 AM, an interview was attempted with R901 regarding their elopement however, they stated, I don't want to talk about it anymore. I'm tired of being here. It's boring and I like to do stuff like take rides, ride horses and smoke cigarettes. On 11/12/2020 at 11:02 AM, the Director of Nursing (DON) was asked how R901 was able to leave the building. The DON walked through the steps that R901 demonstrated to her on how they left the building. R901 entered the code to the locked shower room on the D wing, climbed onto a geriatric chair which was pushed against the wall by a cracked open window, slid the window open further and climbed out. The window was observed to have a lock on the top of the window in an effort to prevent the window from being slid all the way open however, the DON explained that it must have been loose. The DON also explained that the screen to the window had also been knocked out because it was located on the outside of the window. The DON further explained that R901 stated that they had observed the window cracked when they were in the shower room earlier in the day. The DON was asked how the resident was able to gain access to the shower room and explained that R901 refused to disclose how they obtained the code. The DON was asked how R901 was eventually located, and explained that the resident was in the parking lot of an ice cream shop panhandling, and an employee contacted the police and subsequently took the resident to the hospital where the resident provided a fake name. The DON was asked what time the resident returned to the facility and stated, Around 9:30 PM. On 11/12/2020 at 11:25 AM, an interview was completed with Certified Nursing Assistant (CNA A), assigned afternoon CNA for R901 on the date of the incident. CNA A stated, [R901] was my resident for the day. When I come into work, I check all my people and get waters to pass. [R901] was in the dining room .I saw [R901] between 3-4pm. I had 13 residents with three showers. I was very, very busy. CNA A further stated, A lot of my time was spent in the shower room and I did not hear an alarm go off. I always see [R901] walking and they have never tried to escape. I don't know how [R901] got out. When [R901] did return to the facility, I asked them how they got out, and they said, 'Out of the front door.' I asked [R901] when did they leave the building, and they said, 'Right after dinner.' CNA A was asked what time dinner trays come out, and stated, The 1st set of trays come out around 5:15pm, and the other trays come out between 5:15pm and 530pm. CNA A was asked at about what time R901's food tray was observed as untouched and stated, Close to 7pm, I can't remember. CNA A was asked how CNAs are made aware of residents that are wanderers and are at risk of eloping, and stated, I just learned that there is a book at the nurses' station and at the front desk, and we're supposed to check the book. On 11/12/2020 at 12:23 PM, an interview was completed with LPN B, day shift nurse for R901 on the date of the incident. LPN B stated, I wasn't aware [R901] had left the building until I received a call from my administrator. I last saw [R901] between 3-3:30pm that day. I had approximately 32 residents that day and I was preoccupied with a resident who fell , and who kept trying to get up. I do know R901 was a resident that would wander and walk around. On 11/12/2020 at 12:27 PM, an attempt to reach R901's assigned afternoon shift nurse, LPN C to no avail however, their written statement revealed the following, I clock in at 6:45pm. I made a copy of the Nurse Aide so that I would know what Nurse Aides are scheduled on the unit .At approximately 6:50pm, I began to walk the assignment to assess the residents. I thought I saw [R901] in the TV room, so I proceed to walk down to the end of the hall and to each room to visualize each resident .At approximately 8pm I went to the medication cart to prepare [R901's] medications. I believe I was pulled away by (staff member) to look at a resident. I returned to [R901's] room about 8:30 PM. I noticed the food tray was still in the room, so I wondered to myself, 'Where is [R901]?' .I began to ask the staff if they saw [R901]. I returned to the room to search the room and restrooms in an attempt to locate [R901] .It was approximately 8:50 PM .Previously I stated that I saw [R901] in the TV room .I cannot say 100% that I saw [R901] before the incident on Friday (11/6/2020). A review of the facility's 5-day investigation revealed the following, During rounds, certified nursing assistant went to pick up tray and noticed it was untouched by resident. Assigned nurse was alerted. At approximately 8:15 PM LPN B begin to search common areas known to resident. Resident was not located at this time. At approximately 8:30 PM nurse called a code yellow overhead. All staff begin to search for resident in the interior and exterior of the building on foot and in vehicles. At approximately 8:45 PM, staff re-entered the facility and reported to the nurse that they were unable to locate the resident during search .At approximately 8:50 PM (local police), family and physician were notified. At approximately 9:00 PM (local police) arrived at facility and interviewed staff regarding resident and events. (Local Police) reported they had someone that matched the description at (local hospital) and would be sending a unit to verify. Patient identity verified, noted the patient provided [NAME] name and birthday when brought to hospital by police. Patient returned to facility. On 11/12/2020 at 3:56 PM, the DON was asked about the incident regarding R901 and explained that the focus is on employee education regarding keeping an eye on residents. They further explained that they are working on locating another placement for R901 where they can be provided with a less patient to staff ratio such as a memory care unit. On 11/12/2020 at 4:09 PM, the Nursing Home Administrator was asked about the incident and explained that moving forward, the facility will do its best to remain in compliance. A review of the facility's Elopement policy revised 2/5/2020 outlined the following, POLICY: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care. 3. All residents who are at risk for possible elopement/wandering shall be accompanied by staff or responsible party when leaving the residents unit and/or facility grounds. Abatement Plan Providing the following information to demonstrate that the immediacy of the cited deficiency has been removed. Resident # 901 currently is on 1:1 supervision at the facility On [DATE], the resident was assessed upon re-entry to the facility with no apparent injuries or distress. Resident # 901 plan of care was reviewed by the DON with an added intervention of 1:1 supervision. On November 6 to November 7, 2020, the ADM and DON reported to the facility and completed the following: A head count was completed on the residing residents with all residents accounted for per census report. The Licensed Nurses updated all residing residents wandering assessments and ensure plan of care followed. The Elopement Books were reviewed by the DON with no concerns and all residents identified to be at risk are located in the book at the receptionist station and nursing stations. Maintenance verified all secured alarms to be functioning properly Maintenance/designee verified all windows were secured properly per regulation. Maintenance/designee changed the code of the shower room doors and secure care alarms to exterior doors.

Based on observation, interview and record review, the facility failed to ensure appropriate care and management of an indwelling urinary catheter (catheter inserted into the bladder to drain urine) for one sampled resident (#43) of one resident reviewed for urinary catheters, resulting in inconsistent and improper care for a urinary catheter, a current UTI (urinary tract infection), Resident discomfort and pain and the potential for chronic UTIs and decline in overall health status. Findings include: On 12/9/19 at 10:33 AM, Resident #43 was observed to be in their room in bed. The Resident was positioned on their back and an indwelling urinary catheter drainage bag was noted hanging on the right side of the Resident's bed toward the door of the room. The urine in the catheter drainage tubing was cloudy and dark amber in color with visible sediment. An interview was completed with the Resident at this time. When queried, the Resident indicated they had the catheter long term. With further inquiry, Resident #43 stated, It hurts so bad down there (gestured toward peri-area). Resident #43 then stated, My catheter leaks and gets my brief wet. When queried regarding catheter care, Resident #43 indicated facility staff only clean them when they are incontinent of stool. Record review revealed Resident #43 was most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had an indwelling urinary catheter. Review of Resident #43's care plans revealed: (Resident #43) has an Indwelling Urethral Catheter-16F (French) 10CC (Cubic Centimeters) balloon: Dx (Diagnosis) -[MEDICAL CONDITION] bladder. (Initiated: 7/24/18; Revised 10/22/19). The care plan included the interventions: -Catheter care every shift and as needed (Initiated: 9/13/19) -Change catheter/drainage bag per orders (Initiated: 9/13/19) -Indwelling urethral Catheter 16 F 10cc and Foley Bag Dx: [MEDICAL CONDITION] to dependent drainage: change for displacement or dislodgement as needed (Initiated: 9/13/19) -Monitor/document for pain/discomfort due to catheter (Initiated: 7/24/18) -Monitor/record/report to MD for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns (Initiated: 7/24/18) On 12/10/19 at 2:33 PM, Resident #43 was observed to be in their room. The Resident was in bed, positioned on their back. Their indwelling urinary catheter drainage bag was on the right side of the bed facing the door of the room. The urine in the catheter drainage tubing was cloudy and dark amber in color with sediment noted. Visible perspiration was observed on the Resident's forehead and face although the ambient room air temperature was not hot. When queried how they were feeling, Resident #43 stated, I'm in so much pain. When asked where their pain was located, Resident #43 replied, Where my cath (urinary catheter) goes in. When asked if they had informed staff, Resident #43 revealed they had. Nursing Assistant D entered the Resident's room at this time. When queried regarding the Resident sweating and complaints of pain, Nursing Assistant D stated to the Resident, Do you want me to tell the Nurse again (about pain)? Review of Resident #43's Treatment Administration Record (TAR) revealed the treatment, Foley Catheter Care q (every) shift. Every day and night shift for foley care. No documentation was completed during day shift on 12/6/19. An interview was conducted with Nurse N on 12/11/19 at 10:05 AM. When queried regarding documentation on Resident #43's TAR indicating catheter care was completed and what is included as part of catheter care per facility policy/procedure, Nurse N indicated the catheter was cleaned. When asked if facility nurses document completion on the TAR, Nurse N replied, Yes. When asked if facility nurses complete catheter care, Nurse N replied, No. The CNAs (Nursing Assistants) do it. When asked if they were saying they document catheter is completed, but do not complete catheter care, Nurse N replied, We watch the CNAs. When queried if they observe every time catheter care is provided to Resident #43 by Nursing Assistant staff, Nurse N did not provide a response. On 12/11/19 at 12:49 PM, Resident #43 was observed to be in their room in bed, positioned on their back. The Residents catheter drainage bag was positioned on the right side of the bed. Cloudy, dark amber colored urine with visible sediment was observed in the tubing. An interview was conducted with Nursing Assistant D at this time. When queried regarding Resident #43's catheter, Nursing Assistant D stated, It (catheter) leaks. (Resident #43's) brief has been wet. When asked about the color and sediment in the urine drainage tubing, Nursing Assistant D revealed they had informed the nurse about the urine and the catheter leaking. Review of Resident #43 health care provider orders and Medication Administration Record [REDACTED]. Give 1 tablet by mouth one time only for UTI for 1 Day. An interview was conducted with Unit Manager K on 12/11/19 at 12:58 PM. When queried regarding Resident #43's indwelling urinary catheter leaking, Unit Manager K stated, (Resident #43) does have [MEDICAL CONDITION] bladder and when they have spasms it leaks. If it is leaking excessively, it gets changed. When queried regarding observations of the Residents urine and medication order, Unit Manager K replied, (Resident #43) had a UTI. With further inquiry, Unit Manager K stated, (Resident #43) gets UTI's frequently. Review of the Resident's laboratory testing results for the last six months occurred with Unit Manager K at this time. Review revealed the following Urinalysis testing: -Collected: 6/14/19 . Received: 6/17/19 . Reported: 6/20/19 . Organism Proteus Mirabilis (Gram Negative Bacterium) . -Collected: 10/31/19 . Received: 10/31/19 . Reported: 11/3/19 .Urine Culture . Three (3) or more organisms isolated . -Collected: 12/9/19 . Received: 12/9/19 . Reported: 12/10/19 . Culture in Progress . When queried regarding the time frame between urine collection, being received at the lab, and results being reported to the facility, Unit Manager K did not provide an explanation. When queried regarding the Resident having frequent UTI's, Unit Manager K indicated it was due to their long term urinary catherization. When asked if alternatives to an indwelling catheter had been explored including suprapubic catheter placement, Nurse Manager K did not respond. On 12/11/19 at 1:06 PM, an interview was conducted with Nursing Assistant C and Nursing Assistant D. When asked how often the Resident is checked for incontinence during their shift, Nursing Assistant D replied, (Resident #43) will tell you (if they need to be changed). When queried if facility nurses observe them complete catheter care, Nursing Assistant C and Nursing Assistant D both replied, No. Observation of daily care for Resident #43 occurred at this time with Nursing Assistant C and Nursing Assistant D. Nursing Assistant C and Nursing Assistant D restored the Resident's hygiene following an episode of bowel incontinence. During care, Nursing Assistant D was observed wiping up and down over the Resident's catheter insertion site with a towel saturated in stool. While wiping up and down, stool was pushed into the Resident's labial area and catheter insertion site as well as on to the catheter tubing. An interview was completed with Nursing Assistant C on 12/11/19 at 2:20 PM. When queried regarding facility policy/procedure pertaining to indwelling urinary catheter care, Nursing Assistant C indicated you are supposed to wipe away from the catheter and then down the catheter tubing. When queried regarding the observation of them wiping towards the catheter insertion site with a towel saturated in stool in an up and down motion causing stool to be pushed into the labial region, the catheter insertion site, and the catheter tubing, Nursing Assistant C stated, I didn't realize. I won't do it again. When queried regarding the Resident having a UTI, Nursing Assistant C revealed they were unaware the Resident had an infection. An interview was conducted with the Director of Nursing (DON) on 12/11/19 at 2:23 PM. When queried regarding facility policy/procedure pertaining to indwelling urinary catheter care, the DON stated, Should wipe around it, the (catheter) insertion site and then down. When queried if appropriate technique is to clean away from the catheter insertion site, the DON indicated it was. When queried regarding appropriate wiping technique, the DON did not provide a response. When asked if appropriate technique is to wipe from front to back and away from the catheter insertion site, the DON indicated it was. When queried if a visibily soiled cloth should be used to wipe around the catheter, the DON stated, You have to get them clean. No further explanation was provided. The DON then stated, We will do staff education. Review of facility policy/procedure entitled, Policy/Procedure - Nursing Clinical: Catheter, Indwelling Care of (Dated: 7/11/18) revealed, It is the policy of this facility to improve hygiene/reduce infection by insuring that catheter care is done at least daily . 6. Wash, rinse and dry around urinary opening. Be sure to wash catheter tubing extending from urinary opening with soap and water using washcloth and soap. 7. Wash and rinse peri area from front to back and two (2) to three (3) inches of catheter tubing (for female) . 11. Document all appropriate information in medical record .

This citation pertains to intake: MI 5. Based on observation, interview and record review, the facility failed to provide consistent hydration and monitor weight loss for three sampled residents (#'s 701, 702, and 707) out of four residents reviewed for weight loss and hydration, resulting in dehydration requiring IV (intravenous) hydration, weight loss, and complaints of not receiving water timely. Findings include: Resident #701 On 11/25/19 a review of the complaint intake revealed an allegation of It was alleged the facility failed to give the resident (#701) anything to drink for an extended period of time. A review of Resident #701's medical record revealed, Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment, dated 10/11/2019 noted, Resident #701 with an intact cognition and required set up assistance with eating. Resident #701 was discharged on [DATE]. A review of Resident #701's care plan noted, Focus: The resident has dehydration or potential fluid deficit r/t: family reports hx low fluid intake to decrease urination episodes constipation Date Initiated: 10/14/2019. Interventions: Monitor vital signs as ordered/per protocol and record. Notify MD (Medical Doctor) of significant abnormalities. offer preferred beverages with meals, offer fluids with medication and between meals, encourage fluid intake, see nutritional care plan, review fluid status with IDT (Interdisciplinary Team) Date Initiated: 10/14/2019. Focus: The resident has alteration in nutritional status AEB (as evidence by): potential for glycemic reaction due to DM (Diabetes Mellitus) impaired skin related to abrasions/lesion wt goal decrease episodes constipation dau reports hx (history) low fluid intake to decrease urination hx elevated A1C (glycated hemoglobin). Date Initiated: 10/14/2019. Interventions: carb control diet, set-up meals, cater to prefs, offer prune juice daily, offer fruit for dessert (preferred), offer milk and water with meals, review glucose control, nut/hydration parameters with IDT, encourage safe slow weight decrease. Date Initiated: 10/14/2019. Interventions: Provide, serve diet as ordered. Monitor intake and record q (every) meal. Report changes in consumption to nurse and/or dietician. Date Initiated: 10/14/2019 A continued review of Resident #701's medical record noted, 10/17/2019 09:43 General Progress Note: Patient received resting in bed with eyes closed, no s/s (signs or symptoms) of distress observed, 0.9NS (normal saline) infusing @ (at) 80ml (milliliters)/hr (hour) for dehydration, patient tolerating fluids well, IV site to RUE (Right upper extremity) clean, dry and intact, foley patent and draining amber color urine, family at bedside @ 9:30am to take patient home R/T (related to) schedule D/C date, nurse notify Dr. and new order noted to postpone D/C (discharge) until IV (intravenous) therapy is completed and labs are repeated . A review of Resident #701's admission Dietary Evaluation, dated 10/09/19 revealed, .Section B. Most Recent Weight: 181.4 (Lbs) Date: 10/4/2019 . Observations: C. What is the patient's usual level of acceptance of fluids? 1. Accepts most fluids offered . A review of Resident #701's weight revealed the following: 10/16/2019 17:00 (5:00 PM) 171.8 Lbs (pounds) Standup scale 10/15/2019 20:53 (8:53 PM) 172.0 Lbs Wheelchair scale 10/4/2019 18:24 (6:24 PM) 181.4 Lbs Standup scale 10/4/2019 17:02 (5:02 PM) 181.4 Lbs Standup scale Further review of Resident #701's medical record revealed no documentation for Resident #701's weight for the second week of admission, no documentation regarding the weight loss, no documentation by the dietician regarding the weight loss, and no documentation of the weight loss being reported to the physician. On 11/25/19 at 1:59 AM, Unit Nurse A was asked about Resident #701's weight loss. Nurse A stated, (Resident #701) was confused and in for a fall. (Resident #701) was eating and drinking ok. Nurse A was asked to provide the food acceptance record. Nurse A was observed to attempt but was unable to pull up the record. An observation of Resident #701's electronic medical record (EMR) was conducted with Nurse [NAME] At that time the record was noted to have an alert in red writing regarding weight loss. Nurse A was asked was the weight loss addressed by the facility. Nurse A was observed to search the EMR and stated, I don't see any weight notes, the system was triggered about the weight loss. On 11/25/19 at 2:08 PM, Unit Manager Nurse B provided Resident #701's food acceptance record which revealed the following: 10/4/19 -10/10/19 noted meals consumed by resident at 75%-100% three times per day. 10/11/19 Meal 100% Eaten, Meal Resident Refused. Two meals only. 10/12/19 Meal Resident Refused. One meal only 10/13/19 Meal 100% Eaten, Meal 100% Eaten, Meal 50%. 10/14/19 Meal Refused, Meal Refused, Meal 100% Eaten. 10/15/19 Meal 100% Eaten. One meal only. 10/16/19 Meal Resident Refused, Meal Resident Refused. Two meals only. The medical record did not reveal any documentation addressing the decrease in eating, refusals, or missed meals. The medical record did not reveal that the Dietician or Physician was notified of the changes with Resident #701's eating consumption. On 11/25/19 at 2:52 PM, the Director of Nursing (DON) explained, They were very upset when they left here. The time came for (Resident #701) to leave, but (they) had some health problems that we were treating. We didn't want (Resident #701) to leave because it wasn't a safe discharge. We started an IV for low sodium and had an abdomen x-ray done because we thought (Resident #701) had a bowel obstruction. On 11/25/19 at 3:10 PM and 5:18 PM, the Dietician was contacted via phone, voice mail left. A return call was not made by the end of this survey. On 11/25/19 at 4:25 PM, the DON stated, We did noticed (Resident #701) weight on 10/15 at 172 (lbs) then reweigh on the 16th and saw that was pretty much true. The DON was asked after the facility noticed the weight change on 10/15/19 what was put in place. (Resident #701) was sick and the Doctor ordered more labs. On 11/25/19 at 5:03 PM, the DON addressed Resident #701's weight and stated, Weight on 16th at 5pm was a reweigh. The Certified Nursing Assistant (CNA) writes it on paper and gives it to the Nurse. The DON was asked what was done on the 15th or 16th after the weight loss. Was there any documentation by the Nurse, RD, or Physician to address the weight loss. The DON stated, We would have done something if (Resident #701) was still here. The DON was asked if it was the facility's procedure to wait until the next day to notify the RD, Physician, and or family about the weight loss. The DON stated, It was not documented because (they) left. The DON was asked if the facility notified the RD, Physician, or family about Resident #701's change in eating. The DON stated, I'm sure we did. This Physician is in the facility daily, we communicated it verbally. Resident #702 On 11/25/19 at 9:44 AM, Resident #702 was observed in their room sitting in a wheelchair. Resident #702's overbed table was observed with a cup with red writing on it 11-7. Resident #702 was asked what did the writing on the cup mean. Resident #702 stated, The night shift. Resident #702 was asked if they had received any water by the day shift today. Resident #702 stated, No. Days does not give water all the time. A review of Resident #702 medical record revealed, Resident #702 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. A review of the annual MDS assessment, dated 3/19/2019 noted Resident #702 with an impaired cognition and required assistance with activities of daily living. Resident #703 On 11/25/19 at 11:53 AM, Resident #703 was observed laying in bed. Resident #703 overbed table was observed to not have any water on the table or in the room. Resident #703 was asked if the facility provided water to them on each shift. Resident #703 stated, Not all the time. A review of Resident #703's medical record revealed, Resident #703 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED].#703 with an impaired cognition and required assistance with activities of daily living. On 11/25/19 at 3:38 PM, CNA D was asked if they had passed water during the shift. CNA D states, No. I am about to pass the water now. I was busy today and was not able to pass water at the beginning of my shift. On 11/25/19 at 5:30 PM, the DON was asked the policy and procedure for water pass and if it was to be done at the beginning of each shift. The DON stated, It should be done sometime during the shift. Afternoon shift has a habit to pass at the beginning and have it done by 4:00 PM. The DON was asked if the day shift passing water at 3:38 PM for the first time on the shift, was ok. The DON stated, No. A review of the facility policy titled, Hydration dated 07/11/2018, noted, Policy: It is the policy of this facility to encourage fluid intake to maintain the resident's hydration in compliance with physician orders . PR[NAME]EDURE: 3. Fluids will be offered at a minimum of every two (2) hours for the dependent resident, unless contraindicated . Policy titled Nutrition Monitoring & Management Program dated, 07/11/2018, Policy: 2. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of weight loss/gain and the intervention(s) required. a. Once weight gain or loss as described above is identified, the Interdisciplinary Team will: i. identify and implement appropriate interventions ii. update and revise the care plan, as appropriate iii. notify the family member or responsible party iv. notify the attending physician v. notify the Registered Dietician .

