Every finding on record at Medilodge of Ludington

This citation pertains to intake 3042861 Based on observation, interview, and record review, the facility failed to ensure staff were deployed in sufficient numbers to meet the needs of 6 residents (R3, R10, R5, R6, R7 and R9) out of 10 residents reviewed for staffing. Findings include:R3Review of a Face Sheet reflected R3 admitted to the facility with diagnoses that included Parkinson's disease with dyskinesia, age related osteoporosis, orthostatic hypotension, repeated falls and depression. Review of a Care Plan initiated on 6/3/2025, reflected R3 had an Activities of Daily Living (ADL) self-care deficit related to her diagnoses and needed one person to assist with ambulation and toileting. The care plan also specified encourage use of visual prompts on beside table for reminder to use call light and walker. Further review of the entire care plan indicated R3 was at risk for falls and was on a toileting program to prevent falls and address R3's risk for incontinence. During an interview on 6/23/26 at 11:13 AM, R3 reported that she has had to wait too long for her call light to be answered and had accidents (incontinence) which made her feel disgusted. R3 said, I don't feel like I'm not treated well, just not treated.R10Review of a Face Sheet reflected R10 admitted to the facility with diagnoses that included mild dementia without behavioral disturbances, congenital agranulocytosis (a rare inherited bone marrow disorder causing a lack of adequate white blood cells critical for fighting bacterial infections), erosive osteoarthritis (an aggressive subtype of osteoarthritis that primarily affects the small joints of the hands) and generalized anxiety. R10 was on hospice. During an observation and interview beginning on 6/23/2016 at 1:55 PM, R10's call light was observed on over R10's door. Multiple staff walked past the activated call light. On 6/23/2026 at 2:23 PM, the surveyor observed R10 seated on the side of the bed, a sheet over her lap, the hospice chaplain was at the bedside. The Hospice Chaplain reported R10 needed her diaper changed. R10 said she had pressed the call light and needed a clean diaper and reported a Certified Nurse Aide (CNA) came into her room a while ago but never returned and R10 did not know why the aide never returned. The surveyor remained in R10's room with her permission to wait for staff to answer the light. R10 said the staff are busy and need more help. At 2:32 PM, CNA B entered R10's room and asked R10 what she needed and then proceeded to provide care, nearly 40 minutes from the time the call light was first observed activated. R5Review of a Face Sheet reflected R5 admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, major depression, and neuralgia (a sharp, shocking, or burning pain that follows the pathway of damaged or irritated nerves) and neuritis (inflammation of one or more peripheral nerves). Review of a Care Plan initiated on 1/09/2026, reflected R5 needed 2 people assist and the use of a mechanical lift for transfers. During an interview on 6/24/26 at 9:37 AM, R5 reported that most of the time staff will transfer her with 2 people assisting but sometimes only one person will complete the transfer with the mechanical lift because there isn't enough help. R6Review of a Face Sheet reflected R6 admitted to the facility with diagnoses that included unspecified cord compression, morbid obesity with alveolar hypoventilation (occurs when breathing is too shallow or too slow to meet the body's metabolic needs), fusion of cervical spine, spondylosis (a form of spinal osteoarthritis) without myelopathy or radiculopathy, lumbago (lower back pain) with sciatica (pain that radiates along the path of the sciatic nerve) on the right and left side, osteoporosis decreased bone mass making bones fragile and susceptible to fractures), arthrodesis (orthopedic procedure that permanently immobilizes a joint)Review of a Care Plan initiated on 5/09/2026, reflected that R6 had an ADL self-care deficit related to his diagnoses and required two people, a sit-to-stand lift, and hard c-collar (cervical collar) to assist with transfers.During an interview on 6/24/2026 at 9:03 AM, R6 reported that sometimes only one person completes a transfer with the mechanical lift instead of two. R6 said that it makes no difference if he presses the call light for assistance, because staff do not respond to his call light in a timely manner. According to R6, people at the facility are here to make money and there isn't enough help.R7Review of a Face Sheet reflected R7 admitted to the facility with diagnoses that included peripheral vascular disease, obesity, and acquired absence of left leg above the knee. Review of a Care Plan initiated on 6/19/2025, reflected that R7 had an ADL self-care deficit related to her diagnoses and was transferred with 2 people assist and a mechanical lift.During an interview on 6/24/2026 at 9:51 AM, R7 reported that staff use only one person to transfer her with the mechanical lift the majority of the time because there is not enough staff. Luckily, I have not been hurt! They are so understaffed that they can't get to you in a timely manner. R7 said it would be nice if the facility had more mechanical lift slings because sometimes there are not enough and she can't get up to take her showers. R7 said, I enjoy my showers, and I miss them when I cannot get them. R9Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE] reflected R9 admitted to the facility from the hospital on 2/6/2024 with diagnoses that included spondylosis (degeneration affecting the discs, joints, and bones of the spine) with myelopathy (neurological deficits caused by spinal cord compression. Symptoms can include balance and gait issues, numbness, weakness or hyperreflexia), thoracic (upper/mid back) region, osteoarthritis and low back pain. The assessment reflected R9 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. R9 had functional limitations in range of motion of both lower extremities and was dependent on staff for toileting and transfers. During an interview on 6/24/26 at 8:35 AM, R9 reported that he needs two people to transfer him and typically there is only one person 50% of the time. R9 said he feels bad when he has to wait a long time for assistance, It ain't right! Nobody comes down here to help if they are short-handed. There needs to be more teamwork. There are a lot of things I would change around here. There should be somebody in the hall watching the lights (nurse call lights).Review of a policy Quality of Care last reviewed 1/01/2022 reflected, It is the policy of (name of corporation) that each resident receives the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with each resident's comprehensive assessment and plan of care. The policy specified, Each facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and plans of care.

This citation pertains to Intake 3042861 Based on interview and record review, the facility failed to ensure residents who required two people to assist with transfers, were transferred by two people at all times for 4 residents (R5, R6, R7, and R9) out of 10 residents reviewed for accidents and hazards. Findings include:During an interview on 6/23/2026 at 10:30 AM, Confidential Informant (CI) K reported that there are 6 people on the hall she is assigned to that require two people for assistance with transfers but there is not enough staff to get to everyone in time leading to making residents wait for help. CI K said that when one person goes on break, staff can't help everyone who needs it. During an interview on 6/24/2026 at 8:12 AM, CI K reported that they will often transfer residents who require a mechanical lift with only one person. According to CI K, there should always be two people assisting with transfers that require either a lift or a sit to stand, but that isn't possible due to not being able to find help when needed. During an interview on 6/24/2026 at 8:59 AM, CI E reported they do most of the two person assist transfers by themself because there is not enough help first thing in the morning. During an interview on 6/24/2026 at 12:25 PM, the Director of Nursing (DON) reported that it is the policy of the facility that any resident who requires the use of a mechanical lift or a sit-to-stand machine for transfers, be assisted by two staff at all times. R5Review of a Face Sheet reflected R5 admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, major depression, and neuralgia (a sharp, shocking, or burning pain that follows the pathway of damaged or irritated nerves) and neuritis (inflammation of one or more peripheral nerves). Review of a Care Plan initiated on 1/09/2026, reflected R5 needed 2 people assist and the use of a mechanical lift for transfers. During an interview on 6/24/26 at 9:37 AM, R5 reported that most of the time staff will transfer her with 2 people assisting but sometimes only one person will complete the transfer with the mechanical lift because there isn't enough help. R6Review of a Face Sheet reflected R6 admitted to the facility with diagnoses that included unspecified cord compression, morbid obesity with alveolar hypoventilation (occurs when breathing is too shallow or too slow to meet the body's metabolic needs), fusion of cervical spine, spondylosis (a form of spinal osteoarthritis) without myelopathy or radiculopathy, lumbago (lower back pain) with sciatica (pain that radiates along the path of the sciatic nerve) on the right and left side, osteoporosis decreased bone mass making bones fragile and susceptible to fractures), arthrodesis (orthopedic procedure that permanently immobilizes a joint)Review of a Care Plan initiated on 5/09/2026, reflected that R6 had an ADL self-care deficit related to his diagnoses and required two people, a sit-to-stand lift, and hard c-collar (cervical collar) to assist with transfers.During an interview on 6/24/2026 at 9:03 AM, R6 reported that sometimes only one person completes a transfer with the mechanical lift instead of two. R7Review of a Face Sheet reflected R7 admitted to the facility with diagnoses that included peripheral vascular disease, obesity, and acquired absence of left leg above the knee. Review of a Care Plan initiated on 6/19/2025, reflected that R7 had an ADL self-care deficit related to her diagnoses and was transferred with 2 people assist and a mechanical lift.During an interview on 6/24/2026 at 9:51 AM, R7 reported that staff use only one person to transfer her with the mechanical lift the majority of the time because there is not enough staff. Luckily, I have not been hurt!.R9Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE] reflected R9 admitted to the facility from the hospital on 2/6/2024 with diagnoses that included spondylosis (degeneration affecting the discs, joints, and bones of the spine) with myelopathy (neurological deficits caused by spinal cord compression. Symptoms can include balance and gait issues, numbness, weakness or hyperreflexia), thoracic (upper/mid back) region, osteoarthritis and low back pain. The assessment reflected R9 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. R9 had functional limitations in range of motion of both lower extremities and was dependent on staff for toileting and transfers. During an interview on 6/24/26 at 8:35 AM, R9 reported that he needs two people to transfer him and typically there is only one person 50% of the time.

This citation pertains to intake 2646749 Based on interview and record review the facility failed to appropriately stabilize 1 resident after a fall (R93), out of 2 residents reviewed for falls, resulting in increased pain, transfer to the hospital, and death. Findings:Resident #93 (R93)Review of an admission Record reflected R93 admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, osteoarthritis, spondylosis without myelopathy or radiculopathy (age-related degeneration of the spine involving disc wear and bone spurs without spinal cord compression), wedge compression fracture of T5-T6 (thoracic vertebra), and multiple fracture of ribs, bilateral. Review of a Nursing Evaluation Summary dated [DATE] reflected, (R93) was educated on call light use and the importance of using the call light system and the importance of calling for assistance, however, she has continuously been getting herself out of bed and into the bathroom on her own without calling for assistance. Education on fall risk and safety has been provided.Review of an IDT (Interdisciplinary) Progress Note dated [DATE] reflected R93 had low O2 (oxygen) saturation and had been very fatigued with confusion and anxiety . (R93) has had 2 falls today, does not ask for assistance, self-transfers. Will move to room closer to desk. Review of a Pertinent Charting - Skin note dated [DATE] indicated R93 sustained a small gash from recent fall and hitting side of face. Review of a Nurses' Notes dated [DATE] reflected (R93) had another fall in her bathroom after attempting to get up and transfer to bathroom on her own; (R93) developed a small gash under R (right) eye and a goose egg on forehead.Review of a Nurses' Notes dated [DATE] at 9:34 PM reflected (R93) continues to be agitated and SOB (short of breath). Constantly standing up and trying to walk to BR (bathroom) or climbing out of bed and wheelchair. Resident was toileted and had dinner but continued to be agitated.Review of a Nurses' Notes dated [DATE] at 1:23 AM reflected, Resident (R93) was told not to leave her wheelchair without assistance. When everyone was gone, she moved from her wheelchair to a sedentary chair, the tried to move back to wheelchair and landed on her Rt (right) side on the floor. Assessed resident and her Rt hip was causing her pain. Got her up by maxi lift (a machine used to lift totally dependent residents in a sling) and put to bed. Still complaining of hip pain called (physician) and they wanted her sent to hospital for x-ray.Review of an Un-witnessed Fall incident report dated [DATE] reflected Resident (R93) moving from her chair to wheelchair and wheelchair moved and caused resident to fall on her Rt side. Complaints of Rt hip pain putting any pressure on it causes her to cry out in pain. Got her in Maxi lift and put to bed. Where she is non-stop rubbing her Rt hip. The incident report indicated R93 was sent to the hospital. During a telephone interview on [DATE] at 5:31 AM, Registered Nurse (RN) U reported R93 was sitting near the (nurse) desk in a chair and no one was with her when she fell. RN U said R93 complained of her leg hurting. RN U said she assessed R93 by working from the head down, palpating the body and asking if R93 hurt anywhere. RN U reported R93 only cried out in pain at her hip. RN U said that R93 was lifted off the floor into her wheelchair and then from the wheelchair into bed with a maxi lift. RN U reported R93 complained of increased pain after being transferred and was sent to the hospital within 30 minutes of the fall due to the severity of the pain. RN U reported that it is facility policy to use a maxi lift to transfer anyone who falls in the facility. Review of a hospital Imaging Report dated [DATE] reflected Per (Long Term Care Facility) report, (R93) had unwitnessed fall, was found down. (Long Term Care Facility) used hoyer lift to get (R93) up, states (R93) cried of hip pain while they used the lift. When asked where they picked (R93) up from (Long Term Care Facility) gave 4 different locations of possibility. (R93) c/o (complained of) hip pain, unsure which hip. (R93) poor historian. The imaging report indicated that R93 was diagnosed with a Minimally displaced intertrochanteric fracture of the right hip. Further review of the hospital records dated [DATE] reflected R93 was transferred to a bigger hospital for evaluation, was not optimized for surgery and admitted to end of life care. Review of a Certificate of Death reflected R93 died on [DATE] Due to (or as a consequence of) Medical complications of right hip fracture. Approximate Interval Between Onset and Death: Days.During an interview on [DATE] at 8:17 AM, the Director of Nursing reported that after a resident falls the first priority is to rule out abuse and then the nurse would do a head to toe assessment. The DON said starting with the head and neck, assess for skin tears, bruising, immediate redness or obvious deformities. If the resident does complain of leg pain you would assess for evenness and not move the resident from the floor because it could worsen the injury. The nurse would call 911 and wait for EMS (emergency medical services) to arrive and ensure the resident was transferred safely. The DON reported it is not the facility policy to use a full lift to move residents after a fall.

Based on interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak for 2 of 18 residents (Residents #35 and #59) and all residents residing in the facility, reviewed for infection prevention and control.Findings:Employee Line ListReview of the February Infection Surveillance Report revealed:A Registered Nurse called off of work for GI with an onset date of 2/2/26.An Activities Staff Member called off of work for GI with an onset date of 2/9/26.A Registered Nurse called off of work for GI with an onset date of 2/11/26.A Certified Nursing Assistant called off of work for Other with an onset date of 2/13/26.A Certified Nursing Assistant called off of work for GI with an onset date of 2/13/26.A Certified Nursing Assistant called off of work for Other with an onset date of 2/16/26.An office staff member called off of work for Other with an onset date of 2/16/26.There was no documentation of the unit(s) the staff members worked on or residents they came in contact with. There was no description of the GI symptoms experienced or follow-up documentation for other. There was no tracking of housekeeping staff or therapy staff.During an interview on 03/11/2026 at 2:10 PM, Infection Control Preventionist (ICP) A reported that she was responsible for tracking facility outbreaks for employees and residents.ICP A reported that employee call-off slips were sent to HR (human resources) and were then emailed to her. The call-offs were reviewed daily and tracked on her computer system. Once an employee called off, she would determine, based on their symptoms, when they could return to work. ICP A reported that if the call-off slip did not include the symptoms the staff member was experiencing, she would just put sick and would follow up when they returned to work. ICP A reported that on her employee line list, she did not include the date they last worked or the unit they were assigned. ICP A reported she did not track call-offs/illnesses for housekeeping staff or therapy staff despite their direct and/or close contact with residents. ICP A was not aware that there had been multiple staff call-off's related to GI (gastrointestinal) illness. When presented with the information that there had been multiple staff GI call-offs, ICP A reported that some staff would call-off for symptoms that she did not believe they were experiencing.Resident #35 (R35)Review of an admission Record revealed R35 was a [AGE] year-old female, admitted to the facility on [DATE].Review of R35's Order Summary dated 2/17/26 revealed, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 1 tablet by mouth every 4 hours as needed for diarrhea for 3 Days.Review of the Practitioner Communication Log located at the nurses' station revealed a handwritten note dated 2/17/26 that R35 was experiencing congested cough + diarrhea-Imodium?Review of R35's Practitioner Note dated 2/17/26 revealed, .History of Present Illness: Cough, congestion, diarrhea for 1 day.Review of R35's Order Summary dated 2/17/26 revealed, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 1 tablet by mouth every 4 hours as needed for diarrhea for 3 Days.Resident #59 (R59)Review of an admission Record revealed R59 was a [AGE] year-old female, admitted to the facility on [DATE].Review of the Practitioner Communication Log revealed a handwritten the following notes:2/11/26 R59 has had diarrhea for days with a handwritten note beneath Why didn't anyone call for Imodium?2/16/26 R59 c/o (complains of) diarrhea-wants Imodium.Review of R59's Progress Note dated 2/17/26 revealed, .Order received for.Imodium r/t (related to) c/o diarrhea.Review of R59's Order Summary dated 2/17/26 revealed, Imodium A-D Oral Tablet 2 MG (Loperamide HCl) Give 1 tablet by mouth every 4 hours as needed for diarrhea for 3 Days.During an interview on 03/11/2026 at 2:10 PM, ICP A reported that for the residents, she kept an active line listing for residents experiencing any symptoms of infection. ICP A reported residents were added to the line list following her daily review of the 24-hour report daily. Nursing notes and PRN (as needed) medication administration were included in the 24-hour report which allowed her to identify any residents experiencing symptoms of an infection/illness. ICP A was asked if she had identified a potential GI outbreak for residents to which she stated, that's not ringing a bell. R35 and R59, residing on the same unit, received an order for Imodium on 2/17/26 for similar GI symptoms. Their GI symptoms were not listed on the line list and the potential for an outbreak was not investigated.Review of the facility policy, Infection Prevention and Control Program last reviewed/revised 12/27/23 revealed, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment Performance Improvement. c. Licensed nurses participate in surveillance through assessment/evaluation of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections.

This citation pertains to intakes #: 2652909 and 2646749Based on interview and record review, the facility failed to provide sufficient staff with the knowledge and skills sets to support and assist residents experiencing agitation and confusion and implement meaningful behavioral interventions for 5 of 18 residents (Residents #67, #19, #91, #57, and #85), reviewed for behavioral health needs.Findings:Review of a Complaint Investigation Report dated 10/17/25 the following anonymous complaint, Complainant states that there are quite a few residents with mental health issues on the floor that aren't safe, and they should not be in this facility Complainant states that management should be coming in to assist when there are not enough staff present, but they don't .Resident #67 (R67)Review of an admission Record revealed R67 was a [AGE] year-old male, admitted to the facility on [DATE].Review of a Minimum Data Set (MDS) assessment for R67, with a reference date of 2/8/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R67 was cognitively intact. During an interview on 3/9/26 at 2:20 PM, R67 reported that R19 should not be a resident at the facility as he was verbally aggressive towards staff and residents. R67 reported that R19 has been caught urinating outside in front of others, yells at people from the community that are walking by while he's smoking, does not follow smoking rules, refuses to bathe, frequently uses profanity directed at staff and residents, and attempts to intimidate the staff and residents in order to get what he wants. R67 reported feelings of frustration, annoyance, and discontentment with R19's behaviors in the facility and his perception that the facility staff were not making attempts to get control of his behavior or find other placement for R19.Resident #19 (R19)Review of an admission Record revealed R19 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: alcohol dependence with withdrawal, anxiety disorder, and cognitive communication deficit.Review of R19's late entry Social Services Progress Note dated 1/31/26 but created on 2/20/26 revealed, Per nursing report, on 1/30/26 resident was noted being inappropriate and using offensive language directed toward staff/peers. SSD met with resident on 1/31/26 to address the above with limited results. Resident has hx (history) of similar behaviors and is noted to be dismissive and easily frustrated when approached by staff. Resident presents w/ (with) limited insight, poor impulse control skills, and is at times hard to redirect.Staff continue to closely monitor resident and utilize the following interventions: redirection, reassurance, firm limit-setting, and distraction.The facility did not initiate enhanced supervision and R19's Care Plan was not updated with interventions for his new behavior of offensive language directed towards residents.Review of R19's late entry Social Services Progress Note dated 2/6/26 but created on 2/20/26 revealed, Per nursing report, resident reported w/ physical aggression on 2/6/26, specifically throwing an object when frustrated. No injuries reported. Resident has hx of behavioral dysregulation associated with poor impulse control skills. SSD met with resident 1:1 on 2/9/26 to address the above. Resident presents calm with no additional reports of physical aggression. SSD continues to meet with resident w/ emphasis on coping skills, calming techniques, firm limit-setting, and appropriate expression of needs/frustrations. Staff continue to closely monitor for any changes in mood/behaviors, offering immediate interventions as indicated.The facility did not initiate enhanced supervision and R19's Care Plan was not updated with interventions for his behaviors of physical aggression and throwing objects.Review of R19's Pertinent Charting-Behavior dated 2/8/26 revealed, Resident was backing up in his wheelchair down the hall in front of south nurse's station. This nurse heard resident say, move you f***ing c**t, Another resident was in their wheelchair behind the resident, (R19) was trying to back up into the other resident. This nurse intervened and was able to move the other resident safely. (R19) yelled, stating I asked her nicely to move. This nurse and other south nurse had conversation with (R19), letting him know this behavior is inappropriate, and that he can't talk to people like that, or attempt to push people out of the way. (R19) verbalized understanding, stating I asked her 5 times.The facility did not initiate enhanced supervision and R19's Care Plan was not updated with interventions for his new behavior of aggressive physical contact with other residents.Review of R19's Social Services Progress Note dated 2/18/26 revealed, Per nursing report, resident noted on 2/18/26 with inappropriate toileting (urinating in non-designated area). Resident has hx of poor judgment and behavioral concerns. SSD addressed behavior with resident with emphasis on hygiene, and appropriate toileting practices. Staff continues to closely monitor resident reinforce facility policies and provide reminders, cueing, monitoring, and redirection.The facility did not initiate enhanced supervision and R19's Care Plan was not updated/modified with interventions for his behavior of urinating in inappropriate areas. R19's urinating in non-designated areas care plan had not been updated with new interventions since 10/24/25.During an interview on 03/11/2026 at 12:05 PM, Social Service Director (SSD) S reported R19 has many behaviors and he frequently uses profanity at staff stating if staff look at him the wrong way and he says something. SSD S reported R19's behavior of using profanity at other residents had not been reported as verbal abuse. SSD S reported that a verbal altercation could be considered a form of abuse and it should have been investigated. SSD S reported she did not know what the follow-up was for his behavior of swearing at other residents.SSD S reported that interventions for his behaviors are redirection, limit setting, reality setting, identifying the root cause of frustration and changing out staff that have a better relationship with R19.During an interview on 03/11/2026 at 5:08 PM, SSD S reported that her progress note dated 1/31/26 was from secondhand information and could not confirm that R19 had used profanity at other residents. Regional Director of Operations (RDO) C reported that she would discuss with R19 alternate placement with less restrictions that may be a better fit for him. RDO C reported she would also look into his ability to be his own decision maker.Resident #91 (R91)Review of an admission Record revealed R91 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with severe agitation and behavioral disturbances.Review of a Complaint Investigation Report dated 10/17/25 the following anonymous complaint, .Complainant states that (R91) is very violent, and he resides in the Northeast Unit. Complainant states that (R91) has severe dementia, and he is supposed to be a one-on-one assist. Complainant states that (R91) has gone through the facility and smacked/kicked/punched residents and staff. Complainant states that it is unknown if residents have sustained injuries from this. Complainant states that (R91) pulls his pants down and pees in other residents' rooms while the residents are in there .Review of R91's behavior Care Plan initiated on 10/8/26 revealed, Resident has behavior(s) related to (SPECIFY: diagnosis/reason) as evidenced by: exit seeking, physically aggressive toward staff, resident uses 3-4 word sentencesReview of R91's IDT-Interdisciplinary Progress Note dated 10/8/2025 revealed, Resident having sundowners behaviors in the evening. Walking towards front door and attempting to exit in view of staff, they prevented any exiting. Was being combative with staff and was a 1:1 for a short time last night.The facility did not initiate enhanced supervision and R91's Care Plan was not updated with interventions for increased agitation/behaviors in the evening despite R91 requiring 1:1 supervision for a short time.Review of R91's IDT-Interdisciplinary Progress Note dated 10/10/2025 revealed, Resident is a 5 day hospice respite. Has confusion and behaviors. Increased behaviors in the evening/at night. Not redirectable. Social worker to speak to family about more appropriate placement.The facility did not initiate enhanced supervision and R91's Care Plan was not updated with interventions for increased agitation/behaviors in the evening.Review of R91's Pertinent Charting-Behavior note dated 10/10/2025 revealed, Continuously going into other residents' rooms. Pushes and slaps staff when they try to redirect. Resident is very confused and is unable to follow directions.The facility did not initiate enhanced supervision and R91's Care Plan was not updated with interventions to prevent R91 from entering other residents rooms.Resident #57 (R57)Review of an admission Record revealed R57 was a [AGE] year-old male, admitted to the facility on [DATE].Resident #85 (R85)Review of an admission Record revealed R85 was a [AGE] year-old female, admitted to the facility on [DATE].Review of an Incident Investigation Report dated 10/11/25 revealed, At approximately 7:30 pm on 10/11/25, (nurse-name omitted) called (name omitted), the Administrator and notified him the (R91) has had increased behaviors and struck (R57) in the forearm while holding a spoon as well as enter the rooms of (R1) and (R85) while naked. (R91) was immediately redirected and placed on a one on one. (R85) saying, Get out, get out of here. I turned around and saw (R91) in the room in front of (R85) with no shirt on, and his pants pulled down just above his knees. (R91) was approximately 2 - 3 ft into the room just staring at (R85). (R85) stated to me that she could tell someone was there that wasnt supposed to be, and that's why she was yelling for him to get out. I ran over to pull his pants up and redirected him back to his room.Investigation Summary: The investigation found that (R91) was assisted by staff back to his room, and the nurse placed her medication cart across from his door for increased supervision. (R91) was placed on a 1 on 1 for increased supervision.Review of R91's behavior Care Plan revealed revisions were completed following the incident of resident to resident abuse: .Staff 1:1 with resident revised on 10/11/25 Resident has behavior(s) related to (diagnosis/reason) as evidenced by: exit seeking, physically aggressive toward staff, verbal out bursting, rejection of care, refuses medications, wanders into other rooms. revised on 10/23/25Review of the Facility Assessment last updated 9/12/25 revealed the facility was assessed and able to care for, .Mental health and behavior (Specific Care or Practices) Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.