This citation pertains to intakes 8. This citation has two deficient practice statements. Deficient Practice statement #1. Based on interview and record review, the facility failed to implement interventions for one (#801) of five sampled residents, reviewed for respiratory treatment, with a known behavior of self-removal of a tracheotomy tube, resulted in immediate jeopardy when Resident #801 removed [MEDICAL CONDITION] [DATE] for the second time and was found unresponsive for an unknown period of time. CPR (cardiopulmonary resuscitation) was initiated, and Resident #801 transferred by emergency to the local hospital. This deficient practice caused serious harm with the likelihood of death. Findings include: The IJ was started on [DATE] and identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 11:32 AM. The Administrator was asked for a plan to remove the immediacy. The IJ was removed on [DATE] based on the facility's implementation plan and verified onsite on [DATE]. Although the immediacy was removed, the deficient practice was not corrected and remained at isolation with actual harm that is not immediate jeopardy. On [DATE] at 8:45 AM, an interview was conducted with R#801's Confidential Witness A in regards to any concerns at the facility. Confidential Witness A stated, They (facility) did not have the equipment or a plan to take care of (R#801). When (R#801) pulled out [MEDICAL CONDITION] first time. I begged them to create a plan, but they did nothing. A review of the resident's general progress note revealed the following: On [DATE] at 7:33 pm, Patient presented to be SOB (short of breath) at 6:15 PM. Assigned nurse (Nurse C) [MEDICAL CONDITION] and it was partially pulled out. Elevated BP (blood pressure) and HR (heart rate) noted. Assigned nurse (Nurse C) notified other nurse (Nurse D) on staff to assist with consoling patient while assigned nurse called 911. Patient continued to pull at tracheotomy and be combative. EMS (Emergency Medical Services) arrived and took patient to local hospital. On call manager called voicemail full. PA (physician assistant) B notified of patient transfer. A review of EMS document titled Patient Care Record dated [DATE], revealed, (R801). Clinical Impression: Chief Complaint Rep (Respiratory) Distress. Signs & Symptoms Respiratory - Dyspnea. Duration 15 minutes. Barriers of Care: Speech Impaired . dispatched priority 1 to the above assisted living location for a (R801) pt (patient) pulled out (their)[MEDICAL CONDITION] . Staff states the pt is there for long term care from a cerebral incident. Pt has pulled out (their) tube before and staff normally can get it back in and repaired. Today they were unable. LFD (Local Fire Department) improvised blow by O2 (oxygen) around (their) partially displaced tube . Pt was sheet dragged to stretcher, secured and moved to squad for ALS (advanced life support) assessment. Pts arm were secured by seatbelts and (R#801) sheets to prevent (R801) from pulling the tube. Additional record review revealed on [DATE] at 3:01 am, (R#801) back from local hospital [MEDICAL CONDITION], no bleeding at this time, alert and calm, vital signs/ blood sugar stable. All due medications restarted with breathing treatment and suction . A review of Unusual Occurrence Report, revealed, Person involved: (R#801) dated [DATE], Time: 8:30 pm. Description of the Occurrence: Resident observed on floor face up next to bed and in front of door . Resident was repositioned mult (multiple) times since admission at 7:25 pm. Resident continues to throw legs over edge of bed. Two sons now at bedside and able to calm resident . A [MEDICAL CONDITION] occurred two days later per review of R#801's medical record. A general progress note revealed the following: On [DATE] at 1:53 pm, (R#801) was observed about 12:55 pm with [MEDICAL CONDITION] and laying on their chest, non-responsive to verbal or physical stimuli, nurse (Nurse F) went in [MEDICAL CONDITION] met no resistance, code called and CPR started, 911 arrived about 1:10 pm, patient was transported to local hospital via 911, MD (medical doctor) and family notified. A review of EMS document titled Patient Care Record dated [DATE], revealed,R801. Clinical Impression: Chief Complaint: [MEDICAL CONDITION]. Duration 10 minutes. Patient's Level of Distress: Severe. Signs & (and) Symptoms: Cardiovascular - [MEDICAL CONDITION]. Flow Chart: Treatment: CPR, Description: EMS was sent to the above location for a resident experiencing respiratory distress. EMS staff arrived with Cardiopulmonary resuscitation in progress. Resident has a tracheotomy whereas Cardiopulmonary resuscitation ventilation were given. Resident was given [MEDICATION NAME] three times, one dose of calcium, and one dose of sodium [MEDICATION NAME]. After the third administration of [MEDICATION NAME], the resident converted from asystole to Ventricular fibrillation. Resident was shocked one time and then converted to sinus rhythm with a strong pulse. Resident was moved to the cot and secured with continued respiratory ventilation's through the tracheotomy. Upon arrival by EMS to the emergency department, the resident went into [MEDICAL CONDITION]. Cardiopulmonary resuscitation was initiated. Resident was then transferred to the hospital bed and care was turned over to the nurse and the physician. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed, that R#801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Care plan created [DATE] revealed (R#801) shows cognitive loss as evidence by being unable to complete cognition assessment and depression scale due to communication deficits and dementia. Date Created/Initiated: [DATE]. Intervention: Cue, reorient and supervise as needed. Date Created/Initiated: [DATE]. (R801) shows potential for change in mood r/t (related to) anxiety. Date Created/Initiated: [DATE] Intervention:Monitor/record/report to MD prn (as needed) mood patterns s/sx (signs and symptoms) of depression, anxiety, sad mood as per facility behavior monitoring protocols. Date Created/Initiated:[DATE]. No other care plan related to tracheotomy tube noted in medical record. On [DATE] at 1:50 PM, the Director of Nursing (DON) was asked, are there any assessment and monitoring notes for the tracheotomy tube prior to the two dislodgement's, the DON stated, No. When queried why the care plan was not added or updated with interventions after the first dislodgment, the DON stated, We have two weeks to complete the comprehensive care plan. On [DATE] at 12:51 PM, the DON was later asked if the facility would wait two weeks to put in interventions for a known behavior. The DON stated, We have pulled staff for residents that show anxiousness or for safety to sit with the resident. The DON continued and explained, It was not pulled out. It was partially out. It was not dislodged. (Referring to [DATE]) The DON was asked how did [MEDICAL CONDITION] out. The DON stated, I am not sure. The DON was asked did R#801 have behaviors of pulling at their trach. The DON stated, (They) had some anxiety. The DON was asked what interventions were put in place after the first time R#801 pulled out their trach. The DON stated, It didn't come out a first time. It was only one time. The DON was asked about the progress note dated [DATE] and the EMS documentation that noted R#801 having a history of pulling out their trach. The DON stated, (They) did not pull out the trach. The DON volunteered, We have inservices about dealing with residents that have restlessness. The DON was asked when was the last inservice and if it included residents with trach's. The DON stated, I would have to check. Documentation regarding the inservice was not provided by the end of this survey. On [DATE] at 12:23 PM, Nurse C was asked about R#801'[MEDICAL CONDITION] on [DATE]. Nurse C stated, R#801 was anxious all day. The resident was so anxious, the resident was unable to complete their therapy. While their son was present at the bedside, the resident was calmer. Unfortunately, the son left, and the resident became anxious again. I had to give (R#801) anxiety medication. During my rounds, I found the resident'[MEDICAL CONDITION] out. I could tell that the resident was having difficulty breathing, high heart rate and blood pressure reading. I immediately called (Nurse D) into the resident's room. (Nurse D) tried to reinsert [MEDICAL CONDITION] was unsuccessful. (Nurse D) stated, 'we need to call 911.' Nurse C was asked if they had received any education on handling anxious residents with a tracheotomy tube. Nurse C stated, No! Looking back, I should've utilized a sitter at the bedside. On [DATE] at 12:50 PM, Nurse D was asked about R#801'[MEDICAL CONDITION] on [DATE]. Nurse D stated, I was called into (R#801's) room. I saw [MEDICAL CONDITION] partially out. I immediately tried to reinsert the trach, but [MEDICAL CONDITION] met with resistance, I told the nurse to call 911 immediately since we lost (R#801's) airway. Nurse D was asked if they had received any education on handling anxious residents with a tracheotomy tube. Nurse D stated, No training about dealing with residents with behaviors. On [DATE] at 3:23 PM, Nurse F was contacted via phone and was asked about R#801's [MEDICAL CONDITION] on [DATE]. Nurse F stated, I remember R#801'[MEDICAL CONDITION] out. I don't remember the details on what happened. A request for the facility's policies and procedure regarding resident with behaviors, non compliance to care, and assessment and monitoring [MEDICAL CONDITION] made at 12:13 PM and at 1:00 PM with the Administrator, but not provided by the end of this survey. The facility Plan of Correction: RESIDENT AT RISK 1. All residents with a tracheotomy tube are at risk IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% audit was completed on [DATE] by the facility clinical team a. The audit consisted of reviewing all of the current residents with a tracheotomy tube to identify any concerns with accidental or self-inflicted decannulation 1. 0 out of 3 had accidentally or self-inflicted decannulation of their [MEDICAL CONDITION] in the past 6 months PR[NAME]ESSES IMPLEMENTED TO PREVENT FURTHER [NAME]CURRENCE 1. In-servicing for all nursing staff was start on [DATE] at 2:15 PM by the Regional Respiratory Therapists. At this point 8 out of 107 have been in-serviced. Staff will not be able to work the floor until they are in-serviced. Currently, there is no nursing staff on vacation or LOA or FMLA. The in-service addressed the following: a. [MEDICAL CONDITION], Care and Cleaning of; Policy and Procedures which includes but is not limited an extra cannula of the correct size as well as a suction machine and catheter should be at the bedside at all times for emergency use and what to do should a resident accidentally or self-inflict a decannulation b. Addressing [MEDICAL CONDITION] residents that are displaying behaviors and interventions that can be implemented. 2. All new hire nurses will go through Clinical Orientation (see attached outline) a. Nurses will attend 3 day of Clinical Orientation (see attached outline) which includes a Mock Drill for Respiratory Events 3. The Care Plans for all residents with a [MEDICAL CONDITION] were reviewed to ensure they addressed appropriate intervention in emergency situations such as an accidental or self-inflicted decannulation 4. All residents with a [MEDICAL CONDITION] had their rooms checked to ensure they had an extra cannula of the correct size at beside as well as a suction machine and catheter MONITORING 1. The DON or designee will review all respiratory events to ensure appropriate actions were taken at the time of the event 2. The DON or designee will review all residents with a [MEDICAL CONDITION] weekly times 4 weeks and then monthly thereafter times three months regarding Care and Cleaning of [MEDICAL CONDITION] and a review of appropriate actions during an emergency event to ensure appropriate steps were taken and the plan of care was updated with appropriate interventions to prevent further events 3. Results will be reported to the QA committee for monitoring and follow-up 4. Director of Nursing is responsible for substantial compliance of this Plan of Action The facility alleges the immediacy of these discrepancies have been removed on [DATE]. Deficient Practice statement #2. Based on observation, interview and record review, the facility failed to implement behavior interventions for one (R805) of five sampled residents reviewed for respiratory treatment, resulting in the likelihood of the resident pulling out their [MEDICAL CONDITION] causing injury and/or death. Findings include: On [DATE] at 3:20 PM, R805 was observed in bed moving around in an anxious manner. The resident was non-interviewable and severely cognitively impaired. A patient sitter was observed in the room. A review of R805's medical record revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the following progress notes: [DATE] 17:25 (5:25pm) General Progress Note: Patient arrived at facility about 5:15pm accompanied by EMT (emergency medical technician) staff, patient was observed pulling [MEDICAL CONDITION] peg tube binder, Dr. (doctor) notified and advice nurse to call DON (Director of Nursing) for decision, on call nurse called and notified nurse to send patient back to the hospital, patient sent back to hospital via EMT staff that transport (R805) to facility. [DATE] 19:53 (7:53pm) General Progress Note: Patient received resting in bed with eyes closed, patient later woke up and noted constantly removing gown and underwear,[MEDICAL CONDITION] and attempting to pull [MEDICAL CONDITION] peg tube, cena (certified nursing assistant) changed bed linens *3 (3 times) this shift, Dr. was in facility and was notified, script received and to pharmacy for PRN (as needed) [MEDICATION NAME] (anxiety medication) . [DATE] 06:37 (6:37am) General Progress Note: patient received laying in bed and very agitated, pulling clothes away and reach out to belongings and trying to get out of bed. writer administered a one time order of [MEDICATION NAME] 0.5mg (milligrams) 2tabs which was effective . [DATE] 08:11 (8:11am) General Progress Note: Patient is alert with confusion, (R805) is incontinent of b/b (bowel and bladder), restless, unable to make (R805) needs known, has a trach, (R805) is a TF (tube feed), total assist. (R805) had a fall prior to change of shift, no injuries I/A (incident and accident report) complete, administered anti-anxiety medication . [DATE] 16:45 (4:45pm) Respiratory Therapy Note text: RT (respiratory therapist) entered room to find resident had [MEDICAL CONDITION] and broken aerosol jar from the compressor. RT replaced aerosol jar with a new one and placed the set up back on the resident. (R805) also removed (R805's) gown which I put back on (R805). (R805) will not stop grabbing for things . Reported to charge nurse about resident's agitation. [DATE] 08:00 (8:00am) General Progress Note: Patient received in bed at change of shift, (R805) is alert, has a tracheotomy, restless at times . [DATE] 03:00 (3:00am) General Progress Note: At approx.(approximately) 2315 (11:15pm) pt (patient) observed on the floor next to bed in a lying position. pt assessed no injuries noted, vitals taken and stable, ROM (range of motion) completed within limits, Neuro-checks initiated. pt unable to state what happened. patient assisted via hoyer. MD (medical doctor) and first emergency contact notified via VM (voicemail). No new orders at this time, will continue with plan of care. A review of R805's medical record revealed that their care plan did not address the resident's anxiety until [DATE]. R805's [MEDICAL CONDITION] care plan was not initiated until [DATE]. On [DATE] at 3:51 PM, the DON was interviewed regarding R805's behaviors. The DON stated, Anytime someone becomes agitated for any reason as far as a trach, or looking like they are going to fall, we will put a 1:1 with them. We have done it often. They said (R805) seems restlessness. The 1:1 helps, and seeing a familiar face helps. The DON was asked why R805's care plan had not been initiated until [DATE] related to their anxiety. The DON stated, We note every behavior and everything that happens, we go through a 24 hour summary and act upon every case that needs to be acted on. A review of the facility's policy titled Tracheotomy Care and Cleaning dated, [DATE], was reviewed and did not address adding the care needs or intervention for a resident with a trach. A request for the facility's policies and procedure regarding resident with behaviors, non compliance to care, and assessment and monitoring [MEDICAL CONDITION] made and not provided by the end of this survey.

This citation refers in part to MI 337. Based on interview and record review, the facility failed to ensure a resident was monitored and in a safe position during care and revise the care plan to reflect the needs of the resident, for one sampled resident (R901) of three reviewed for falls in a total sample of four, resulting in resident injury and fracture from falling out of bed. Findings include: On 01/15/17 a review of the facility medical record revealed that R901 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) Assessments dated 06/17/18 and 09/17/18 which indicated impaired cognition and required extensive two person assistance with bed mobility, transfer, dressing, hygiene, and toilet needs. Range of motion was impaired for both upper extremities and one lower extremity. Nursing care plans: with revision date of 05/08/18 indicated, At risk for falls due to [MEDICAL CONDITION], restlessness, [MEDICAL CONDITION] right flaccid (limp) [MEDICAL CONDITION] (paralysis); a nursing care plan created 03/10/17, last revised 06/29/18, Has an ADL (activities of daily living) self care deficit as evidenced by [MEDICAL CONDITION] right flaccid [MEDICAL CONDITION], assist with daily hygiene, grooming, dressing oral care as needed dated initiated 03/10/17; a has urinary/bowel incontinence [MEDICAL CONDITION] right flaccid [MEDICAL CONDITION], initiated 03/22/17, care plan, which indicated, provide incontinence care as needed, initiated 03/22/17; an at risk for falls (related to) r/t weakness, impaired balance, (history) hx of [MEDICAL CONDITION], psych meds and dependence on staff for bed mobility and transfers, revised 03/15/18 care plan which indicated, assist with turning and positioning needs (as needed) PRN initiated 01/17/18, two person mechanical lift with all transfers, initiated 01/17/18. The Kardex (not dated) (certified nursing assistant-CNA care guide) revealed: assist with toileting and incontinence care as needed, resident uses a trapeze bar to assist with positioning, provide assistance with toileting, provide incontinent care as needed. The nursing care plan nor the Kardex indicated the number of staff to use for incontinence care. A Nursing Home to Hospital Transfer Form dated 12/18/18, 1030 AM by Nurse A which revealed, reason for transfer: fall, unplanned, pain location: right trochanter (hip) 8/10. A Physician Assistant (PA) note dated 12/18/18 revealed, Patient was complaining of right hip and right forearm pain. Patient also states that (they) hit (their) head. Patient has chronic contractures of the lower extremities but due to pain and a fall patient was not moved and transferred to hospital via (emergency medical service) EMS for concern of possible right hip or pelvic fracture as well as potential right forearm injury. On 01/15/19 at 10:05 AM, a representative of R901 was queried about their knowledge of the fall and stated, (R901) was being changed, there was a commotion in the room, and (R901) rolled out of bed. (R901) had multiple fractures. (R901) had to have been rolled as (R901) was immobile. (R901) is paralyzed on one side so there is no way (they) rolled (themselves) out of bed. Prior to the fall (R901) was eating, getting double portions, improving. Now (they) are in pain and not thriving. On 01/15/19 at 11:07 AM, CNA B was asked about R901's fall and stated, I was here. (R901's) spirits had improved and could hold a conversation. (They) were a total (care). Asked if R901 could roll themselves CNA B stated, No. You had to turn (them). They were a two person, one or two depending but could not turn by (themselves). On 01/15/19 at 11:16 AM, CNA C stated, (R901) knew what (they) wanted. Did not have any falls until about a month ago. (R901) couldn't move or turn (themselves). On 01/15/19 at 11:43 AM Nurse D was asked about R901 and any education done after R901's fall and stated, (R901) was incontinent, did not walk, had limited upper extremity movement and needed assistance to turn though (they) could move slightly, only one fall. The education was to have two aides in room at all times, one on each side. I believe she was a two person, all care and turning. On 01/15/19 at 12:51 PM, CNA G was asked about R901's fall and education after and stated, I was in the room with one of my co workers (CNA H). We proceeded to do care when one of the residents (R24) barged in. I turned and stepped away to pull the drape. (R901) was facing toward me. I stepped away and the resident was on the floor. Education after was how to prevent falls incidents and that you should have not have stepped away or rolled the resident back onto their back. On 01/15/19 R24 was asked about the incident with R901 and stated, The door was open and drape was closed. I think it was that she slipped off the mattress. There should have been two in there but there wasn't. It wasn't (CNA G). There was one aide at the bed. The water was running, maybe they needed the water running. It all happened when I turned around and shut the door. The lady was naked. On 01/15/19 at 1:15 PM, CNAI was asked about the use of the Kardex and education after the fall and stated, I did hear about it. The education was about patient care. You must be careful how you turn someone. You have to go into Kardex (to find out), if doesn't say anything, you ask the nurse. On 01/15/19 at 2:01 PM, CNA H was asked about R901's fall and education after and stated, (R901) was one of my favorite residents. A little confused and total care. (R901) needed to be fed, clothed, changed and bathed. When asked if R901 could reposition themselves CNAH stated, No. (R901) was paralyzed. (R901) had not had any falls before. I was her aide that day and have , taken care of (them) before that. I was there when (R901) fell . I felt so bad. I had seen her progress. It was a check and change. We always go in with a two person assist. My hand was never taken off (R901). I washing (R901) her up, her lower half was exposed, my hand was wet, she was partially wet. We had all the supplies. The resident (R24) came in, tried to pull the drape away.(NAME)pulled it back to make sure it didn't open. (CNAG) only turned partially. (R901) was a two person assist. All total care patient's are a two person assist. They told us to never leave the side of a two person assist. Especially with the type of mattress she was on. I went to get the nurse. On 01/15/19 at 2:20 PM, Nurse A was asked about R901 and stated, (R901) could feed themselves if set up. The last two weeks (R901) was feeling better, in better spirits. (R901) could not do large movements to move self. I was told about the fall by (CNAH). (R901) rolled off the bed. CNA E came in after I went into assess her. (CNA H) went to go get the doctor. The PA saw (R901) and had us send (them) out. Both her room mates were in the room. I wasn't able to go right in I had to lock up my cart. I don't know if anybody else was in or out. I did here water running. I didn't see (CNA G). I am not aware if was anyone else (staff) in there. I really don't know. (R901) kept saying (they) had pain and the right hip and arm were bothering (them). On 01/15/19 at 2:37 PM, a review of R901's fall was conducted with the Director of Nursing (DON) who stated., I did education after the fall. We wanted to ensure staff were having a person on each side of the bed and if you have to step away for any reason at all. Put the resident back on their back. Have every thing ready. I interviewed the aides who knew more than the nurse. (CNA H) says (they) got assistance from (CNA G), a roommate came into the room, tried to open the curtain, asking loudly, why water was running, one of aides and reached over to shut it. That resident never even saw anything. I interviewed the resident (R24), but they didn't know anything, basically not wanting to tell anything. The aides told me the resident did see (R901) after the fact because the resident was on the floor. The other roommate is not alert and oriented. I did education, one to one with each of the (CNAs). I examined the mattress and chose to keep it. It was the Tempurpedic type. The family liked this aide, pretty much the only one. I have no doubts that there were two people in room during care. On 01/15/19 at 3:31 PM, the Administrator was asked about R901's fall and stated, There were two aides in performing care, an irate patient came in, screaming and yelling, one of the aides stepped away for a second to calm the resident and the patient (R901) rolled out of bed. The patient was sent to the hospital. I am aware that there was a fracture. I can't recall where. When asked about the number of staff required to provide incontinence care. The Administrator reviewed the electronic record for evidence of only a one person assist and stated, I answered my own question, it just says assistance. On 01/15/19 at 4:23 PM, the DON with Administrator stated, Your concern worries me, that there are conflicting stories. I have what they showed me. They stepped over to the curtain , but didn't leave the side of bed. They didn't go away. They only stepped. We re-enacted this in my office. The DON and Administrator were asked if they would like to provide investigation and statements would include in report. One to one in-service records for CNA G and H dated 12/18/19 were provided which stated, While changing a resident with two person assist in bed. If resident is laying on (their) side in bed, do not leave (them) unattended. Place resident back onto (their) back. An ADL CARE in-service (page not dated) indicated, While providing two person assistance with pericare, if the resident is side laying, place the resident onto their back if you need to leave the bedside for any reason. On 01/15/19 at 5:45 PM, the DON, Administrator and a unit manager provided additional information which the DON reported, (R901) was to have two staff present when a resident is lifted with the Hoyer lift per the care plan but when in bed staff could use one person for care as it only notes the need for assist in the care plan. The DON further noted, The CNA is not necessarily taught to pull a resident towards them to blindly clean if only one person. A CNA looking at the Kardex (for R901) would say only one person is required since it does not say. The DON confirmed the last revision of the falls care plan prior to the fall was 03/15/18 on page 19 of 24. On 01/15/19 at 6:15 PM the facility, Fall Prevention policy dated 07/11/18 revealed: policy: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department and if appropriate, a fall prevention protocol will be initiated. Purpose: 1. To identify residents at risk in a timely manner. 2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. 3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls.