Based on interview and record review, the facility failed to ensure medications were administered in accordance with physician orders for 2 of 8 residents (Resident #6 and #8) reviewed for nursing professional standards of practice.Findings:Resident #6 (R6) Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety. Review of R6's Order Summary dated 8/13/26 revealed, LORazepam (Ativan) Tablet 0.5 MG Give 0.25 mg by mouth in the morning for anxiety Give 1/2 tab in the morning. Review of R6's Order Summary dated 8/12/26 revealed, LORazepam Tablet 0.5 MG Give 0.5 mg by mouth at bedtime for anxiety Give 1 tab PO at bedtime. Review of R6's Control Substance Record revealed that on 2/14/26 at 7:30 PM and 2/15/26 at 8:30 PM, R6 was dispensed Ativan 0.25 mg (1/2 tablet). Review of R6's February Medication Administration Record revealed that on 2/14/26 at 7:30 PM and 2/15/26 at 8:30 PM Ativan 0.5 mg (1 tablet) was documented as administered. Review of R6's Electronic Medical Record revealed no documentation pertaining to the incorrect doses of Ativan (0.25 MG) administered on 2/14/26 or 2/15/26. During an interview via email on 03/11/2026 at 1:24 PM, the Director of Nursing (DON) was provided with the information listed above with a request for documentation to invalidate the medication error. The DON confirmed R6's medication error on 2/14/26 or 2/15/26 and stated she, Initiated occurrence reports and will follow up with nurse education per policy. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 705). Elsevier Health Sciences. Kindle Edition. Resident #8 (R8)Review of an admission Record reflected R8 admitted to the facility with diagnoses that included paroxysmal atrial fibrillation (an irregular heart rhythm often caused by damage to the heart's electrical system). Review of R8's February 2026 Medication Administration Record reflected an order for Digoxin Tablet (a prescription medication used to treat heart failure and arrhythmias) 125 MCG (microgram) Give 1 tablet by mouth at bedtime for heart failure Hold if HR (heart rate) less than 60 (beats per minute) – Start Date- 11/10/2025. The MAR reflected the medication had been administered each day in February. No pulse was recorded on the MAR in the spaces provided. Review of R8's March 2026 MAR reflected the same digoxin order with the same parameters to hold if HR less than 60. The MAR revealed the medication was administered without recording a heart rate in the spaces provided March 1-March 8, 2026. Review of a Pulse Summary from January-March 2026 did not reflect R8's pulse was taken at the time of medication administration daily as ordered. During an interview on 3/11/2026 at 11:35 AM, the Director of Nursing (DON) reported that it would be a standard of care to assess a resident's pulse prior to administering Digoxin. The DON said the pulse (heart rate) should be recorded on the MARs but the order was entered incorrectly.

Based on interview and record review, the facility failed to obtain dental services to replace a missing lower denture in a timely manner for 1 resident (R10) out of 1 resident reviewed for dental services.Resident #10 (R10)Review of an admission Record reflected R10 admitted to the facility on [DATE] with diagnoses that included osteoporosis without current pathological fracture, depression and anxiety.Review of a Care Plan Report initiated on 10/15/2024 R10 has a dental problem related to being edentulous, with a goal of reduced complications related to dental/oral issues. Interventions included in the Care Plan included Refer to dental services as needed.During an interview on 3/09/2026 at 10:12 AM, R10 states that she lost the lower denture when she accidentally put them on a meal tray and they got thrown away. R10 indicated the Nursing Home Administrator (NHA) is aware and told her he wanted to wait to see what Medicaid would cover. R10 reported it's been a long time since she lost her lower denture, and she does not like to eat around others because of how she has to chew her food. Review of a Quality Assurance Form dated 1/7/2025 indicated (R10) reported she dropped her dentures yesterday and they broke. The form indicated that the lower denture could not be found and an appointment was made for 2/20/2025 at a dental clinic. It was not clear if the lower dentures were ever located. Review of a Quality Assurance Form dated 8/20/2025 indicated Bottom dentures lost-resident left them on a tray and didn't realize it, now they're gone. Was choking on the dentures at the time and took them out. About 3 months ago (when the dentures were lost). The Findings indicated the NHA Spoke with R10 about replacement of the dentures. Facility contacted dental office on getting a quote to see if Medicaid will cover replacement. If insurance will not cover, will reach out to the [NAME] to see if financial assistance if available. The dietitian wrote a note that reflects R10 had not had any unplanned weight loss as a result of the missing denture. Review of an email communication between the facility and the dental clinic dated 11/25/2025 (two months after the second concern form was created) reflected the dental clinic provided a ledger of R10's denture creation in 1/5/2024 as an estimate. Review of another email communication between the facility and the dental clinic dated 12/5/2025 reflected .Regarding (R10). We are trying to replace (R10's) bottom set of dentures for her as they are suspected to have gotten thrown away. I was wondering if there is any way you can send me an invoice just for those bottom dentures. The facility would really like to get them replaced for her but administration is asking for an invoice before we are able to do so. If you have any questions, please feel free to email or call me. I will be glad to help in any way I can. The reply from the dental clinic was received on 12/8/2025 that indicated the clinic was not able to print an invoice for a patient that did not have an outstanding balance. During an interview on 3/11/2026 at 11:40 AM, the Director of Nursing (DON) reported the facility would be responsible for replacing the lower denture if it had been thrown out after being put on a meal tray. During an interview of 3/11/2026 at 3:00 PM, the NHA reported that he did not have any evidence of communication with the tribal leaders related to financial assistance for replacing the denture.Review of a facility policy Dental Services revised 10/30/2023 reflected Routine and 24-hour emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. 6. The facility will promptly refer residents with lost or damaged dentures for dental services. Social Service staff/dietary manager or designee will document what was done to ensure the resident could still eat and drink adequately while awaiting dental services and will describe extenuating circumstances around the delay. 7. The facility shall no charge a resident for the loss or damage of dentures when it is determined to be the facilities responsibility. Circumstances when the loss or damage of dentures is the facility's responsibility are: a. facility staff personally handling, cleaning, or storing dentures when they are lost or damaged.

Based on interview and record review the facility failed to include the Interdisciplinary Team (IDT) and psychiatric provider in the process of the gradual dose reduction of an antipsychotic medication for 1 of 5 residents (Resident #83) reviewed for psychotropic medication use.Findings:Resident #83 (R83)Review of an admission Record revealed R83 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with agitation with psychotic disturbances.During an observation on 03/09/2026 at 10:33 AM, R83 was observed in the hallway loudly yelling, I want to get out! She continued to yell in the hallway and self-propelled herself in her wheelchair across the hall and attempted to enter room [ROOM NUMBER]. The resident in room [ROOM NUMBER] stated R83 was always yelling and attempting to enter other rooms. The resident reported her behaviors were constant.Review of R83's Psychiatry Follow-up note dated 1/13/26 revealed, GDR quetiapine (seroquel) 25 mg tablet. Diagnosis: Dementia with associated psychotic and/or agitated behaviors. Symptom(s): Other: agitation, yelling, wanting to leave.Practitioner response: A gradual dose reduction is contraindicated.In an effort to maintain behavioral symptoms this medication will be continued.I feel that the benefits of this medication outweigh the risks of adverse events for this resident.In an effort to maintain the current efficacy of Quetiapine and Donepezil and avoid the potential risk of an escalation in behaviors this medication will be continued.Review of R83's Physician Recommendations signed by the physician on 1/13/26 revealed, Quetiapine 25mg BID (twice a day) and 50mg HS (at night) for Dementia with associated psychotic and/or agitated behaviors since being increased 07/24/25.Resident with good response, maintain the current dose as a dosage reduction would likely cause unnecessary distress for the resident.Review of R83's Order Summary dated 1/15/26 revealed, QUEtiapine Fumarate (Seroquel) Oral Tablet 25 MG-Give 2 tablet by mouth at bedtime AND QUEtiapine Fumarate Oral Tablet 25 MG-Give 1 tablet by mouth in the morning.Review of the Physician Communication Binder located at the nurses station revealed a handwritten entry on 2/10/26 for R83 that (psychiatry consultation group) rec (recommends) GDR seroquel to 25mg BID (twice a day).Review of R83's Electronic Medical Record revealed no documentation that the contracted psychiatry group completed an assessment on R83 in February 2026.Review of the Physician Communication Binder revealed a handwritten entry on 2/11/26 for R83 Please don't reduce her seroquel again. She was miserable.Review of R83's Practitioner Note dated 2/12/26 revealed, .(R83) is an [AGE] year-old hospice patient with dementia with agitation and anxiety. She takes sertraline, Seroquel, Aricept, and Ativan.(Contracted psychiatry group) is recommending a gradual dose reduction of her Seroquel from 25 mg in the morning and 50 mg at bedtime to 25 mg twice daily. She has a history of a failed gradual dose reduction of Seroquel. We will monitor her anxiety, agitation, and psychosis .Review of R83's Pertinent Charting-Change in Condition note dated 2/13/26 revealed, Change identified: GDR of SeroquelAssessment: GDR Seroquel from 25mg po in am and 2 tabs at bedtime, changed to Seroquel 25mg po BID (twice a day).Review of R83's Order Summary dated 2/13/26 revealed, SEROquel Oral Tablet 25 MG Give 1 tablet by mouth two times a day.During an interview on 03/11/2026 at 12:05 PM, Social Service Director (SSD) S reported that the psychiatric consultation group conducts assessments and gives recommendations to either attempt a GDR or that a GDR would be contraindicated. SSD S confirmed that R83 had recently failed a GDR of seroquel and stated that the facility would not necessarily attempt again after a failed one and a decision would be made with the interdisciplinary team and the resident's representative to attempt the GDR again. SSD S reported she was unable to locate the psychiatric consultation groups recommendation from February but did recall discussing another attempt to GDR R83's seroquel in a recent behavioral meeting.During an interview on 3/11/2026 at 1:42 PM, Regional Director of Operations (RDO) C and SSD S reported that a GDR of R83's seroquel was attempted in December and in January it was determined that R83 had failed the reduction. At that time, R83's seroquel was increased to 25mg in the morning at 50mg at bedtime.During an interview on 03/11/2026 at 5:08 PM, RDO C confirmed that there was no psychiatric consultation completed in February for R83 and was unable to determine where the recommendation that the facility physician referenced originated or any other correlating documentation.During an interview on 03/11/2026 at 9:55 AM, Family Member (FM) T reported that he had noticed over the last month that R83 was less calm and more talkative. FM T reported he had noticed that R83 had been attempting to get out of her wheelchair more frequently. FM T reported he was aware of the recent GDR of seroquel in February and reported he felt more comfortable have the physician and management staff make the decisions on the appropriateness of the GDR stating, I leave it up to them to make the decisions they are the professionals.Review of R83's Pertinent Charting-Behavior dated 3/6/26 revealed, Behavior Displayed: restless, agitated, going in other residents room, bothering other residents.Precipitating factors/events: res (resident) kept going in other res room and bothering res by getting into their things and not wanting to leave their things alone, going up to other res and bothering them by constantly talking to them and when the res says they dont want to talk or doesnt respond res keeps on or trys (sic) to run into them with her wheelchair, or wont quit talking to them, res bothering res in the DR (dining room) by going around to the tables and talking and being disruptive.Intervention(s) attempted: res removed to a different table and redirectedIntervention results: res kept bothering/upsetting them by constantly (sic) talking and not being quiet when asked, res kept quiet once her food tray arrived.Review of the facility policy Use of Psychotropic Drugs and Gradual Dose Reductions last reviewed/revised 10/24/22 revealed, .Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated.3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team.15. For any individual who is receiving a psychotropic medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: a. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and 16. The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.

Based on observation, interview, and record review, the facility failed to perform a comprehensive root cause analysis and implement meaningful interventions/preventative measures following a fall for 1 of 9 residents (Resident #27) reviewed for accidents and hazards.Findings:Resident #27 (R27)Review of an admission Record revealed R27 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity. Further review of R27's admission Record on 3/10/26 at 2:24 PM revealed that R27's niece (Family Member [FM] P) was documented as his Responsible Party-Clinical and Emergency Contact #1.Review of a Minimum Data Set (MDS) assessment for R27, with a reference date of 3/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R27 was cognitively intact. Review of R27's Witnessed Fall incident report dated 2/24/26 revealed: Incident Description: Resident was on his right side with staff on both sides of his bed. This LPN (Licensed Practical Nurse [LPN] O) was changing the bandage on his left hip on the left side of his bed and his CNA (Certified Nursing Assistant [CNA] R) was on his right side. Resident said he was slipping then fell over his bed to the floor. CNA blocked the fall with his body as he slide (sic) to the floor. Was put back in bed with a hoyer lift. Said I told you I was slipping. Said his back hurt. Complaint of pain 8 out of 10 in his back. When asked if he wanted to be evaluated at the hospital he said no. Just took evening Norco prior to the fall. Given PRN Tizanidine for back spasms. Left toe had a skin tear. Toe was washed and bandaged. Doctor notified and ordered a back x-ray.Root cause: body habitus, air mattress, resident position in bed (prefers left side, was on right side).Intervention: monitor residents' position while doing treatments to reduce the risk of sliding and falling.Statement: (CNA R) He was assisting in turning resident so nurse could do dressing change. Resident was rolled to the right side. (CNA R) was standing right next to him holding him, he states the resident was holding the mobility bar and his belly area came over the edge of the air mattress and his legs started to come off the bed and the resident slid down the side of the bed, (CNA R) attempted to buffer the fall and assisted to lower him to the floor. The nurse attempted to come around the bed to help but it happened pretty fast.Review of R27's Standards of Care Meeting dated 2/25/26 revealed, Resident was in his bed getting dressing change to left hip. There was a nurse on his left side and a CENA on his right side. Resident stated he was slipping. He then slid out of bed to the floor. CENA blocked the fall with his body and the resident slid to the floor onto his stomach. Root cause: body habitus, air mattress, resident position in bed.Fall Follow Up Actions: Monitor resident's position when doing treatments to reduce the risk of sliding/falling.Name of Responsible Party Notified/Updated related to fall(s): (R27). FM P was not notified of the fall.Review of R27's fall Care Plan last revised 2/25/26 revealed, Resident is at risk for falls/injury related to dependent with transfers, morbid obesity, non ambulatory, weakness, legally blind, history of falls.Monitor resident's position during treatments to reduce the risk of sliding/falling. No other interventions were implemented.Review of R27's skin impairment Care Plan revealed, .APM (alternating pressure mattress) to bed Date Initiated: 09/11/2025. There were no specific details for the settings of the mattress.During an observation and interview on 03/11/2026 at 11:52 AM, R27's alternating pressure mattress was set on alternate every 10 minutes. There were options for alternate, Static, and Max Firm. The weight was set for 660 pounds. (R27's weight on 2/21/26 was 335.4 pounds) R27 was in bed on his back. Because of R27's size, there was minimal space between his left and right side and the edge of the bed, thus impeding the staff's ability to turn and reposition R27 due to lack of bed surface area.Review of R27's APM manufacturer's guideline revealed an option for static mode and max firm mode. Max Firm-Press to set the air mattress in quick inflation mode, which facilitates nursing and caring.During an interview on 3/11/26 at 11:58 AM, LPN O reported that she was completing a dressing change on one side of R27's bed and CNA R was on the other side holding him on his right side. LPN O reported that she believed that while he was on his side, he repositioned his legs causing one leg to go over the side of the bed and once that leg was over the edge of the bed gravity took over and caused him to fall. LPN O reported that she felt R27 needed a bigger bed because of his large size and the difficulty staff had with safely rolling him to his side away from the edge of the bed.During an interview on 03/11/26 2:30 PM, LPN O confirmed that R27 had an alternating pressure mattress. LPN O reported she was not aware of and had never used other modes on the mattress. LPN O reported she had never been told to use other functions. (static mode or max firm-stops the alternating movement and evenly distributes the support surface. Minimizing resident movement during treatments/care.)During an interview on 03/11/2026 at 3:55 PM, CNA R reported that he was assisting LPN O with R27's dressing change on 2/24/26 by holding R27 on his right side. CNA R reported they rolled him as usual which was difficult based on his large size and the inadequate size of the bed. CNA R reported there was minimal room to roll him because his body took up the entirety of the bed. CNA R reported that typically if a resident is to be rolled, they are pulled towards the opposite way they are to roll in order to keep them at the center of the bed. However, they were unable to do that for R27 which left him turned/positioned directly at the edge of the bed. CNA R reported that there was a slight change in his position which caused just enough of a shift that R27 fell off of the bed. CNA R was unable to determine if the shift was caused by the resident's movement or if the alternating pressure mattress caused the position change. CNA R reported that the CNAs do not touch the pressure settings of the mattress and he had not set it to any other modes. CNA R reported that R27 needed a larger bed to prevent another fall because there's no room to roll him.During an observation and interview on 03/11/2026 at 11:47 AM, R27 vividly remembered his fall and stated, it hurt me and still scares me now. R27 stated that at the time of his fall I told them to pay attention because I was slipping and then I hit the ground. R27 reported he felt that he could experience another fall because they (facility staff) haven't changed anything and haven't done anything different. R27 reported that he felt he needed a bigger mattress or additional side rails at his feet so my legs don't fall off. R27 reported that he would have wanted and expected the facility to notify his niece of his fall.During an interview on 03/11/2026 at 4:42 PM, Regional Director of Operations (RDO) C reported that R27 preferred his pressure mattress firm, and the Director of Nursing (DON) had documented a progress note and updated R27's care plan to reflect his preference.Review of R27's Nurses Note written by the DON and dated 3/11/26 at 2:22 PM revealed, Spoke with resident along with maintenance regarding his air mattress. Asked if he was comfortable on it and he stated yes he was. Asked if he felt it was too firm or too soft and he replied it's in the middle, asked if he was just right and he said yes. He stated he didn't want it changed it was just right and to keep it where it's at as he is comfortable with it.Review of R27's skin impairment Care Plan revealed, Focus.Requests APM mattress to be left on current setting at firm side for his comfort. Revision on: 03/11/2026.Adjust air mattress setting per resident request and comfort Date Initiated: 03/11/2026. There were no specific details for the settings of the mattress.Review of the facility's alternating pressure mattress selection (received 3/11/26 at 4:54 PM) revealed, .Routinely check the mattress and pump to ensure proper function, inflated properly, and the pump is set to alternating pressure with the static function used only for care.Review of the facility policy Fall Prevention Program last reviewed/revised 10/26/23 revealed, .4. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. 5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 6. When any resident experiences a fall, the facility will. d. Notify physician and family. e. Review the resident's care plan and update as indicated.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Positioning begins on one side of the bed so that turning to other side does not cause patient to roll toward edge of bed. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Air-assisted devices have a limitation. Once a transfer begins, the friction-reduction capability contributes to an increase in momentum, making it more difficult to stop the transfer. Use caution to be sure the patient does not slide beyond or even off the stretcher or bed . [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Specialty Air Beds: Bed surface material slippery; patients can easily slide down mattress or out of bed when being transferred. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

This citation pertains to intake #: 2646749Based on interview and record review, the facility failed to 1.) implement the facility policy for pressure injury prevention and management 2.) ensure pressure injury assessments were comprehensive and accurate, and 3.) ensure treatments were ordered and completed for 1 of 2 residents (Resident #27) reviewed for pressure injury prevention and management.Findings:Resident #27 (R27)Review of an admission Record revealed R27 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity. Further review of R27's admission Record on 3/10/26 at 2:24 PM revealed that R27's niece (Family Member [FM] P) was documented as his Responsible Party-Clinical and Emergency Contact #1.Review of a Minimum Data Set (MDS) assessment for R27, with a reference date of 3/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R27 was cognitively intact. Review of a Complaint Investigation Report dated 10/17/25 the following anonymous complaint, Complainant states that (R27) resides in the Northeast Unit. Complainant states that (R27) is obese, and the staff don't want to get him up because he is very big.so he has to lay in bed.Complainant states that he (R27) wants to be able to get out of bed.Review of R27's Occupational Therapy Note dated 3/4/26 revealed, .Bed Mobility Roll left and right=Dependent Review of R27's ADL (Activities of Daily Living) Care Plan revealed, Resident is dependent on staff for mobility Date Initiated: 06/11/2024.Review of R27's skin Care Plan revealed, .Encourage resident to reposition self if able Date Initiated: 09/08/2023. Encourage/assist as needed to elevate heels off the mattress as tolerated. Revision on: 12/05/2024. heel protector bilateral feet as tolerated. Revision on: 07/28/2025.Review of R27's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 2/20/26 revealed a score of 14, indicating R27 was at moderate risk for the development of a pressure injury. Sensory Perception: Slightly limited. Moisture: Very moist. Activity: Bedfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Adequate. Friction and shear: No apparent problem.During an observation on 03/09/2026 at 10:33 AM, R27 was in bed, on his back, with no repositioning devices (offloading wedge, pillow) in place.During an observation on 03/09/2026 at 2:31 PM, R27 was in bed, on his back, with no repositioning devices in place.During an observation on 03/09/2026 at 3:57 PM, R27 was in bed, on his back, with no repositioning devices in place.During an observation and interview on 03/10/2026 at 8:15 AM, R27 reported that staffing was an issue, reporting that there were insufficient staff and they don't get me up. R27 reported that following his readmission to the facility he was receiving therapy services stating, therapy wants me up and therapy was more effective when I'm out of bed. R27 stated he would get sore sitting in bed all the time and reported he had sores on his buttocks. R27 reported he needed assistance with repositioning stating he would ask for assistance with offloading/repositioning but it doesn't always get done. R27 was in bed on his back with no repositioning devices in place. There was a thin pillow on the floor between his bed and the window and wedges on his dresser. R27's heel protecting boots had fallen almost entirely off of his feet and were not protecting his heels (his heels were directly on the mattress.)During an observation and interview on 03/10/2026 at 1:38 PM, R27 was in bed on his back with no repositioning devices in place. His heel protectors were not in place, and his heels were directly on the mattress. R27 confirmed that he had not been repositioned or out of bed.During an observation on 03/10/2026 at 4:15 PM, R27 was in bed on his back with no repositioning devices in place. His heel protectors were not in place, and his heels were directly on the mattress.During an interview on 03/11/2026 at 8:09 AM, Licensed Practical Nurse (LPN) O reported that she and another staff member just boosted R27 up in bed for breakfast. LPN O reported that R27 had some skin breakdown on his left upper posterior thigh/lower left buttocks. LPN O reported that R27 required assistance with repositioning in bed and reported that R27 had gone downhill (declined) since his hospitalization from 2/10/26-2/20/26. LPN O reported that the CNAs (certified nursing assistants) were to reposition R27 every couple hours and reiterated that R27 required a lot of assistance with his care/repositioning. LPN O did not report that R27 would refuse care.During an observation on 03/11/2026 at 9:09 AM, R27 was in bed on his back. There was a thin pillow under his right side. He had heel protectors on, but he was positioned low in the bed, and his feet were resting on the footboard.Review of R27's Nursing readmission Evaluation dated 2/20/26 revealed R27 had a left buttock pressure injury. There was no assessment of R27's wound. (Per the Fundamentals of Nursing, comprehensive wound assessments are to include location, dimensions, description of wound bed, exudate type, exudate amount, presence of odor, wound edges, peri-wound assessment, tunneling/undermining, and pain.)Review of R27's Skin Assessment dated 2/20/26 revealed a new abnormal skin area on his left buttock-open area.Treatment initiated? Yes.Review of R27's Nursing readmission Evaluation dated 2/21/26 revealed R27 had a left buttock pressure injury and a sacral pressure injury.Review of R27's Skilled Charting dated 2/21/26 revealed his skin was intact.Review of R27's Skilled Charting dated 2/22/26 revealed R27's skin was not intact but only referenced Skin tears, abrasions, bruises. Pressure ulcer-any stage was not checked.Review of R27's Electronic Medical Record (EMR) revealed no documentation that the provider or FM P were notified of the newly identified pressure injuries on 2/20/26, 2/21/26, or 2/22/23.Review of R27's Order Summary and Treatment Administration Record revealed no new treatments initiated for the pressure injuries on 2/20/26, 2/21/26, or 2/22/23.Review of R27's Wound Assessment revealed no documentation that measurements, a wound description, or pictures were obtained for the pressure injuries on 2/20/26, 2/21/26, or 2/22/23.Review of R27's Skin Issues dated 2/23/26 revealed, Skin Issue: #001: New skin Issue. Location: Left Gluteal Fold. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound was present on admission. Painful: Yes. Wound pain (Frequency): At dressing. Pain description: Sharp. Wound pain interventions: Change in position . Length (cm): 0.85 Width (cm): 1.34 Depth (cm): 0.1.primary dressing: Medi honey Secondary dressing: Foam. Additional care: Incontinence management.Heel suspension/Protection device.Moisture control.Turning/repositioning program.Skin issue notification: Provider. Skin issue notification: Manager.Review of R27's Order Summary and Treatment Administration Record revealed, Cleanse left buttock with gauze and NS (normal saline), apply medihoney, and apply a 4x4 bordered foam dressing in the evening with a start date of 2/23/26. (3 days after the pressure injury was identified).Review of R27's Order Summary with a start date of 2/24/26 revealed, Cleanse wound to left buttock with normal saline and wound cleanser, pat dry, apply thin layer of Medi honey to wound bed, cover with a 2x2 silicone foam dressing. Followed by barrier cream around dressing every evening shift AND as needed.Review of R27's skin Care Plan on 3/10/26 at 3:00 PM revealed, Focus-Resident is at risk for impaired skin integrity related to severe morbid obesity, incontinence, DM (diabetes mellitus), CHF (congestive heart failure), PVD (peripheral vascular disease), lymphedema, history of healed pressure, venous and DM ulcers, prefers to be in bed most of the time. Revision on 06/11/2024.Interventions-assist with Turn and re-position upon rising, before and after meals, prior to bed, with care rounds during the night, and as resident allows. Revision on: 02/23/2026 and 03/05/2026. However, that intervention had been implemented and in place since 12/05/2024. R27's Care Plan did not reflect a turning/repositioning program following the wound assessment on 2/23/26 as directed.Review of R27's Skilled Charting dated 2/23/26 revealed R27's skin was not intact but only referenced Skin tears, abrasions, bruises. Pressure ulcer-any stage was not checked.Review of R27's Skilled Charting revealed no assessment was completed on 2/24/26.Review of R27's Skilled Charting dated 2/25/26 revealed his skin was intact.Review of R27's Skilled Charting dated 2/26/26 revealed R27's skin was not intact but only referenced Skin tears, abrasions, bruises and MASD (moisture acquired skin damage [i.e., rash, redness]). Pressure ulcer-any stage was not checked.Review of R27's Standards of Care Meeting dated 2/27/26 revealed R27 had a pressure injury identified upon readmission to the facility (readmitted on [DATE]). Provider notified? No. Responsible party notified related to wound(s)? No. Readmit with pressure area from hospital dr (doctor) notified on admission. wound care orders in place. Air mattress in place. Resident tends to favor that side.Review of R27's Skilled Charting dated 2/27/26 revealed his skin was intact.Review of R27's Skilled Charting dated 2/28/26 revealed his skin was intact.Review of R27's Skilled Charting revealed no assessment was completed on 3/1/26.Review of R27's EMR revealed he did not receive a dietary consult until 3/2/26 and the consult did not reference R27's pressure injury.Review of R27's Skin Issues dated 3/2/26 revealed, Skin Issue: #001: Skin issue is resolved.Review of R27's Skin Assessment dated 3/2/26 revealed, Lft (left) buttock wound, tx is in place. Indicating ongoing skin breakdown.R27's skin Care Plan focus was updated on 03/05/2026 to include prefers to not be repositioned, prefers to lean to the left side. Confirming R27's care plan was not updated with new interventions following the identification of the pressure injury. Only the focus was updated 13 days after the identification of the pressure injury.Review of R27's Skin Assessment dated 3/9/26 revealed, Lft buttock tx in place.Review of R27's Order Summary dated 2/23/26 revealed, Cleanse left buttock with gauze and NS, apply medihoney, and apply a 4x4 bordered foam dressing in the evening. This order was not discontinued until 3/10/26, indicating an ongoing area of breakdown.Review of R27's Bed Mobility Task revealed that from 2/20/26-3/10/26 R27 consistently required Extensive Assistance (resident involved in activity, staff provide weight-bearing support) to Total Dependence (Full staff performance).Review of R27's Bladder Elimination revealed that from 2/20/26-3/10/26 R27 was incontinent of urine for every entry except for 1 entry on 3/7/26 (increasing his risk of further skin breakdown).Review of R27's Bowel Elimination revealed that from 2/25/26-3/10/26 R27 was incontinent of his bowels for every entry except for 4 entries on 3/3/26, 3/4/26, 3/7/26, and 3/10/26 (increasing his risk of further skin breakdown).Review of R26's EMR revealed no documentation that R27 would refuse to be repositioned.During an interview on 03/11/2026 at 11:47 AM, R27 reported that his niece is his decision maker for medical and financial concerns. R27 reported that prior to his hospitalization (from 2/10/26-2/20/26) the facility was to notify his niece of any medical concerns. R27 reported that he wanted his niece to be involved with both his medical and financial decisions as he was unable to manage his care and finances independently any longer. R27 reported that he would have expected the facility to notify FM P pressure injuries upon his readmission to the facility. R27 reported that he continued to experience soreness on his buttocks.During an interview via email on 3/11/26 at 10:23 AM, the DON provided a Skin Timeline which revealed: 2/9/26 Resident had house ointment (zinc) to ischium buttocks.2/20/26 readmitted to the facility. admission skin assessment noted areas to Lt (left) buttock. Resident continued with house ointment (zinc).(confirming there was no treatment change for the newly identified pressure injury/worsening of the pressure injury).2/23/26 Wound nurse re-evaluated and per picture and measurements, wound remains unchanged and does not support stage 3 or decline in wound. Wound has 0.1 (cm) depth and no slough; not indicative of stage 3.N.O. (new order) received for wound treatment (confirming the delay in treatment).2/27/26 IDT (Interdisciplinary Team) reviewed and completed Wound SOC (Standards of Care). (The wound SOC did not identify the multiple contradicting notes regarding R27's pressure injury).3/2/26 Skin area closed within 11 days (confirming inaccurate assessments with Skin Assessment dated 3/9/26 showing ongoing concern OR ongoing breakdown with treatment continued from the order dated 2/23/26 until 3/10/26).3/5/26 IDT reviewed and completed Wound SOC.Review of the facility policy Pressure Injury Prevention and Management last reviewed/revised 1/1/22 revealed, .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care. f. Interventions will be documented in the care plan and communicated to all relevant staff. 5. Monitoring a. The attending physician will be notified of: i. The presence of a new pressure injury upon identification. 6. Modifications of Interventions. b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i. Changes in resident's degree of risk for developing a pressure injury.Review of the facility's alternating pressure mattress selection (received 3/11/26 at 4:54 PM) revealed, .Residents who have heel wounds need additional pressure relief interventions (i.e. boots, elevated surface) as a specialty mattress does not relieve heel pressure.

Based on interview and record review, the facility failed to ensure the resident's right to designate a representative was supported and accurately recorded in the medical record for 1 of 8 residents (Resident #27) reviewed for resident rights.Findings:Resident #27 (R27)Review of an admission Record revealed R27 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity.Review of a Minimum Data Set (MDS) assessment for R27, with a reference date of 3/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R27 was cognitively intact. Review of R27's Care Plan dated 9/8/23 revealed, Resident plans to stay long-term in the Skilled Nursing Facility.Actively involve the resident/family in the resident's plan of care.Encourage on-going involvement with family and friend(s).Review of R27's admission Record on 3/10/26 at 2:24 PM revealed that R27's niece (Family Member [FM] P) was documented as his Responsible Party-Clinical and Emergency Contact #1.During an interview on 03/11/2026 at 8:09 AM, Licensed Practical Nurse (LPN) O reported that R27 had gone downhill and declined since his return to the facility following his hospitalization. Indicating a need for increased family involvement in decision-making and care planning.Review of R27's Standards of Care Meeting dated 2/27/26 revealed R27 had a pressure injury identified upon readmission to the facility (readmitted on [DATE]).Review of R27's Standards of Care Meeting revealed R27 sustained a fall on 02/24/2026 at 5:30 PM. FM P was not notified of R27's fall.Review of R27's Electronic Medical Record revealed no documentation that FM P was notified of R27's pressure injury or fall.Review of R27's Advance Directive dated 2/11/26 revealed R27 had signed Durable Power of Attorney paperwork appointing FM P to make health care decision when he was no longer able to make decisions on his own.Review of R27's Palliative Care Note dated 2/13/26 revealed, There is an advance directive on file in (hospital computer system). This document names (FM P) as his sole health care advocate. When speaking with family, I shared my impression, in the (R27) does not appear that he's able to make his own medical decisions; however, I made family aware that a capacity assessment would have to be done by the Primary team.During an interview on 03/11/2026 at 11:47 AM, R27 reported that he wanted his niece (FM P) to be his medical and financial decision maker. R27 reported that prior to his hospitalization (from 2/10/26-2/20/26) the facility was to notify his niece of any medical concerns. R27 reported that he signed documentation when he was at the hospital for his niece to become his Durable Power of Attorney (DPOA) even though he was still cognitively intact. R27 reported that he wanted his niece to be involved with both his medical and financial decisions as he felt he was unable/unfit to manage his care and finances independently any longer.R27 reported that he would have expected the facility to notify his niece of his fall and his skin breakdown stating, that's what I signed for believing the documentation he signed at the hospital had activated her status as his DPOA. R27 confirmed that had been no discussion of FM P assuming the role of patient advocate following his readmission to the facility.During an interview on 03/11/2026 at 12:05 PM, Social Service Director (SSD) S reported she was not aware that R27 had signed Advance Directive paperwork at the hospital or his preference to have FM P more involved in his decision making and care.Review of R27's Electronic Medical Record revealed no documentation that the facility discussed with R27 his wishes to have his niece more involved and act as his patient advocate with both his financial and medical decisions following his return from the hospital. There was no documentation that his care plan was updated to reflect his preferences and/or goals for his niece and her increased participation in his care. There was no documentation that the facility provider addressed the palliative care note regarding his ability to make his own medical decisions.Review of R27's Care Plan initiated on 12/5/23 revealed, Focus-Resident has chosen not to formulate advanced care planning. Goal- Resident's preference will be honored through next review. Target Date: 03/13/2026. Interventions. Periodically review choice for no advanced care planning with resident/family.Review of R27's admission Record received from the Director of Nursing on 03/11/2026 at 10:23 AM revealed FM P was no longer listed as R27's Responsible Party-Clinical and was now only listed as Emergency Contact #1.Review of the Facility Assessment last updated 9/12/25 revealed, .Offer and assist resident and family caregivers (or other proxy as appropriate) to be involved in person-centered care planning and advance care planning .Review of the facility policy Fall Prevention Program last reviewed/revised 10/26/23 revealed, .6. When any resident experiences a fall, the facility will. d. Notify physician and family.Review of the facility policy Pressure Injury Prevention and Management last reviewed/revised 1/1/22 revealed, .e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, For patients experiencing acute or chronic illnesses, diseases, or trauma, patients' family members and surrogate decision makers become active partners in decision making and care .When possible, patients and family caregivers want to participate in shared decision making about treatment options and ongoing symptom management. Incorporating a patient's and family's cultural beliefs, values, and communication patterns is essential to provide individualized patient/family-centered care. When developing a plan of care, consider all resources available to patients. The family plays a key role .Engaging the family or designated surrogate is a fundamental skill of patient-centered care [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

This citation pertains to intake # 2646749Based on observation, interview and record review, the facility failed to provide timely care to one (Resident #33) of three residents reviewed for dignity. Findings: Resident #33 (R33) Review of a Face Sheet revealed R33 was an [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of dementia and a stroke that caused weakness to the left side of his body. R33 was dependent on one staff person for all activities of daily living. During an observation on 3/09/26 at 10:02 AM, R33 laid in bed resting with his eyes closed, knees bent, and his heels resting on the mattress. The room smelled strongly of feces. R33 laid in a large, dried area of diarrhea. During an interview on 3/09/26 at 10:15 AM, Certified Nurse Aide (CNA) F reported not checking on R33 since arriving on the unit at 7:00 AM. CNA F stated that she had not yet gotten to R33 due to being the only CNA on the north-east hall this am and the high acuity levels. During an observation on 3/09/26 at 10:22 AM CNA F and Registered Nurse (RN) H provided care to R33 and indicated that the stool was dried to R33's skin and this has been here quite a while. R33's buttocks were red and non-blanchable with no open areas noted.

Based on interview and record review the facility failed to assess and treat two residents (Resident #1 and Resident #2) for acute changes, out of four residents reviewed, resulting in the need for emergency medical attention for both residents. Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old-female, originally admitted to the facility on [DATE], with pertinent diagnoses of presence of a cardiac pacemaker, a prosthetic heart valve, and implanted cardiac defibrillator, morbid obesity, high blood pressure, chronic kidney disease stage 3, atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. Review of a physician progress note for R1, dated 06/27/25, reflected .(R1s) multiple medical issues necessitate frequent clinical evaluations, placing (R1) at moderate risk for readmission to the hospital without frequent monitoring and skilled intervention .frequent monitoring and management by trained clinicians is essential to safeguard (R1's) well-being, enhance recovery, and prevent clinical decline.Review of a Physician Progress Note for R1 dated 07/05/25 revealed .(R1) states she is having worse pain than when she arrived, complains of severe cramping deep in posterior (back side) of right leg .unable to palpate right pedal pulse (found on top part of the foot) .notified nurse who will speak with facility physician .recommend ultrasound to rule out a deep vein thrombosis (blood clot in the leg). During an interview on 08/29/25 at 9:11 AM, Registered Nurse (RN) A confirmed working and speaking with the provider on 07/05/25 about R1 and the concern with no right pedal pulse. RN A indicated that she also checked for a right pedal pulse and could not appreciate a pulse and stated that she did not check for additional pulses at the ankle or behind the knee. A STAT (immediately) ultrasound was ordered by the physician and placed into the computer by RN A. Review of an Ultrasound Order for R1 dated 07/05/25 at 11:54 AM revealed an order for a right lower leg doppler ultrasound and the priority was listed at ASAP (as soon as possible) and not STAT (immediately and without delay) as the physician had ordered. Review of R1's Electronic Health Record (EHR) showed the ultrasound was not completed prior to R1 going to the emergency room (ER) on 07/06/25. Further review of the EHR showed no nursing assessments nor evaluations of R1's right leg were completed prior to R1 going to the ER on [DATE]. During an interview on 08/29/25 at 8:17 AM, Licensed Practical Nurse (LPN) C stated that on 07/06/25 R1 told LPN C that her leg hurt, LPN C gave her a Norco (opioid pain medication), and R1 stated that her leg still hurt so LPN C sent her to the ER. That's all I remember.During an interview on 08/29/25 at 10:36 AM, R1 stated that the morning of 07/06/25 she woke up and her right leg was blue and cold. The nurse did not look at my leg, instead gave me a Norco. I told the aide an hour later that it was not any better and the aide came back and told me that the nurse was busy with other residents and that I needed to let the medication work. R1 then stated that the wound nurse came into her room after 2:00 PM and R1 told that nurse what was happening with her right leg. The wound nurse looked at my leg, told me not to move, and they were quickly sending me to the hospital. I had to have emergency surgery to save my leg. R1 stated that she felt like the nurse ignored her concerns and did not assess the problem. Review of an SBAR communication Form for R1, dated 07/06/25 and written by LPN C reflected: (a) resident requesting to go to emergency room, feels she may have a blood clot behind her knee, (b) other relevant findings .resident assessed. No additional information was documented regarding an assessment of the right leg and the status of circulation, i.e., color and temperature of the skin, capillary refill time, whether pulses could be felt in the right leg, (c) that a STAT ultrasound of R1's right leg had been ordered by the physician on 07/05/25 and had not yet been completed, and (d) RN assessment-what do you think is going on with the resident, LPN C documented UTI (urinary tract infection). Review of emergency room progress notes for R1 dated 07/06/25 at 3:30 PM revealed . acute right lower limb ischemia (lack of blood flow) .right leg pain with pallor (pale), coolness, unable to palpate distal pulses and unable to obtain pulses with a doppler .will emergently obtain a CT of the pelvis to rule out an occluded artery. Contacted (a level 1 trauma hospital in Grand Rapids) and we reviewed the films, R1 had a complete occlusion (blockage) of the right iliac artery the main blood supply to the lower leg and located at the top of the leg in the groin area). Unfortunately, Aero Med is not flying at this time because of bad weather. We will initiate a priority 1 transfer for immediate vascular surgery. Resident #2 (R2)Review of an admission Record revealed R2 was a [AGE] year-old-female, last admitted to the facility on [DATE], with pertinent diagnoses of multiple sclerosis and constipation. Review of a bowel elimination task monitoring for R2, completed each shift by direct care staff, reflected R2 had a medium size bowel movement the afternoon of 08/15/25. R2 did not have another bowel movement until the early morning of 08/18/25, which was documented as small in size. This was the last documented bowel movement before R2 was urgently sent to the hospital on [DATE]. (18 shifts between bowel movements). Review of an electronic medication administration record (Emar) for R2, dated August 2025, reflected the following PRN (as needed) orders for bowel protocol: (a) Milk of Magnesia give 30 milliliters (ml's) by mouth every 72 hours as needed for no bowel movement for 3 days, (b) Dulcolax Suppository as needed for constipation if no result from Milk of Magnesium after 9 shifts, (c) Fleets Mineral Oil enema if no result from Dulcolax after 10 shifts and if no results call the doctor. Documentation revealed none of the above listed medications were administered to R2 nor was the doctor notified. Review of a Transfer Form for R2 dated 08/24/25 at 1:00 PM revealed R2 was sent to the hospital for abdominal distention and rigidity with brown emesis (vomit) and nausea. Review of a Hospital Progress Note dated 08/27/25 reflected that R2 had extreme constipation with large stool burden and distal impaction.During an interview on 08/29/25 at 9:30 AM, the Director of Nursing stated the facility became aware of the bowel management concern with R2 yesterday (08/28/25) and were looking into the matter.