This citation pertains to intake # Based on interview and record review, the facility failed to honor the rights of one (#701) of one resident reviewed for resident rights, from a total sample of three, by providing Cardio [MEDICAL CONDITION] Resuscitation (CPR) to a resident against their wishes, and attempting to revive them after found deceased on the floor, resulting in not following the wishes of the resident. Findings include: On [DATE] at 8:52 AM, an interview via telephone was completed with Resident #701's Durable Power of Attorney (DPOA) (Family Member A). Family Member A stated, I came to visit (Resident #701) daily. On that particular day I came in between 6 - 6:30 PM. I looked in his room and saw he was lying on the floor face down. I went out to get the nurse (Licensed Practical Nurse/LPN B) and asked her to come look at something with me. She said she would be there in a few minutes so I went to the nurse (LPN D) at the nurses station. She was on the phone but hung up and came with me to (Resident #701)'s room. When we entered the room, LPN D yelled, 'Oh my God!' She (LPN D) flipped him over and started doing CPR on him (Resident #701) and yelled for help. I heard someone call a 'Code Blue' and EMS (Emergency Medical System). EMS came in and they asked me if I was the next of kin and I said, 'yes', he then asked me what his (Resident #701)'s code status was and I told him a 'DNR' (do not resuscitate) and the EMS guy told me 'sorry for your loss' and left. On [DATE] at 11:10 AM a record review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 had a Brief Interview of Mental Status (BIMS) score of 14, indicating an intact cognition. The MDS also revealed that Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:45 AM, a review of the Progress Notes and Physician Orders revealed that Resident #701 had a DNR order written on [DATE] and a Palliative Care consult order on [DATE]. The Progress Notes revealed the following: [DATE] 18:54 (6:54 PM), authored by LPN B stated, Responded to a code blue over head. Came into the room where I observed the (Resident #701) on the bed unresponsive and a nurse doing chest compressions, putting oxygen on and two or three aides assisting as well. One aide called EMS. I immediately left out to check his code status which was a DNR. It was told to the other nurse and compressions were immediately stopped. Family Member (A) was outside the door .EMS arrived and asked for paperwork regarding (Resident #701). That was given .Aides passed (Resident #701)'s dinner tray and stated he was sitting up in bed responsive. He showed no signs of distress all through the day. Per the Administrator, LPN B was terminated (for other reasons) from the employment of the facility. An attempt was made to interview LPN B by the phone number provided by the facility, but the number was no longer valid. [DATE] 18:31 (6:31 PM), authored by RN C, stated, Overheard a code blue overhead .Observed (Resident #701) on the floor lying on left side. No tactile or verbal stimulation noted. No pulse noted. Immediately started chest compressions. Other nurse grabbed crash cart and called a code blue. Directed aide to call [DATE]. Transferred (Resident #701) from floor to the bed and continued with CPR until EMS arrived .(Family Member A) was directed to wait outdoors at this time. On [DATE] at 1:27 PM, a record review of the DPOA papers revealed that Family Member A was the appointed DPOA for Resident #701. The document was signed by Resident #701 on [DATE] and Family Member A had signed the document on [DATE]. The document also stated, Declaration-If I should have an incurable or irreversible condition that will cause my death in a relatively short time .I direct my attending physician to with hold or withdraw medical treatment or procedures .that merely prolong the dying process and are not necessary for my comfort . A DNR order was signed by the resident and the guardian ([DATE]). On [DATE] at 1:33 PM, an interview was completed with the Director of Nursing (DON) over the phone. In regards to the incident that occurred on [DATE], involving Resident #701, the DON stated, I was called by (Administrator) and told they (the nurses) had started CPR on (Resident #701) when he was a DNR. We did a disciplinary action and I got statements from the nurses and aides. Typically, a nurse is supposed to check the patient, if there are no vital signs and check the code status (of the patient/resident). The code status is located in the chart and in (EMR-Electronic Medical Record). On [DATE] at 1:55 PM, a record review of the Doctor visit on [DATE] for Resident #701 stated the following: Changed code status to DNR. [MEDICAL CONDITION] malignant. On [DATE] at 2:34 PM, an interview was completed via phone with RN C. RN C stated, One nurse called overhead because they needed immediate assistance and LPN D came in with me. (Resident #701) was on his left side, flaccid. I checked his pulse and asked what his code status was, I had asked (Family Member A) and another resident to step out of the room. LPN D hurried up and ran out and got a crash cart and we hooked up the AED (Automated External Defibrillator-a device that sends electric currents through the body in attempt to get the heart to resume beating), to (Resident #701). We were unable to revive him. We did CPR (with AED) for ,[DATE] minutes. We started CPR because we didn't know what else to do, I asked (LPN B) what his code status was and she went to go check it. [DATE] arrived and asked for the code status and took over. I went up to the nurses station and asked (LPN B) again what the code status was for (Resident #701) and that's when I realized he was a DNR and told everyone and stopped CPR. On [DATE] at 2:46 PM, a record review of the Incident Report dated [DATE] authored by LPN B stated the following: (Resident #701) found on floor, next to bed unresponsive to voice and touch. No BP (blood pressure) or Pulse detected. CPR started by RN and 911 called . On [DATE] at 2:47 PM, a record review of the facility policy titled, Cardio-Pulmonary Resuscitation: Adult revealed the following: Key Points-Be aware of patient's wishes including: Do Not Resuscitate (DNR), advanced directives or limited treatment orders before proceeding. On [DATE] at 3:50 PM, an interview was completed with the Administrator in regards to Resident #701 receiving CPR when he was a DNR, the Administrator explained that she was new to her position and did not offer and explanation to the above situation.

This citation pertains to Intake # Based on interview and record review, the facility failed to investigate the cause of a sudden death and fall for one (#701) of two residents reviewed for a fall, from a total sample of three, that was found unresponsive on the floor, resulting in the potential for facility deficient practices to go unrecognized and the root/cause/analysis of the fall and subsequent death to be undetermined. Findings include: On [DATE] at 8:52 AM, an interview via telephone was completed with Resident #701's Durable Power of Attorney (DPOA) (Family Member A). Family Member A stated, I came to visit (Resident #701) daily. On that particular day I came in between ,[DATE]:30 PM. I looked in his room and saw he was lying on the floor face down. On [DATE] at 11:10 AM a record review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 had a Brief Interview of Mental Status (BIMS) score of 14, indicating an intact cognition. The MDS also revealed that Resident #701 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On [DATE] at 11:45 AM, a record review of the Progress Notes revealed the following: [DATE] 18:54 (6:54 PM), authored by LPN B stated, Responded to a code blue over head. Came into the room where I observed the (Resident #701) on the bed unresponsive and a nurse doing chest compressions, putting oxygen on and two or three aides assisting as well. One aide called EMS. I immediately left out to check his code status which was a DNR. It was told to the other nurse and compressions were immediately stopped. Family Member (A) was outside the door .EMS arrived and asked for paperwork regarding (Resident #701). That was given .Aides passed (Resident #701)'s dinner tray and stated he was sitting up in bed responsive. He showed no signs of distress all through the day. [DATE] 18:31 (6:31 PM), authored by RN C, stated, Overheard a code blue overhead .Observed (Resident #701) on the floor lying on left side. No tactile or verbal stimulation noted. No pulse noted. Immediately started chest compressions. Other nurse grabbed crash cart and called a code blue. Directed aide to call [DATE]. Transferred (Resident #701) from floor to the bed and continued with CPR until EMS arrived .(Family Member A) was directed to wait outdoors at this time. On [DATE] at 1:33 PM, an interview was completed with the Director of Nursing (DON) over the phone and was queried whether or not an investigation was completed in regards to Resident #701 being found on the floor deceased on [DATE], The DON stated, Well, yeah, I did do one (an investigation), I am just not sure where it is, I would have to come in and look for it. On [DATE] at 2:00 PM, the Administrator came in and handed a folder with staff statements in it. There was no other documentation in the folder. At that time, an incident/accident report was requested. The Administrator stated, I don't think we did one because he (Resident #701) was a DNR, I will check. On [DATE] at 2:46 PM, a record review of the Incident Report dated [DATE] authored by LPN B stated the following: (Resident #701) found on floor, next to bed unresponsive to voice and touch. No BP (blood pressure) or Pulse detected. CPR started by RN and 911 called . Upon further review of the report, the following was revealed: Incident Cause Describe cause of incident, if known: N/A Correction Action Describe corrective action taken following incident, if applicable: N/A On [DATE] at 3:50 PM, an interview was completed with the Administrator. The Administer was queried in regards to any visible injuries noted to Resident #701 since he was observed on the floor deceased . The Administrator, Well, I am not really sure. When queried in regards to actions taken after the incident, the Administrator stated, We didn't really discipline anybody because we couldn't really pinpoint who was wrong. On [DATE] at 3:55 PM, a request was made for the fall policy and procedure, and a policy on the investigation of unusual occurrences was made but not received by the end of the survey. According to the Administrator, there were no such policies.

This citation pertains to MI 523 and MI 917. Based on observation, interview and record review the facility failed to adequate supervision, monitoring, care planning and staffing to prevent an elopement from the facility for one sampled resident (R902) of three reviewed for accidents in a total sample of five resulting in the resident exiting the facility without staff knowledge, frostbite to the fingers of both hands and the need for increased assistance with activities of daily living. Findings include: On 01/30/18 at 8:15 a.m. and 10:08 a.m., the facility (MIACTS # ) five day report was reviewed and revealed, On 01/04/2018 resident (R902) eloped from the facility sometime between 9:30 and 10 PM. R902 was found by Southfield Police & Fire Department that same night at approximately 11 PM at Nine Mile and Telegraph Rd. (This was about four miles from the facility.) Resident was taken to hospital for evaluation. Southfield Police (not the facility) notified resident's emergency contact via resident's cell phone. Emergency contact then notified facility. Resident (R902) was last seen in (their) room sometime between 9:30 and 10 PM. Resident returned to the facility on [DATE]. Resident does have frost bite on bilateral hands with dressing changes to be completed twice daily. Resident (R902) did elope from the facility on 01/04/2018 and has since readmitted on [DATE]. On 01/30/18 at 10:30 a.m., a review of the facility exit doors revealed: Each door had an emergency release mechanism which allowed the door to be opened after pressing on the door release mechanism for 15 seconds. If this were to occur an alarm would sound. A second alarm was noted to each door which also alarmed if the door was opened with a key. The exit doors also required a code to be entered via a key pad. The main entrance door had a video camera to identify who was at the door. On 01/30/18 at 11:08 a.m., R902 was queried about walking out of the facility on 01/04/18. R902 paused after the question mumbled a few things about going out but declined to talk about the event or discuss why R902 left the facility. It was not clear if R902 recalled the event. R902 was observed to have both hands wrapped with rolled gauze forming a mitten like look for the hands. CNA (certified nursing assistant) B who sat with R902 indicated R902 to be steady when up walking. R902 was dressed in street clothes. On 01/30/18 at 12:27 p.m., a review of the medical record for R902 was conducted and revealed: R902 was admitted into the facility on [DATE] and readmitted on [DATE] [DIAGNOSES REDACTED]. The MDS (minimum data set assessment) dated 10/23/17 indicated severely impaired cognition and the need for supervision with locomotion/walking. A review of the nursing care plans for R902 did not indicate any propensity for wandering or wanting to go home or exit seeking. This was noted after R902's return from the hospital post elopement. A progress note dated 01/09/18 at 12:37 revealed: readmitted into facility with DX ([DIAGNOSES REDACTED]. The nursing care plan dated 1/15/18 further indicated a self care deficit s evidenced by decreased ADL (activities of daily living) related to wounds in bilateral hands resultant if (of) frostbite. On 01/30/18 at 1:30 p.m., CNA C was queried about any staffing concerns and about getting report on residents at shift change and stated, We don't get report. We don't crossover shift times. CNA C was asked about working short on the afternoon and night shift and stated, It is not just the night shift. When CNA C was asked if the facility was consistent about getting staff in to work when someone called in CNA C stated, No. On 01/30/18 at 2:22 p.m., Nurse D was queried if R902 wandered around the facility and stated, (R902) would go up and down the hall from their room to the dining room. Not constantly but four to five times during the shift. Nurse D further reported the wandering appeared without a purpose. On 01/30/18 at 2:39 p.m., the medical psychiatric progress notes for R902 were reviewed and revealed: On 11/10/17 R902 expressed frustration that (R902) is here and upset that girlfriend brought (them) here and had limited insight and questionable judgement. On 11/11/17 expresses distress over being kept here, I gotta get back to work. On 11/22/17 R902 stated, I won't be here much longer. He is confused, not sleeping well and has a lot on (their) mind. On 12/01/17 Presents as anxious and mildly agitated about being here. States he want to leave, wants to know why being held here. Problem adjusting to facility, receptive to repeated efforts of reassurance and redirection. On 12/14/17 Main focus is not wanting to be here. It's time for me to go. My boss needs me. On 12/29/17 R902 indicated, It's time to get back to work. I am the kind of (person) who works. I need to get out of here. On 01/30/18 at 3:15 p.m., the staffing sign in for 01/04/18 was reviewed and revealed four of five scheduled nurses and four of five scheduled CNAs signed in for work on the the south station and five of six nurses and five of six CNA signed in for the north station for the three p.m. to 11 p.m., shift. On 01/30/18 at 3:37 p.m., CNA E was queried about R902 and indicated they had not seen R902 on 01/04/18 when working their shift that evening. On 01/30/18 at 3:42 p.m. receptionist staff F was queried about the main entrance door safeguards and confirmed the door could be opened if the emergency release bar was pressed for fifteen seconds, but would alarm. Staff F also reported the ability to buzz people in and out could be done by staff at the south nurses' station and they had the same video set up there. The transfer to the south nurses station was one after seven p.m. as there was no longer a receptionist staffed at the front desk. On 01/30/18 at 3:45 p.m., the Maintenance Director Staff G was queried about testing of the doors and indicated no problems with the alarms or door interlock devices. Staff G indicated the alarm could not be shut off unless cleared at the nurses station and or key pad. When queried as to a possible explanation as to how R902 was able to exit the facility without the facility knowing, Staff G stated, (R902) may have looked like a family member or walked out with a family member. On 01/30/18 at 4:03 p.m., CNA H (working the afternoon shift) was queried about the wandering habits of R902 and stated, (R902) would walk back and forth from the TV room and up and down the halls (to the ends). CNA H reported this was a normal behavior since admission. On 01/30/18 at 4:35 p.m., the DON (Director of Nursing) confirmed that some family members were in on 01/04/18 and some sign in and out and some don't. On 01/30/18 at 4:55 p.m., CNA J was queried about working the afternoon shift on 01/04/18 and stated, It was hectic. We only had four aides on our (R902's) side. CNA J stated they last saw R902 around 8:30 p.m. to 9:00 p.m. CNA J was queried about family in the facility that evening and confirmed there was. CNA J also noted that some family members may get tired of waiting to get buzzed and just push the door open. On 01/30/18 at 5:12 p.m., CNA K was queried about R902's behavior the night of 01/04/17 and stated, Nothing was different. CNA K stated, It was busy that night. CNA K reported it may be difficult to hear a door alarm when inside a resident's room. CNA K further noted a code green (missing person) would be called if a door alarm was heard. CNA K reported last seeing R902 in bed between 9:30 p.m. and 10:00 p.m. On 01/31/18 at 10:34 a.m. and at 1:10 p.m., the Administrator and DON were queried about the elopement of R902. When queried if R902 had a wander guard (a device which will prevent opening of the door and alarm if exit through a door) at the time of the elopement the answer was No. When queried for the criteria for placement of a wander guard the administrator stated, Those that say they don't want to be here. When asked how the facility concluded R902 was able to leave the facility the Administrator stated, (R902) had followed people out the door. When queried if they were aware of family leaving the facility without being buzzed out, the DON and Administrator indicated they were not. The DON and Administrator also confirmed R902 did not have frostbite prior to the elopement on 01/04/18 and was found by emergency personnel about four miles away On 01/31/18 at 4:02 p.m., the Staffing Coordinator Staff L was queried about the staffing on 01/04/18 on the north station and confirmed five of the six CNAs had signed in for a census of 59 and stated, I try to have six because of all the showers. On 01/31/18 at 12:12 p.m., the facility Behavior Practice Guide (2015) revealed, Wandering is believed to be related to an individuals unmet need .the interdisciplinary teamworks to identify the trigger and structures the plan of care to meet the need of the patient specific trigger, preferably prior to the onset of wandering or exit seeking. The facility training for Wandering and Exit Seeking (slide nine) revealed: Non goal directed wandering requires a response that addresses both safety issues for the patient and the root cause of the wandering.

This citation pertains to intake: MI 203. Based on observations, interviews, and record review, the facility failed to ensure one of four sampled residents (#503) reviewed for abuse and neglect in a total sample of four was free from rough treatment from staff, resulting in feelings of fear, and the the potential for injury, and increased anxiety and depression. Findings include: According to the facility's incident report dated 9/8/17 at approximately midnight, Licensed practical Nurse ( LPN 'D') went to R#503's room in response to R#503's screaming and yelling out loudly. When LPN 'D' entered R#503's room, she found the resident in bed, with Certified Nursing Assistant (CNA 'H') standing near his bed. While LPN 'D' was in the room, assessing R#503, CNA' H' walked out. At that time the R#503's roommate, R#504 reported that he saw CNA 'H' pick R#503 up off the floor and throw him (R#503) down on the bed two times and told him to stay in the bed. R#504 also reported that he thought the CNA had pulled his arm back, like he was going to hit R#503, but he did not actually see the CNA hit R#503. During an interview with the facility Administrator on 9/28/17 at 11:30 a.m., she said the facility had reported allegations of abuse to the local Police Department and State agency on 9/8/17 for R#503, based on interviews of the resident's roommate, (R#504), and the initial statement from R#503. CNA 'H', had been suspended immediately after the allegations, and was then terminated from employment at the facility. CNA 'H's information was reported to the State Agency. A review of the facility's investigation file revealed that the CNA's information had been sent to the State Agency for Licensing, along with the local police report file number #17- . On 9/28/17 at 11:10 a.m., R#503 was asked about the incident on 9/8/17. R#503 said he could not recall too much about the incident, but there was a guy who had threw him on the bed a couple times and called him 'bad names'. R#503 said he thought it was some agency guy that wanted him to leave the facility. R#503 said he wanted to stay in the facility because his wife was there, and he wanted to be near her. R#503 could not recall anything specific regarding the incident due to cognition deficits. R#503 denied pain at this time. According to the medical record, R#503 is a [AGE] year old male with multiple [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated that the resident's cognition level is severely impaired, with a BIMS score (brief interview for mental status) of 3/15. A review of the resident's skin assessments from 9/8/17 did not reveal any signs of injury. A social work note dated 9/8/17 indicated that the R#503 felt 'a little fearful', but could not verbalize why. On 9/28/17 at 11:50 a.m., R#504 was interviewed regarding the incident on 9/8/17. R#504 said he did not know the exact date, but recalled the night that R#503 'got attacked'. R#504 reported that CNA 'H' was rough with R#503 when he got him off the toilet and put him to bed. After then, when R#503 got out of bed, and crawled onto the floor, CNA 'H' grabbed him off the floor, picked him up, and body slammed him (#503) on the bed two or three times. CNA 'H' was yelling at him and verbally abusing him. The CNA then pulled the curtain and I couldn't see the whole thing, but it looked like the CNA threw his arm back and then forward in a downward motion. It looked like he was hitting R#503, but I couldn't exactly see him make contact. According to the medical record, R#504 was a [AGE] year old male who admitted to the facility with multiple [DIAGNOSES REDACTED]. The MDS indicated that R#503 had no cognition deficits with a BIMS score of 15/15. During a phone interview with LPN 'D' on 9/28/17 at 5:45 p.m., she said that on 9/8/17 at around midnight she heard R#503 yelling and screaming out, which he does sometimes. LPN 'D' said she went into his room to reassure him and saw CNA 'H' standing at the resident's bedside. When the CNA walked out, R#503's roommate (R#504) said he wanted to tell me something. R#504 reported that he saw CNA 'H' grab R#503, throw him on the bed and was hitting on him. I had R#504 repeat the incident and he did not change his report at all. LPN 'D' said she went to LPN 'C' and interviewed #503 and completed assessment. There was no signs of any injury or swelling. The resident denied pain. LPN 'D' said she called the local police, then the administrator and ensured that CNA 'H' was away from residents until he could be escorted out of the building. During a phone interview with LPN 'C' on 10/2/17 at 4:40 p.m., she said that on 9/8/17 she was present during an interview and assessment with R#503 and LPN 'D'. R#503 said, 'a security guard came in my room, and hit me in my face'. LPN 'C' said that R#503 did not have any signs of injury, but during two different inquiries said the was beat up and hit in the face. During an interview with the Social Worker, (SW 'B') on 9/28/17 at 1:00 p.m., she said the she interviewed R#503 on 9/8/17, about the incident the previous night, and he could not recall very much, but did feel 'fearful'. SW 'B' said R#503 could not explain why he felt that way. Senior Wellness Group was consulted for assessment and possible treatment after the incident. However, no change in treatment was recommended. A review of the Senior Wellness Group notes dated 9/8/17 and 9/13/17, revealed that the resident did not recall the incident on 9/8/17, and the resident indicated that he felt 'safe' here.