This citation pertains to Intake 1268402Based on observations, interview, and record review, the facility failed to ensure 1 resident (Resident#1) of 3 was free from verbal abuse when a staff member swore about the resident's behavior. Findings include:Review of Policy Abuse, Neglect and Exploitation last revised 1/10/24 revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy defined Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Findings:Review of an admission Record reflected Resident #1 (R1) admitted to the facility with pertinent diagnoses that include Bipolar Disorder, Obsessive Compulsive Disorder, persistent mood disorder, anxiety disorder and frontal lobe and executive function deficit (Damage to the frontal lobe can lead to deficits in functions resulting in difficulties with planning, organization, decision-making and emotional regulation.)During an interview on 7/08/25 at 9:10 AM, DON revealed R1 is behavioral, has hoarding tendencies, he scrubs his body raw while cleaning himself using the bathroom sink and floods the flooring. DON further revealed resident is afraid of the dark/night, has poor eyesight, is derogatory towards women, a germaphobe, and is followed by CMH (Community Mental Health).During an interview on 7/08/25 at 11:30 AM, NHA & DON provided past non-compliance for this intake. DON stated, We wrote ourselves up. On 7/08/2025 at 12:10 PM, Lunch was observed being delivered to R1's room. Resident was observed in bed wearing a brief and sheet. During the interview R1 stated, I am a sick, sick man. Staff come when I do not want to see them and don't come when I want to see them. Resident#1 was asked if staff came when he pushed his call light. R1 replied, of course staff come when I push my call light, they have to, it's their job. The resident further revealed he did not like 3rd shift, and that he did have a problem with someone, but she's gone. They have to wait on me and do everything I say cause it's their job. (Resident#1 became very loud and agitated during the interview.) Interview concluded when R1 started muttering under his breath, I'm done, done, done.During an observation/interview on 7/08/25 at approximately 12:15 PM, R1's Guardian D was observed sitting in a chair and stated, He is in a bad mood today. He is acting like he can't hear a thing. R1's Guardian D states her son likes the staff; he just does not like nights. Staff are very good overall & I have no issues with them communicating with me. She further stated that he needs to go away for a psyche stay. Review of an Incident Report dated 5/24/25 reflected that Certified Nurse Aide (CNA) L and Registered Nurse (RN) K witnessed/heard R1 yelling and swearing at CNA J in his room and the hallway about ice and ice water. R1 further yelled to CNA J she was to listen to him and no one else. CNA J responded to R1 stating you have the wrong butt wiper, and I don't F*cking care. CNA J then shut R1's door and walked to the desk. The report reflected initial actions taken were to ensure R1's safety, contact NHA, DON and guardian, remove/suspend staff member (CNA J), assess the resident and collect statements. Review of CNA J's written statement 5/23/25 at 12:30AM, I answered his call light with ice water in hand. I had gloves on, he opened the lid to the cup and said there is only four cubes in there, but the cup was full of ice, and so he was getting upset, I walked to his bathroom and cleaned up the wet linen and dried up the wet floor. He wanted a cup with just ice so I came out to get his ice and when I came back to his room the nurse was talking to me, and the resident was still in bed yelling at me about the ice. I couldn't hear the nurse, so I told him to wait a minute because I was talking to the nurse. He didn't like that and started yelling and cursing at me and saying I'm to only listen to him and no one else. So, I spoke his language and said I didn't F*cking care, and he didn't have to yell at me like that. He says I hurt him, but I don't see how, I was never close to him.Review of CNA L's handwritten statement on 5/24/25 at 12:30 AM, CNA L wrote I was sitting at the nurses' station when she heard patient and (Name of) CNA J arguing about ice in a cup. CNA L stated she was trying to tell CNA J how he liked it when he yelled to (Name of CNA J) to listen to him and not out there. She responded you got the wrong butt wiper. I don't F*cking care. As the patient was yelling, she shut the door and walked to the desk. He came out and stuck his head out yelling at her to get him ice and she needed to call (Name of NHA) and if she doesn't, he was going to call the police. She said, ok you do that and shut the door while he was by it. CNA L further stated I did not see if the door hit him or pulled him when she pulled the door shut. But he started yelling and screaming that she hurt his bad arm when she shut the door. As soon as this happened (Name of RN K) then went in and checked on patient. Patient was on the phone with his mom. Review RN K's written statement dated 5/24/25 at 12:30AM, I was sitting at nurse's station when I heard the patient and CNA ( J) start arguing about ice water. He was still yelling at her, and she told him he has got the wrong butt wiper, and she don't f*cking care. He said to get him ice, and she needed to call (Name of NHA), or he was going to call the police then she stated you go ahead and do that I don't care. She grabbed the door and shut it, he was on the other side shutting it and claimed it hurt his left inner arm. Because of it being slammed shut. RN K reported she talked to patient's mom, NHA and DON.Review of Certified Nurse Aide (CNA) M's written statement dated 5/24/25 (no time provided) I was charting on North and heard yelling coming from South, then I heard a door slam on South. I told my nurse (Name of Registered Nurse (RN) N) on North that something's going down there!Review of RN N's written statement dated 5/24/25(No time provided) I heard a man yelling from South. Could not understand what was being said.Review of a Facility Reported Incident (FRI) dated 5/24/25 reflected the facility reported an allegation of staff to resident abuse on 5/24/25 and the facility substantiated verbal abuse based on employee admission and corroborating witness accounts. No physical abuse was substantiated following medical assessment, reenactment, and resident report.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:1. On 5/24/25 at approximately 1:30 AM, it was reported to the facility administrator that resident (Name of R1), wasn't a verbal altercation with the staff member (Name of CNA J). (Name of) CNA J was immediately suspended pending investigation. Dr. and Guardian notified.2. On 5/24, 5/25 and 5/26 skin and pain assessments were completed. No new concerns identified. 3. On 5/24/25 at 2:45 AM the incident was reported to the state by the facility administrator.4. On 5/24/25 Witness statements from staff were gathered.5. On 5/24/25 Residents in the immediate vicinity were interviewed regarding the incident. No Concerns identified.6. On 5/24/25 at approximately 11:00 AM DON and the Administrator spoke with the resident's mother/guardian, the witness statement completed.7. On 5/26/25 IDT review of resident Care Plan. Updated it with water preference and added a laundry basket to the resident room. It was determined that Resident's linen situation and water preference could increase his behaviors.8. 5/26/25 an audit of (Name of CNA J's) file was conducted. No concerns were identified.9. 5/26/25 Abuse PNC in place, residents with BIM's (Brief Interview for Mental Status) score >10 and staff audits are being conducted.10. 5/28/25 NHA and DON reviewed the policy and procedure for Abuse, neglect and Exploitation and deemed it appropriate.11. 5/29/25 An AD_HOC QAPI meeting was held and reviewed the abuse PNC plan.12. 5/30/25 [NAME] Police Department Notified and investigated.13. 6/2/25 Facility substantiated verbal abuse and (Name of CNA J) was terminated. On 7/09/2025, this surveyor reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was cited by the state agency as of 6/02/2025.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intakes M100151387 and M100151421. Based on observation, interview and record review, the facility failed to prevent hospitalization , monitor, assess, intervene, document, and provide appropriate care of nephrostomy tubes for 2 (R1 and R2) of two residents reviewed for nephrostomy care, resulting in hospitalization and infection. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] and readmitted to the facility after a hospitalization on [DATE]. Pertinent diagnoses include hydronephrosis (urine build up on kidney) with renal and ureteral calculous (kidney stones) obstruction (1/14/23), infection and inflammatory reaction due to nephrostomy catheter (3/31/25), acute pyelonephritis (kidney infection) (3/31/25), urinary tract infection (3/31/25), and Escherichia coli (E. coli, a bacterium that causes infection, 3/31/25). Review of the Minimum Data Set (MDS) dated [DATE] for R1 revealed she is cognitively intact had an assessment for mood/depression score of 00. No behaviors documented and required substantial/maximum assistance with lower body dressing and toileting. In an interview on 4/15/25 at 1:30 PM, the Registered Nurse (RN) A reported R1 had been in the hospital several times in the last few months to have her nephrostomy tube (catheter) replaced and expressed concern the facility is not competently providing nephrostomy care. On 3/20/25, R1 went to the hospital and the 3-way stopcock on the nephrostomy tube was in the off position and not draining. The exit site was red and had some drainage as well. Once the stopcock was opened, they were able to drain about a half liter of puss like drainage that later tested positive for E. coli bacterial infection. R1 was then transferred to another hospital for an inpatient stay for antibiotic therapy and monitoring. RN A reported R1 had a nephrostomy tube placed on 10/27/24 and exchanged on 11/20/24, exchanged again on 12/4/24, new replacement on 1/11/25 because it may have been pulled out, on 1/16/25 it was checked, changed and repositioned, on 2/5/24 it was dislodged, and 2 sutures were put in place. On 2/25/25 the facility called them about a suture not being intact with redness at the exit site and she had low urine output and was to go to Big Rapids and not sure if R1 went. On 3/11/25 the nurse at the facility called with concerns about the nephrostomy tube for R1 and then R1 was sent to the hospital on 3/20/25. The resident could not speak. Review of the Hospital Medical Records for R1 revealed: History of Present Illness: . chronic severe right hydronephrosis who had an IR (Interventional) appointment today to look at her nephrostomy tube which was found to not be draining, they replaced it and had 548 mL (milliliters) of purulent urine. Apparently, there was some concern about a possible fistula between the renal pelvis and duodenum and was sent to the emergency department for limited CT scan. Interventional Radiology documented: Findings: The stitches holding the nephrostomy catheter are noted to be intact. The stopcock was in the off position and purulent drainage was noted around the catheter. Aspiration yielded 540 cc (cubic centimeters) of green, purulent fluid. A sample was sent for culture. Impression: The nephrostomy tube was noted to be in the off position with purulent material draining from around the catheter. A large volume of purulent fluid was evacuated from the kidney. Contrast injection revealed a possible fistula between the renal pelvis and duodenum. Pictures provided revealed R1 had redness and drainage at the exit site upon arrival to the hospital. R1 had a low blood pressure of 98/43 and afebrile. (Not documented in the facility medical records.) Review of Hospital medical records for R1's hospital stay from 3/20/25 to 3/31/25 revealed: In regards to her pyelonephritis, she has a heavily infected kidney with frank purulence. She was identified to have ESBL (Extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales are resistant to common antibiotics and may require complex treatments) producing E coli. She was seen in consultation with the infectious disease team and was started on meropenem as well as micafungin. The interventional radiology team, recommended flushing the tube, to help with drainage. Given the extent of infection as well as the concern for renal duodenal fistula, Urology was consulted, ultimately it was decided from Urology standpoint the patient was not felt to be a surgical candidate. Infectious Disease recommended changing from meropenem (broad spectrum antibiotic) and micafungin (antifungal) to ertapenem (antibiotic for severe infections). They recommended therapy through 3/31. There was discussion about PICC (peripherally inserted central catheter) line and outpatient IV (intravenous) ertapenem, but given limited access with HD (hemodialysis), she was kept inpatient to complete her abx (antibiotics) therapy. This was done without complication. No further concerns about fistula. Patient clinically improved with abx. Review of the Electronic Medical Records (EMR) for R1 revealed no ongoing assessing, monitoring, or output of nephrology tubing and exit site care. Review of the January Medication/Treatment Administration Record (MAR/TAR) for R1 revealed an order for a nephrostomy dressing change dated 11/20/24 to 2/6/25 25 Change Nephrostomy drain dressing daily, clean site with soap and water, apply a small amount of triple antibiotic, Cover with gauze. May shower-do not bath or submerge tube underwater. Change tube attachment or tape as needed to keep from pulling on tube. in the evening for Nephrostomy care. Care was documented/not documented as done on 1/7 (sleeping), 1/10 (no data entry), 1/11 (hospital), 1/13 (no data entry), 1/16 (other see nurses notes), 1/23 (other, see nurses notes), 1/24 (sleeping). Review of the Nursing Progress notes revealed no documentation to reflect 1/13, on 1/16 the nurse documented R1 was sleeping at this time and no follow up, and 1/23 no follow up documentation. Review of the Nursing Progress notes dated 1/10/25 for R1 revealed the resident went to dialysis and pulled out her nephrostomy tubing. On 1/11/25 R1 had it replaced. Review of the February Medication/Treatment Administration Record (MAR/TAR) for R1 revealed an order dated 11/20/24 to 2/6/25 Change Nephrostomy drain dressing daily, clean site with soap and water, apply a small amount of triple antibiotic, Cover with gauze. May shower-do not bath or submerge tube underwater. Change tube attachment or tape as needed to keep from pulling on tube. in the evening for Nephrostomy care. Care was documented/not documented as done on 2/7, 2/10, 2/11, 2/13, 2/16, 2/23, and 3/7. -An order for R1 dated 11/20/25 and discontinued on 2/6/25 to Empty and record nephrostomy drain and record output every shift. No documentation indicating the nephrostomy output was being monitored. No follow up documentation in the EMR to show any concerns of drainage or redness at the exit site before hospitalization on [DATE]. Review of the March MAR/TAR for R1 revealed a continued order from February for dressing changes every other day and was discontinued on 3/11/25. A new order started on 3/12/25 to: Change the right Nephrostomy dressing, Do not pull on the tube. Do not use scissors for the dressing because you could cut the tube or the stitch. Wash the area with mild soap and water, rinse, and pat dry with a clean Washcloth. Look at the site after your dressing is removed. Check for redness around the tube exit site. Check for any discolored or odor. Inspect the suture to verify that it is still anchored in the skin. Place gauze around the tube where it exits the body and cover Tegaderm (sic) in the evening every other day. On 3/10 (sleeping, no follow up documentation or reapproached). After the dressing change on 3/8/25, the next dressing change was 3/12/25. -No orders to document or monitor the output from the nephrostomy tubing. Review of the April MAR/TAR for R1 revealed she had an order for a nephrostomy dressing change every other day and received a dressing change on 4/1/25 after readmission from the hospital. On 4/3 (refused), no documentation as to why and if reapproached, 4/5 (see nursing notes) and no nursing progress notes documented, 4/7 (sleeping) and no progress notes reflecting the resident was reapproached. R1 did not receive any dressing changes after 4/1/24 until 4/9/25. On 4/11 no dressing change was done, and the nursing progress notes reflected the nephrostomy tubing was out about 5 centimeters on 4/9/25 and 10 cm by 4/10/25 and documented as dislodged by the end of the day. No root cause documented, no anchoring or securing devices was documented as used and no frequent supervision of cares. -An order 4/1/25 to Record output to nephrostomy. Notify MD (physician) any abnormal urine output and change in Urine (cloudy, foul-smell, or bloody) every shift. Between 4/1 and 4/17 there were 30 shifts of 0 output and on 4/14 it is documented as n/a, See Nurses Notes. There were no nursing notes for 4/14/25. Review of a Nursing Progress note dated 4/9/25 for R1 revealed: nephrostoy (sic) tube appears to be pulled out approx. 5 cm (centimeters) as stitch is approx. that far out. Drng (dressing) (sic) is the bag, approx. 5 ml. Nephrologist paged via number on (R1's chart at this time. (R1) has no c/o (complaints of) pain, no bleeding, drng (sic) or redness at nephrostomy site. Review of a Nursing Progress note for R1 dated 4/9/25 revealed the on-call facility provider was notified her nephrostomy tube concerns and requested to watch closely and if the tube dislodges or has any drainage to call them immediately. Review of a Nursing Progress note dated 4/10/25 for R1 revealed advanced radiology was notified her nephrostomy tubing is out about 10 cm now and the sutures are no longer intact with no c/o (complaints of) pain or discomfort and very little output. Radiology to get an appointment as soon as possible. No more nursing progress notes addressing concern or if the resident was sent out to have her nephrostomy tube replaced. No follow up assessments. Review of a Skilled Daily-Medically Complex document dated 4/10/25 for R1 revealed: nephrostomy output appears clear to turbid light. without obvious red. resident denies pain. site without redness or site drainage. (sic) Review of a Medicare Coverage Evaluation for R1 dated 4/16/25 revealed: Dressing change ordered to nephrostomy site. Monitor amount of drainage. Nephrostomy tube became dislodged on 4/10/25, sent out to have it replaced in GR (Grand Rapids hospital). During an observation and an interview on 4/16/25 at 1:30 PM, RN C went to R1's room and reported her nephrostomy bag was draining because the pigtail of the stopcock was pointing towards the injection/flushing port even though we just saw another resident who had her nephrostomy stopcock pigtail pointing towards the drain bag tubing. RN C reported R1's dressing (which was an undated 22 gauze with tape and the tubing was not secured) and RN C reported her stitches securing the tubing was fine. The resident was lying in bed, and her pants were partially over the nephrostomy, but under the exit site potentially tugging on the tubing. In an interview on 4/16/25 at approximately 1:40 PM, RN B reported she has not heard of any concerns with R1 having her nephrology tubing displaced or replaced recently. RN B reported she did not know who last changed the nephrostomy dressing and acknowledged there was no date on it. RN B reiterated an earlier conversation of staff not getting treatments done as ordered and at times they are documenting they are done even if they did not complete them. RN B reported management is aware of concerns. In an interview on 4/16/25 at 3:33 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) H reported R1 has pulled out her nephrostomy catheter several times because she has OCD (obsessive compulsive disorder, not listed as a diagnosis for R1 on her Face Sheet). UM H continued alleging R1 is non-compliant. UM H reported R1 had her nephrostomy tubing dislodged on 4/10 and went to [name of another city where second hospital was located] on 4/11 to have her tubing replaced. When asked if anchoring her tubing would help, UM H reported there is no order for one and did not think it would help. When queried about the hospitalization in March, UM H reported she did not know why R1 went into the hospital and started looking into the computer. UM H reported she is the Unit Manager but gets pulled to the floor to work often implying that is why she did not know what is going on with R1 and reiterated she has had her catheter dislodged several times but didn't know all the details. When asked about the lack of charting of care, assessments, and transfers outside the facility for R1 in the EMR, UM H reported she herself would put in a progress note and verified there was no transfer form in the computer when R1 went to the hospital on 3/20/25 and 4/11/25. UM H reported residents do not get a transfer form for outside appointments, but the MAR and the Face Sheet will get with the resident and the last set of vital signs. When asked about the standards of care for nephrostomy's, UM H reported the doctors do not usually order output monitoring unless the nurses ask for them and elaborated that after this last hospitalization , she did add the output monitoring to the nurses charting. UM H was questioned about the 0 output documented in the MAR and said they did not have parameters to notify the physician but expected nurses to know when to notify the physician for anything abnormal. When asked about the nurses being educated on nephrostomy care, UM H reported they get educated but thinks they may need more. When questioned about the stopcocks on the nephrostomy bags for R1 and R2, UM H reported that if there are instructions, they will put those instructions in the order as what needs to be done or will put them in an education binder for the nurses. During an observation and an interview on 4/16/25 at 3:35 PM, the Unit Manager/Licensed Practical Nurse (LPN) H was asked about the nephrology tubing for R1 and reported the pig tail of the stop cock was pointing toward the flushing/irrigation port. At this time, UM H did not know if the stopcock was opened or closed to draining. Resident #2 (R2) Review of a Face Sheet revealed R2 originally admitted to the facility on [DATE] and readmitted after a hospitalization on [DATE] and has pertinent diagnoses of Urinary tract infection, bacteremia (blood infection), methicillin resistant staphylococcus aureus infection, multiple sclerosis, hydronephrosis. During an observation and an interview on 4/16/25 at 11:35 AM, R2 was in bed and her nephrostomy tube was on her right side and R2 reported that hardly anything comes out. RN B reported the stopcock on the nephrostomy tube was draining and can tell the tubing is stable. The pigtail of the stop cock was facing the tubing of the drain bag. During an observation and an interview on 4/16/25 at 1:30 PM, RN C went to R2's room and reported the nephrostomy bag was draining because the pigtail of the stopcock was pointing toward the tubing of the drain bag which means it is on. During an observation and an interview on 4/16/25 at 3:25 PM, the Unit Manager/Licensed Practical Nurse (LPN) H was asked about the nephrostomy tubing for R2 and asked this surveyor if the attending nurse was questioned. When UM H was asked to look at R2's nephrostomy tubing, UM H looked at the stopcock and verified the pigtail of the stopcock was pointing toward the drain bag and said she would have to get her bifocals to read if it says it is in the off position because she was not sure at this time. When asked what a typical assessment would include, UM H reported the drainage and any color, pain, discomfort, sediment, and would look at the exit site. When asked what an abnormal reporting for this resident would be and what the expectations of staff would be, she reported she would document her findings, look at the history. UM H did report there was some scant sediment in the drain bag and small amount of blood fluid in the tubing, but no measurable amount of body fluid at this time. Review of the April MAR/TAR for R2 revealed an order to Empty nephrostomy bag and enter amount every shift dated 4/7/25 revealed until 4/17/25 there are 22 shifts of 0 output from the nephrostomy bag and one shift with no documentation. The highest output was 40 ml (milliliters) on 4/7/25 when the monitoring began post hospitalization . On the 4/17/25 night shift, after questioning the nephrostomy care, 575 ml of fluid output was documented. In an interview on 4/16/25 at 5:00 PM, UM H reported that stopcock for R1 which had the pig tail pointing towards the irrigation port was not in the right position and will educate her staff on the correct position which is towards the drain bag like it was for R2. Review of the Care Plan for R2 revealed no nephrostomy care plan or interventions. In an interview on 4/17/25 at 1:21 PM, the Director of Nursing (DON) reported they educated the nurses yesterday and all the nurses today before they start their shift on nephrostomy care and reported the nurses could demonstrate the appropriate positioning of a nephrostomy stopcock. The DON reported R1 has a history of pulling out her nephrostomy tubing and is always fidgeting with it. R1 and R2 are dialysis patients, and it is hard to know how much urine output they will have. The DON reported R1 is OCD with her tubes and other devices she has and just cannot leave them alone. The UM H made sure her dressing was secured with a Tegaderm, and the tubing was anchored well yesterday. The DON verified the dressing is to be secured with a Tegaderm and acknowledged it was not. The DON reported she thought there was an order to anchor the nephrostomy tubing in place but could not find it. When asked if dressings should be dated, the DON reported it is preferred. When asked if there were concerns that staff reported dressing changes were not being done but were charting, they were? The DON reported it had been a while but did not have anything solid to prove the nurses were doing this. When asked what was included in the nephrostomy care education the day before, the DON was to provide the information and reported the staff know which position the stopcock should be in to drain the nephrostomy. During an observation on 4/17/25 at 1:45 PM, Licensed Practical Nurse (LPN) I and surveyor went to R2's room and verified the stopcock was pointing towards the drain bag which meant that it is draining. Afterward, LPN I verified the stopcock was pointed toward the drain bag and said it was draining, but not confidently, with a little blood-tinged urine noticed in the bag. In an interview on 4/17/25 at 2:00 PM, the RN A reported the pigtail of the stopcock is the off position. Wherever that pigtail is pointing, that means it is blocking the flow to that area. It should always be pointing toward the irrigation port so the nephrostomy tubing can drain to the bag. RN A then reported if it is pointing toward the drain bag, it is not draining. In an interview on 2/17/25 at 2:19 PM, the DON reported she went to R2's room and saw the pigtail of the stopcock was pointed towards the drain bag and R1's pigtail was pointed towards the port. The DON reported UM H misunderstood what position the stopcock needed to be in and is going around re-educating staff right now. In an interview on 2/17/25 at 2:30 PM, the facility Staff Educator/RN U reported the staff were educated yesterday on the correct positioning of the stopcock for R1 and R2 and the pigtail should be pointing towards the flushing port. RN U reported she knew this yesterday and educated the staff by showing them a picture. RN U reported she went to R1's room yesterday and the stopcock was in the correct position, but today it was pointing towards the drain bag indicating it is not open. RN U reported she educated the staff and the Unit Manager by reviewing the policy and talking about it. The Unit Manager misunderstood and those she educated, were informed wrong. Today, the started to re-educate staff again with pictures of the stopcock and that the pigtail should always be pointed toward the flushing port for draining into the bag. Review of a policy titled Nephrostomy and Cystostomy Tube Care and Maintenance last revised on 1/1/22 revealed: Residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1.As part of the comprehensive assessment and care planning process, the type of tube will be clearly documented in the resident's medical record. When the type of tube is not clear, the nurse will call the surgeon, other physicians, family members, or other individuals, as needed, to make the determination. 2.The care and maintenance of nephrostomy/cystostomy tubes shall be in accordance with physician orders. The orders shall specify the type and frequency of dressing changes and emptying of collection bags along with any special instructions. 3.Nephrostomy/cystostomy tubes shall be managed by licensed nurses. Nurse aides may handle the collection bags in accordance with facility procedures for handling urinary drainage bags. 4.The resident's goals and preferences for care and treatment of the tube(s) will be used to formulate a plan of care (i.e. self-care, dependent care, family caregiver). Interventions may include but are not limited to: a. Frequency of dressing changes and emptying of collection bags. b. Self/family care instructions, where applicable. c. Monitoring for and responding to any signs of resident's discomfort associated with the tube(s). d. Interventions to prevent complications or promote dignity associated with the tube(s). I. Fluid preferences, and need for increased fluid intake. ii. Monitoring for symptoms of blockage (reduced or absent urinary output), urinary tract infection (fever, chills, back pain, new onset delirium, foul smelling or cloudy urine), or dislodgement (tube falls out, leaking urine around tube, increase in tube length). iii. Monitoring for skin breakdown or signs of infection (redness, warmth, swelling, abnormal exudate) around the insertion site(s). iv. Physical management of tubing and collection bags to prevent infection or dislodgement. 6. Considerations for care: a. Check tube(s) frequently for kinks or obstructions. These are likely to occur if the resident lies on the insertion site. b. Keep the drainage bag below the level of the kidney at all times. Keep bags covered for dignity. c. Monitor output for changes in amount, color, clarity, or odor. d. Monitor for signs of urinary tract infection or infection of insertion site. e. Monitor resident for discomfort associated with the tube(s) or procedures. f. Record output from each tube. Specify location of output. g. Document abnormalities and report to physician immediately. According to Corona, L., [NAME], K., Lucas-[NAME], C., United Ostomy Associations of America, Inc. (UOAA), [NAME], Z. L., [NAME], S. C., [NAME], H. C., Advent Health Medical Group Urology, Kaiser Santa [NAME], & Double Nephrostomate. (n.d.). NEPHROSTOMY. https://www.ostomy.org/wp-content/uploads/2024/01/UOAA_Nephrostomy_Facts_Booklet_2024-01a.pdf, If your nephrostomy tube has a 3-way stopcock valve (the longest port is labeled off) (p. 9) . Tube blockage/obstruction: Signs and symptoms o Drainage has decreased or stopped, greater than 2 hours o Leakage of urine around insertion site If you think your tube is blocked or obstructed o Check to make sure the tube is not kinked - use a mirror to assess your back o Check to make sure the valve is open so urine can flow into the bag o Check to make sure the collection bag is not damaged. If it is, change it. o Attempt to flush the tube with no more than 10 cc of sterile water or sterile normal saline. Do not withdraw fluid after irrigation. If fluid does not go in easily you can try to gently pull back on the syringe to dislodge any obstructing particles. Reattempt flushing using gentle pressure. If you have any pain while attempting this intervention, stop. (See tube flushing) If none of these interventions produce normal urine flow, contact your physician or interventional radiologist.

This citation pertains to intakes M100151387 and M100151421. Based on observation, interview and record review, the facility failed to ensure staff were competent to manage care for two (R1 and R2) of two residents reviewed for nephrostomy care, resulting in hospitalization and repeated incompetent care. Findings include: Review of the State Operations Manual (SOM) 483.35(a)(3) reflected, The facility must ensure that licensed nurses have specific competencies and skill set necessary to care for residents' needs, as identified through .assessments and .in the plan of care. Resident #1 (R1) Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] and readmitted to the facility after a hospitalization on [DATE]. Pertinent diagnoses include hydronephrosis (urine build up on kidney) with renal and ureteral calculous (kidney stones) obstruction (1/14/23), infection and inflammatory reaction due to nephrostomy catheter (3/31/25), acute pyelonephritis (kidney infection) (3/31/25), urinary tract infection (3/31/25), and Escherichia coli (E. coli, a bacterium that causes infection, 3/31/25). In an interview on 4/15/25 at 1:30 PM, the Registered Nurse (RN) A reported R1 had been in the hospital several times in the last few months to have her nephrostomy tube (catheter) replaced and expressed concern the facility is not competently providing nephrostomy care. On 3/20/25, R1 went to the hospital and the 3-way stopcock on the nephrostomy tube was in the off position and not draining. The exit site was red and had some drainage as well. Once the stopcock was opened, they were able to drain about a 1/2 liter of puss like drainage that later tested positive for E. coli bacterial infection. R1 was then transferred to another hospital for an inpatient stay for antibiotic therapy and monitoring. RN A reported R1 a nephrostomy tube placed on 10/27/24 and exchanged on 11/20/24, exchanged again on 12/4/24, new replacement on 1/11/25 because it may have been pulled out, on 1/16/25 it was checked, changed and repositioned, on 2/5/24 it was dislodged, and 2 sutures were put in place. On 2/25/25 the facility called them about a suture not being intact with redness at the exit site and she had low urine output and was to go to Big Rapids and not sure if R1 went. On 3/11/25 the nurse at the facility called with concerns about the nephrostomy tube for R1 and then was sent to the hospital on 3/20/25. Review of the Hospital Medical Records for R1 revealed: History of Present Illness: . chronic severe right hydronephrosis who had an IR (Interventional) appointment today to look at her nephrostomy tube which was found to not be draining, they replaced it and had 548 mL (milliliters) of purulent urine. Interventional Radiology documented: Findings: The stitches holding the nephrostomy catheter are noted to be intact. The stopcock was in the off position and purulent drainage was noted around the catheter. Aspiration yielded 540 cc (cubic centimeters) of green, purulent fluid. A sample was sent for culture. Impression: The nephrostomy tube was noted to be in the off position with purulent material draining from around the catheter. A large volume of purulent fluid was evacuated from the kidney. During an observation and an interview on 4/16/25 at 1:30 PM, RN C went to R1's room and reported her nephrostomy bag was draining because the pigtail of the stopcock was pointing towards the injection/flushing port even though we just saw another resident who had her nephrostomy stopcock pigtail pointing towards the drain bag tubing. RN C reported R1's dressing (which was an undated 22 gauze with tape and the tubing was not secured) and RN C reported her stitches securing the tubing was fine. The resident was lying in bed, and her pants were partially over the nephrostomy, but under the exit site potentially tugging on the tubing. In an interview on 4/16/25 at 3:33 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) H reported R1 has pulled out her nephrostomy catheter several times because she has OCD (obsessive compulsive disorder, not listed as a diagnosis for R1 on her Face Sheet). UM H continued alleging R1 is non-compliant. UM H reported R1 had her nephrostomy tubing dislodged on 4/10 and went to [name of another city where second hospital was located] on 4/11 to have her tubing replaced. When asked if anchoring her tubing would help, UM H reported there is no order for one and did not think it would help. When queried about the hospitalization in March, UM H reported she did not know why R1 went into the hospital and started looking into the computer. UM H reported she is the Unit Manager but gets pulled to the floor to work often implying that is why she did not know what is going on with R1 and reiterated she has had her catheter dislodged several times but didn't know all the details. When asked about the lack of charting of care, assessments, and transfers outside the facility for R1 in the EMR, UM H reported she herself would put in a progress note and verified there was no transfer form in the computer when R1 went to the hospital on 3/20/25 and 4/11/25. UM H reported residents do not get a transfer form for outside appointments, but the MAR and the Face Sheet will get with the resident and the last set of vital signs. When asked about the standards of care for nephrostomy's, UM H reported the doctors do not usually order output monitoring unless the nurses ask for them and elaborated that after this last hospitalization , she did add the output monitoring to the nurses charting. UM H was questioned about the 0 output documented in the MAR and said they did not have parameters to notify the physician but expected nurses to know when to notify the physician for anything abnormal. When asked about the nurses being educated on nephrostomy care, UM H reported they get educated but thinks they may need more. When questioned about the stopcocks on the nephrostomy bags for R1 and R2, UM H reported that if there are instructions, they will put those instructions in the order as what needs to be done or will put them in an education binder for the nurses. During an observation and an interview on 4/16/25 at 3:35 PM, the Unit Manager/Licensed Practical Nurse (LPN) H was asked about the nephrology tubing for R1 and reported the pig tail of the stop cock was pointing toward the flushing/irrigation port. At this time, UM H did not know if the stopcock was opened or closed for draining. In an interview on 4/16/25 at 5:00 PM, UM H reported that stopcock for R1 which had the pig tail pointing towards the irrigation port was not in the right position and will educate her staff on the correct position which is towards the drain bag like it was for R2. Resident #2 (R2) Review of a Face Sheet revealed R2 originally admitted to the facility on [DATE] and readmitted after a hospitalization on [DATE] and has pertinent diagnoses of Urinary tract infection, bacteremia (blood infection), methicillin resistant staphylococcus aureus infection, multiple sclerosis, hydronephrosis. During an observation and an interview on 4/16/25 at 11:35 AM, R2 was in bed and her nephrostomy tube was on her right side and R2 reported that hardly anything comes out. RN B reported the stopcock on the nephrostomy tube was draining and can tell the tubing is stable. The pigtail of the stop cock was facing the tubing of the drain bag. During an observation and an interview on 4/16/25 at 1:30 PM, RN C went to R2's room and reported the nephrostomy bag was draining because the pigtail of the stopcock was pointing toward the tubing of the drain bag which means it is on. During an observation and an interview on 4/16/25 at 3:25 PM, the Unit Manager/Licensed Practical Nurse (LPN) H was asked about the nephrostomy tubing for R2 and asked this surveyor if the attending nurse was questioned. When UM H was asked to look at R2's nephrostomy tubing, UM H looked at the stopcock and verified the pigtail of the stopcock was pointing toward the drain bag and said she would have to get her bifocals to read if it says it is in the off position because she was not sure at this time. When asked what a typical assessment would include, UM H reported the drainage and any color, pain, discomfort, sediment, and would look at the exit site. When asked what an abnormal reporting for this resident would be and what the expectations of staff would be, she reported she would document her findings, look at the history. UM H did report there was some scant sediment in the drain bag and small amount of blood fluid in the tubing, but no measurable amount of body fluid at this time. Review of the April MAR/TAR for R2 revealed an order to Empty nephrostomy bag and enter amount every shift dated 4/7/25 revealed until 4/17/25 there are 22 shifts of 0 output from the nephrostomy bag and one shift with no documentation. The highest output was 40 ml (milliliters) on 4/7/25 when the monitoring began post hospitalization . On the 4/17/25 night shift, after questioning the nephrostomy care, 575 ml of fluid output was documented. After the first staff education on 4/16/25: In an interview on 4/17/25 at 1:21 PM, the Director of Nursing (DON) reported they educated the nurses yesterday and all the nurses this day before they start their shift on nephrostomy care and reported the nurses could demonstrate the appropriate positioning of a nephrostomy stopcock. The DON reported R1 has a history of pulling out her nephrostomy tubing and is always fidgeting with it. R1 and R2 are dialysis patients, and it is hard to know how much urine output they will have. The DON reported R1 is OCD with her tubes and other devices she has and just cannot leave them alone. The UM H made sure her dressing was secured with a Tegaderm, and the tubing was anchored well yesterday. The DON verified the dressing is to be secured with a Tegaderm and acknowledged it was not. The DON reported she thought there was an order to anchor the nephrostomy tubing in place but could not find it. When asked if dressings should be dated, the DON reported it is preferred. When asked if there were concerns that staff reported dressing changes were not being done but were charting, they were? The DON reported it had been a while but did not have anything solid to prove the nurses were doing this. When asked what was included in the nephrostomy care education the day before, the DON was to provide the information and reported the staff know which position the stopcock should be in to drain the nephrostomy. During an observation on 4/17/25 at 1:45 PM, Licensed Practical Nurse (LPN) I and surveyor went to R2's room and verified the stopcock was pointing towards the drain bag which meant that it is draining. Afterward, LPN I verified the stopcock was pointed toward the drain bag and said it was draining, but not confidently, with a little blood-tinged urine was noticed in the bag. In an interview on 4/17/25 at 2:00 PM, the RN A explained how the stopcock functions and reported the pigtail of the stopcock is the off position. Wherever that pigtail is pointing, that means it is blocking the flow to that area. It should always be pointing toward the irrigation port so the nephrostomy tubing can drain to the bag. RN A then reported if it is pointing toward the drain bag, it is not draining. In an interview on 2/17/25 at 2:19 PM, the DON reported she went to R2's room and saw the pigtail of the stopcock was pointed towards the drain bag and R1's pigtail was pointed towards the port. The DON reported UM H misunderstood what position the stopcock needed to be in and is going around re-educating staff right now. In an interview on 2/17/25 at 2:30 PM, the facility Staff Educator/RN U reported the staff were educated yesterday on the correct positioning of the stopcock for R1 and R2 and the pigtail should be pointing towards the flushing port. RN U reported she knew this yesterday and educated the staff by showing them a picture. RN U reported she went to R1's room yesterday and the stopcock was in the correct position, but today it was pointing towards the drain bag indicating it is not open. RN U reported she educated the staff and the Unit Manager by reviewing the policy and talking about it. The Unit Manager misunderstood and those she educated, were informed wrong. Today, the started to re-educate staff again with pictures of the stopcock and that the pigtail should always be pointed toward the flushing port for draining into the bag. Review of the April MAR/TAR for R2 revealed an order to Empty nephrostomy bag and enter amount every shift dated 4/7/25 revealed until 4/17/25 there are 22 shifts of 0 output from the nephrostomy bag and one shift with no documentation. The highest output was 40 ml (milliliters) on 4/7/25 when the monitoring began post hospitalization . On the 4/17/25 night shift, after questioning the nephrostomy care, 575 ml of fluid output was documented. Review of a Job Description for the Unit Manager revealed: Summary: Responsible for directing the entire operation of a nursing unit in a long-term facility. Essential Functions: Performs General Management Functions such as hiring, disciplining and evaluating employees Plans and facilitates meetings and committees to address resident care issues for the unit Manages area of responsibility with the goal of achieving and maintaining the highest quality of care possible. Participates in developing, implementing and evaluating programs that promote the recruitment, retention, development and continuing education of nursing staff members. Contacts physicians as necessary and ensures physicians interventions are timely and appropriate. Reviews staffing patterns and census of nursing units and reassigns personnel when necessary to ensure staffing meets resident needs and budgetary controls. Monitors the clinical operations of the unit and resident's conditions and ensures that appropriate and quality care is administered. Obtains medications, supplies and medical records needed to provide safe, efficient and therapeutic care to residents on a continuing basis. Assists in the orientation of new personnel, monitors their skills and guides and observes staff that may need assistance with procedures. Participates in facility QA program. Performs other tasks as assigned. Review of a Licensed Practical Nurse (LPN) Job Description revealed: Summary: Coordinates and provides nursing care for residents and provides supervision and guidance to clinical staff members. Scope of work may be modified by state specific rules under the Nurse Practice Act.Essential Functions: (included but not limited to): Documents the resident's condition and nursing needs. Accurately and promptly implements physicians' orders. Administers medications and performs treatments for assigned residents, and documents that treatment as required by Company, and local, state and federal rules and regulations. Assigns nursing care to team members in accordance with the resident's needs and the person's capabilities and qualifications. Reports and records pertinent observations and reactions regarding residents. Coordinates nursing care of residents when scheduled for therapy or procedures by other departments. Assists with or institutes emergency measures for sudden adverse developments in residents. Supervises nursing unit, which includes scheduling and directing the nursing staff to extent permitted by state practice act. Performs other tasks as assigned. Review of the Employee training files for Registered Nurse (RN) B, RN P, RN C and Licensed Practical Nurse (LPN)/Unit Manager LPN H revealed no education for nephrostomy care.

Based on interview and record review, the facility failed to follow their policy for transfers for one (R61) of one resident reviewed for hospital transfers. Findings Include: Review of a policy titled Transfer and Discharge (including AMA (Against Medical Advice)) last reviewed/revised 10/30/23 revealed: Emergency Transfers/Discharges- . a. obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. d. Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: Review of a Face Sheet for R61 revealed she originally admitted to the facility on [DATE]. Review of the SBAR (Situation-Background-Assessment-Recommendation) dated 2/6/25 for R61 revealed she had a change of condition and was sent to the hospital. This form is to be sent with the resident to the hospital. Review of the Electronic Medical Record (EMR) for R61 revealed there were no physician orders to transfer to the hospital on 2/6/25 and no Transfer Form that provided a medication list to the hospital staff for the continuity of care. In an interview on 2/13/25 at 3:11 PM, the Director of Nursing (DON) reviewed R61's EMR and could not locate a Transfer Form for the resident's hospital visit on 2/6/25. The DON reported that the SBAR contained much of the relevant information about the resident's condition to accompany her to the hospital. However, the DON confirmed that the SBAR lacked R61's medication list and the EMR did not have an order for the resident's transfer.

Based on interview and record review, the facility failed to provide a bed hold policy to one (R61) of one resident reviewed for hospitalization . Findings include: Review of a Face Sheet for R61 revealed she originally admitted to the facility on [DATE]. Review of the SBAR (Situation-Background-Assessment-Recommendation) dated 2/6/25 for R61 revealed she had a change of condition and was sent to the hospital. Review of the EMR (Electronic Medical Records) for R61 revealed no Bed Hold Policy was provided for her transfer to the hospital on 2/6/25. In an interview on 2/13/25 at 3:11 PM, the Director of Nursing (DON) reviewed R61's EMR and could not find documentation indicating that the resident received a Bed Hold Policy when she transferred to the hospital on 2/6/25, noting that she should have received one. Review of a policy titled Transfer and Discharge (including AMA (Against Medical Advice)) last reviewed/revised 10/30/23 revealed: Emergency Transfers/Discharges- . a. obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. i. Prove a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer.

Based on observation, interview, and record review, the facility failed to provide needed services to ensure the dignified well-being of three residents (R47, R5, and R71) and the potential for all dependent residents to have unmet needs. Findings include: R47 The medical record reflected R47 admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease and Protein Calorie Malnutrition. The Minimum Data Set (MDS) dated [DATE] reflected R47 was moderately cognitively intact, had a urinary catheter, was frequently incontinent of stool, and was receiving end-of-life care. On 2/11/25 at 10:20 AM an observation and interview were conducted with R47 in his room. A soft-touch call light was observed at his side and urinary catheter tubing and a collection bag were noted. R47 reported several instances when he had soiled himself and had to wait for over an hour for staff to help him. When asked about using his call light R47 reported If I can find it (the call light) that the response wait times were long and gave a thumbs-down sign when asked how this made him feel. R47 reported he doesn't get out of bed often because staff don't like working with him indicating staff feel he has a bad attitude. R47 reported he has complained to supervision about the wait for assistance but was told you just have to wait. R47 stated he wants to be home. R5 Review of the medical record reflected R5 admitted to the facility on [DATE] with medically complex conditions that included diabetes mellitus and a hip fracture. The MDS dated [DATE] reflected R5 was cognitively intact, frequently incontinent of bowel and bladder, required assistance with rolling side to side in bed, and was dependent on staff for transfers. On 2/12/25 at 8:58 AM an interview was conducted with R5 as she lay in bed. R5 reported, after initiating a call light, she often must wait a long time to be cleaned after wetting or soiling herself. R5 reported that there wasn't much (she) could do about it. R5 reported she has complained to staff that she has waited over an hour to be cleaned, and staff tell her, Well .we're busy. Review of the Resident council Minutes reflected documentation of resident complaints of delayed call light response times on third shift in October 2024, December 2024, and January 2025. R71 Review of the medical record reflected R71 admitted to the facility on [DATE] with diagnoses that included Dementia and Anxiety. The MDS dated [DATE] reflected R71 was severely cognitively impaired, frequently incontinent of bowel and bladder, and was dependent on staff for toileting and transfers. On 2/11/25 at 7:26 AM an observation of R71 was conducted in her room. R71 was observed in a Geri-chair (a high back wheelchair), dressed, and sitting in front of a television. R71 did not have a call light in reach as it was placed across the room. R71 was repeating help in a soft voice that could not be heard unless standing close to the Resident.

This citation pertains to intake #MI00147480 Based on observation, interview, and record review, the facility filed to provide care to accommodate the needs of 5 of 5 residents reviewed. Findings: During an observation on 10/23/24 at 8:10 AM, the resident in bed 48-1 laid in bed resting with eyes closed. The call light was clipped to the privacy curtain out of sight and out of reach of the resident. During an observation on 10/23/24 at 8:20 AM, the following were noted for the resident in bed 2-1: (a) the touch pad call light laid on the residents lower right quadrant of his torso. The resident stated he could not reach the touch pad to call for assistance because he is a quadriplegic, (b) an empty cup with a straw sat on the over the bed table and the resident stated he was very thirsty but was not able to alert staff that he needed more water, (c) the resident's lips were dry and cracked, (d) both legs had contractures and there was not a pillow between his legs to reduce pressure, and (d) there were no pressure reducing boots or devices on or under the resident's feet/ankles. During an observation on 10/23/24 at 8:55 AM the resident in bed 25-1 laid in bed resting with her eyes closed, her left leg hung off the side of the bed, and her left foot rested on the floor. Certified Nurse Aide (CNA) K entered the room, removed the untouched breakfast tray and did not reposition the resident so that her leg was back up on the bed. During an observation on 10/23/24 at 8:54 AM, the resident in bed 13-1 called out help me help me. From the hallway the resident could be seen making two attempts to stand up on her own. A nurse stood just outside room [ROOM NUMBER] at the medication cart and did not respond to the call for help. When asked about the cognition of the resident in bed 13-1, the nurse indicated that both residents in room [ROOM NUMBER] had dementia and were very confused at baseline and that was why they had been placed in a room closer to the front of the hall, so that staff could keep a closer eye on them. During an observation on 10/23/24 at 9:00 AM, the resident in bed 2-1 did not have a pillow or any pressure reducing devices between his knees or under his feet. The empty cup of water, dated 10-22 sat on the over bed table. During an observation on 10/23/24 at 9:50 AM, the resident in bed 64-1 sat in bed awake. The cord for the light fixture above the resident hung behind the head board and on the floor, out of sight and out of reach. During an interview on 10/23/24 at 11:51 AM, CNA G reported that every time staff enter a room they are to check for call light placement, offer something to drink, and make sure things the resident might need are within reach. During an observation on 10/23/24 at 4:00 PM, the resident in bed 2-1 sat in bed and the call light touch pad laid on the bed next to his right hip, out of reach of the resident. The resident stated that he was hungry but could not call for staff to let them know. During an observation on 10/24/24 at 7:50 AM, the resident in bed 2-1 sat in bed and the call light touch pad sat on his chest. When asked if he could reach the touch pad, he attempted and stated that he could not. Review of the facility policy Resident Hydration last reviewed on 01/01/2022, revealed: The facility will endeavor to provide adequate hydration and to prevent and treat dehydration.