Based on observation, interview, and record review, the facility failed to consistently implement interventions for two (# 701 and #712) of eight sampled residents reviewed for skin integrity from a total of 18, resulting in the development and worsening of facility acquired pressure sores. Findings include: Resident # 701(R#701) On 8/8/17, record review of clinical documents revealed R#701 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].#701 has severe cognitive impairment and is exstensive assist with all Activities of Daily Living (ADL's) and transfers. On 8/8/17 at 12:30p.m., observation of R#701 lying in bed with eyes closed, bed was in a low position with regular mattress, heels were not floated on a pillow or with any devices to help prevent pressure. On 8/9/17 at 1:00 p.m., R#701 was observed sitting in wheel chair with only a sock and bandage protecting right foot. On 8/10/17 at 8:37 a.m., observed wound care done by Wound Care Nurse O(WCNO), R#701 right heel (Pressure ulcer #1) revealed a Stage III (full thickness skin loss with dead tissue) 3cm x 2cm x 0.1cm , wound bed center was yellow slough(dead tissue) encircling slough wound bed was pink/red moist tissue with a macerated (skin exposed to excess moisture) perimeter and moderate serosanguinous(blood mixed with body fluid) drainage. Interview with Wound Care Nurse O, when asked about the stage of this wound, Wound Care Nurse O replied, They (facility) are calling this a blister. Pressure Ulcer #2, right medial upper foot reveals a Stage III pressure ulcer 3cm (centimeters) x 2cm x0.1 cm slough centered wound bed with a pink/red moist perimeter encircling wound bed with a macerated perimeter and moderate serosanguinous drainage. Interview during observation with WCN O, were both of these areas developed while in this facility, WCNO replied Yes. During record review of Wound Consultant progress note it is staged as Unstageable (not able to stage). Interview with WCNO, when asked if wound was still unstageable today, WCNO stated No. On 08/10/17 at 12:30 p.m., Interview with Director of Nursing (DON), when asked if the pressure ulcers were acquired in the facility, DON replied, Yes. When asked if these pressure ulcers were preventable DON replied, I do not have an answer for that question. On 8/10/17, record review of Braden Scale (risk assessment for skin) dated 6/20/17, R#701's score was six. A score of six was at very high risk for pressure ulcers. On 6/20/17, an Admission Assessment was done with no documentation of pressure ulcers on right heel or right medial foot. Reviewed General Progress Note dated 6/20/17 created by Nurse K on readmission from hospital. Skin assessment completed and showed no open areas. Review of R701's care plan documents, Stage II pressure ulcer to right medial foot initiated on 8/4/17. Interventions- Air mattress on bed. Review of Kardex (Information on resident's special needs) under Skin Care- Air Mattress on bed. During observations no air mattress was on R#701's bed during three day survey. Review of Skin Practice Guide provided by facility documents under FYI- F314-483.25(C) Pressure Sores. Based on the comprehensive assessment of a patient, the center must ensure that- 1. A patient who enters the center without a pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable . Resident #712- On 8/9/17 at 3:45 PM, resident #712's skin was observed with wound care nurse 'O'. The resident was lying in bed, alert, immobile and non-verbal. The resident's hands and elbows were elevated on pillows and a dressing was on the right elbow. There was a 0.8 centimeter (cm) by 1 cm, stage III (full thickness skin loss), bright red, open pressure sore underneath the dressing. The resident was wearing bilateral, foam, pressure relief boots. There was a dressing on the left ankle. A 0.8 cm by 0.7 cm pressure sore with a small scab was observed on the ankle bone underneath the dressing. When asked how and why the sores developed, if pressure relief interventions were in place, nurse 'O' said that the wounds were already present when she recently took over her position and was unable to answer. She said, I will get her some elbow protectors (pressure relief pads). At 4 PM, per review of the resident's clinical record, the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data completed 5/23/17 noted that the resident had severe cognitive impairment, required extensive assistance for bed mobility and had no pressure sores. A Braden (pressure sore risk) scale dated 2/22/17 noted that the resident was at very high risk for development due to very limited response to pressure-related discomfort, complete immobility and a problem with skin friction/shearing that required complete lifting of body parts rather than sliding against sheets. A Braden scale dated 5/23/17 noted the resident was at high risk for development due to very limited mobility. The resident's care plans noted the following: -At Risk For Pain to the left ankle related to arthritis initiated 2/8/17; interventions included: Encourage/Assist to reposition frequently to position for comfort. -At Risk For Alteration In Skin Integrity related to impaired mobility, boggy (soft, mushy) heels, dependent for care, initiated 2/8/17; interventions included: Encourage to reposition as needed, use pillows/positioning devices as needed. (No mention of pressure relief boots or elbow protectors.) Per the resident's progress notes: On 5/15/17 and 5/17/17, bilateral hand [MEDICAL CONDITION] tender to touch and hands elevated on pillows (no mention of elevation of arms and elbows). On 5/22/17, an open area measuring 0.5 cm by 0.5 cm was observed on the right elbow. A wound treatment and dressing were initiated. On 5/25/17, [MEDICAL CONDITION] noted to bilateral upper extremities. On 5/30/17, a blister (stage II (partial skin loss) pressure sore popped on the left lateral ankle. (There was no prior documentation of a blister being present.) A wound treatment and dressing were initiated. On 6/13/17, the right elbow pressure sore measured 1 cm by 1 cm at stage II and the left ankle sore measured 1.8 cm by 2 cm. On 6/27/17, the right elbow sore measured 0.5 cm by 0.5 cm and the left ankle sore measured 2 cm by 2.5 cm. On 8/1/17, the right elbow sore measured 0.7 cm by 1 cm and the left ankle sore measured 0.7 cm by 0.7 cm. Both sores were then at stage III. On 8/10/17 at 11 AM, when asked how and why pressure sores developed to the resident's left ankle and right elbow, if protective, pressure relief interventions were in place for prevention and asked if elbow protectors were available and used at the facility, the Director of Nursing said, I have to look into it. On 8/10/17 at 5 PM, per review of the facility's Skin Practice Guide dated 2013: Pressure ulcers are caused by pressure and typically occur over bony prominences in bed It is important to identify any primary etiology such as diabetes, [MEDICAL CONDITION] Factors affecting wound healing inflammation diabetes immobility, friction and shear forces prevention interventions-reposition frequently in bed Use patient positioning device to reduce friction and shear Identification of risk factors and potential pressure points for a particular patient is important in developing a skin prevention care plan. Pressure points are areas of risk for skin breakdown Care plans and risk factors need to be individualized to meet patient specific needs and risk factors

This citation has two deficient practices. Deficient practice #1 pertains to intake #MI 036. Based on interview and record review, the facility failed to provide a correct therapeutic diet as prescribed by the Physician to one (#704) of three sampled Residents reviewed for identified allergies in a total sample of nine, resulting in the Resident with a known severe green pepper allergy being served an alternate lunch meal which contained green peppers and subsequent [MEDICATION NAME] (an immediate, life-threatening systemic reaction that can occur on exposure to a particular substance) as well as the Resident receiving another meal entree three days later with another known food allergy (pineapples). Findings include: On 11/1/16 at 2:00 p.m., review of the facility's reported incident and investigation dated 8/8/16 for Resident #704 completed by the Director of Nursing (DON) included: .On 8/8/16 patient was served tray that had stew tomatoes, which contained green peppers, which the patient ate. Patient had known allergy to green peppers . .Timeline of Events: Patient was serviced lunch tray and stated didn't like the ham and beans; Alternative tray served at 1:20 pm that contained stew tomatoes (which had green peppers in it); At approximately 2 pm patient noted to have a reaction to the green pepper, PTA (Physical Therapy Assistant) present with patient at the time and immediately called for help; NP (Nurse Practitioner) responded to call for help. Administered epi-pen and [MEDICATION NAME] . .Summary of Critical Information Obtained During Investigation: Patient tray ticket not brought to the kitchen when alternative tray was requested. Kitchen did not ask to see tray ticket for the alternative tray. No one checked food allergies on this patient . .Conclusion: The patient did experience a reaction due to consuming a known food allergy, however she was quickly cared for and suffered no long-term harm as a result . The facility's investigation also included a second incident on 8/11/16 which Resident #704 received food which contained a known food allergy (pineapples) that included: .Resident #704 stated that on 8/11/6 she was served pineapple on her dinner tray. CNA (Certified Nursing Assistant U) the CENA had brought in her tray and she immediate stated are those pineapples?. She (Resident #704) then asked the CNA U to take them off her tray and give them to her roommate to taste. Her roommate tasted them and confirmed that they were indeed pineapple. Resident #704 then stated she was very upset and did not eat her dinner tray . Review of NP M's progress note dated 8/8/16 documented, .Nursing staff request urgent visit secondary to stridor (a high-pitched, wheezing sound caused by disrupted airflow) and dyspnea (subjective sensation of breathlessness associated with discomfort). Patient reports she ate a green pepper which she has experience [MEDICATION NAME] with in past. Patient reports she was eating lunch and thought it was celery. patient is flushed and appears dyspnea .c/o (complaint of) tightness in throat . Review of the statement by PTA S who was the therapy staff identified as present with Resident #704 during the incident on 8/8/16 included: .I was working with (Resident #704) at around 2pm. Resident #704 stated she didn't feel well and then she stated her lips were tingling then said there must have been peppers in my food I'm having an allergic reaction . Review of the statement by Nurse T who was the nurse identified as assigned to Resident #704 during the incident on 8/8/16 included: .Resident #704 was my resident on 8/8/16 I was at lunch approximately 2 pm when a code was called to her room. So I ran down to her room along the way I grabbed the crash cart. Resident #704 was sitting on side of bed, hyperventilating, red faced, struggling to bring in oxygen. NP was also in the room under her instruction I went to the med room and obtained an epi-pen and [MEDICATION NAME] (injections) administered both .After injections Resident #704 returned back to base line . The facility's documentation further identified this incident as a past non-compliance, however there was no identified date of compliance, and the supporting documentation provided was incomplete. Further review of the clinical record revealed Resident #704 was admitted into the facility on [DATE] and discharged home on[DATE]. According to the face sheet, [DIAGNOSES REDACTED]. Identified allergies included green peppers and pineapples. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #704 was cognitively intact and was on a therapeutic diet while a resident in the facility. On 11/1/16 at 2:00 p.m., an interview and record review was completed with the DON. When asked about the reported incident on 8/8/16, the DON confirmed the Resident had been provided with food that contained a known severe allergy to. At that time, the DON reported all staff had been inserviced and that the facility had identified a past non-compliance. Upon review of the documentation for the alleged past non-compliance, the DON confirmed there was no identified date of compliance and the supporting documentation provided was incomplete. The DON was unable to offer any explanation as to how the Resident received another meal with food known to be allergic to on 8/11/16. At that time the DON was requested for any additional documentation for the second incident, however there was no further documentation provided by the end of the survey. On 11/1/16 at 2:10 p.m., an interview and record review was completed with the Administrator. At that time, the Administrator confirmed the lack of identified date of compliance within the facility's alleged past non-compliance documentation as well as the incomplete supporting documentation. The Administrator reported that the dietary staff on 8/8/16 had been written up for the non-compliance. There was no additional information provided for the non-compliance with the food served on 8/11/16. The Administrator was unable to offer any additional information or clarification as she reported she was not in the facility at the time of the incident and that the investigation was handled by the DON. According to the facility's Dietary eKardex-Best Practices policy provided dated July 2014, .Print and keep a copy of the following reports on hand for access to patient meal profiles .Allergies/Sensitivities . According to the undated Dietary Department policy provided, It is the responsibility of the dietary department to know the food allergies of all patients .The tray tickets are reviewed for allergies by the dietary staff as the tray passes through the line .If a patient requests an alternate meal, the dietary staff must ask the name of the patient requesting and check the allergies and sensitivity report along with the diet order census report prior to serving a patient an alternate meal. ( ) Deficient practice #2 pertains to intake #MI 241. Based on observation, interview and record review, the facility failed to implement physician ordered interventions for treatment of [REDACTED].#708) of three sampled Residents reviewed for wound care in a total sample of nine, resulting in the potential worsening of vascular ulcers and development of pressure ulcers. Findings include: During the abbreviated survey conducted from 10/31/16 - 11/1/16, the following observations were made of Resident #708 without identified interventions in place: On 10/31/16 10:20 a.m., Resident #708 was observed laying in bed leaning slightly to the right side with the heels of both feet observed pressing down onto the mattress. The feet were not propped/elevated off the mattress. There was no specialty mattress observed (such as an alternating pressure mattress). On 10/31/16 at 3:00 p.m., Resident #708 was observed laying in bed leaning slightly to the right side of the bed. The feet were covered by a blanket and with Resident's permission, upon lifting the blanket, the left heel was observed not propped/elevated and pressed directly into the mattress. On 11/1/16 at 7:55 a.m., Resident #708 was observed laying in bed leaning slightly to the right side of the bed. While both feet were observed propped on a pillow, the toes on the Resident's left foot were observed pressed directly onto the footboard of the bed. At that time, Certified Nursing Assistant (CNA L) acknowledged the position of the toes on the footboard and went to reposition the Resident. When asked about the positioning of the Resident, CNA L reported, He tends to favor that side (right). CNA L was unable to offer any explanation as to the inadequate positioning of the Resident which resulted in the Resident's toes touching the footboard. On 10/31/16 at 11:50 a.m., during an observation of the Resident's wound care with Wound Care Nurse E, the Resident's bandages on both feet were loose and there was visible red tinged drainage on the bed sheets and bedspread. At that time, Wound Nurse E confirmed the placement of the Resident's heels directly on the mattress and when asked about the preventative interventions reported, Should have feet elevated. I've tried heel protectors but he won't allow them. When asked about any other interventions given the preference to favor the right side and lack of allowing the heel protectors such as a specialty mattress, Wound Nurse E reported, He used to have an APM (alternating pressure mattress) when he was here before and upon return, it wasn't ordered. This is a pressure relieving mattress. I can get the information about it for you. When asked about the type of wounds Resident #708 had, Wound Nurse E reported, Vascular but the wound Dr. feels pressure too since its on the heel which is commonly a pressure area. (There was no further documentation about the mattress in use provided by the end of the survey.) During the wound care observation, the following wounds were identified and reported by Wound Nurse E as: Left calf - 0.3 cm width (W) by 0.3 cm length (L) thin scab Left heel with necrotic cap with slough on medial side - 6 cm (W) by 7.3 cm (L) (this area is the exact area observed directly touching the mattress) Right heel has a big clean necrotic cap (Per WN E next step is a wound vac.) Right posterior heel - 13 cm (W) by 4 cm (L) by 0.5 cm depth (D) Right calf with skin bridge - 11 cm (W) by 3 cm (D) by 0 cm (D) According to the wound care plan initiated 8/5/16 and revised 8/8/16, documentation included: Resident #708 is at risk for alteration in skin integrity related to: admit with wounds, [MEDICAL CONDITIONS], debility, res. scratching and picking at skin, Braden on admit 12 Goal: Decrease/minimize skin breakdown risks Interventions included: Float heels as able (initiated 8/8/16) Pressure redistributing device on bed/chair (initiated 8/8/16) Use pillows/positioning devices as needed (initiated 8/5/16) Encourage to reposition as needed; use assistive devices as needed (initiated 8/8/16) On 10/31/16 at 12:30 p.m., Wound Nurse E was asked how Certified Nursing Assistants were informed/aware of the Resident's wound care interventions such as positioning devices and keeping the heels floated. At that time, review of the documentation available to the CNAs revealed an electronic care guide which would show on a Kardex and interventions listed under Tasks. Further review of Resident #708's Kardex care guide with Wound Nurse E revealed there was no documentation directed to elevate the heels while in bed as identified on the wound care plan. At that time, Wound Nurse E reported, It's on the plan of care - should be in place on here. I'll add that now. On 10/31/16 at 12:40 p.m., an interview was conducted with Certified Nursing Assistant (CNA I). When asked about the Resident's plan of care for positioning, CNA I stated, Wound Care Nurse E goes in and changes the wounds. A lot of times he (Resident #708) doesn't want to be bothered. I'm not sure what the specific needs are. On 10/31/16 at 12:45 p.m., an interview with Nurse J who was assigned to Resident #708 was conducted. When asked if the Resident should have his feet elevated, Nurse J reported, He's difficult to position. Try to reposition off that side (right side) but doesn't cooperate and often goes back to the same position. Further review of the clinical record revealed Resident #708 was admitted into the facility on [DATE] and readmitted don 8/5/16 with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) assessment dated [DATE], Resident #708 had significant cognitive impairment (scored 6/15 on mental status exam), exhibited no behavior concerns, had weight loss not prescribed by the Physician, had a stage one or greater pressure ulcer, was at risk for developing pressure ulcers, had one unhealed pressure ulcer at stage 1 or higher, had one unsteagable pressure ulcer due to coverage of wound bed by slough and/or eschar which was suspected deep tissue injury in evolution, which measured 11.5 cm length by 8.0 cm width, which were present on admit, as well as two venous and arterial ulcers. Skin and Ulcer Treatments included pressure reducing device for chair and bed. Review of the most recent wound care progress note dated 10/25/16 at 16:53 included: .