This citation pertains to intake MI00133465. Based on interview and record review, the facility failed to appropriately assess, monitor, document, implement treatment/ resources, and notify the physician promptly for changes in condition for 2 (Resident #1 and Resident #4), resulting in both residents being hospitalized and one resident receiving pain medications potentially masking underlying condition. Findings include: Review of a policy titled Notification of Changes last reviewed [DATE] revealed The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Resident #1 (R1) Review of a Face Sheet revealed R1 was a [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses of paraplegia, pressure ulcers, open wounds, history of bariatric surgery, and bipolar. Review of the Minimum Data Set (MDS) dated [DATE] revealed R1 was cognitively intact and required extensive assistance of two staff for transfers and extensive assistance of one staff for bed mobility. She had limited range of motion on one side of her upper extremity and impairment on bilateral lower extremities. She had 2 stage III pressure ulcers upon admission and one stage IV pressure ulcer upon admission. In an interview on [DATE], the complainant reported R1 complained of her stomach hurting really bad around [DATE] or [DATE] and had told several of the staff at the facility and family members several times. Concerned she was just given pain medications to cover the pain, but the root cause of her pain was not addressed. She was sent to the hospital and found out she had a bowel obstruction and died . She also had several pressure sores and a septic infection that spread. Concerned staff were nice but not doing appropriate care. Review of the Hospital Medical Records dated [DATE] revealed R1 went to the hospital emergency room around 6:30 PM with pertinent diagnoses of small bowel obstruction, peristomal hernia, and lactic acidosis. When she arrived, she had an elevated heart rate (tachycardic) in the 140s (,d+[DATE] is normal) and rapid breathing (tachypneic) and sweating (diaphoresis). She had abdominal pain with decreased colostomy output. Given patient's comorbidities and current critical illness it was recommended that patient be transferred to a higher level of care. However, general surgery at the higher level of care felt patient needed operative intervention sooner and recommended exploration prior to transfer in assessment for transfer postoperatively. In an interview on [DATE] at 1:13 PM, Licensed Practical Nurse (LPN) C reported the day R1 went to the hospital ([DATE]), she was the day shift nurse for her that day and was told in report that morning that R1 had some stomach aches which was normal for her and R1 wanted to see the doctor. Her vital signs were normal with the exception of a lower-than-normal temperature, and she just seemed to be acting out of sorts more than normal. She did have some bowel sounds, seemed weak and chilled. She had some pain but could not rate it because she was just kinda out of it. LPN C reported she called the doctor around ,d+[DATE]:00 AM that day and had to leave a message for the doctor who did not return her call. The doctor came late that day around 5:00 PM or so. LPN C reported the doctor did not call back because she was going to be in later that day. LPN C reported she had not worked with R1 for a couple of days and does not always work in the same halls with the same residents to always know how the residents were during that week but reported R1 has not always been right. LPN C remembers R1 had some vaginal discharge that was an infection and sure the doctor did a vaginal swab. She also had a foley catheter. She had a colostomy that had different consistencies in her (fecal) output and would try different things to get her colostomy to flow nice. She did not have any output in her colostomy the day she went to the hospital and not sure what her output if any the day before. When the doctor saw R1, she didn't see any true problems, but LPN C insisted that this was not normal for the resident and that is when the doctor ordered the resident to be sent to the emergency room . Review of Physician Orders for R1 revealed on [DATE] an order for Norco 7XXX,d+[DATE] mg (milligrams) was ordered as needed twice a day for pain but not specifically indicated for what pain. On [DATE] one dose was given for pain rated ,d+[DATE] and discontinued on [DATE]. Acetaminophen 500 mg X 2 tablets was ordered to be given twice a day for pain (unspecific) starting [DATE] and discontinued on [DATE] when the resident was discharged . Another order for Acetaminophen 500 mg X 2 tablets as needed was ordered on [DATE] and given on [DATE] for pain rated ,d+[DATE] with no indication where or what the pain was. Review of Physician orders for R1 revealed on [DATE] an order for Norco (narcotic) 7XXX,d+[DATE] mg to be given one time a day for pain around 4:00 PM. This order discontinued on [DATE]. No indication what pain. Review of the Medication Administration Record (MAR) for [DATE] through [DATE] revealed she had an average pain rated at ,d+[DATE] when given Norco or acetaminophen. On [DATE] a pain rated ,d+[DATE], [DATE], pain ,d+[DATE]. No follow up documentation or assessments as to where or what the pain was. Review of Physician orders for R1 revealed on [DATE] an order for Norco (narcotic) 7XXX,d+[DATE] mg to be given three times a day for pain around 4:00 PM and discontinued on [DATE]. Specific pain was not indicated, and neither was the times. R1 did receive 2 doses on [DATE] for pain rated ,d+[DATE]. Review of Physician Orders for R1 revealed on [DATE] an order for Norco 7XXX,d+[DATE] mg was ordered once a day as needed for pain and discontinued [DATE]. Not specifically indicated for what pain. No doses of this order were given. Review of Physician Orders for R1 revealed on [DATE] an order for extra strength Tylenol (500 mg tablets X 2) was scheduled twice a day for pain but not specific to what pain. Review of a Physician Assistant Progress note for R1 dated [DATE] revealed the resident was seen for ulcers on her bilateral ischium and coccyx and stated the wounds on her bottom are painful at times. She offers no other complaints today. Resident is also noted to have vaginal discharge with an odor again, resident has recurrent vaginitis, will refer her to gynecology as the discharge makes it difficult for the dressings to be able to adhere. Review of a Physician Assistant Progress note for R1 dated [DATE] revealed the resident was seen for ulcers on bilateral ischium and coccyx only. Review of a Physician Progress note dated [DATE] for R1 revealed it was a Federal Regulatory Visit and there were no documented complaints of abdominal concerns or pain being addressed. Review of the Electronic Medical Records (EMR) for R1 revealed no Nursing Progress notes on [DATE] addressing R1s pain that was rated at an ,d+[DATE] or any follow up assessments and/or physician notifications. Review of a Physician Progress note dated [DATE] for R1 revealed: She's complaining of nausea and abd pain today. Not wanting to eat or take any meds. She had a vaginal ID test done and shows some BV, but that shouldn't cause these symptoms. By the time I could see her this evening, she was feeling much worse. Severe abd (abdominal) pain. I recommend send to ER. Review of an Order Summary for R1 revealed an order for a referral to Gynecology for recurrent vaginitis that was discontinued on [DATE]. Review of the EMR revealed no assessment, labs, or appointments for Gynecology or vaginitis. Pressure Ulcers Review of the September Medication Administration Record (MAR) for R1 revealed orders for bilateral ischial wounds dressing changes ordered [DATE] revealed 5 treatments not documented, Zinc oxide cream to coccyx every shift ordered [DATE] not documented done 4 times, and Prevalon boots to bilateral feet at all times not documented as done 4 times. Review of the October MAR for R1 revealed an order for Bilateral ischial wound treatment orders dated [DATE] and discontinued on [DATE] revealed 8 treatments were not done. Review of the November MAR for R1 revealed an order on [DATE] for Bilateral ischial wounds treatment once a day and the resident did not get treatment for 8 days. An order for the left medial thigh wound treatment ordered daily on [DATE] and discontinued [DATE] missed 2 days of treatments. Zinc oxide cream to coccyx every shift and as needed missed 6 treatments. Prevalon boots to bilateral feet every shift missed 6 opportunities. Review of a Care Plan for R1 revealed Focus: The resident has/is at risk for [chronic] pain related to paraplegic, osteomyelitis, chronic ulcer of back, pressure ulcers, osteoarthritis, impingement disorder of shoulder, calculus of ureter, chronic pain syndrome last revised [DATE] (after discharge). Interventions: Administer pain medications as ordered. 1. Give ,d+[DATE] hour before treatments or care, initiated [DATE], last revised and canceled on [DATE]. 2. Evaluate the effectiveness of pain interventions on the following frequency. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, last revised and canceled on [DATE]. 3. Monitor/document/report to physician any side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls last revised and canceled on [DATE]. 4. Monitor/record/report to Nurse any signs or symptoms of non-verbal pain, last revised and canceled on [DATE]. 5. Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss last revised and canceled [DATE]. 6. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, initiated [DATE] and last revised and canceled [DATE]. 7. NON-MEDICATION INTERVENTION FOR PAIN: offer repositioning to resident when having pain/discomfort, initiated [DATE] and last revised and canceled [DATE]. 8. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain, initiated [DATE], last revised and canceled on [DATE]. 9. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease movement or range of motion, withdrawal or resistance to care. 10. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease movement or range of motion, withdrawal or resistance to care, last revised and canceled [DATE]. 11. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences, last revised and canceled [DATE]. 12. Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods (i.e., positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound), last revised and canceled [DATE]. 13. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to (signs or symptoms) or (complaints of) pain or discomfort, last revised and canceled [DATE]. Review of a bacterial vaginitis care plan for R1 initiated on [DATE] and resolved on [DATE]. In an interview on [DATE] at 2:37 PM, the DON reported R1 went to the resident council meeting the day before she was hospitalized , then on the morning of [DATE] she complained of not feeling well. The doctor came in around 10:00 AM and the resident kept progressing and feeling worse with generalized stomach pain. When the doctor came in, she said her pain was greater than a 10. Resident #4 (R4) Review of a Face Sheet revealed R4 is a [AGE] year-old female who originally admitted to the facility on [DATE] with pertinent diagnoses of end stage renal disease, diabetes, recent diagnoses of pulmonary embolism, hemiplegia, and hemiparesis (one sided weakness), and convulsions. Review of the MDS for R4 dated [DATE] revealed she was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility and totally dependent on staff for transfers. She had limited range of motion on the upper and lower extremity on one side. Review of hospital records dated [DATE] for R4 revealed she had an altered mental status, with 1. acute encephalopathy, 2. hypoglycemia, 3. Severe sepsis, 4. Seizures, 5. Hyperammonemia, 6. Hepatic steatosis and a bloody nose. Patient apparently had skipped dialysis on Friday, 3 days ago, because she did not want to go. When the nursing home went to wake her up for dialysis this morning, she had minimal responsiveness, and it was thought she may have had a seizure. They noticed blood around her mouth without any obvious trauma. EMS states the patient's blood sugar was in the 80s per their glucometer. Concern at this time is intracranial hemorrhage as she is on Eliquis, new liver disease, nonspecific sepsis but concerning for CNS disease, urinary tract infection, drug intoxication, or drug effect leading to the above etiology. Review of the December MAR for R4 revealed an order for 5 mg of Eliquis (anticoagulant) to be given twice a day for pulmonary embolism started on [DATE]. Buspirone 5 mg twice daily ordered [DATE] and again on [DATE]. Escitalopram 10 mg ordered [DATE] and again on [DATE]. Review of an Order Note for R4 revealed a severe drug interaction warning for Buspirone 5 mg twice daily and Escitalopram Oxalate 10 mg increasing the risk for serotonin syndrome. Another warning for 81 mg of aspirin concurrently taken with Escitalopram 10 mg has a moderate risk of an increase in upper gastrointestinal bleeding. No indication the physician was notified and addressed the interactions. Review of Nursing Progress Notes dated [DATE] revealed R4 refused to go to dialysis (a treatment to remove waste, chemicals, and fluid from your blood when the kidneys no longer function well.) Review of the EMR for R4 revealed no assessments done since refusals of dialysis or indication the social worker was notified. Review of a Nurses Progress note dated [DATE] at 5:10 AM for R4 revealed she was found unresponsive except to pain/sternal rub. Dried blood around mouth, she also had blood from her mouth yesterday afternoon but unsure where it came from in her mouth. No documentation indicating the resident was assessed and the physician was notified the of blood coming from her mouth the day before. In an interview on [DATE] at 1:13 PM, LPN C reported R4 went to the hospital earlier in December because she had a stroke and then was found unresponsive at 5:00 AM on [DATE] when they went to get her up for dialysis. The week before she went out, she was very upset with the passing of her roommate earlier that month because they were very close and felt her roommate gave her a purpose. She started to refuse care, dialysis, and activities. In an interview on [DATE] at 1:54 PM, the dialysis center reported the last dialysis treatment R4 received was on [DATE] at their facility. In an interview on [DATE] at 2:10 PM, Social Worker (SW) D reported she had not been at the facility since [DATE] when she found out that R4s roommate had passed away. SW D reported she was not aware of R4 not adjusting well after the passing of her roommate and was not sure who would have followed up with the resident after such a loss. In an interview on [DATE] at 2:37 PM, the Director of Nursing (DON) reported she expects nurses to document in the progress notes any changes in a resident and noted there are different assessments they can do. If a resident was found bleeding from her mouth, she would expect it to be documented so it would pull over on an interdisciplinary (IDT) note and put it in the doctors note. Would also expect an assessment to be done. If it is unknown where the bleeding was coming from, the DON would expect the physician to be called. If a resident refuses to go to dialysis, she would expect that an alternate day be arranged, and informing the physician of her refusals. The DON reported it would be great if the nurses would document when a resident refuses to go to dialysis. The medical record is a legal document and is used to protect the patient as well as the professional practice of those in healthcare. Documentation of the care you give is proof of the care you provide .Charting is objective, not subjective. This means chart only what you see, hear, feel, measure, and count - not what you infer or assume. All nurses know that if it wasn't charted, it wasn't done the patient's complete and accurate medical record the most reliable source of information on the care of that patient. Proper nursing documentation prevents errors and facilitates continuity of care. https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). Nursing assessment is the deliberate and systematic collection of data of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. ([NAME] & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved [DATE], from http://www.hgexperts.com/article.) Nursing judgment is critical when medications that are ordered PRN (as needed) are given. The nurse documents the assessment made and the time of medication administration. The nurse should make frequent evaluation of the effectiveness of the medication and record findings in the appropriate record (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby

This citation pertains to intake: MI00128848 and MI00132982 This citation has 2 Deficient Practice Statements (DPS) DPS 1 Based on interview and record review, the facility failed to accurately perform post fall assessments for 2 residents (Resident #57, and #218) reviewed for falls, resulting in the potential for neurological changes to go undetected and a delay in treatment. Findings: Resident #57 (R57) Review of an Admission Record revealed R57 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease. Review of R57's Incident Report dated 10/19/22 revealed, Un-witnessed .Nurse heard resident yelling, nurse found resident sitting on her bottom in the bathroom in front of her WC (wheelchair), in front of sink .States she was trying to blow her nose cause it was bleeding and slipped . Review of R57's Progress Note dated 10/19/22 revealed, Resident was in bathroom after lunch, lost her footing and slipped onto floor, landed on her bottom; no inuuries, (sic). Review of R57's Fall-Initial assessment dated [DATE] at 1:34 PM revealed a neurological assessment was completed. (Neurological Assessment/neurological examination is completed to ensure no trauma/damage occurred following a fall). Review of R57's Fall-Follow-up assessment dated [DATE] at 7:57 PM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 3:53 AM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 9:18 PM revealed a neurological assessment was completed. Indicating a neurological assessment for R57 was not completed every shift x72 hours following a fall. (Neurological assessments were complete on all 3 shifts on 10/22/22). Review of R57's Incident Report dated 11/11/22 revealed, Un-witnessed .staff gathering residents for dinner noted resident sitting on her bathroom floor with back against the wall .resident stated 'I had to pee in the toilet. Review of R57's Progress Notes revealed no documentation of R57's fall on 11/11/22. Review of R57's Fall-Initial assessment dated [DATE] at 6:03 PM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 11:03 AM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 12:57 AM revealed a neurological assessment was completed. Review of R57's Fall-Follow-up assessment dated [DATE] at 12:57 PM revealed a neurological assessment was completed. Indicating a neurological assessment for R57 was not completed every shift x72 hours following a fall. No additional Fall-Follow-up assessments for R57 were received prior to survey exit. Resident #218 (218) Review of an Admission Record revealed R218 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and unsteadiness on feet. Review of R218's Incident Report dated 8/11/22 revealed, Resident fell out of his wheelchair onto the floor. The fall was witnessed. He did not hit his head .Resident unable to give description . Review of R218's Progress Notes revealed no documentation of R218's fall on 8/11/22. Review of R218's Fall-initial dated 8/11/22 at 10:35 AM revealed a neurological assessment was completed. Review of R218's Fall-Follow-up dated 8/11/22 at 11:24 PM revealed, Follow up to fall that occurred on: 7/26/22. R218's neurological assessment was completed. Review of R218's Incident Report dated 8/12/22 revealed, Resident in the hall in his W/C (wheelchair) and slid out of his chair reaching down to get something. Witnessed by Cena (Certified Nursing Assistant) . Review of R218's Progress Notes revealed no documentation of R218's fall on 8/12/22. Review of R218's Fall-initial dated 8/12/22 at 9:46 AM revealed a neurological assessment was completed. Review of R218's Fall-Follow-up dated 8/12/22 at 6:24 PM revealed a neurological assessment was completed. Review of R218's Fall-Follow-up dated 8/13/22 at 10:24 AM revealed, Follow up to fall that occurred on: 7/26/22. R218's neurological assessment was completed. Indicating a neurological assessment for R218 was not completed every shift x72 hours following a fall on 8/11/22 and 8/12/22. No additional Fall-Follow-up assessments for R218 were received prior to survey exit. During an interview on 12/12/22 at 2:51 PM, Unit Manager (UM) L reported that following a witnessed or unwitnessed fall, neurological assessments are completed every shift for 72 hours unless ordered more frequently by the physician. During an interview via email on 12/13/22 at 11:21 AM, Regional Director of Operations (RDO) K reported that per the risk management program, any resident that experienced a fall/head injury would have neurological assessments completed every shift for 72 hours whether the incident was witnessed or unwitnessed. RDO K reported that facility nurses are required to complete the neurological assessments and document the assessment in the Fall-Initial assessment and the Fall-Follow-up assessments. RDO K reported that neurological assessments are completed every shift for 72 hours unless the physician orders the neurological assessments to be completed more frequently. Review of the facility policy Fall Prevention Program last revised 1/1/22 revealed, Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate the resident's all risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. 5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 6. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of an injury. On 12/12/22 at 2:47 PM requested Fall Prevention Program policies in their entirety. No additional policies were provided prior to survey exit. Review of Fundamentals of Nursing (Potter and Perry) 10th edition revealed, The health care record provides a way for members of the interprofessional health care team to communicate about multiple aspects of patient care, including patient needs and response to care and therapies; clinical decision making; and the content and outcomes of consultations, patient education, and discharge planning. Information communicated in the health care record allows health care providers to know a patient thoroughly, facilitating safe, effective, timely, and patient-centered clinical decision making. The health care record is the most current and accurate, continuous source of information about a patient's health care status, allowing the plan of care to be clear to anyone who accesses the record. To enhance communication and promote safe patient care, you document assessment findings and patient information as soon as possible after you provide care (e.g., immediately after providing a nursing intervention or completing a patient assessment) . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition. 31771 DPS 2 Based on observation, interview, and record review the facility failed to provide quality care to one resident (R58) resulting in a fall, poor communication, unmet needs, unfulfilled choices and psychosocial harm for R58 and the potential for all facility residents to not have their needs met and choices honored. Findings: Review of the facility Admission Record reflects R58 was admitted to the facility 8/8/22 with pertinent diagnosis that included: Amyotrophic Lateral Sclerosis (ALS), Adult Failure to Thrive, and Cognitive Communication Deficit. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R58 was cognitively intact. Section G of the MDS reflected that R58 required 2+ staff for bed mobility and was non-ambulatory. Section G0300 reflected that when moving on and off the toilet R58 was not steady and could only stabilize with staff assist. Review of the Facility Reported Incident (FRI) received by the state agency on 11/13/22 reflected an allegation of neglect against CNA (Certified Nurse Aide) giving care. CNA was immediately suspended pending investigation. The FRI reflected that on 11/12/22 at approximately 7:15 PM R58 fell off the toilet. The FRI reflected a CENA (Competency Evaluated Nurse Aide, a term used in the industry for those trained and certified to provide direct care to residents in a health care setting) had transported R58 to the bathroom and toilet by herself using a mechanical lift. The FRI reflected that the CENA unhooked R58 from the mechanical lift and left him unattended on the toilet. The FRI alleged that R58 had told the CENA he wanted privacy. The FRI reflected the CENA was interviewed and acknowledged the fall but revealed that an Orientee had assisted her in using the mechanical lift to transport R58 to the toilet. Onsite review of documents provided by the facility reflected a summary of the incident after an investigation had been completed. The facility document titled Investigation Summary reflected a repeat of the information of the actions of the CENA and the orientee about the fall of R58. Further review of facility documents revealed the CENA and the orientee were not certified staff. The facility staff schedule reflected that the CENA involved was a Hospitality Aide and that the Orientee was orienting as a Hospitality Aide. Review of the undated Job Description for Hospitality Aide reflected, Note: The hospitality aide may not provide or assist with resident care. The facility document reflected no Experience was listed or Licenses/Certification for the position. The document did not list that Essential Functions included transferring residents, toileting residents or the use of mechanical lifts. The document reflected the entirety of listed Knowledge/Skills/Abilities for the position of Hospitality Aide were: Ability to communicate effectively with residents and their family members. Ability to learn infection control techniques. Ability to be patient and polite. The document provided by the facility revealed that the staff members that transferred and left R58 unattended were not qualified to perform the actions documented that occurred on 11/12/22. Review of the FRI and Investigation Summary submitted by the facility to the state agency did not include or attempt to convey information that the staff members involved in the fall of R58 were not trained or certified to perform the actions documented. On 12/7/22 at 2:53 PM an observation and interview were conducted with R58 in his room. R58 was observed in bed with both hands curled at the wrists toward his forearms. No splints or braces were observed on the Resident or in the room. No wheelchair was observed in the room. R58 was observed to be nonverbal and two communication boards about the size of large placemats were observed on an over-the-bed table. The communication boards had phrases, pictures, letters, and numbers that could be used to communicate with R58. R58 attempted to point towards characters on the communication board but the curled wrists made it unclear what R58 was pointing to. Communication was achieved through the nodding and shaking of the head for yes and no. R58 communicated that he remembered the fall from the toilet on 11/12/22. R58 communicated that the staff that transferred him at the time of the incident had done so several times before but not since the incident. R58 communicated that he did not want to be left alone on the toilet and fell because he could not support himself. R58 communicated that no call light was in reach. R58 also communicated other care issues. These included being left wet and soiled for extended periods. R58 indicated that although initial call light response may have been prompt staff would turn off the call light and may or may not return later. R58 communicated that staff did not perform range of motion (ROM) exercises with him and that he did not have splints or braces for his wrists and hands. R58 indicated that he gets shaved, and his nails cut but the rest of him does not get cleaned well. R58 conveyed that he would like a shower. R58 communicated that he would like to get out of bed occasionally. R58 communicated that the biggest problem that he has is communicating with staff. R58 indicated that he communicated well with only a few staff but that he is not able to communicate his needs or preferences to most staff. R58 indicated that most of his concerns could be resolved with improved communication with staff. Review of the MDS dated [DATE], Section G - functional status reflected that R58 required 2+ staff for bed mobility and was non-ambulatory. Section G0300 reflected that when moving on and off the toilet R58 was not steady and could only stabilize with staff assist. Review of the EMR at risk for falls Care Plan for R58 revealed that while in bathroom staff must be stand-by assist at all times was not implemented until 11/13/22 despite the findings documented in Section G of the MDS of 8/14/22. Review of the EMR documentation of Task - ADL (activities of daily living) toilet Use from 11/9/22 to 12/8/22 reflected documentation of 29 incidents of Total Dependence on staff for toilet use. Review of the Electronic Medical Record (EMR) for R58 reflected a Doctor's Order dated 10/14/22 for Restorative Nursing Program for 1) ROM, 2) Eating. No documentation was found in the EMR that ROM had been performed with R58. Review of the EMR Task ADL Bathing (showers Mon and Thurs AM) with a 30-day look-back period prior to 12/5/22 reflected no showers had been given. The documentation reflected in the 30-day time period reviewed 5 bed baths had been performed, and no resident refusals were documented. Review of the EMR revealed a Quarterly Social Services Review had been conducted on 11/28/22. The documentation reflected that R58 understands and is independent with daily decision-making skills, and documented that R58 is only sometimes understood. The Social Services Review reflected that in the section for Things that make you become anxious/agitated was documented Resident is nonverbal and does not reflect that an attempt was made to query R58 to complete this section. The section for Things that calm or soothe you was blank as are the sections for ADLs and Mobility. Section I for the topic of Social Services Intervention Status is also blank and does not identify the area of communication as a Problem to specifically address in this section despite documentation in this review that R58 is non-verbal, understands but is only sometimes understood. Review of the handwritten Quarterly Care Conference note dated 11/16/22 reflected that R58 is showered on Sundays and Thursdays despite EMR documentation of only bed baths. The Care Conference note reflects Activities are with the pad. The Care Plan note did not reveal active Resident involvement in the Care Conference despite that R58 is cognitively intact and, per the Social Services Review, is independent with daily decisions. On 12/7/22 at 4:47 PM an interview was conducted with Social Worker (SW) J. SW J reported that she, Hospice, and the Guardian for R58 were present for the Care Conference. SW I acknowledged that it was tough to communicate with R58. SW I reported that the Guardian had brought in an iPad (the pad) to assist R58 with communication. SW I indicated that R58 could not use the device and got disgusted with it. Review of the MDS dated [DATE] revealed Section C - cognitive patterns was not completed. Section G - functional status, reflected R58 had full range of motion of both upper and lower extremities and used a wheelchair for mobility. On 12/7/22 at 4:23 PM an interview was conducted with MDS Registered Nurse (RN) I who reported that the information for Section C of the 11/14/22 was not provided to her in time to be included in this MDS. MDS RN I was informed of the curled wrist of R58 observed throughout the survey and the findings of section G of this MDS. MDS RN I was informed that no wheelchair was found in the room of R58. MDS RN I reported that she doesn't always do in-person assessments of the residents when completing an MDS. MDS RN I reported she will visit a resident only if she is not able to complete the MDS by reviewing the documentation in the medical record. The interview continued at 5:07 PM when MDS RN I reported she went to the room of R58 and stated I saw what you saw about the curled wrists of R58. MDS RN I reported that she was able to do passive ROM with the hands and wrists of R58. The MDS RN reported she did find the Residents wheelchair as it had been stored in another room. On 12/8/22 at 2:12 PM a telephone interview was conducted with the Director of Nursing (DON) The DON was informed that R58 had conveyed that he did not want to be left alone on the toilet, that he wanted to get out of bed occasionally, that he wanted showers instead of bed baths. and that staff were turning off his call light and leaving him wet and soiled for extended periods. The DON was informed that R58 had conveyed that most staff do not communicate well with him, and that often his needs were not met. The DON was informed that R58 had conveyed that most of his concerns could be resolved with improved communication with staff. The DON was informed that the wrists of the Resident had been observed to be curled throughout the survey and that no braces or splints were observed to be in use. Also, that R58 indicated that staff do not do ROM with him. The DON reported that after the fall of 11/12/22 R58 had been able to point with his finger at the communication board and that the curled wrists was a change for him. The DON was informed that the EMR did not reveal documentation of this change. As of exit no further pertinent information was provided by the facility.

This citation pertains to intake # MI 737 Based on interview and record review, the facility failed to ensure diabetic residents received care in accordance with professional standards: 1.) Failed to notify the provider of blood glucose results greater than 400 and/or less than 70. 2). Failed to routinely assess resident blood glucose levels. 3.) Failed to obtain laboratory tests ordered by the physician. 4.) Failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #104) reviewed for quality of care, resulting in an immediate jeopardy when, beginning on [DATE], the facility staff failed to ensure diabetic care interventions were in place including physician notification of a change of condition and abnormal blood glucose results. This deficient practice placed all residents at risk for serious harm, injury and/or death. On [DATE] the Administrator was verbally notified and received written notification of the immediate jeopardy that was identified on [DATE] due to the facility's failure to provide quality care following professional standards of practice for diabetic residents. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]: 1. Identification of Residents Affected or Likely to be Affected: An assessment of all diabetic residents will be completed by a Licensed Nurse to ensure there are no signs or symptoms of hyper/[CONDITION(S)]. Any residents noted to have S/S (signs and symptoms) of hypo/[CONDITION(S)] will have a physician notification completed by [DATE]. A 100% audit was completed on any resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . All diabetics will have orders clarified to include blood glucose reading by [DATE]. A 100% audit completed on residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A 100% audit was completed on all diabetic residents to ensure no like residents had insulin held without a physician order or notification for the past 30 days. Any identified insulins held will have physician notification completed by [DATE]. All residents with insulin will have Blood Glucose monitoring orders by [DATE]. 100% of physician ordered labs will be reviewed and the facility will ensure labs have been ordered through the lab provider for the past 30 days by [DATE]. 2. Actions to Prevent Occurrence/Recurrence: All Licensed nurses will be educated on Blood Glucose Policy, Lab process, Notification of Changes and Changes in Condition by [DATE]. Any Licensed nurse not educated by [DATE], will be educated prior to working next shift. 3. DON (Director of Nursing) will be reeducated on clinical morning meeting start up and lab monitoring by RDCS (Regional Director of Clinical Services) by [DATE]. 4. Starting [DATE], the Regional Director of Clinical Services or designee will audit VS (Vital Signs), including blood sugar values, resident change in condition and notification of changes to physician 2X/wk (2 times a week) for one month then weekly for one month and then monthly until substantial compliance is maintained. 5. Starting [DATE], DON or designee will monitor VS and blood sugar values daily during clinical start up for one month and then 3 times per week for one month and then weekly for one month until substantial compliance is maintained. 6. Starting [DATE], DON or designee will monitor lab orders for completion daily during clinical start up for one month and then 3 times per week for one month and then weekly for one month until substantial compliance is maintained. 7. Starting [DATE], DON or designee will monitor nurses notes and complete room rounds to identify resident change of condition and review that physician was notified of changes of condition and that it is documented daily during clinical start up for one month and then 3 times per week for one month and then weekly for one month until substantial compliance is maintained. 8. Starting [DATE], the DON will review findings in QAPI monthly for three months or until substantial compliance is maintained. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE] Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency. Findings include: Review of the facility Care Path for Acute Mental Status Change (No Date) revealed, New Mental Status Changes Noted .Decreased level of consciousness (sleepy/lethargic) .Take Vital Signs *Temperature * BP (blood pressure), pulse .*Respirations *Oxygen Saturation* Finger stick glucose (diabetics) .Vital Sign Criteria (any met?) .Finger stick glucose (less than) 70 or (Greater than 300 .Notify MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physician Assistant) Review of the facility form (No Date) Change in Condition: When to report to the MD/NP/PA-Immediate Notification Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A Marked [NAME] (i.e. more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed . Review of the facility form (No Date) Signs and Symptoms D's .Diabetes, poorly controlled-(Immediate) Any diabetic with altered mental status, or an acute infection, OR hypoglycemic episode in someone or hypoglycemic episode in someone on hypoglycemic medication or not responding to additional glucose; Glucose (greater than) 300 or (less than) 70 mg/dl .(Non-Immediate-Usually stable diabetic with change in oral intake, thirst, or urination, fluctuating or rising blood sugars . Review of the facility policy Laboratory and Diagnostic Guidelines implemented on [DATE] revealed, This guideline is set up to track the timely completion, reporting and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident and/or therapeutic medication levels. Policy Explanation and Compliance Guidelines .9. The physician should be notified of all refused lab/diagnostic test orders and reason why. 10. The physician should be notified if the lab/diagnostic test is unable to be completed, reason why, and request for new order .12. All notifications, attempts at notifications, response should be noted in the resident's medical record. 13. Results should also be reported to the resident and/or responsible party, including any new orders . Review of the facility policy Provision of Quality Care implemented on [DATE] revealed, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person centered care plans, and the residents' choices. Policy Explanation and Compliance Guidelines-1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 3. Responsibility for interventions on the care plan will be clearly identified. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. 5. To ensure persons are qualified, department heads, in collaboration with facility leadership and the HR (Human Resources) department, will be responsible for verifying credentials of all employees prior to hire, oversight to ensure ongoing employee competency, and education regarding areas of employee weakness. 6. Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. b. Violations of policies and procedures will result in disciplinary action up to and including termination. 7. The facility will employ on a full-time, part-time or consultant basic those professionals necessary to carry out the provisions of the residents'' care plans. 8. The facility will follow relevant procedures to ensure professional staff are licensed, certified, or registered in accordance with applicable state laws. Review of the facility policy Notification of Changes implemented on [DATE] revealed, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification .Circumstances requiring notification include .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition . Review of the facility policy Medication-Insulin implemented on [DATE] revealed, It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. Policy Explanation and Compliance Guidelines: 1. All insulin will be administered in accordance with physician's orders. 2. For current insulin orders, an adequate supply of insulin will be maintained for each resident. Insulin will be reordered as needed according to facility policy. 3. For new or emergency orders for insulin, the facility may use medication from the emergency kit. 4. Insulin administration will be coordinated with meal times and bedtime snacks unless otherwise specified in the physician order. Review of the facility in-service dated [DATE] revealed, All blood sugars ordered by physician MUST be obtained (and) charted in (Electronic Health Record). Physician must be notified of any blood sugars out of parameter. If no parameters ordered request parameters or call if blood sugar (less than) 80 or (greater than) 400. All labs ordered must be obtained, results must be obtained (and) uploaded into (Electronic Health Record) ALL lab results to be given to unit managers. Medications, including insulin cannot be held without a physician's order. Nurses must notify physician of any change in residents' condition. Review of Medical Surgical Nursing: Assessment and Management of Clinical Problems revealed, A1C measures the amount of glycosylated hemoglobin as a percentage of total hemoglobin .When blood glucose levels are elevated over time, the amount of glucose attached to hemoglobin molecules increases. This glucose remains attached to the red blood cell (RBC) for the life of the cell (approximately 120 days). Therefore, the A1C test provides a measurement of glycemic control over the previous 2 to 3 months, with increases in the A1C reflecting elevated blood glucose levels .The ADA identifies an A1C goal for patients with diabetes of less than 7.0%. The American College of Endocrinology recommends an A1C of less than 6.5%. Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume, 10e by [NAME] L., [NAME] RN PhD CEN CNE, Linda, [NAME] RN PhD FAAN, [NAME] M., [NAME] PhD RN CNE, [NAME] M., [NAME] DNP M [NAME] RN PhD page 1124 Review of Medical Surgical Nursing: Assessment and Management of Clinical Problems revealed Diabetic ketoacidosis (DKA) is caused by a profound deficiency of insulin and is characterized by [CONDITION(S)], ketosis, acidosis, and dehydration. It is most likely to occur in people with type 1 diabetes but may be seen in people with type 2 diabetes in conditions of severe illness or stress when the pancreas cannot meet the extra demand for insulin. Precipitating factors include illness and infection, inadequate insulin dosage, undiagnosed type 1 diabetes, poor self-management, and neglect . Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume, 10e by [NAME] L., [NAME] RN PhD CEN CNE, Linda, [NAME] RN PhD FAAN, [NAME] M., [NAME] PhD RN CNE, [NAME] M., [NAME] DNP M [NAME] RN PhD page 1142 Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old male, originally admitted to the facility on [DATE] with the most recent admission on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Review of Resident #101's Care Plan revealed, The resident has Diabetes Mellitus Date Initiated: [DATE] .o The resident will be free from any s/sx (signs or symptoms) of [CONDITION(S)] through the review date. Date Initiated: [DATE] Revision on: [DATE] .The resident will have no complications related to diabetes through the review date. Date Initiated: [DATE] Revision on: [DATE] .Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: [DATE] .Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: [DATE] .Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: [DATE] .Monitor/document/report to MD PRN any s/sx of [CONDITION(S)]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal) pain, Kussmaul breathing (deep breathing or hyperventilation), [MEDICATION(S)] breath (smells fruity), stupor, coma. Date Initiated: [DATE] LPN RN o Monitor/document/report to MD PRN (as needed) any s/sx of [CONDITION(S)]: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: [DATE] . The resident has [CONDITION(S)] Date Initiated: [DATE] Revision on: [DATE] . Educate resident/family/caregivers on the importance of getting regularly scheduled follow up [CONDITION(S)] levels as ordered by the physician. Date Initiated: [DATE] Review of Resident #101's Order Summary Report revealed that on [DATE] a HA1C (laboratory blood test to monitor how well blood glucose is controlled) was ordered. Review of Resident #101's Electronic Health Record (EHR) revealed that the HA1C was not completed. Review of Resident #101's Order Summary Report revealed that on [DATE] a HA1C was ordered. Review of Resident #101's EHR revealed that the HA1C was not completed. During an interview on [DATE] at 10:19 A.M., Unit Manager (UM) D verified that the HA1C ordered on [DATE] and [DATE] had not been completed. Review of Resident #101's Laboratory Result dated [DATE] revealed a Hemoglobin A1C result of 7.5 (reference range 4.,d+[DATE].6) and a TSH ([CONDITION(S)] Stimulating Hormone) level 114 (reference range 0.,d+[DATE]). Review of Resident #101's Hospital Discharge Summary revealed a handwritten note for Accuchecks BID) (Blood Glucose Assessment twice a day). (Date the Hospital Discharge Summary was received and verified by Nursing Home Administrator (NHA) A as [DATE]). Review of Resident #101's Order Summary Report revealed, [MEDICATION(S)] [MEDICATION(S)] Solution Pen-injector 300 UNIT/ML (Insulin [MEDICATION(S)] (1 Unit Dial)) Inject 5 unit subcutaneously at bedtime for diabetes mellitus .order date [DATE]. Review of Resident #101's Order Summary Report revealed no parameters for withholding insulins. Review of Resident #101's Order Summary Report revealed no order for Blood Glucose Assessments. Review of Resident #101's Blood Sugar Summary revealed, [DATE] 10:31 (AM) 154.0 mg/dL, [DATE] 08:34 (AM) 88.0 mg/dL, [DATE] 20:02 73.0 mg/dL, [DATE] 17:42 (5:42 PM) 315.0 mg/dL, [DATE] 18:35 (6:35 PM) 107.0 mg/dL, [DATE] 18:37 (6:37 PM) 116.0 mg/dL, [DATE] 08:56 (AM) 174.0 mg/dL, [DATE] 08:26 (AM) 171.0 mg/dL, [DATE] 09:27 (AM) 125.0 mg/dL, [DATE] 08:56 (AM) 154.0 mg/dL, [DATE] 07:08 (AM) 298.0 mg/dL, [DATE] 09:18 (AM) 270.0 mg/dL, [DATE] 09:52 (AM) 116.0 mg/dL, [DATE] 20:56 (8:56 PM) 194.0 mg/dL, [DATE] 20:56 (8:56 PM) 255.0 mg/dL, [DATE] 21:13 (9:13 PM) 195.0 mg/dL, [DATE] 08:57 (AM) 368.0 mg/dL, [DATE] 08:57 (AM) 368.0 mg/dL, [DATE] 19:01 (7:01 PM) 109.0 mg/dL, [DATE] 15:57 (3:57 PM) 456.0 mg/dl. (Indicating that Resident #101's blood glucose level was not consistently assessed nor was it reassessed after [DATE]). Review of Resident #101's Progress Notes revealed no documentation that the physician was notified of Resident #101's Blood Glucose Level of 456 on [DATE]. Review of Resident #101's Orders-Administration Note dated [DATE] at 8:03 P.M. revealed, [MEDICATION(S)] [MEDICATION(S)] Solution Pen-injector 300 UNIT/ML Inject 5 unit subcutaneously at bedtime for diabetes mellitus Insulin held at this time d/t (due to) blood sugar of 73 and patient only ate approximately 50% of his evening meal. Review of Resident #101's Progress Notes revealed no documentation that the physician was notified of the blood glucose level of 73 and an order to hold Resident #101's insulin was not obtained. Review of Resident #101's Physician assessment dated [DATE] revealed, Reviewed resident's total program of care, including medications and treatment plan. Patient continues to require skilled nursing care for general well0being, and help with ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living) .Glucoses usually in the 100s .Pt (patient) up in wheelchair-Comfortable-Awake .A&Ox1 (alert and oriented to self) confused .Type 2 diabetes mellitus with diabetic chronic kidney disease, stable, continue current meds, ordered HA1C . Review of Resident #101's Dietary Progress Note dated [DATE] revealed, RD (Registered Dietician) asked to evaluate resident for wt (weight) loss related to general change in condition. Resident has lost weight (4.1%; weight loss 7#) in 30 days .Dietary and nursing state he is hard to wake up and sleeps through meals often. (Indicating a change in Resident #101's condition). Review of Resident #101's Nurses' Notes dated [DATE] at 10:11 P.M. revealed, Late Entry: Note Text: Resident was found unresponsive at approx. 6:30 PM. Vitals were: BP (blood pressure) ,d+[DATE], O2 (oxygen saturation) 74, weak pulse, mottled extremities, clammy skin, and labored breathing. 911 and on-call physician were notified, EMS (Emergency Medical Services) arrived within 15 minutes and took resident to (Name Omitted) hospital . Review of Resident #101's Vital Signs revealed that Resident #101's blood pressure, pulse, respirations, and oxygen level were not assessed on [DATE] or [DATE]. Resident #101 did not have his vital signs assessed until he was unresponsive on [DATE]. Review of Resident #101's Hospital Record dated [DATE] revealed, Diagnosis . Diabetic ketoacidosis without coma associated with diabetes mellitus due to underlying condition . Patient presents to the emergency room from (facility) and is poorly responsive initially and has improved during his initial ER (emergency room ) stay. He is found to be clinically quite dehydrated with [CONDITION(S)] and initial chemistry results show .glucose 978 (reference range ,d+[DATE]) . Statistically the patient's prognosis is quite poor and the patient's wife will be informed of this . He is ill appearing .Mucous membranes are dry .77 yo (year old) male with dementia from (facility) who presented with decreased responsiveness to the emergency department. He was found to be in acute renal failure with severe [CONDITION(S)] and metabolic acidosis .He remained unresponsive through his hospital stay with occasional restlessness and expired on [DATE] at 0725 with family at bedside. During an interview on [DATE] at 2:39 P.M., Family Member (FM) O reported that she had a Zoom call with Resident #101 3 days prior to him being sent to the hospital ([DATE]) and had concerns that Resident #101 was more lethargic and confused than his baseline. FM O reported that she notified the nursing staff at that time of her concerns and requested that the facility staff assess his blood sugar. FM O reported that the facility nursing staff reported that Resident #101 did not get his blood glucose levels assessed routinely. FM O reported that the facility staff did not assess Resident #101 or notify the physician of a change in his condition at that time. During an interview on [DATE] at 3:52 P.M., Certified Nursing Assistant (CNA) L reported that she provided care for Resident #101 up until his transfer to the hospital. CNA L reported that he had had a significant decline the week leading up to his transfer to the hospital: poor nutritional intake, lethargic, weak, and no longer able to walk. CNA L reported that all residents in the facility are to have vital signs assessed daily. CNA L reported that Resident #101 never refused vital signs and there was no reason not to get (Resident #101's) vital (signs). During an interview on [DATE] at 3:59 P.M., Registered Nurse (RN) K reported that Resident #101 did not have routine Blood Glucose Assessments ordered. RN K reported that the physician should be notified of any blood glucose result greater than 400 and the blood glucose should also be reassessed. RN K reported once the physician is notified of a concern a progress note should be written. RN K reported that residents are to have their vital signs assessed every day and should be reviewed by the nursing staff. RN K reported that the CNA's obtain the vital signs and document them in the residents' electronic health record. During an interview on [DATE] at 5:06 P.M., Licensed Practical Nurse (LPN) M reported that she was the nurse caring for Resident #101 on [DATE] when he was sent out to the hospital. LPN M reported that Resident #101 was to have his blood sugar checked every night before his insulin was administered. LPN M reported that Resident #101 had had a change in his condition especially that week prior to his transfer to the hospital. LPN M stated, (Resident #101) was so lethargic the last few times I worked with him. LPN M reported that vital signs should be obtained daily for all residents. LPN M reported that the physician should be notified of any blood sugar over 300 or under 90. LPN M reported that any time a physician is notified of a concern a progress note should be written. During an interview on [DATE] at 9:18 A.M., Medical Director (MD) F reported that the expectation is that facility staff members notify her of any blood glucose assessments over 400 immediately and any blood glucose assessments over 300 by the next day. MD F reported she definitely would have wanted to be notified about Resident #101's blood glucose assessment of 456 on [DATE]. MD F reported that Resident #101 should have had his blood glucose assessed at least daily and would have preferred to have his blood glucose assessed twice daily. MD F reported that the last time she assessed Resident #101 was on [DATE] and an A1C lab test was ordered. MD F was not notified that the A1C was not collected on [DATE] or on [DATE]. MD F reported that she was not notified about Resident #101's increased lethargy and stated she would have wanted to know about increased lethargy. MD F reported that she should have been notified of Resident #101's TSH level so medication adjustments could have been made. During an interview on [DATE] at 10:19 A.M. UM D reported that she was the Unit Manager for Resident #101 since he moved to her unit on [DATE]. UM D reported that when residents are on a long acting insulin it is up to the physician to order blood glucose assessments and the frequency of the test. UM D reported that if a resident has stable blood sugars the physician doesn't always order blood glucose assessments. UM D reported that nurses follow general parameters for blood glucose assessment; if a blood glucose assessment is greater than 400 nursing staff notify the physician. UM D reported she did not know why Resident #101's blood glucose was not reassessed after [DATE]. UM D reported that the resident's nurse is responsible for notifying the physician of abnormal results. UM D reported that when a physician orders a laboratory test the facility nurses fill out a slip and unit managers monitor the labs as well. UM D reported she did not know why Resident #101's A1C laboratory tests were not completed on [DATE] or [DATE]. Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of Resident #102's Care Plan revealed, The resident has Type 2 Diabetes Mellitus Date Initiated: [DATE] Revision on: [DATE]. The resident will be free from any s/sx of [CONDITION(S)] through the review date. Date Initiated: [DATE] Revision on: [DATE] . Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: [DATE] . o Educate regarding medications and importance of compliance. Obtain and document resident's understanding. Date Initiated: [DATE] o Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, Obtain and document understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: [DATE] o Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: [DATE] . Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: [DATE]. Monitor/document/report to MD PRN any s/sx of [CONDITION(S)]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing, [MEDICATION(S)] breath (smells fruity), stupor, coma. Date Initiated: [DATE] o Monitor/document/report to MD PRN any s/sx of [CONDITION(S)]: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: [DATE]. Review of Resident #102's Order Summary Log revealed, NovoLOG Solution (100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals for hypergylcemia dated [DATE] .[MEDICATION(S)] FlexTouch Solution Pen-injector 100 UNIT/ML (Insulin Detemir) Inject 65 unit subcutaneously in the morning for Diabetic **CONSULT WITH DR [NAME] PRIOR TO HOLDING [MEDICATION(S)]** dated [DATE]. Review of Resident #102's Order Summary Log revealed Call if Blood sugar (greater than) 400, or (less than) 70 and symptomatic with meals. Start Date [DATE]. Review of Resident #102's Blood Sugar Summary dated [DATE] at 1:33 P.M revealed a result of 431.0 mg/dL. Review of Resident #102's Progress Notes revealed no documentation that the physician was notified of the elevated blood glucose. Review of Resident #102's General Note dated [DATE] 6:04 P.M. revealed, BS (blood sugar) been low this evening, not giving evening insulin. Review of Resident #102's EHR revealed no documentation that the physician was notified of the blood glucose result and an order to hold the insulin was not obtained. Review of Resident #102's Orders-Administration Note dated [DATE] at 12:33 P.M. revealed, NovoLOG Solution 100 UNIT/ML Inject 15 unit subcutaneously with meals for [CONDITION(S)] BS was 84, resident did not eat much lunch, few bites, was not hungry, held insulin due to low BS and not eating much lunch. Review of Resident #102's EHR revealed no documentation that the physician was notified of the blood glucose result and an order to hold the insulin was not obtained. Review of Resident #102's Blood Sugar Summary dated [DATE] at 08:21 A.M. revealed a result of 434.0 mg/dL. Review of Resident #102's Progress Notes revealed no documentation that the physician was notified of the elevated blood glucose. Review of Resident #102's Blood Sugar Summary dated [DATE] at 1:03 P.M. revealed a result of 406.0 mg/dL. Review of Resident #102's Progress Notes revealed no documentation that the physician was notified of the elevated blood glucose. Review of Resident #102's Orders-Administration Note dated [DATE] at 1:18 P.M. revealed, NovoLOG Solution 100 UNIT/ML Inject 15 unit subcutaneously with meals for [CONDITION(S)] BS 71, resident did not eat much for lunch, only small piece of ham; holding at this time. Review of Resident #102's EHR revealed no documentation that the physician was notified of the blood glucose result and an order to hold the insulin was not obtained. Review of Resident #102's Orders-Administration Note dated [DATE] at 12:37 P.M. revealed, NovoLOG Solution 100 UNIT/ML Inject 15 unit subcutaneously with meals for [CONDITION(S)] held res bs was only 94 did not eat much lunch. Review of Resident #102's EHR revealed no documentation that the physician was notified of the blood glucose result and an order to hold the insulin was not obtained. Review of Resident #102's Orders-Administration Note dated [DATE] at 7:56 P.M. revealed, NovoLOG Solution 100 UNIT/ML Inject 15 unit subcutaneously with meals for [CONDITION(S)] BS 94 did not eat a lot of dinner. insulin held. Review of Resident #102's EHR revealed no documentation that the physician was notified of the blood glucose result and an order to hold the insulin was not obtained. Review of Resident #102's Nurses' Note dated [DATE] at 7:40 P.M. revealed, (Physician Q) also ordering that he is to be consulted with prior to patients [MEDICATION(S)] being held in the future. Review of Resident #102's Blood Sugar Summary dated [DATE] at 6:46 P.M. revealed a result of 579.0 mg/dL. Resident #102's blood glucose was not reassessed until [DATE] at 07:38 A.M. Review of Resident #102's Progress Notes revealed no documentation that the physician was notified of the elevated blood glucose. Review of Resident #102's Orders-Administration Note dated [DATE] at 07:39 A.M. revealed, [MEDICATION(S)] FlexTouch Solution Pen-injector 100 UNIT/ML Inject 65 unit subcutaneously in the morning for Diabetic **CONSULT WITH (Physician Q) PRIOR TO HOLDING [MEDICATION(S)]** bs 116 not given. Review of Resident #102's EHR revealed no documentation that the physician was notified of the blood glucose result and an order to hold the insulin was not obtained. Review of Resident #102's Blood Sugar Summary dated [DATE] at 5:38 P.M. revealed a result of 62.0 mg/dL. Resident #102's blood glucose was not reassessed until [DATE] at 8:1 [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide sanitary treatment and prevent the development of pressure ulcer for 1 (#43) of 2 Residents reviewed for pressure ulcers, resulting in Resident #43 who was admitted on [DATE] with no pressure ulcer, to develop a stage II pressure ulcer to the coccyx region with a dressing applied with no cleansing of the wound site prior to application. Finding include: Record review of the facility 'Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol' policy dated 11/28/2017, revealed that based on the comprehensive assessment or 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 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. Record review of the facility's 'Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol' dated 6/20/2016, revealed the purpose was for the nursing staff to monitor and document the weight and dietary intake of residents in a format which permits readily available comparison over time. Record review of the facility's 'Dressings, Dry/Clean' policy dated 2/2018, revealed the purpose of the procedure was to provide guidelines for the application of dry, clean dressings. Resident #43: Record review of Resident #43's Admission Minimum Data Set ((MDS) dated [DATE], revealed a male Resident admitting with Brief Interview of Mental status (BIMs) score of 12 out of 15, modified independence, some difficulty with new situations. Medical [DIAGNOSES REDACTED]. Section M: Skin Conditions- noted Resident #43 to be at risk for pressure ulcers, with no pressure ulcer noted upon admission. Record review of Resident #43's thirty day Minimum Data Set ((MDS) dated [DATE], revealed a male Resident with added [DIAGNOSES REDACTED]. Section M: Skin Conditions- noted Resident #43 to be at risk for pressure ulcers, with no pressure ulcer noted upon admission. Record review of Resident #43's History and Physical dated 5/28/19 revealed the admitting [DIAGNOSES REDACTED]. Record review of Resident #43's Admission Norton Plus Pressure Ulcer scale dated 5/22/19 score of 13- moderate risk (of pressure ulcer development). Record review of Resident #43's Kardex for Certified Nursing Assistance (CNA) to provide care printed 7/18/19, revealed: Skin inspections by CNA during care and showers/baths. Report changes to licensed nurse immediately. Bed Mobility: Extensive with assist of one staff member. During an observation on 07/16/19 at 01:51 PM of Resident #43's Hoyer lift transfer from wheelchair to bed with Licensed Practical Nurse (LPN) T and Certified Nurse Assistant (CNA) X, the staff members removed Resident #43's pants tugging downward catching the Foley catheter in the pants material. There was no catheter strap noted in place by surveyor. In an interview on 07/16/19 at 04:28 PM, Resident #43 stated, My legs don't work, I went to (hospital) I had infection in my spine and came here. Now I have a bed sore on my tailbone. Resident #43 stated that the bed sore hurt to sit or lay on his buttocks. Record review of resident #43's weight log revealed an admission weight of 138.2 pounds on 5/22/19. Review of the weight log over a 60-day period from 5/22/19 through 7/15/19 noted a weight loss of 10.4 pounds, 7.53% wt. loss in 60 days. In an interview on 07/17/19 at 02:09 PM with Registered Dietitian (RD) R, reviewed Resident #43's weight log with the state surveyor regarding the admission wt. 138.2 on 5/22/19, admission assessment for nutrition done on 5/28/19, six days after admission. RD R stated When he started to loss wt., I did a dietary progress note. I spoke with physician and started IV fluids, we had a Standards of Care meeting, and IV fluids for 24 hours. We did preferences, we gave a deli sandwich between lunch and dinner at the 3PM snack pass. We offer a snack at bedtime. On 7/17/19, at the end of above interview, the state surveyor walked the RD R down to the resident's room to interview the resident and Resident #43 stated, I like squash, potatoes, beets, I didn't like Brussel sprouts today. I'd like ice cream, 3-4 weeks ago I stopped eating the sandwich, I don't want the sandwich. The RDR asked about the 'Always available menu' and looked about the resident's room for the menu. Resident #43 stated, No always available menu in room, I don't have one. RD R pinched the back of Resident #43's hand to check for tenting (dehydration). RD R stated, I see improvement, no skin tenting, no complaint of dry mouth. With the loss of 10 pounds, and with IV fluids, he just did not rebound. Record review of Resident #43's Certified Nurse Assistant (CNA) task documentation monitoring of skin observations noted: On 7/10/19 open area, and on 7/14/19 red area. It was noted that on 7/16/18 and 7/17/19 that the CNA's did not document any open areas. Record review of Resident #43's 'Skin assessment' form dated 7/10/19 noted: Are there any new abnormal skin areas? No, was checked. By check this box, I confirm that I conducted a full skin assessment and no new abnormal skin areas were observed. Record review of Resident #43's nursing progress notes dated 7/14/19 revealed there was no mention of a red skin observation or the location. Record review of Resident #43's wound information authored by Registered Nurse (RN) U revealed that on 7/16/19 Resident #43 sustained an open pressure sore measuring 0.5/0.5/0.1 cm, facility acquired from pressure with [MEDICATION NAME] wound bed. Barrier cream was ordered. Observation and wound dressing application on 7/17/19 at 3:22 PM, of Resident #43's coccyx wound with Registered Nurse (RN) S, revealed there was no barrier cream in place and measurements of 0.5/0.5 cm on the coccyx with redness was noted. RN S washed her hands and donned gloves and then opened the foam boarder dressing and applied the dressing on to the coccyx wound. There was no cleansing of the wound or ant treatment applied. Observed no air mattress on bed, regular facility mattress. Cushion noted in wheelchair with Hoyer sling left in place when up in wheelchair. In an interview on 7/17/18 at 3:22 PM, during the dressing application with Resident #43, the resident stated, It (pressure ulcer) hurt's, it's a bed sore. (Rated at a 7 on pain scale of 0-10) I've been in bed too much, they have to get me up with that machine (Hoyer). It hurts when I sit or lay on it. In an interview and record review on 7/18/19 at 11:05 AM, Registered Nurse (RN)/Assistant Director of Nursing V revealed Resident #43 developed a Stage II this week on Tuesday 7/16/19. Resident #43's last skin assessment was on 7/10/19 and he had no pressure ulcer noted. RN V stated that the facility used a wound documentation system for skin assessments. RN V stated that Resident #43 was admitted with no pressure ulcers on 5/22/19. RN V was asked if the pressure ulcer was avoidable? RN V stated I don't know what to say. In an interview on 7/18/19 at 12:35 PM, Nurse Practioner H revealed that a stage II pressure ulcer that was open should have been cleansed with normal saline or something (wound cleaner) prior to the dressing being applied. Record review of Resident #43's revised Care Plans page 1-18, revealed: Resident has a stage II pressure ulcer to coccyx related to decreased mobility, following recent biopsy to back with post-operative infection. Revision date of 7/17/19. Although a CNA documented open are on skin observation on 7/10/19 and again a red area on 7/14/19, and Registered Nurse U documented open area on 7/16/19 the care plan and interventions were not updated until 7/17/19.