(Name of Wound Care Physician) in with wound team to assess res. current status. L calf thin scab; L heel open vasc ulcer 6 x 8 cm necrotic tissue; R calf 12 x 3.5 cm with skin bridge. Red with necrotic tissue peeling up into center. Moderate serosan drainage; R posterior heel 12 x 3 cm thick necrotic tissue; R underside of heel DTI (deep tissue injury) is noted very light; Bilateral legs [MEDICAL CONDITION] cont . On 11/1/16 at 8:50 a.m., the Director of Nursing (DON) was asked about the lack of interventions implemented to elevate the Resident's feet/heels but was unable to offer any explanation as to the lack of follow through from staff. When asked about the lack of a pressure reducing device for the Resident's bed given his preference to lean to the right side, and declining health, the DON offered no specific explanation. The DON did report that the facility had other Residents with alternating pressure mattresses but was unable to explain why Resident #708, who had an alternating pressure mattress prior to his hospitalization in August, did not have one reapplied upon his return to the facility, or decline in health status. According to the facility's Skin Practice Guide dated Issue Date: 01/2013: .Prevention Interventions Reposition frequently in bed and chair .Use patient positioning devices to reduce friction and shear .Elevate heels .Select appropriate support surfaces .Centers may develop and utilize a system for monitoring patient turning and repositioning while continuing to incorporate individualized patient turning and positioning needs as clinically indicated. Patient schedules are included on the .Kardex and Task List . ( )

Based on observation, interview, and record review, the facility failed to provide one Resident (#906), of 18 Residents reviewed for accomodation of needs, with transportation to offsite podiatry appointments which would accommodate the Resident's bariatric wheelchair resulting in the Resident repeatedly using a small wheelchair resulting in the development of two, bilateral, unstageable pressure sores (deep tissue injuries) located on the Resident's outer thighs. Findings include: On [DATE] at 2:10 P.M., wound care for Resident #906, performed by Treatment Nurse "H" was observed. Resident #906 was alert and oriented, with good recall of past and previous events. Resident #906 was morbidly obese, and stated, "I've lost 120 pounds since admission. It was all fluids. I had [MEDICAL CONDITION] (localized tissue swelling and fluid retention) in my legs. I didn't have any pressure sores there when I came here. I was admitted in April. A while later, I started feeling these hard lumps developing inside my thighs, and it got worse and worse. I told my therapist, and said, 'feel that', but she didn't know what it was. I told (Treatment Nurse "H") about the hard lumps in my skin, some time after that, and he said it was a deep tissue injury. I feel like I was burned. It hurts like I 've been burned to charcoal on both legs. See the scars on the bottom of my feet? I had really deep non healing sores on both feet when I got here, and (Treatment Nurse "H") healed them for me." On [DATE] at 2:10 P.M., observation of Resident #906's two lateral thigh pressure sores revealed the following: Resident #906's right lateral (outer) thigh pressure sore was a 11 centimeter (cm) long, by 9.5 cm wide area of discolored dusky induration (hard swelling) surrounding black, hard eschar (dead tissue) extending from the resident's hip area to mid thigh. Resident #906's left lateral thigh pressure sore was a 26.5 cm by 11 cm area of black eschar with pale edges, surrounded by raised purple indurated tissue, located in the same area of the thigh as the one on the right was. Treatment Nurse "H" stated, "The Wound Care Physician was telling her that she might need a minor surgery to remove all that necrotic (dead) tissue." On [DATE] at 2:30 P.M., Treatment Nurse "H" was interviewed and stated, "One day, about two and a half months ago, while I was doing the treatments on her feet (wounds), (Resident #906) said to me,'Feel that. What's this hard lump?' It was a hard lump, way under the surface, about 10 cm in diameter on the outside of each thigh. I suspected it was a Deep Tissue Injury (DTI - "A pressure-related injury to subcutaneous tissues under intact skin. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment." National Pressure Ulcer Advisory Panel). I couldn't see anything, I could just feel it. Eventually the area came to the surface and turned black. (Wound Care Physician) did say that they were pressure sores. It's not your usual spot for a pressure sore. It's not over a bony prominence. Her coccyx (tailbone) is spotless. She obviously had some sort of [MEDICATION NAME] or pressure on her outer thighs at some point, that caused a deep tissue injury." On [DATE] at 3:05 P.M., Resident #906's clinical record was reviewed. According to Resident #906's face sheet, the Resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #906's admission Minimum Data Set (MDS) Assessment, dated [DATE], 7 days after admission into the facility, revealed the Resident's cognition was intact, the Resident required extensive assistance of one person for dressing/hygiene and required extensive assistance for ambulation using a wheelchair. The MDS also indicated the Resident was at risk for the development of pressure sores, weighed 405 pounds and was 66 inches in height. Resident #906's initial Nursing Assessment, dated [DATE], was reviewed. According to the Initial Nursing Assessment, the Resident was admitted into the facility from the hospital, and upon admission was assessed as a "13", or was at moderate risk on the scale to predict the risk of the Resident developing a pressure sore. The Assessment also indicated the Resident was admitted with pressure sores on the right foot and the left foot, a popped blister on the right scapula (shoulder area), and bilateral lower extremity and Right breast gross lymph [MEDICAL CONDITION]. Resident #906's assessments to determine the potential for the Resident to development pressure sores, completed [DATE] and [DATE], scored the Resident at "14" and "18" respectively, which indicated the Resident was at "moderate risk" and "low risk" for the development of pressure sores, despite the Resident being admitted with multiple pressure sores. On [DATE] at 1:40 P.M., Unit Manager, Nurse "A", was interviewed in regards to Resident #906's bilateral thigh pressure sores. When Nurse "A" was queried as to how Resident #906's deep tissue injuries (pressure sores) occurred, Nurse "A" responded, "She had [MEDICAL CONDITION]. She's diabetic. Its (the pressure sores) on the outer thighs. It's pressure (pressure on the thighs caused the sores), that's what the doctor says. If the doctor says its pressure, it's pressure. She doesn't lay on that spot (on her thighs). She lays on her back. The tissue died somehow. She's not ambulatory. She's got circulation issues." On [DATE] at 10:30 A.M., Wound Care Nurse, Nurse "H", and Nurse "A" were interviewed in regards to the development of Resident #906's bilateral thigh pressure sores. Nurse "H" stated, "About 3 or 3 and a half weeks ago, she (Resident #906) noted and informed me her upper thighs were sore. I checked and she had nodules under the surface (skin surface of the thighs), bilateral. I do frequent checks (of Resident #906's skin) anyway, because she was very high risk." When Nurse "H" was queried as to if pressure from the wheelchair or Hoyer lift could cause that type of injury to the Resident's thighs, Nurse "H" replied, "It could've caused the deep tissue injury from trauma." When Nurse "H" was queried as to why Resident #906 had a new wheelchair, Nurse H stated, "She's (Resident #906) had a couple of wheelchairs. The old one was too wide to get her to her doctor's appointments. We measured the exact fit of the transportation company's van. The first chair was too big to fit on the lift. The second one was 24 inches. It was a little bit snugger. It was a smaller wheelchair. Now she has a 28 inch wheelchair. We're the ones that decided she needed a smaller (wheel)chair (for offsite appointment). (The chair replacement) It wasn't run by (assessed by) therapy. They (the transportation company) were here to get her and the (Resident's original) wheelchair wouldn't fit." Nurse "H" continued, "It happened here (the development of the residents bilateral thigh pressure sores) , I never said it didn't happen here. I wish I could pinpoint the incident, accident or whatever happened. Something (trauma to cause injury) happened. Now we're seeing the results. She went to the foot doctor a bunch of times. Each time she got put in the small wheelchair. It's the only one (wheelchair) that would fit (in the transportation vehicle)." Nurse "A" and Nurse "H" both agreed each time the Resident went to an offsite appointment to see the podiatrist (foot doctor) a smaller wheelchair was used for Resident #906. Nurse "A" was queried as to who helped the Resident to get into the smaller wheelchair when Resident #906 had an offsite appointment and Nurse "H" was not available to help. Nurse "A" replied, "We would have the staff do it (switch the Resident from a bariatric wheelchair to the smaller wheelchair for transport)." On [DATE] at 10:50 A.M., the Resident was observed lying in bed watching television. Resident #906 was interviewed and queried as to if she had been placed into a different wheelchair when going out to see her podiatrist. Resident #906 stated, "It (the wheelchair) was touching my thighs. It was. And, I was in it all day, anytime I was sitting in the wheelchair, I went to see my foot doctor. Yes, it was a smaller wheelchair." At this time, Nurse "H" measured the girth of Resident #906 using a tape measurer. Nurse "H" stated, she is 22 and a half inches wide, but if she sits down she will be wider (than 22 and a half inches). It was a 24 inch wheelchair that we got her into that day. The negative is squeezing her in the wheelchair, (but it was) necessary to get her to the doctor." The Resident added, "If (Nurse "H") wouldn't have helped me, I wouldn't have been able to get into it (the smaller wheelchair provided for offsite appointments)." Nurse "H" measured Resident #906's wheelchair she was currently using, a bariatric which sat against the wall in her room, using a tape measure. According to Nurse "H", this wheelchair was 26 inches (measurement taken by Nurse "H" across the seat of the wheelchair from one arm to the other). Resident #906 indicated her current wheelchair gives her room (does not put pressure on thighs). On [DATE] at 11:45 A.M., Resident #906's physician, Physician "N", was interviewed in regards to Resident #906's bilateral thigh pressure sores. Physician "N" stated, "The Residents diabetes and complications put her at high risk for Deep Tissue Injury (pressure sore). If the transportation can't transport her (in her bariatric wheelchair which she needs) she has to go by gurney (to outside appointments. We don't expect such great tissue damage from a small wheelchair." On [DATE] at 1:20 P.M., Resident #906 stated, When I went to see the doctor for my arm, I was put on a stretcher. Whenever I went to see my food doctor, I got put in a smaller chair." On [DATE] at 1:30 P.M., the facility's Therapy Director was interviewed in regards to the process for assessing a Resident to ensure appropriate wheelchair size. The Therapy Director indicated that Physical Therapist perform a generalized wheelchair assessments for each Resident at admission, but no documentation of such assessments are maintained. The Director indicated that Physical Therapy, after the wheelchair assessments are completed, submit a work order for the size wheelchair that the Resident needs. On [DATE] at 2:00 P.M., wheelchair records/work orders were requested facility's Maintenance Director for Resident #906. The Maintenance Director was able to provide one wheelchair work order for room [ROOM NUMBER]b (Resident #906's room), dated [DATE], which read, "Need bariatric wheelchair. No larger than 34 inch wide." The work order did not list the name of the employee completing the work order. The Maintenance Director indicated he had no other work orders for wheelchairs for Resident #906. On [DATE] at 2:50 P.M., a review of Resident #906's clinical record revealed the Resident went offsite to see her podiatrist (where a smaller wheelchair was used for transport) included the following dates: [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 3:00 P.M., the facility's Director of Nursing (DON) was interviewed in regards to the development of Resident #906's bilateral thigh pressure sores. The DON was queried as to why the Resident was assessed as being at "moderate" and "low" risk for the development of pressure sores when the Resident was admitted with pressure sores. After reviewing the Residents assessments to determine the risk for the development of pressure sores, reports dated [DATE] and [DATE], the DON stated, "With not knowing the Resident, it's hard to say if the assessment is accurate." When the DON was queried as to why a transportation company was used to take the Resident to her offsite podiatry appointments which could not accommodate the Resident's bariatric wheelchair, the DON stated, "You would think they could provide a truck to accommodate a bariatric wheelchair." On [DATE] at 3:30 P.M., the facility's "Skin Practice Guide Process FlowChart", copyright 2013, was reviewed and revealed the process the facility follows to assess Residents upon admission, but did not address how to prevent the development of pressure sores. The facility's policy on pressure sore prevention and wound prevention was requested, but was not received by survey exit. (,[DATE])

Based on observation, interview, and record review, the facility failed to prevent the development of a preventable, facility acquired pressure sore (a deep tissue injury) and relieve pressure off the Resident's bilateral thighs, for one (#906) of five sampled Residents reviewed for pressure sores, from a total sample of 18 Residents, resulting in the development of bilateral, unstageable pressure sores located on the Resident's outer thighs. Findings include: On [DATE] at 2:10 P.M., wound care for Resident #906, performed by Treatment Nurse "H" was observed. Resident #906 was alert and oriented, with good recall of past and previous events. Resident #906 was morbidly obese, and stated, "I've lost 120 pounds since admission. It was all fluids. I had [MEDICAL CONDITION] (localized tissue swelling and fluid retention) in my legs. I didn't have any pressure sores there when I came here. I was admitted in April. A while later, I started feeling these hard lumps developing inside my thighs, and it got worse and worse. I told my therapist, and said, 'feel that', but she didn't know what it was. I told (Treatment Nurse "H") about the hard lumps in my skin, some time after that, and he said it was a deep tissue injury. I feel like I was burned. It hurts like I 've been burned to charcoal on both legs. See the scars on the bottom of my feet? I had really deep non healing sores on both feet when I got here, and (Treatment Nurse "H") healed them for me." On [DATE] at 2:10 P.M., observation of Resident #906's two lateral thigh pressure sores revealed the following: Resident #906's right lateral (outer) thigh pressure sore was a 11 centimeter (cm) long, by 9.5 cm wide area of discolored dusky induration (hard swelling) surrounding black, hard eschar (dead tissue) extending from the resident's hip area to mid thigh. Resident #906's left lateral thigh pressure sore was a 26.5 cm by 11 cm area of black eschar with pale edges, surrounded by raised purple indurated tissue, located in the same area of the thigh as the one on the right was. Treatment Nurse "H" stated, "The Wound Care Physician was telling her that she might need a minor surgery to remove all that necrotic (dead) tissue." On [DATE] at 2:30 P.M., Treatment Nurse "H" was interviewed and stated, "One day, about two and a half months ago, while I was doing the treatments on her feet (wounds), (Resident #906) said to me,'Feel that. What's this hard lump?' It was a hard lump, way under the surface, about 10 cm in diameter on the outside of each thigh. I suspected it was a Deep Tissue Injury (DTI - "A pressure-related injury to subcutaneous tissues under intact skin. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment." National Pressure Ulcer Advisory Panel). I couldn't see anything, I could just feel it. Eventually the area came to the surface and turned black. (Wound Care Physician) did say that they were pressure sores. It's not your usual spot for a pressure sore. It's not over a bony prominence. Her coccyx (tailbone) is spotless. She obviously had some sort of [MEDICATION NAME] or pressure on her outer thighs at some point, that caused a deep tissue injury." On [DATE] at 3:05 P.M., Resident #906's clinical record was reviewed. According to Resident #906's face sheet, the Resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #906's admission Minimum Data Set (MDS) Assessment, dated [DATE], 7 days after admission into the facility, revealed the Resident's cognition was intact, the Resident required extensive assistance of one person for dressing/hygiene and required extensive assistance for ambulation using a wheelchair. The MDS also indicated the Resident was at risk for the development of pressure sores, weighed 405 pounds and was 66 inches in height. Resident #906's initial Nursing Assessment, dated [DATE], was reviewed. According to the Initial Nursing Assessment, the Resident was admitted into the facility from the hospital, and upon admission was assessed as a "13", or was at moderate risk on the scale to predict the risk of the Resident developing a pressure sore. The Assessment also indicated the Resident was admitted with pressure sores on the right foot and the left foot, a popped blister on the right scapula (shoulder area), and bilateral lower extremity and Right breast gross lymph [MEDICAL CONDITION]. Resident #906's assessments to determine the potential for the Resident to development pressure sores, completed [DATE] and [DATE], scored the Resident at "14" and "18" respectively, which indicated the Resident was at "moderate risk" and "low risk" for the development of pressure sores, despite the Resident being admitted with multiple pressure sores. On [DATE] at 1:40 P.M., Unit Manager, Nurse "A", was interviewed in regards to Resident #906's bilateral thigh pressure sores. When Nurse "A" was queried as to how Resident #906's deep tissue injuries (pressure sores) occurred, Nurse "A" responded, "She had [MEDICAL CONDITION]. She's diabetic. Its (the pressure sores) on the outer thighs. It's pressure (pressure on the thighs caused the sores), that's what the doctor says. If the doctor says its pressure, it's pressure. She doesn't lay on that spot (on her thighs). She lays on her back. The tissue died somehow. She's not ambulatory. She's got circulation issues." On [DATE] at 10:30 A.M., Wound Care Nurse, Nurse "H", and Nurse "A" were interviewed in regards to the development of Resident #906's bilateral thigh pressure sores. Nurse "H" stated, "About 3 or 3 and a half weeks ago, she (Resident #906) noted and informed me her upper thighs were sore. I checked and she had nodules under the surface (skin surface of the thighs), bilateral. I do frequent checks (of Resident #906's skin) anyway, because she was very high risk." When Nurse "H" was queried as to if pressure from the wheelchair or Hoyer lift could cause that type of injury to the Resident's thighs, Nurse "H" replied, "It could've caused the deep tissue injury from trauma." When Nurse "H" was queried as to why Resident #906 had a new wheelchair, Nurse H stated, "She's (Resident #906) had a couple of wheelchairs. The old one was too wide to get her to her doctor's appointments. We measured the exact fit of the transportation company's van. The first chair was too big to fit on the lift. The second one was 24 inches. It was a little bit snugger. It was a smaller wheelchair. Now she has a 28 inch wheelchair. We're the ones that decided she needed a smaller (wheel)chair (for offsite appointment). (The chair replacement) It wasn't run by (assessed by) therapy. They (the transportation company) were here to get her and the (Resident's original) wheelchair wouldn't fit." Nurse "H" continued, "It happened here (the development of the residents bilateral thigh pressure sores) , I never said it didn't happen here. I wish I could pinpoint the incident, accident or whatever happened. Something (trauma to cause injury) happened. Now we're seeing the results. She went to the foot doctor a bunch of times. Each time she got put in the small wheelchair. It's the only one (wheelchair) that would fit (in the transportation vehicle)." Nurse "A" and Nurse "H" both agreed each time the Resident went to an offsite appointment to see the podiatrist (foot doctor) a smaller wheelchair was used for Resident #906. Nurse "A" was queried as to who helped the Resident to get into the smaller wheelchair when Resident #906 had an offsite appointment and Nurse "H" was not available to help. Nurse "A" replied, "We would have the staff do it (switch the Resident from a bariatric wheelchair to the smaller wheelchair for transport)." On [DATE] at 10:50 A.M., the Resident was observed lying in bed watching television. Resident #906 was interviewed and queried as to if she had been placed into a different wheelchair when going out to see her podiatrist. Resident #906 stated, "It (the wheelchair) was touching my thighs. It was. And, I was in it all day, anytime I was sitting in the wheelchair, I went to see my foot doctor. Yes, it was a smaller wheelchair." At this time, Nurse "H" measured the girth of Resident #906 using a tape measurer. Nurse "H" stated, she is 22 and a half inches wide, but if she sits down she will be wider (than 22 and a half inches). It was a 24 inch wheelchair that we got her into that day. The negative is squeezing her in the wheelchair, (but it was) necessary to get her to the doctor." The Resident added, "If (Nurse "H") wouldn't have helped me, I wouldn't have been able to get into it (the smaller wheelchair provided for offsite appointments)." Nurse "H" measured Resident #906's wheelchair she was currently using, a bariatric which sat against the wall in her room, using a tape measure. According to Nurse "H", this wheelchair was 26 inches (measurement taken by Nurse "H" across the seat of the wheelchair from one arm to the other). Resident #906 indicated her current wheelchair gives her room (does not put pressure on thighs). On [DATE] at 11:45 A.M., Resident #906's physician, Physician "N", was interviewed in regards to Resident #906's bilateral thigh pressure sores. Physician "N" stated, "The Residents diabetes and complications put her at high risk for Deep Tissue Injury (pressure sore). If the transportation can't transport her (in her bariatric wheelchair which she needs) she has to go by gurney (to outside appointments. We don't expect such great tissue damage from a small wheelchair." On [DATE] at 1:20 P.M., Resident #906 stated, When I went to see the doctor for my arm, I was put on a stretcher. Whenever I went to see my food doctor, I got put in a smaller chair." On [DATE] at 1:30 P.M., the facility's Therapy Director was interviewed in regards to the process for assessing a Resident to ensure appropriate wheelchair size. The Therapy Director indicated that Physical Therapist perform a generalized wheelchair assessments for each Resident at admission, but no documentation of such assessments are maintained. The Director indicated that Physical Therapy, after the wheelchair assessments are completed, submit a work order for the size wheelchair that the Resident needs. On [DATE] at 2:00 P.M., wheelchair records/work orders were requested facility's Maintenance Director for Resident #906. The Maintenance Director was able to provide one wheelchair work order for room [ROOM NUMBER]b (Resident #906's room), dated [DATE], which read, "Need bariatric wheelchair. No larger than 34 inch wide." The work order did not list the name of the employee completing the work order. The Maintenance Director indicated he had no other work orders for wheelchairs for Resident #906. On [DATE] at 2:50 P.M., a review of Resident #906's clinical record revealed the Resident went offsite to see her podiatrist (where a smaller wheelchair was used for transport) included the following dates: [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 3:00 P.M., the facility's Director of Nursing (DON) was interviewed in regards to the development of Resident #906's bilateral thigh pressure sores. The DON was queried as to why the Resident was assessed as being at "moderate" and "low" risk for the development of pressure sores when the Resident was admitted with pressure sores. After reviewing the Residents assessments to determine the risk for the development of pressure sores, reports dated [DATE] and [DATE], the DON stated, "With not knowing the Resident, it's hard to say if the assessment is accurate." When the DON was queried as to why a transportation company was used to take the Resident to her offsite podiatry appointments which could not accommodate the Resident's bariatric wheelchair, the DON stated, "You would think they could provide a truck to accommodate a bariatric wheelchair." On [DATE] at 3:30 P.M., the facility's "Skin Practice Guide Process FlowChart", copyright 2013, was reviewed and revealed the process the facility follows to assess Residents upon admission, but did not address how to prevent the development of pressure sores. The facility's policy on pressure sore prevention and wound prevention was requested, but was not received by survey exit. (,[DATE]) On [DATE] at 2:10 P.M., wound care for Resident #906, performed by Treatment Nurse "H" was observed. Resident #906 was alert and oriented, with good recall of past and previous events. Resident #906 was morbidly obese, and stated, "I've lost 120 pounds since admission. It was all fluids. I had [MEDICAL CONDITION] (localized tissue swelling and fluid retention) in my legs. I didn't have any pressure sores there when I came here. I was admitted in April. A while later, I started feeling these hard lumps developing inside my thighs, and it got worse and worse. I told my therapist, and said, 'feel that', but she didn't know what it was. I told (Treatment Nurse "H") about the hard lumps in my skin, some time after that, and he said it was a deep tissue injury. I feel like I was burned. It hurts like I 've been burned to charcoal on both legs. See the scars on the bottom of my feet? I had really deep non healing sores on both feet when I got here, and (Treatment Nurse "H") healed them for me." On [DATE] at 2:10 P.M., obervation of Resident #906's two lateral thigh pressure sores revealed the following: Resident #906's right lateral (outer) thigh pressure sore was a 11 centimeter (cm) long, by 9.5 cm wide area of discolored dusky induration (hard swelling) surrounding black, hard eschar (dead tissue) extending from the resident's hip area to mid thigh. Resident #906's left lateral thigh pressure sore was a 26.5 cm by 11 cm area of black eschar with pale edges, surrounded by raised purple indurated tissue, located in the same area of the thigh as the one on the right was. Treatment Nurse "H" stated, "The Wound Care Physician was telling her that she might need a minor surgery to remove all that necrotic (dead) tissue). On [DATE] at 2:30 P.M., Treatment Nurse "H" was interviewed and stated, "One day, about two and a half months ago, while I was doing the treatments on her feet (wounds), (Resident #906) said to me,'Feel that. What's this hard lump?' It was a hard lump, way under the surface, about 10 cm in diameter on the outside of each thigh. I suspected it was a Deep Tissue Injury (DTI - "A pressure-related injury to subcutaneous tissues under intact skin. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment." National pressure ulcer advisory panel, 2002). I couldn't see anything, I could just feel it. Eventually the area came to the surface and turned black. (Wound Care Physician) did say that they were pressure sores. It's not your usual spot for a pressure sore. It's not over a bony prominence. Her coccyx (tailbone) is spotless. She obviously had some sort of [MEDICATION NAME] or pressure on her outer thighs at some point, that caused a deep tissue injury." ( )

This citation has two deficient practices. Deficient practice #1: This citation pertains to intake #MI 965 Based on interview and record review, the facility failed to administer an anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) for a total of six days as prescribed by the physician, and monitor blood levels for its therapeutic efficacy (effectiveness) for one (#902) of two sampled residents reviewed for the treatment of [REDACTED].#902. Findings include: On 7/8/14 at 3:00 p.m., Resident #902 was observed sitting in a chair in his bedroom painting. He was alert, but only answered questions with two to three words. When Resident #902 was queried regarding him receiving his medications as ordered, he responded by saying, "Not getting medications." Resident #902 was further queried and was asked to expand on what he meant. Resident #902 did not respond. On 7/8/14 at 3:10 p.m., review of Resident #902's current clinical record revealed the following: Resident #902's face sheet indicated an original admission into the facility on [DATE] and a re-admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/19/14, indicated that Resident #902's cognition was moderately impaired and required minimal to extensive assistance with activities of daily living (ADLs). Review of Resident #902's hospital Discharge Summary, dated 7/7/14, revealed the following documentation: "This [AGE] year-old male presented from his ECF (extended care facility), to a witnessed [MEDICAL CONDITION] with a history of [MEDICAL CONDITION]. Patient had been off his [MEDICATION NAME] for approximately 4 years prior to this breakthrough [MEDICAL CONDITION]. He was admitted for further workup..." Review of the facility's "Investigation Report," dated 7/3/14, revealed the following documentation: "On 7/3/14 at 9:50 a.m., Resident #902 had a [MEDICAL CONDITION] and was transferred to the emergency room for evaluation and treatment. Upon record review it was noted that the resident's anticonvulsant medication [MEDICATION NAME] was discontinued on 6/27/14 by licensed Nurse "O." Upon interview of the nurse (Nurse "O"), she stated she knew the resident was on [MEDICATION NAME] for his [MEDICAL CONDITION] disorder, she did not remember discontinuing the medication nor did she ever have a physician's orders [REDACTED]." The "Summary of Critical Information Obtained During the Investigation," included: "Resident's [MEDICATION NAME] was inadvertently discontinued by the nurse on 6/27/14. Resident's hospital discharge records are inaccurate stating that the resident has been off his [MEDICATION NAME] for four years. Resident was off his [MEDICATION NAME] for six days..." On 7/8/14 at 3:20 p.m., the Administrator was queried regarding the incident that involved Resident #902 (missed [MEDICATION NAME] doses). The Administrator reported that Nurse "O" was currently in the facility taking a refreshers course on inputting medication orders into the computer system due to the medication error for Resident #902. The Administrator offered to assist in getting an interview with Nurse "O" regarding the incident. On 7/8/14 at 3:50 p.m., the Unit Nurse Manager (Nurse "A") was queried regarding the discontinued [MEDICATION NAME] and the blood levels for the medication. Nurse "A" stated, "He (Resident #902) had no levels drawn for over a year. When I found out I came in on the 4 th of July and drew levels on all residents that were on anti [MEDICAL CONDITION] medications. I know that before he (Resident #902) left the hospital he was therapeutic (adequate medication level in blood to prevent further [MEDICAL CONDITION]). He has been here for five years and has never had a [MEDICAL CONDITION]. The nurse did not follow the process. She made a mistake. She screwed up. It was my responsibility to review the orders the doctors write within 24 hours. I did not catch the discontinued order for [MEDICATION NAME]. I saw the other two new orders for that day, but not the order to discontinue the [MEDICATION NAME] because there was no carbon copy to review. She (Nurse "O") has had other incidents like this." On 7/8/14 at 4:00 p.m., Nurse "O" was interviewed regarding the deletion of the medication order of [MEDICATION NAME] for Resident #902 that resulted in the missed doses of [MEDICATION NAME]. Nurse "O" stated, "I don't remember discontinuing the [MEDICATION NAME]. I really don't know what happened." On 7/8/14 at 4:15 p.m., review of the physician's orders [REDACTED]." On 7/11/14 at 11:50 a.m., Resident #902's physician (Doctor "N") was interviewed regarding the missed doses of [MEDICATION NAME] and the monitoring of therapeutic blood levels for the use of [MEDICATION NAME]. Doctor "N" stated, "He should've had levels drawn...at least once a year. I ordered them yearly." Doctor "N" was informed of the facility reporting that no levels for the administration of [MEDICATION NAME] were drawn. Doctor "N" provided no explanation. On 7/11/14 at 12:05 p.m., review of Resident #902's "Anticonvulsant therapy to treat [MEDICAL CONDITION]" care plan, initiated on 1/26/11 and last revised on 2/24/14, revealed the goal as: "Will maintain blood level in therapeutic range." The interventions included: "1. Administer per physician's orders [REDACTED]. Monitor blood levels and report results to physician, as per order." On 7/11/14 at 12:30 p.m., Resident #902's Durable Power of Attorney (DPOA) was interviewed regarding the incident. The DPOA stated, "They (the facility) called and told me that they were sending him out to the hospital (7/3/14) because they thought he was having a stroke. When I made it to the Emergency Center at the hospital, the hospital staff told me he had a [MEDICAL CONDITION] at the nursing facility. I actually witnessed the second [MEDICAL CONDITION] at the hospital and it was horrific. It was really bad. Nobody informed me of any medication changes. When I approached the (facility's)Administrator about not being informed, he told me that he (Resident #902) was his own person, responsible for himself. I pointed out to him that I was his DPOA. Anybody could see that he (Resident #902) is not capable of making medical decision on his own (for himself) after talking two to three minutes with him." On 7/11/14 at 3:55 p.m., review of the facility's policy entitled, "Medication Administration: Medication Pass," dated 3/2010, did not include information or instruction on transcribing orders or inputting medications changes/orders into the electronic medical record. The interim Director of Nurses (DON) was interviewed regarding the accidental discontinuation of Resident #902's [MEDICATION NAME]. The DON reported that she was unable to provide input due to the fact that she had just started the first day of the annual survey. ( ) Deficient Practice Statement #2: Based on observation, interview and record review, the facility failed to ensure that one supplemental sample resident (#7) of 10 residents reviewed for medication administration (Medpass) received the correct dose of an antihypertensive (blood pressure lowering) medication, resulting in the potential for uncontrolled blood pressure. Findings include: On 7/9/14 at 8:10 A.M., Nurse "K" was observed during administration of Resident #7's morning medications. Nurse "K" was observed to administer one tablet of Carvedilol (an antihypertensive medication) 6.25 milligrams (mg). On 7/9/14 at 10:50 A.M., review of Resident #7's physician's orders [REDACTED]. Give 12.5 mg by mouth every 12 hours for hypertension." On 7/9/14 at 10:55A.M., Nurse "K" was asked what dosage of carvedilol was administered to Resident #7 for the morning dose on 7/9/14. Nurse "K" stated, "I gave (Resident #7) one (carvedilol) 6.25 mg. That's what it says to give on the Medication Administration Record [REDACTED] Review of Resident #7's July 2014 MAR indicated [REDACTED]. Give 12.5 mg by mouth every 12 hours for hypertension", was scheduled to be given at 9:00 A.M. When queried about this, Nurse "K" stated, "It's not clear the way it was written on the electronic MAR. I didn't understand what was written. It wasn't clear." On 7/10/14 at 9:05 A.M., the Acting Director of Nursing (DON) was interviewed about the medication administration error for Resident #7 and stated, "The electronic MAR indicated [REDACTED]. I get eye strain myself from looking at it. Usually, an order like that would clearly state give two tablets instead of just listing the total dosage to be given." ( )

THIS DEFICIENT PRACTICE HAS TWO HEADERS. BASED ON OBSERVATIONS, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT WATER TEMPERATURES AT THE HANDWASHING SINKS WERE WITHIN A SAFE RANGE FOR ONE ( # 220) OF FIVE RESIDENTS WHOSE WATER TEMPERATURE WAS 126.1 DEGREES FAHRENHEIT, RESULTING IN THE POTENTIAL FOR SERIOUS HARM, INJURY, OR DEATH FROM SCALDING. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 8/30/11 AT 1:30 PM. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 8/30/11 AT 5:25 PM. THE IJ WAS REMOVED ON 8/30/11 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 8/30/11, AS VERIFIED ONSITE ON 8/31/11. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS ISOLATED. ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. DURING AN ENVIRONMENTAL TOUR ON 8/30/11 AT 1:15 P.M., THE HOT WATER TEMPERATURE IN C WING WAS OBSERVED TO EXCEED THE MAXIMUM ALLOWABLE TEMPERATURE OF 120 DEGREES FAHRENHEIT. THE HOT WATER TEMPERATURE IN THE TOILET ROOM CONNECTED TO RESIDENT # 220'S ROOM WAS RECORDED AT 126.1 DEGREES FAHRENHEIT. THE MIXING VALVE HOT WATER TEMPERATURE SERVING C WING WAS OBSERVED TO BE 123 DEGREES FAHRENHEIT PUTTING ALL THE C WING RESIDENTS AT RISK AS THE HOT WATER DYNAMIC CHANGES. ON 8/30/11 AT 2:15 PM RESIDENT # 220 WAS INTERVIEWED AND STATED "THE WATER TEMPERATURE IS TOO HOT. I TEST THE WATER WITH MY FINGER, AND I ADJUST THE TEMPERATURE SO I DO NOT GET BURNED." ON 8/30/11 AT 2:40 P.M., RESIDENT #220 WAS INTERVIEWED IN THE ROOM, AND WAS NOTED TO BE ALERT AND ORIENTED, AND WAS MOVING AROUND THE ROOM INDEPENDENTLY IN A WHEELCHAIR. RESIDENT #220 HAD SEVERAL PACKAGES OF SNACKS ON THE BEDSIDE TABLE AND DRESSER, AND REPORTED OPENING AND EATING THEM WITHOUT STAFF ASSISTANCE. WHEN INTERVIEWED, RESIDENT #220 REPORTED SHE NEEDED STAFF ASSISTANCE TO TRANSFER TO THE TOILET, BUT THAT SHE DID RINSE HER HANDS IN THE SINK INDEPENDENTLY AT TIMES, OFTEN BEFORE SNACKING. WHEN QUERIED WHETHER THE WATER IN THE RESTROOM SINK WAS A COMFORTABLE TEMPERATURE, THE RESIDENT REPORTED THAT THE WATER WAS TOO HOT, BUT THAT SHE "TURNS IT ON JUST A LITTLE FIRST", "CHECKS THE TEMPERATURE WITH A FINGER, AND THEN TURNS THE WATER ON ALL THE WAY AND WASHES (HER) HANDS." WHEN QUERIED, RESIDENT #220 STATED SHE HAD NOT SUFFERED BURNS IN THE FACILITY. REVIEW OF RESIDENT #220'S CLINICAL RECORD REVEALED A FACE SHEET WHICH DOCUMENTED THAT THE RESIDENT WAS ORIGINALLY admitted to the facility on [DATE], WITH MOST RECENT ADMISSION ON 9/25/10. [DIAGNOSES REDACTED]. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT #220 HAD NO COMMUNICATION IMPAIRMENTS, WAS COGNITIVELY INTACT, HAD NO INDICATIONS OF DELIRIUM, DID NOT EXHIBIT PROBLEM BEHAVIORS, NEEDED EXTENSIVE STAFF ASSISTANCE TO TRANSFER FROM THE WHEELCHAIR AND FOR TOILETING AND HYGIENE AND WAS FREQUENTLY INCONTINENT OF BOWEL AND BLADDER. ON 8/30/11 AT 2:35 P.M., WHEN QUERIED, UNIT MANAGER (DCD) NURSE "A" REPORTED THAT ALL OF THE RESIDENTS IN THIS ROOM WERE COMPLETELY DEPENDENT ON STAFF FOR HYGIENE AND TOILETING, AND THUS WERE NOT AT RISK FOR BURNS FROM THE HOT WATER IN THE AFFECTED SINKS. OBSERVATION AND INTERVIEW OF THESE RESIDENTS AT THIS TIME WITH DCD "A" REVEALED THAT RESIDENT #220 DID ACCESS THE AFFECTED RESTROOM SINK INDEPENDENTLY. THE RESIDENT CARE AREA HOT WATER TEMPERATURE LOG WAS REVIEWED WITH THE MAINTENANCE SUPERVISOR ON 8/30/11 AT 2:50 P.M. THREE LOCATIONS ARE CHECKED PER WEEK DAY BUT THE LOG DID NOT IDENTIFY ANY RECENT PROBLEMS WITH EXCESSIVE HOT WATER TEMPERATURES IN RESIDENT SINKS OR SHOWER ROOMS IN AUGUST. ON 8/31/11 AT 8:30 A.M., THE ADMINISTRATOR REPORTED THAT THE FACILITY HOT WATER MIXING VALVES WERE REPLACED DURING THE PREVIOUS NIGHT BY A LICENSED PLUMBER, THUS CORRECTING THE PROBABLE CAUSE OF THE EXCESSIVELY HOT WATER IN RESIDENT #220'S ROOM. ON 9/8/11 AT 2:00 P.M., FACILITY MAINTENANCE RECORDS, AND HOT WATER TEMPERATURE LOGS WERE REVIEWED WITH THE MAINTENANCE DIRECTOR "Q" AND THE CORPORATE MANAGER OF PLANT OPERATIONS ( CMPO) "R". THE MAINTENANCE DIRECTOR "Q" REPORTED THAT TEMPERATURES WERE TAKEN DAILY IN TWO ROOMS AT THE RESTROOM SINKS, AND IN THE SHOWER ROOM OF EACH UNIT, AND NO TEMPERATURES ABOVE 120 F HAD EVER BEEN NOTED. THE MAINTENANCE DIRECTOR REPORTED THAT DAILY TEMPERATURES WERE ALSO CHECKED DIRECTLY FROM THE TEMPERATURE GAUGES (IN LINE THERMOMETERS) ON THE MIXING VALVES THEMSELVES. LOGS OF THESE WERE PROVIDED AND REVIEWED FOR AUGUST 2011. THE FOLLOWING MIXING VALVE TEMPERATURES (FROM THE IN LINE THERMOMETERS) WERE NOTED TO BE ABOVE THE SAFE HOT WATER TEMPERATURE OF 120 F: "EAST BOILER ROOM" BOILER # 1 (NUMBER ONE)" ON 8/1/11, 8/3/11, 8,4/11, 8/8/11, 8/11/11, 8/16/11, 8/17/11, 8/24/11, AND 8/25/11, THE MIXING VALVE TEMPERATURE WAS DOCUMENTED AS 125 F. ON 8/9/11 AND 8/29/11, THE MIXING VALVE TEMPERATURE WAS DOCUMENTED AS 127 F. ON 8/5/11, AND 8/22/11, THE MIXING VALVE TEMPERATURE WAS DOCUMENTED AS 128 F. ON 8/2/11, 8/18/11, AND 8/23/11, THE MIXING VALVE TEMPERATURE WAS DOCUMENTED AS 130 F. ON 8/15/11, THE MIXING VALVE TEMPERATURE WAS DOCUMENTED AS 132 F. ON 8/31/11, AFTER THE MIXING VALVE WAS REPLACED, THE MIXING VALVE TEMPERATURE WAS DOCUMENTED AS 110 F, WITHIN THE SAFE TEMPERATURE RANGE OF BELOW 120 F. "THE SECOND FLOOR BOILER ROOM" MIXING VALVE TEMPERATURE LOGS FOR AUGUST 2011 DOCUMENTED THE FOLLOWING TEMPERATURES ABOVE 120 F: ON 8/1/11, 8/2/11, 8/3/11, 8/4/11, 8/19/11, AND 8/26/11, THE MIXING VALVE TEMPERATURE WAS DOCUMENTED AS 130 F. ON 8/6/11, 8/7/11, AND 8/13/11, THE MIXING VALVE TEMPERATURE LOG WAS BLANK (NO TEMPERATURE DOCUMENTED), AND VISIBLY EDITED OUT WITH WHITE OUT, ON THE LOG. THE MIXING VALVE TEMPERATURE LOG WAS ALSO BLANK FOR 8/14, 8/20, 8/21, 8/27, AND 8/28. ON 8/31/11, AFTER THE MIXING VALVES WERE REPLACED, THE MIXING VALVE TEMPERATURE WAS DOCUMENTED AS 115 F, WITHIN THE SAFE TEMPERATURE RANGE OF BELOW 120 F. WHEN QUERIED ABOUT THIS, THE MAINTENANCE DIRECTOR STATED THAT THE WATER COOLED DOWN TO SAFE TEMPERATURES IN THE PIPES BEFORE IT GOT TO THE ROOMS OR THE SHOWER, AS TEMPERATURES IN THOSE AREAS WERE ALWAYS BELOW 120 WHEN CHECKED WITH A THERMOMETER AT THE SINKS OR SHOWERS IN THE RESIDENT CARE AREAS. ON 9/8/11 THE MEDICAL DIRECTOR WAS INTERVIEWED IN THE PRESENCE OF THE CMPO AND REPORTED HE DELEGATED MAINTENANCE OF THE BUILDING EQUIPMENT TO PERSONNEL WITH MECHANICAL EXPERTISE, BUT DID PROVIDE OVERSIGHT AND QUALITY ASSURANCE INPUT IF PROBLEMS OCCURRED THAT MAY HAVE AN IMPACT ON HEALTH OF THE RESIDENTS. THE MEDICAL DIRECTOR REPORTED THAT DURING A FACILITY QUALITY ASSURANCE DISCUSSION OF THE UNSAFE WATER TEMPERATURES, IT WAS REVEALED THAT THE MAINTENANCE DIRECTOR HAD BEEN USING A KITCHEN MEAT THERMOMETER TO TAKE THE DAILY HOT WATER DAILY READINGS IN THE RESIDENT CARE AREAS, AND WHEN CHECKED AGAINST A MORE ACCURATE THERMOMETER, WAS FOUND TO RECORD SEVERAL DEGREES LOWER. THE CMPO WAS QUERIED ABOUT THIS, AND REPORTED THAT DURING DISCUSSIONS WITH FACILITY ADMINISTRATION TO IDENTIFY FACTORS THAT COULD HAVE CONTRIBUTED TO THE UNSAFE HOT WATER TEMPERATURES, IT WAS DETERMINED THAT THE MAINTENANCE DIRECTOR WAS NOT CONSISTENTLY USING THE CORRECT TYPE OF THERMOMETER, BUT WAS OFTEN USING A TYPE OF THERMOMETER THAT WAS LESS ACCURATE. ON 9/8/11 THE FACILITY ADMINISTRATOR WAS INTERVIEWED, AND REPORTED THAT DURING A FACILITY INVESTIGATION OF THE IMMEDIATE JEOPARDY, THE MAINTENANCE DIRECTOR HAD REPORTED THAT HE DID NOT CONSISTENTLY USE THE SAME TYPE OF THERMOMETER TO CHECK WATER TEMPERATURES IN THE RESIDENT CARE AREAS. THE ADMINISTRATOR STATED THAT A COMPARISON OF TEMPERATURE READINGS tested WITH EACH OF THE TWO THERMOMETERS USED, REVEALED A DISCREPANCY OF UP SEVERAL DEGREES BETWEEN THEM. THE ADMINISTRATOR STATED THAT ONE OF THE THERMOMETERS USED BY THE MAINTENANCE DIRECTOR WAS MEANT FOR KITCHEN USE, AND WAS NOT AS ACCURATE. WHEN QUERIED, THE ADMINISTRATOR REPORTED THERE WAS NO FACILITY POLICY AND PROCEDURE ON HOT WATER TEMPERATURE READINGS. THE ADMINISTRATOR STATED THAT THE FACILITY NEEDED A NEW POLICY ON THIS TO STANDARDIZE THE TYPE OF THERMOMETER TO BE USED, AS WELL AS THE AMOUNT OF TIME TO LET THE HOT WATER RUN BEFORE TESTING THE TEMPERATURE. ON 9/8/11 AT 2:00 P.M., WHEN QUERIED, THE MAINTENANCE DIRECTOR STATED HE DID NOT KNOW HOW OLD THE MIXING VALVES WERE, OR WHAT THE MANUFACTURER'S RECOMMENDATIONS WERE FOR PREVENTATIVE MAINTENANCE, OR FOR SCHEDULED CLEANING OR REPLACEMENT OF THE MIXING VALVE FILTERS. THE MAINTENANCE DIRECTOR REPORTED HE HAD NO SCHEDULE FOR CHECKING OR CLEANING THE MIXING VALVE FILTERS. THE CMPO "R" REPORTED THAT THE OLD MIXING VALVES (IN PLACE ON 8/30/11) WERE PROBABLY ABOUT 8 YEARS OLD, BUT WAS UNSURE OF THE EXPECTED LIFE SPAN. WHEN QUERIED, THE CMPO REPORTED THAT THE MIXING VALVE FILTERS SHOULD BE CLEANED QUARTERLY IN AREAS WITH A LOT OF MINERALS IN THE WATER, BUT IN THIS PART OF THE STATE, THE FILTERS SHOULD BE CLEANED EVERY SIX MONTHS TO REMOVE SEDIMENT AND MINERAL DEPOSITS. THE CMPO STATED THAT THE MIXING VALVE FILTERS WERE MADE OF COPPER, AND NEEDED REPLACING WHEN CORRODED. THE MAINTENANCE DIRECTOR AND THE CMPO WERE REQUESTED TO PROVIDE DOCUMENTATION OF MIXING VALVE FILTER CLEANING, INSPECTION AND PREVENTATIVE MAINTENANCE, BUT THIS WAS NOT PROVIDED PRIOR TO EXIT. WHEN QUERIED, THE MAINTENANCE DIRECTOR REPORTED HE HAD NOT RECEIVED ANY SCHEDULE OR INSTRUCTIONS ON THIS TYPE OF PREVENTATIVE MAINTENANCE FOR THE MIXING VALVES, AND SO IT HAD NOT BEEN DONE. THE MAINTENANCE DIRECTOR AND CMPO WERE REQUESTED TO PROVIDE COPIES OF THE MIXING VALVE MANUFACTURER RECOMMENDATIONS FOR PREVENTATIVE MAINTENANCE, AND REPORTED THAT THEY WOULD NEED TO CONTACT THE MANUFACTURER, AS THE FACILITY DID NOT HAVE THIS INFORMATION. WHEN QUERIED, THE MAINTENANCE DIRECTOR AND THE CMPO REPORTED THERE WAS NO FACILITY POLICY FOR MIXING VALVE PREVENTATIVE MAINTENANCE. ON 9/8/11 AT 4:00 P.M., "POWERS TECHNICAL INSTRUCTIONS" , DATED 2009 FOR THE HYDROGUARD SERIES MM 430 MASTER MIXING VALVE WAS REVIEWED AND REVEALED THE FOLLOWING: "BEFORE USE CHECK DISCHARGE TEMPERATURE. AFTER COMPLETING REPAIRS, CHECK DISCHARGE TEMPERATURE (115 F) RESET IF NECESSARY. WARNING FAILURE TO PERFORM THIS OPERATION COULD RESULT IN UNSAFE DISCHARGE TEMPERATURE WHICH MAY CAUSE INJURY OR DEATH." ON 8/31/11 AT 11:12 AM, THE FACILITY'S PRESENTED THE FOLLOWING PLAN OF CORRECTION: 1. NO RESIDENTS WERE HARMED RELATED TO THE ALLEGATION THAT THE FACILITY FAILED TO ENSURE THAT WATER FROM THE RESIDENT ROOM HAND WASHING SINKS WAS WITHIN A SAFE TEMPERATURE RANGE. 2. ON 8/30/11 AT APPROPRIATELY 5:15 PM, THE VALVE TO THE SINK IN ROOM 38 WAS IMMEDIATELY SHUT OFF. THE THREE RESIDENTS RESIDING IN ROOM 38 WERE IMMEDIATELY MOVED TO ANOTHER ROOM. LAMPE PLUMBING WAS NOTIFIED AND INFORMED OF THE ISSUE AND INDICATED THEY WOULD ARRIVE AT THE FACILITY WITHIN ONE AND ONE HALF HOUR TO ADDRESS THE MIXING VALVE PROBLEM. THE INTERDISCIPLINARY TEAM (IDT) MET AND CONDUCTED AN AD HOC QUALITY ASSURANCE (QA) MEETING TO DISCUSS THE FACILITY ACTION PLAN. 3. ON 8/30/11 AT APPROXIMATELY 5:20 PM, RESIDENTS, FAMILIES AND VISITORS, AND STAFF INFORMED NOT TO USE RESIDENT ROOM SINKS AND PRESIDENTS ROOM SHOWERS UNTIL ALL WATER TEMPERATURES WERE TAKEN AND MAINTAINED AT APPROPRIATE TEMPERATURES LEVELS. STAFF WERE GIVEN APPROPRIATE CARE PRODUCTS DURING THE INTERIM WHILE PROVIDING CAR TO RESIDENTS. 4. ON 8/30/11 AT APPROXIMATELY 5:30 PM, IDT MEMBERS WERE EDUCATED ON F 323 IN RELATION TO HAZARDS SECONDARY TO WATER TEMPERATURES AND THE FACILITIES PRACTICE FOR OBTAINING WATER TEMPERATURES USING THE APPROPRIATE TEMPERATURE GAUGE. FINDINGS WERE DOCUMENTED ON THE FACILITIES ENVIRONMENTAL OBSERVATION QAPI TOOL. 5. ON 8/30/11 AT APPROXIMATELY 5:35 PM, IDT MEMBERS WERE GIVEN ROOM ASSIGNMENTS, INCLUDING THE THERAPY GYM BATHROOMS AND SHOWER ROOMS, AND BEGAN TAKING TEMPERATURES AND LOGGING THEIR FINDINGS UNTIL THE PLUMBER'S ARRIVAL. 6. ON 8/30/11 AT APPROXIMATELY 6:25 PM, THE FACILITY COMPLETED TEMPERATURE CHECKS THROUGHOUT THE FACILITY AS ASSIGNED. NO NEGATIVE FINDINGS WERE IDENTIFIED. 7. ON 8/30/11 AT APPROXIMATELY 6:30 PM, LAMPE PLUMBING ENTERED THE FACILITY AND AS A PRECAUTIONARY MEASURE, BEGAN REPLACING BOTH FACILITY MIXING VALVES. 8. ON 8/30/11 AT APPROXIMATELY 9 PM, BOTH FACILITY MIXING VALVES WERE REPLACED AND THE FACILITY BEGAN RANDOM WATER TEMPERATURES CHECKS TO ENSURE COMPLIANCE. 9. THE MAINTENANCE DIRECTOR WAS NOTIFIED OF ALL WORK COMPLETED. 10. ON 8/30/11 AT APPROXIMATELY 9:30 PM, STAFF NOTIFIED BY MAINTENANCE DIRECTOR TO RESUME USE OF RESIDENT ROOM SINKS AND SHOWER ROOMS. 11. THE MAINTENANCE DIRECTOR WILL CONTINUE RANDOM AUDITS FOR 3 MONTHS AND REPORT FINDINGS TO THE QA AND A COMMITTEE FOR FURTHER RECOMMENDATIONS AND REVIEW. 12. THE ADMINISTRATOR IS RESPONSIBLE FOR MAINTAINING COMPLIANCE. ( , , , , ) DEFICIENT PRACTICE #2. THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND CONSISTENTLY IMPLEMENT SAFETY DEVICES FOR THREE (#'S 204, 210, AND 213) OF 10 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 21, RESULTING IN FALLS, ACCIDENTS, AND INJURIES, AND THE POTENTIAL FOR FURTHER ACCIDENTS. FINDINGS INCLUDE: ON 8/30/11 AT 10:20 A.M., RESIDENT #204 WAS IN THE HALLWAY IN A WHEELCHAIR. THE RESIDENT WAS ALERT BUT CONFUSED, AND WAS WEARING A TAB ALARM (PERSONAL SAFETY DEVICE). THE RESIDENT HAD A LARGE GAUZE BANDAGE (DRESSING) ON HIS HEAD OVER THE RIGHT TEMPLE. " WHEN QUESTIONED, DCD "A" REPORTED THAT RESIDENT #204 RECENTLY fell OUT OF THE WHEELCHAIR, SUFFERING A HEAD ABRASION (SUPERFICIAL LOSS OF SKIN). ON 9/2/11 AT 11:10 A.M., WOUND CARE BY NURSE "O" FOR RESIDENT #204 WAS OBSERVED. RESIDENT #204'S HEAD WOUND WAS AN OBLONG, PINK, OPEN AREA, DRAINING SEROSANGUINOUS FLUID (TISSUE FLUIDS MIXED WITH BLOOD), THE WIDTH OF A SILVER DOLLAR AND THE LENGTH OF TWO QUARTERS, ABOVE THE RIGHT TEMPLE. ON 8/31/11 AT 2:00 P.M., DCD "A" WAS REQUESTED TO PROVIDE ALL FACILITY INCIDENT AND ACCIDENT REPORTS (I&A) AND NURSING CARE PLANS FOR RESIDENT #204. ON 9/1/11 AT 11:00 A.M., A FACILITY INCIDENT AND ACCIDENT REPORT (I&A), DATED 8/29/11, AND CLINICAL RECORDS FOR RESIDENT #204 WERE PROVIDED AND REVIEWED WITH DCD "A" AND REVEALED THE FOLLOWING: 1. AN ADMISSION/READMISSION NURSING ASSESSMENT (NO DATE INDICATED) REVEALED THAT RESIDENT #204 WAS AT RISK FOR FALLS. ONLY ONE RISK FACTOR OUT OF 12, "UNDERLYING HEALTH CONDITION" WAS CHECKED (SELECTED AS APPLYING TO THE RESIDENT ). THE RISK FACTORS, "HISTORY OF FALLS", "UNSTEADY GAIT", "MUSCLE WEAKNESS", AND "URINARY/FECAL INCONTINENCE" WERE UNCHECKED (NOT SELECTED AS APPLYING TO THE RESIDENT ). 2. A FACE SHEET DOCUMENTED THAT RESIDENT #204 WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. 3. AN ADMISSION MINIMUM DATA SET ASSESSMENT, DATED 5/30/11 REVEALED THAT RESIDENT #204 HAD SEVERELY IMPAIRED COGNITION (DEMENTIA) AND NEEDED EXTENSIVE STAFF ASSISTANCE FOR MOBILITY IN BED, TRANSFERS TO THE WHEELCHAIR, TOILETING, HYGIENE AND EATING, WAS INCONTINENT OF BOWEL AND BLADDER, AND DID NOT WALK. THE MDS ALSO DOCUMENTED THAT THE RESIDENT HAD RANGE OF MOTION ( JOINT FLEXIBILITY) IMPAIRMENTS ON BOTH SIDES OF THE BODY AND HAD UNSTEADY BALANCE. 4. A PHYSICIAN ORDERS [REDACTED]. 5. A PHYSICAL THERAPY CASE MANAGEMENT DOCUMENTATION, DATED 6/14/11 REVEALED THAT RESIDENT #204 WAS UNABLE TO WALK, NEEDED MAXIMUM ASSISTANCE TO STAND AND TRANSFER, AND HAD FAIR TO POOR (PLUS) BALANCE WHEN SITTING. 6. A NURSING CARE PLAN, DATED 5/23/11 FOR RESIDENT #204, TITLED, "AT RISK FOR FALLS DUE TO UNSTABLE HEALTH CONDITION", HAD NO SAFETY DEVICES CARE PLANNED PRIOR TO 8/31/11. SAFETY INTERVENTIONS ACTIVATED PRIOR TO 8/31/11 WERE LISTED AS, "ADMINISTER MEDICATION PER PHYSICIANS ORDER, ASSESS FOR FALL RISK UPON ADMISSION AND REASSESS AS NEEDED, BED IN LOW POSITION. MINIMIZE ENVIRONMENTAL CLUTTER, AND NOTIFY PHYSICIAN AND FAMILY OF ANY FALLS." A SAFETY DEVICE INTERVENTION WAS DATED 8/31/11, THE DATE RESIDENT #204'S CARE PLANS AND I&A WERE REQUESTED, AND STATED, "ENSURE THAT ALARM/DEVICE (TAB ALARM) IS IN PLACE WHEN IN WHEELCHAIR (W/C)/BED/GERICHAIR." 7. A PHYSICIAN'S PROGRESS NOTE DATED 6/16/11 AT 1300 (1 P.M.) DOCUMENTED THE FOLLOWING, "POOR SAFETY AWARENESS (REACHES OVER TO ADJUST FOOT RESTS)" AND "SAFETY/ WHEELCHAIR ALARM" (SAFETY DEVICE). 8. AN FACILITY I&A , DATED 8/29/11 REVEALED RESIDENT #204 WAS FOUND ON THE FLOOR IN THE TV (TELEVISION) ROOM ON 8/29/11 AT 4:30 P.M.. THERE WAS NO DOCUMENTATION OF A WHEELCHAIR ALARM IN PLACE OR OF ANY WITNESSES TO A FALL. THE I&A NOTED, "FOREHEAD CLEANED WITH NORMAL SALINE AND COVERED WITH DRY DRESSING, X-RAY ORDERED." THE SECTION TITLED, "DESCRIBE CAUSE OF INCIDENT IF KNOWN:" DOCUMENTED "RESIDENT LIKES TO REMOVE SOCKS OR SHOES CONSTANTLY." THERE WAS NO DOCUMENTATION OF ANY WITNESSES TO THE FALL, OR OF ANY STAFF SUPERVISION IN THE TV ROOM OR DINING ROOM AT THE TIME OF THE FALL. 9. A NURSING NOTE, DATED 8/29/11 AT 8:25 P.M., WHICH DCD "A" STATED WAS SIGNED BY NURSE "K", DOCUMENTED THE FOLLOWING, "AT 4:30 RESIDENT FOUND ON FLOOR NEAR WHEELCHAIR IN TV ROOM. RESIDENT PLACED INTO WHEELCHAIR. RESIDENT HAS A CARPET BURN ON RIGHT UPPER FOREHEAD." THERE WAS NO DOCUMENTATION OF ANY WITNESSES TO THE FALL OR OF ANY STAFF SUPERVISION IN THE TV ROOM OR DINING ROOM AT THE TIME OF THE FALL. ON 8/31/11 AT 4:00 P.M., RESIDENT #204'S SPOUSE WAS INTERVIEWED STATED THAT THE RESIDENT HAD A LONG HISTORY OF FALLING, BOTH AT HOME, AND IN A PRIOR FACILITY. THE SPOUSE ALSO STATED THAT THE RESIDENT HAD A WHEELCHAIR ALARM SINCE ADMISSION TO THIS FACILITY, AND STATED THAT IT SHOULD HAVE BEEN IN PLACE AT THE TIME OF THE 8/29/11 FALL. ON 9/1/11 AT 11:00 A.M., DCD "A" WAS QUERIED ABOUT RESIDENT #204'S FALL ON 8/29/11 AT 4:30 P.M. WHEN QUERIED WHETHER RESIDENT #204'S WHEELCHAIR ALARM WAS IN PLACE AND FUNCTIONING AT THE TIME OF THE FALL, DCD "A" STATED THAT RESIDENT #204 DID NOT HAVE A WHEELCHAIR ALARM AT THAT TIME, BECAUSE IT WAS NOT CONSIDERED NECESSARY, AS THE RESIDENT HAD NO PRIOR HISTORY OF FALLS. THE DCD REPORTED THAT A WHEELCHAIR ALARM WAS A NURSING INTERVENTION AND THUS DID NOT REQUIRE A physician's orders [REDACTED]. THE DCD ALSO COULD NOT EXPLAIN WHY A RESIDENT WITH A PRIOR HISTORY OF FALLS, MUSCLE WEAKNESS, POOR SEATED BALANCE, POOR SAFETY AWARENESS, AND OBSERVED TO LEAN FORWARD IN THE WHEELCHAIR WOULDN'T BE ASSESSED AS NEEDING A WHEELCHAIR ALARM. THE DCD COULD NOT EXPLAIN WHY THESE RISK FACTORS WERE NOT CHECKED (SELECTED) ON THE ADMISSION NURSING FALLS RISK ASSESSMENT OR ADDRESSED ON THE NURSING CARE PLAN. WHEN QUERIED WHETHER RESIDENT #204 HAD BEEN LEFT IN THE TV ROOM WITHOUT STAFF SUPERVISION AT THE TIME OF THE FALL, DCD "A" REPORTED THAT NURSE "K" HAD BEEN SUPERVISING THE RESIDENTS IN THE TV ROOM AT THE TIME OF THE FALL. THE DCD STATED THAT NURSE "K" WITNESSED RESIDENT #204 LEANING OVER TO ADJUST HIS SHOES, BUT HAD BEEN UNABLE TO REACH RESIDENT #204 IN TIME TO PREVENT THE FALL. DCD "A" WAS UNABLE TO EXPLAIN WHY THE I&A AND THE 8/29/11 NURSE'S NOTE DOCUMENTED THAT RESIDENT #204 WAS FOUND ON THE FLOOR, INDICATING THAT THE FALL WAS UNWITNESSED, AND CONTAINED NO DOCUMENTATION OF ANY WITNESSES TO THE INCIDENT. ON 9/1/11 AT 12:00 P.M., NURSE "K" WAS INTERVIEWED IN THE PRESENCE OF DCD "A", AND REPORTED THAT RESIDENT #204'S FALL ON 8/29/11 WAS UNWITNESSED. NURSE "K" STATED THAT SHE FOUND RESIDENT #204 ON THE FLOOR BY THE WHEELCHAIR IN THE TV ROOM, AND ASSUMED HE HAD FALLEN AFTER LEANING FORWARD TO ADJUST HIS SHOES. WHEN ASKED WHETHER THERE WAS STAFF SUPERVISION OF RESIDENTS IN THE TV ROOM AT THE TIME, NURSE "K" STATED THAT THE FALL HAD OCCURRED BETWEEN MEALS AND SCHEDULED ACTIVITIES, WHEN THERE WERE USUALLY NO STAFF IN THE DINING ROOM OR TV ROOM. ON 9/1/11 AT 4:00 P.M., DCD "A" STATED THAT THE ACTIVITY DIRECTOR HAD BEEN SUPERVISING THE RESIDENTS IN THE DINING ROOM AND TV ROOM AT THE TIME OF RESIDENT #204'S FALL, BUT WAS UNABLE TO PROVIDE ANY DOCUMENTATION OF THIS UPON REQUEST, AND COULD NOT EXPLAIN WHY THE ACTIVITY DIRECTOR HAD NOT BEEN SUGGESTED EARLIER AS A POSSIBLE WITNESS TO RESIDENT #209'S FALL, AND WHY THERE WAS NO DOCUMENTATION OF THIS. REVIEW OF THE FACILITY "FALLS PRACTICE GUIDE", DATED 4/08, REVEALED THE FOLLOWING : "UPON ADMISSION, REVIEW HOSPITAL DISCHARGE RECORDS, TRANSFER SHEETS OR OTHER DATA REGARDING THE RESIDENT'S HISTORY OF OR RISK FACTORS FOR EXPERIENCING A FALL. INTERVIEW THE PATIENT AND FAMILY ABOUT THE PATIENT'S HISTORY OF FALLS, POSSIBLE CAUSES OF THOSE FALLS, AND INTERVENTIONS THAT WORKED OR DID NOT WORK TO PREVENT FURTHER FALLS. SOME RISK FACTORS THAT MAY PREDISPOSE A PATIENT TO FALL MAY INCLUDE: MUSCULOSKELETAL CONDITIONS THAT IMPAIR STRENGTH, HISTORY OF FALLS, UNSTEADY GAIT, MUSCLE WEAKNESS, COGNITIVE IMPAIRMENT, DEMENTIA. IF UPON COMPLETION OF THE NURSING ADMISSION EVALUATION, THE PATIENT IS FOUND TO BE AT RISK FOR FALLS OR HAS A HISTORY OF FALLS, THE PHYSICIAN IS CONTACTED FOR ORDERS, AS APPROPRIATE, AN INITIAL PLAN OF CARE IS DEVELOPED AND INDIVIDUALIED INTERVENTIONS ARE INITIATED. MANAGEMENT INTERVENTIONS WHICH MAY INCLUDE: LOW BEDS, BEDSIDE MATS, CHAIR/BED ALARMS." ( ) THE CLINICAL RECORD AND INCIDENT REPORTS WERE REVIEWED FOR RESIDENT #210. THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. MDS' DATED 10/6/10 AND 7/21/11 NOTED THAT THE RESIDENT HAD MODERATE COGNITIVE IMPAIRMENT AND REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS AND MOBILITY. AN "AT RISK FOR FALLS" CARE PLAN FOR RESIDENT #210 DATED 9/23/10, NOTED THAT THE RESIDENT HAD AN UNSTEADY GAIT. INTERVENTIONS INCLUDED "BED IN LOW POSITION." FALLS OCCURRED AS FOLLOWS FOR RESIDENT #210: 1. ACCORDING TO A FALL assessment dated [DATE], THE RESIDENT HAD A FALL ON 10/26/10 AT 12:30 AM. THE ASSESSMENT NOTED: "RESIDENT REMAINS AT RISK FOR FALLS SECONDARY TO....UNSTEADY GAIT. HE HAS A LOW BED WITH MATS ON BOTH SIDES AND A TAB (CLIP-TYPE) ALARM TO HIS WHEELCHAIR AND BED. WILL CHECK ALARM FOR PLACEMENT AND FUNCTION." 2. RESIDENT #210 HAD A FALL NEXT TO HIS BED ON 2/6/11 AT 8:05 PM PER NURSES NOTES, WITHOUT DOCUMENTED INJURY. THE INCIDENT REPORT NOTED THAT THE TAB ALARM SOUNDED. 3. PER NURSES NOTES DATED 4/18/11 AT 12:45 AM, THE RESIDENT HAD A FALL FROM BED AT THAT TIME. THERE WAS NO DOCUMENTED INJURY. THE NOTES DOCUMENTED: "HAS TAKEN OFF TAB ALARM....TAKES OFF ALARM." IT WAS UNCLEAR THAT IT WAS REMOVED DURING THIS INCIDENT. THE INCIDENT REPORT DID NOT MENTION THAT THE ALARM SOUNDED OR THAT IT WAS REMOVED BY THE RESIDENT. THE CORRECTIVE ACTION TO PREVENT REOCCURRENCE: "MAY CHANGE TO WIDER MATTRESS OR PERIMETER MATTRESS," INDICATING THAT THERE WAS A PROBLEM WITH THE BED AND THAT THE ALARM DID NOT SOUND AS IT SHOULD HAVE. 4. PER NURSES NOTES, THE RESIDENT fell FROM BED ON 5/11/11 AT 10:15 PM WITHOUT DOCUMENTED INJURY. THERE WAS NO MENTION THAT THE ALARM SOUNDED PER THE NOTES OR THE INCIDENT REPORT. THE NOTES AGAIN DOCUMENTED: "PATIENT TAKES OFF SAFETY ALARMS FROM BED AND WHEELCHAIR." IT WAS UNCLEAR THAT THE ALARM WAS REMOVED DURING THIS INCIDENT BY THE RESIDENT. THE CORRECTIVE ACTIONS PER THE INCIDENT REPORT: PLACE A SENSOR PAD ALARM IN THE WHEELCHAIR AND THE BED, AND A PERIMETER MATTRESS. THERE WAS NO MENTION WHY THE RESIDENT DID NOT RECEIVE THE MATTRESS AFTER THE FALL ON 4/18/11. 5. PER NURSES NOTES ON 5/17/11 AT 10 AM, THE RESIDENT HAD A FALL NEAR HIS WHEELCHAIR, WITHOUT INJURY. THE NURSES NOTES AND THE INCIDENT REPORT DID NOT MENTION THAT THE ALARM SOUNDED TO ALERT STAFF OF AN UNASSISTED TRANSFER ATTEMPT. THE CORRECTIVE ACTION: APPLY A NON-SKID PAD ON THE WHEELCHAIR. RESIDENT #210'S 9/23/10 FALL CARE PLAN WAS NOT REVISED UNTIL 5/18/11. THE REVISION INCLUDED INTERVENTIONS: BILATERAL FLOOR MATS, PERIMETER MATTRESS, SENSOR PAD TO BED AND WHEELCHAIR, AND NON-SLIP PAD TO WHEELCHAIR. 6. ON 7/24/11 AT 3 PM, THE RESIDENT fell IN HIS ROOM. THE BEDSPREAD WAS NOTED TO BE ROLLED AROUND HIM. HE SUSTAINED A "BUMP" AND "REDNESS" TO THE "MID, FRONT FOREHEAD." STAT (IMMEDIATE) X-RAYS OF THE SKULL AND FACE WERE NEGATIVE FOR FRACTURE. THERE WAS NO MENTION IN THE NURSES NOTES OR THE FALL ASSESSMENT (DATED 7/25/11) THAT THE ALARM SOUNDED OR THAT THE PERIMETER MATTRESS WAS IN PLACE DURING THE FALL. THERE WAS NO DOCUMENTED CORRECTIVE ACTION. 7. PER A FALL assessment dated [DATE], THE RESIDENT HAD A SECOND FALL ON 7/24/11 (AT 9 PM). THERE WERE NO DOCUMENTED NURSES NOTES OR INCIDENT REPORT. THE FALL ASSESSMENT NOTED: "RESIDENT EXITED THE CHAIR DURING MEAL TIME...." THERE WAS NO MENTION THAT THE ALARM SOUNDED, WHERE THE RESIDENT WAS LOCATED, IF THE FALL WAS WITNESSED, OR WHETHER THERE WAS AN INJURY. THERE WERE NO DOCUMENTED CORRECTIVE ACTIONS. 8. PER NURSES NOTES, ON 8/27/11 AT 10:30 PM, THE RESIDENT fell BESIDE THE BED, WITHOUT DOCUMENTED INJURY. HE "SLID OUT OF BED WHILE USING THE URINAL." THERE WAS NO MENTION THAT THE ALARM SOUNDED IN THE NURSES NOTES OR THE INCIDENT REPORT. PER THE INCIDENT REPORT, THE RESIDENT ATTEMPTED TO USE THE URINAL "BY HIMSELF WITHOUT ASSISTANCE AND SLID OUT OF BED." IT WAS UNCLEAR WHETHER THE URINAL WAS OUT OF THE RESIDENT'S REACH OR NOT. THROUGHOUT EACH DAY OF THE SURVEY, THERE WAS NO PERIMETER OR EXTRA WIDE MATTRESS OBSERVED ON RESIDENT #210'S BED. ON 8/31/11 AT 10 AM, THE RESIDENT WAS IN BED WITH THE BED SENSOR ALARM ATTACHED, BUT THE ALARM COULD NOT BE TURNED ON IN ORDER TO SOUND WHEN NECESSARY. WHEN QUERIED ABOUT THE ALARM, NURSE AIDE 'D' SAID, "MAYBE IT NEEDS BATTERIES." ON 8/31/11 AT 12:50 PM, RESIDENT #210 WAS OBSERVED SITTING IN THE WHEELCHAIR IN THE DINING ROOM DURING LUNCH. THE WHEELCHAIR ALARM COULD NOT BE TURNED ON. WHEN QUERIED ABOUT THE ALARM, NURSE AIDE 'I' SAID THAT THE ALARM WAS "NOT WORKING." SHE WAS UNABLE TO STATE WHY. ON 9/1/11 AT 9:15 AM, THE RESIDENT WAS OBSERVED ASLEEP IN BED WITH HIS LEFT ARM AND LEFT UPPER HALF OF HIS BODY LEANING TO THE LEFT, OFF AND AWAY FROM THE MATTRESS. A NURSE AND AN AIDE STRAIGHTENED THE RESIDENT IN BED. THERE WAS NO MENTION OF THE WHEREABOUTS OF THE PERIMETER MATTRESS. PER THE FACILITY'S "FALLS PRACTICE GUIDE" DATED 4/08: -RISK FACTORS THAT MAY PREDISPOSE A PATIENT TO FALL MAY INCLUDE: UNSTEADY GAIT, COGNITIVE IMPAIRMENT, AND DEMENTIA. -A PLAN OF CARE MUST BE DEVELOPED FOR THOSE AT RISK AND INDIVIDUALIZED INTERVENTIONS MUST BE INITIATED. -INTERVENTIONS WHICH MAY INCLUDE: LOW BEDS, BEDSIDE MATS, AND CHAIR/BED ALARMS. ( ) ON 9/1/11 AT 2 P.M., RESIDENT #213 WAS OBSERVED SITTING IN HER MOTORIZED SCOOTER AT A COMPUTER NEAR THE MAIN DINING ROOM. SHE WAS ALERT AND ANSWERED ALL QUESTIONS APPROPRIATELY. ON 9/2/11 AT 8:45 A.M., REVIEW OF RESIDENT #213'S FACE SHEET REVEALED AN ORIGINAL ADMISSION INto the facility on [DATE] AND A RE-ADMISSION ON 1/1/10 WITH [DIAGNOSES REDACTED]. THE RESIDENT'S MOST RECENT QUARTERLY MINIMUM DATA SET (MDS), dated 8/10/11 INDICATED AN INDEPENDENT COGNITION AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND ACTIVITIES OF DAILY LIVING (ADL'S). ON 9/2/11 AT 9 A.M., REVIEW OF AN INCIDENT REPORT (WITH THE UNIT MANAGER, NURSE 'A') FOR RESIDENT #213, DATED 4/21/11 AT 9:10 P.M., REVEALED A FALL. THE INCIDENT REPORT HAD DOCUMENTATION THAT READ, "RESIDENT OBSERVED SITTING ON THE FLOOR, NEXT TO MOTORIZED CHAIR. STATES SHE WAS TRYING TO TURN CHAIR AROUND, WHEN SHE SLIPPED OFF OF THE SEAT..." THE "AT RISK FOR FALLS CARE PLAN" WAS REVIEWED WITH NURSE 'A.' THE INTERVENTION, "PHYSICAL THERAPY (PT) TO ASSESS WHEELCHAIR FOR SAFETY" WAS ADDED TO THE CARE PLAN ON 4/22/11 BY NURSE 'A.' NURSE 'A' WAS QUERIED REGARDING THE PT ASSESSMENT FOR THE WHEELCHAIR. REVIEW OF THE RESIDENT'S CURRENT CLINICAL RECORDS AND OLD RECORDS (WITH NURSE 'A') DID NOT REVEAL A PT EVALUATION FOR THE RESIDENT'S WHEELCHAIR NOR AN ORDER FROM THE PHYSICIAN FOR THE RESIDENT TO HAVE A WHEELCHAIR EVALUATION DUE TO THE FALL. ON 9/2/11 AT 10:50 A.M., THE DIRECTOR OF REHABILITATION (EMPLOYEE 'L') WAS INTERVIEWED REGARDING THE PT EVALUATION FOR RESIDENT #213'S WHEELCHAIR. EMPLOYEE 'L' STATED, "WE NEVER RECEIVED an order for [REDACTED]. WE CAN'T SEE HER WITHOUT AN ORDER. THE LAST TIME WE SAW HER WAS ON 11/9/10 AFTER SHE WAS readmitted AFTER SHE HAD A FALL FROM HER MOTORIZED CHAIR AND SUSTAINED A FRACTURE THAT HAPPENED HERE." REVIEW OF AN INCIDENT REPORT, DATED 9/2/10 REVEALED RESIDENT #213 fell FROM HER MOTORIZED WHEELCHAIR AND SUSTAINED A LEFT ANKLE FRACTURE. REVIEW OF THE CURRENT CARE PLAN FOR FALLS, IN THE PRESENCE OF NURSE 'A', DID NOT INCLUDE ANY POST FALL INTERVENTIONS FOR THE FALL ON 4/21/11 FROM THE RESIDENT'S MOTORIZED SCOOTER. ON 9/2/11 AT 11:30 A.M., REVIEW OF ANOTHER FALL INCIDENT FOR RESIDENT #213, DATED 6/4/11 AT 8 A.M., INDICATED THE RESIDENT HAD ANOTHER FALL FROM HER MOTORIZED WHEELCHAIR. THE INCIDENT REPORT REVEALED DOCUMENTATION THAT READ, "RESIDENT WAS SITTING IN HER ELECTRIC CHAIR AND SHE TIPPED IT OVER LANDING ON THE BED NEXT TO HER. RESIDENT WAS STILL SEATED IN CHAIR." REVIEW OF THE CARE PLAN FOR FALL INCLUDED THE POST FALL INTERVENTION, DATED 6/6/11, FOR THE PT TO EVALUATE THE RESIDENT FOR WHEELCHAIR SAFETY. AGAIN, THERE WAS NO DOCUMENTATION FROM THERAPY TO INDICATE OR SUPPORT THE RESIDENT WAS INDEED "EVALUATED FOR WHEELCHAIR SAFETY." THE DIRECTOR OF REHABILITATION STATED, "WE NEVER RECEIVED AN ORDER ON 6/6/11 FOR AN EVALUATION." THERE WAS NO POST FALL INTERVENTION RELATED TO THE FALL FROM THE WHEELCHAIR. REVIEW OF THE RESIDENT'S "PATIENT EDUCATION RECORD," INDICATED ON 6/8/11 RESIDENT #213 WAS PROVIDED TEACHING ON "SCOOTER PRECAUTIONS." THERE WAS NO OUTLINE OF THE "SCOOTER PRECAUTIONS' EDUCATION PROVIDED. NURSE 'A' DID NOT PROVIDE AN EXPLANATION BY THE TIME OF EXIT AS TO WHY THERE WAS NO ORDER OBTAINED BY THE PHYSICIAN FOR PT TO DO AN EVALUATION FOR THE WHEELCHAIR ASSESSMENT AS INDICATED ON THE CARE PLAN FOR FALLS, NOR WAS THERE AN EXPLANATION AS TO WHY NO POST FALL INTERVENTIONS WERE IMPLEMENTED AFTER EACH INCIDENT. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS FOR THE PREVENTION OF PRESSURE ULCERS, CONSISTENTLY RENDER TREATMENTS AS ORDERED BY THE PHYSICIAN FOR PRESSURE ULCERS, AND CONSISTENTLY ASSESS AND MEASURE PRESSURE ULCERS FOR TWO (#'S 201 AND 203) OF SIX RESIDENTS REVIEWED FOR PRESSURE ULCERS, OUT OF A TOTAL OF 21 SAMPLED RESIDENTS, RESULTING IN FACILITY ACQUIRED PRESSURE ULCERS AND THE WORSENING OF PRESSURE ULCERS. FINDINGS INCLUDE: ON 8/30/11 AT 10 A.M., DURING THE INITIAL TOUR, RESIDENT #201 WAS OBSERVED LYING IN BED ALERT, CONFUSED, AND UNABLE TO ANSWER QUESTIONS APPROPRIATELY. ON 8/31/11 AT 11:50 A.M., THE TREATMENTS TO RESIDENT #201'S THREE PRESSURE ULCERS WERE OBSERVED WITH THE TREATMENT NURSE (NURSE 'M'). RESIDENT #201 HAD THE FOLLOWING AREAS OF PRESSURE ULCERS: 1. A RIGHT HIP PRESSURE ULCER THAT MEASURED 0.3 CM (CENTIMETERS X 1.5 CM. WITH HEALTHY PINK TISSUE. 2. A LEFT HIP PRESSURE ULCER WAS NOTED WHICH MEASURED 0.3 CM X 0.7 CM. WITH HEALTHY PINK TISSUE. 3. A PRESSURE ULCER TO THE SACRAL AREA MEASURED 1.1 CM X 1.3 CM. WITH HEALTHY PINK TISSUE. PER THE NURSING ADMISSION ASSESSMENT RECORD, RESIDENT # 201 WAS RE-admitted on [DATE] FROM THE HOSPITAL WITH THE SACRAL PRESSURE ULCER ON 9/1/11 AT 9:00 A.M., REVIEW OF RESIDENT #201'S CURRENT AND OLD PAPER AND ELECTRONIC CLINICAL RECORDS REVEALED THE FOLLOWING: RESIDENT #201'S FACE SHEET REVEALED AN ORIGINAL admitted INto the facility on [DATE] AND A RE-admitted ON 8/22/11 WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #201'S ADMISSION MINIMUM DATA SET (MDS), dated [DATE], REVEALED a SEVERELY IMPAIRED COGNITION WAS INDICATED AND THE RESIDENT REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. REVIEW OF RESIDENT #201'S ADMISSION NURSING NOTE, DATED 6/30/11 REVEALED THE FOLLOWING DOCUMENTATION, "SKIN ASSESSMENT DONE--MULTIPLE BRUISING TO UPPER EXTREMITIES AND LOWER EXTREMITIES..." THERE WAS NO NOTATION OR DOCUMENTATION OF PRESSURE ULCERS. REVIEW OF RESIDENT #201'S ADMISSION NURSING SKIN ASSESSMENT, DATED 6/30/11 AT 6:17 P.M., REVEALED NO AREAS OF PRESSURE ULCERS DOCUMENTED. THE BRADEN SCALE (SCALE THAT DETERMINES RISK FOR PRESSURE ULCERS) SCORE WAS DOCUMENTED AS 17, INDICATING THAT THE RESIDENT WAS AT LOW RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS. REVIEW OF A NURSE'S NOTE FOR RESIDENT #201, DATED 7/5/11 REVEALED DOCUMENTATION THAT READ, "LEFT BUTTOCK, PURPLE AREA, DEEP TISSUE INJURY. PREVIOUSLY CALLED BLISTER 5 X 2. RIGHT BUTTOCK EXCORIATED. CHANGE TO [MEDICATION NAME] BILATERAL BUTTOCKS." THIS WAS THE FIRST AND ONLY DOCUMENTATION OF SKIN ALTERATIONS SINCE ADMISSION. REVIEW OF THE CURRENT CLINICAL RECORD (IN THE PRESENCE OF THE MDS NURSE), OLD RECORDS, AND THE COMPUTER, REVEALED NO CARE PLANS FOR THE ACTUAL PRESSURE ULCERS/EXCORIATION, AND/ DEEP TISSUE INJURY. THE MDS NURSE (NURSE 'J') COULD NOT EXPLAIN WHY THERE WAS NO CARE PLAN THAT ADDRESSED ACTUAL PRESSURE ULCERS. NURSE 'J' FURTHER STATED, "I WAS LOOKING IN THE COMPUTER FOR AN ACTUAL PRESSURE ULCER CARE PLAN, BUT I ONLY SAW AN 'AT RISK' CARE PLAN FOR PRESSURE ULCERS, EVEN AFTER THE ULCERS DEVELOPED." NURSE 'J' WAS ALSO UNABLE TO EXPLAIN WHY THE RESIDENT DID NOT HAVE A WEEKLY BRADEN SCALE AS ORDERED BY THE PHYSICIAN. REVIEW OF RESIDENT #201'S TREATMENT ADMINISTRATION RECORD (TAR), USED TO DOCUMENT TREATMENTS AND DESCRIBE WOUNDS, INDICATED ON 7/7/11 THAT THE BRADEN SCALE ASSESSMENT WAS NOT DONE, NOR WAS THE WEEKLY SKIN ASSESSMENT. THE TAR DID NOT DOCUMENT THAT THE treatment of [REDACTED]. THERE WERE MULTIPLE physician's orders [REDACTED]. ON 7/4/11 THERE WAS A physician's orders [REDACTED]. CLEAN FLUID FILLED BLISTER. APPLY [MEDICATION NAME], COVER..." ON 7/4/11 THERE WAS A physician's orders [REDACTED]. ON 7/5/11 THERE WAS A physician's orders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hospital on [DATE], BUT HAD DEVELOPED PRESSURE ULCERS PRIOR TO THE TRANSFER TO THE HOSPITAL. NOR WAS THERE A SECOND WEEKLY BRADEN SCALE AS ORDERED. NURSE 'P' STATED, "DEEP TISSUE INJURY WAS NOTED ON 7/5/11 TO BOTH HER LEFT AND RIGHT BUTTOCKS." NURSE 'P' WAS UNABLE TO PROVIDE AN EXPLANATION AS TO WHY THERE WAS NO CARE PLAN FOR THE PRESSURE ULCERS OR DEEP TISSUE INJURIES. NURSE 'P' WAS QUERIED REGARDING DAILY/ROUTINE SKIN ASSESSMENTS AND SHOWER SHEETS. NURSE 'P' WAS UNABLE TO PROVIDE SHOWER SHEETS FOR RESIDENT #201 (THAT WOULD INDICATE ROUTINE ASSESSMENTS OF THE RESIDENT'S SKIN). REVIEW OF THE HOSPITAL'S emergency room 'S PHYSICIAN'S ASSESSMENT, DATED 7/11/11, REVEALED DOCUMENTATION THAT READ, "TWO SACRAL DECUB (PRESSURE ULCERS) MEASURED APPROXIMATELY 4 CM IN SIZE WITH EXCORIATION." THE FACILITY OFFERED NO FURTHER EXPLANATION BY THE TIME OF EXIT FOR THE LACK OF A PRESSURE ULCER CARE PLAN, MISSED TREATMENTS TO THE WOUND, AND NO DESCRIPTIONS AND MEASUREMENTS OF THE WOUNDS AS THE PHYSICIAN'S TREATMENTS TO THE WOUNDS CHANGED. ( ) ON 8/30/11 AT 10 AM, RESIDENT #203 WAS OBSERVED IN BED. THE RESIDENT WAS ALERT. SHE SAID, "MY FOOT HURTS" AS SHE MOTIONED TO THE RIGHT FOOT. WHEN THE COVERS WERE LIFTED, THE RESIDENT WAS OBSERVED TO BE WEARING SOCKS. THE RIGHT HEEL WAS RESTING ON THE BED. THE LEFT FOOT WAS TURNED OUTWARD WITH THE LATERAL (SIDE) PORTION OF THE HEEL RESTING ON THE BED. WHEN ASKED, RESIDENT #203 STATED THAT HER RIGHT HEEL HURT. WHEN HER RIGHT FOOT WAS LIFTED FROM THE BED, SEROUS DRAINAGE COULD BE SEEN ON THE BED SHEET UNDERNEATH WHERE THE HEEL HAD BEEN RESTING. THE RESIDENT WINCED AND SAID "OUCH, OUCH" WHEN AN ATTEMPT WAS MADE TO SEE UNDERNEATH THE SOCK. NURSE 'B' ENTERED THE RESIDENT'S ROOM. WHEN SHE ATTEMPTED TO REMOVE THE SOCK, THE SOCK WAS STUCK TO AN OPEN PRESSURE SORE ON THE HEEL THAT MEASURED APPROXIMATELY ONE CM (CENTIMETER) IN DIAMETER AT STAGE III (FULL THICKNESS SKIN LOSS INVOLVING NECROSIS (TISSUE DEATH) OF UNDERLYING TISSUE). THE NURSE WAS UNABLE TO EXPLAIN WHY THE WOUND WAS NOT COVERED WITH A DRESSING AND STATED THAT SHE WAS UNAWARE THAT THE RESIDENT HAD THE PRESSURE SORE. UNIT NURSE MANAGER 'A' ENTERED THE RESIDENT'S ROOM, SAW THE DRAINAGE ON THE BED, AND COULD NOT EXPLAIN THE LACK OF A DRESSING AND THE RESIDENT'S HEELS NOT BEING ELEVATED. ON 8/31/11 AT 8:45 AM, RESIDENT #203 WAS OBSERVED IN BED WITH HER HEELS RESTING ON THE MATTRESS. MANAGER 'A' ENTERED THE ROOM AND WAS QUERIED ABOUT THE HEELS NOT BEING ELEVATED AND THE LACK OF PRESSURE RELIEF DEVICES. THE NURSE WAS UNABLE TO EXPLAIN AND SAID, "WELL, YOU GOT ME." RESIDENT #203'S CLINICAL RECORD WAS REVIEWED. THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS NOTED THAT THE RESIDENT WAS NON-AMBULATORY AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE FOR ALL MOBILITY INCLUDING REPOSITIONING AND HAD NO PRESSURE SORES. AN ADMISSION SKIN assessment dated [DATE] NOTED THAT RESIDENT #203 WAS admitted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