Based on observation, interview and record review, the facility failed to provide appropriate and adequate [MEDICAL CONDITION] care for 1 resident (Resident #41) reviewed for [MEDICAL CONDITION] care, from a total sample of 18 residents, resulting in an immediate jeopardy when (1) Resident #41 was readmitted to the facility, on 2/23/18, with a [MEDICAL CONDITION] and no physician orders were in place for [MEDICAL CONDITION] care or suctioning, (2) staff lacked knowledge regarding aseptic technique for suctioning and [MEDICAL CONDITION] care increasing Resident #41's chance for an infection, (3) staff lacked knowledge regarding emergency procedures in the event Resident #41 decannulated, and (4) no system was in place to ensure uninterrupted humidified oxygen delivery. This deficient practice placed 1 resident receiving [MEDICAL CONDITION] care at risk for serious harm, injury and/or death. Findings include: Review of a facility Admission Record and Minimum Data Set (MDS) Quarterly assessment dated [DATE] reflected Resident # 41 was a [AGE] year-old man originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected that Resident #41 was in a persistent vegetative state and required total assistance from two people for all care. Resident #41 was also in contact/droplet precautions due to a recently diagnosed upper respiratory infection [MEDICAL CONDITION] and pseudomonas A (bacteria). Review of a Care Plan initiated on 10/26/2016 reflected that Resident #41 had a [MEDICAL CONDITION] related to [MEDICAL CONDITIONS] with the goal of keeping white blood cell counts and temperature within normal limits, will have no signs or symptoms of infection, will have no abnormal drainage [MEDICAL CONDITION], will have clear and equal breath sounds bilaterally. Interventions included suction as necessary. TUBE OUT PR[NAME]EDURES: Keep [MEDICAL CONDITION] and obturator at bedside. If tube is coughed out, reinsert. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breath spontaneously, elevate head of bed 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. A second care plan for the same condition was provided dated 4/24/18 and included the goal of Provide Humidification. No intervention to match the goal of humidification was noted. The care plan also called [MEDICAL CONDITION] daily and as needed. Review of Resident #41's clinical record revealed there were no physician orders pertaining to Resident #41's [MEDICAL CONDITIONS] mask, [MEDICAL CONDITION] care or endotracheal suctioning. Treatment Administration Records (TARs) were reviewed and indicated staff were [MEDICAL CONDITION] every shift. Suction was not noted. Progress notes were reviewed and did not reflect nurses were regularly documenting respiratory assessments [MEDICAL CONDITION] or suction. Further review of the clinical record indicated Resident #41 had multiple hospitalization s with [DIAGNOSES REDACTED]. Review of facility policies [MEDICAL CONDITION] Care last updated 6/26/2016 and Suctioning the Lower Airway dated 10/2015 reflected acceptable professional standards were used to formulate the procedures. On 5/8/18 at 10:25 a.m., [MEDICAL CONDITION] care was observed being given by RN E. RN E was not able to locate or verbalize what supplies would be needed in the event of an decannulation, was unable to locate an obturator and [MEDICAL CONDITION] in the event of an emergency and did not verbalize or demonstrate competency related to management and monitoring of Resident #41'[MEDICAL CONDITION] device. In addition, Resident #41's [MEDICAL CONDITION] was observed to be partially occluded with partially dried, sticky/gummy brown phlegm that was protruding from the inner cannula of the trach, a mask over [MEDICAL CONDITION] attached to blue corrugated tubing intended to deliver forced, humidified air, was soiled with thick phlegm. The water canister on the aerosol compressor was dry. Blue corrugated tubing connected to the compressor led down to the water trap bag that was resting in a puddle of water in a pink wash basin on the floor. Another blue hose led up from the water trap and was connected to Resident #41'[MEDICAL CONDITION]. When asked, RN E explained that there should be water in the canister to provide humidified air to Resident #41, to prevent his secretions from drying out. RN E also explained that the water trap needed to be at the lowest level of the hose to collect condensation and was periodically emptied to prevent water from backing up into the hose, preventing humidified air from reaching Resident #41. RN E also explained that the collection bag was in the wash basin because it was leaking. Upon [MEDICAL CONDITION], RN E did not assess Resident #41, despite obvious copious secretions. RN E was not familiar with the contents of [MEDICAL CONDITION] kit, and was surprised to see peroxide solution was provided, along with pipe-cleaners. RN E had obtained an unopened bottle of peroxide solution and extra sterile gloves when she had left the room to get more water for the humidifier. When the inner cannula was removed it was observed with bright red blood and thick brown sputum inside the cannula. RN E soaked the inner cannula in a peroxide/sterile-water solution and had to use a sterile q-tip and three pipe cleaners to dislodge a chunk of dried sputum that was stuck to the inner cannula. When the procedure was complete, RN E did not assess the resident before leaving the room. On 5/9/18 at 11:40 a.m., Resident #41 was observed without a dressing around [MEDICAL CONDITION] the water canister was empty. The aerosol compressor water trap was full, resting in a pool of water with a phlegm-like substance in the water, with water backed up into the proximal tubing, visibly bubbling and inhibiting airflow/mist from the compressor to the resident. RN F said she had been in the room about 45 minutes prior to the observation and said there was about an inch of water in the canister at that time. RN F was unable to find distilled water in the room to refill the canister and could not locate emergency supplies in the event Resident #41 decannulated. RN F said she had never seen an obturator and didn't know if there was one in the building. RN F said that if Resident #41 were to decannulate, she would send him to the Emergency Department. RN F said she [MEDICAL CONDITION] to Resident #41 at 6:30 a.m. that morning and thought maybe one of the nurse aides had taken the dressing off. RN F reported that she usually worked nights and that the nurse aides would change the sponge dressing and clean him up. When asked what supplies were used to [MEDICAL CONDITION], RN F could not locate them and said she would use sterile water and a q-tip to clean around the trach. RN F did not describe cleaning the inner cannula. RN F was asked to assess the vital signs for Resident #41. No dedicated equipment was in the room (despite Resident #41 being in contact/droplet precautions). When RN F called for an aide to bring a vitals machine, she admitted she did not know how to use it, further explaining that she was going to see if the nurse aides had gotten any vitals on the resident that morning, rather than assess Resident #41 herself after discovering him without humidified air and an obstructed forced air system. When asked, RN F described Resident #41's breath sounds as phlegmy and wet. RN F was asked about suctioning Resident #41 and was unable to locate sterile suction equipment, reaching instead for a package containing a gastrostomy tube cleaner. RN F reported she has worked at the facility for [AGE] years and it's been a long time since she had gotten education about [MEDICAL CONDITION] care and admitted there was a lot she didn't know. Review of an Occurrence Report dated 1/8/18 at 5:25 a.m. reflected RN F was informed by Certified Nurse Aide (CNA) I that Resident #41 had extubated while providing routine care. No attempt was made to replace the [MEDICAL CONDITION] and the Resident was sent to the Emergency Department. Follow-up education was provided to the CNA regarding care with repositioning residents with tracheostomies, but no education was provided to the nurse who did not know how to replace the [MEDICAL CONDITION] in an emergency. During an interview on 05/10/18 08:28 AM, Certified Nurse Aide (CNA) I' reported he was providing care to Resident #41 without a partner working with him the morning of 1/8/18 when Resident #41 decannulated. CNA I reported he ran outside of the room and got the RN F. CNA I reported RN F came into room, checked pulse ox, left on to monitor Resident #41's 02 saturation and asked CNA I to stay with resident while she called 911, and does not recall RN F trying to reinsert the [MEDICAL CONDITION]. CNA I does not recall getting formal education, just told to be careful with providing care. During an interview on 5/9/18 at 1:20 PM, Staff Development Coordinator and Infection Control Nurse RN D reported she had not educated staff on tracheostomies [MEDICAL CONDITION] including suction. RN D could not describe how to properly set up, monitor and maintain the aerosol compressor. When asked to [MEDICAL CONDITION] using [MEDICAL CONDITION] kit, RN D was unaware of the contents of [MEDICAL CONDITION] kit and did not know how to use all the items in it. Upon opening [MEDICAL CONDITION] kit, RN D said she would not use the peroxide. RN D said she would pour the sterile water into a sterile specimen cup for use and cleaning of the trach. RN D said she has never assisted a nurse with developing competency [MEDICAL CONDITION] at the bedside. On 05/09/18 Administrator A was notified of Immediate Jeopardy that began on 01/08/18. On 5/14/18 the State Agency verified the facility completed the following to remove the immediacy: 1) Resident #41 was transferred to the local hospital to meet his [MEDICAL CONDITION] needs. He was admitted under observation. 2) Medical record for resident #41 has been reviewed. Upon return to facility, physician orders related to [MEDICAL CONDITIONS] mask,[MEDICAL CONDITION], and suctioning will be obtained. Treatment records will be reviewed and updated to reflect current orders. Care plan will be revised to include [MEDICAL CONDITION]. On 5/9 dedicated equipment was placed in the resident's room. 3) Licensed nurses have been re-educated [MEDICAL CONDITION], Emergency care, Reinsertion, Suctioning, Humidification and Equipment policies by Respiratory Therapist on 5/12/2018. Any nurse not in attendance will be removed from schedule until 1:1 training and return demonstration is completed by nurse management. The Respiratory Therapist also validated nurse management competency for training subsequent licensed nurses moving forward. 4) Licensed nurses have been re-educated on physician orders, assessment, care planning, and documentation related to [MEDICAL CONDITION] care on 5/12/2018. Any nurse not in attendance will be removed from schedule until 1:1 training is completed by nurse management. Although the immediate jeopardy was removed on 05/12/18, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed.

Based on observation, interviews, and record review, the facility failed to develop and implement comprehensive, person centered care plans for 2 residents (Resident #41 and #37), of 18 residents reviewed, resulting in facility acquired infections, hospitalization , unmet care needs and negative medical and psychosocial outcomes. Findings include: Resident #41 Review of a facility Admission Record and Minimum Data Set (MDS) Quarterly assessment dated [DATE] reflected Resident # 41 was a [AGE] year old man originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected that Resident # 41 was in a persistent vegetative state and required total assistance from two people for all care. Review of a Care Plan initiated on 10/26/2016 reflected that Resident #41 had a [MEDICAL CONDITION] related to impaired breathing mechanics status [REDACTED].#41) will have no signs or symptoms of infection, will have no abnormal drainage [MEDICAL CONDITION], will have clear and equal breath sounds bilaterally, relieve dyspnea/control wheezing, (Resident #41's) [MEDICAL CONDITION]/cannula cleaning needs will be met by staff as evidenced by patency of [MEDICAL CONDITION], maintain oxygen saturation greater than or equal to 88%. Interventions included suction as necessary,[MEDICAL CONDITION] daily and as needed, universal precautions. TUBE OUT PR[NAME]EDURES: Keep [MEDICAL CONDITION] and obturator at bedside. If tube is coughed out, reinsert. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breath spontaneously, elevate head of bed 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. Review of a Care Plan initiated on 5/7/18 reflected Resident #41 had a respiratory infection related to [MEDICAL CONDITION]. Goals of the care plan were that Resident #41 would be free from signs and symptoms of infection by review date and free of symptoms of respiratory distress. Interventions included: antibiotic therapy as ordered by the physician, document response to treatment (antibiotic therapy), emphasize good handwashing technique to all direct care staff and monitor/document the amount of sputum, character, amount, color, odor and presence of hemoptysis. No mention of isolation precautions implemented to address the contact and droplet precautions initiated by the facility were noted, despite the precautions being started on 5/7/18 upon review of the laboratory results indicating Resident #41's sputum culture [MEDICAL CONDITION] and pseudomonas A bacteria. Review of Resident #41's clinical record revealed there were no physician orders pertaining to Resident #41's [MEDICAL CONDITIONS] mask, [MEDICAL CONDITION] care or endotracheal suctioning. Treatment Administration Records (TAR's) were reviewed and indicated staff were [MEDICAL CONDITION] every shift. Suction was not noted. Progress notes were reviewed and did not reflect nurses were regularly documenting respiratory assessments [MEDICAL CONDITION] or suction. Further review of the clinical record indicated Resident #41 had multiple hospitalization s with [DIAGNOSES REDACTED]. Review of the medical record reflected that Resident #41 was diagnosed with [REDACTED]. An isolation cart with gowns and gloves along with linen and trash receptacles was observed outside resident #41's room was noted on the afternoon of 5/7/18. No sign directing visitors or staff was present indicating additional precautions/instructions from the nurse were needed. During an observation on 5/8/18 at 9:50 a.m., Certified Nurse Aide (CNA) G and CNA H were observed providing direct personal care to Resident #41. No signage was posted directing staff to ask the nurse for further instructions. Neither CNAs were observed wearing eye protection despite being within 3 feet of Resident #41, known to have copious sputum/respiratory secretions. Upon completion of personal care for Resident #41, CNA G was observed washing her hands at the nurses station in the North Hall for less than 10 seconds. During an observation of [MEDICAL CONDITION] care on 5/8/18 at 10:25 a.m., Registered Nurse E was observed setting up supplies for the sterile procedure on an unclean, visibly wet over-bed table. RN E washed her hands for less than 15 seconds, first getting her hands wet, then applying soap and promptly rinsing the soap off her hands before lathering and applying friction to all surfaces of her hands. RN E did not follow sterile technique when cleaning Resident #41's inner cannula and did not allow the inner cannula of the [MEDICAL CONDITION] to soak in peroxide solution for 10 minutes per policy. In addition to the procedure, Resident #41's humidified oxygen system was observed sitting in a pool of unclean water in a pink wash basin on the floor. On 5/9/18 at 11:40 a.m., Resident #41 was observed without a dressing around [MEDICAL CONDITION] the water canister was empty. The aerosol compressor water trap was full, resting in a pool of water with a phlegm-like substance in the water, with water backed up into the proximal tubing, visibly bubbling and inhibiting airflow/mist from the compressor to the resident. RN F said she had been in the room about 45 minutes prior to the observation and said there was about an inch of water in the canister at that time. RN F was unable to find distilled water in the room to refill the canister and could not locate emergency supplies in the event Resident #41 decannulated. RN F said she had never seen an obturator and didn't know if there was one in the building. RN F said that if Resident #41 were to decannulate, she would send him to the Emergency Department. RN F said she [MEDICAL CONDITION] to Resident #41 at 6:30 a.m. that morning and thought maybe one of the nurse aides had taken the dressing off. RN F reported that she usually worked nights and that the nurse aides would change the sponge dressing and clean him up. When asked what supplies were used to [MEDICAL CONDITION], RN F could not locate them and said she would use sterile water and a q-tip to clean around the trach. RN F did not describe cleaning the inner cannula. RN F was asked to assess the vital signs for Resident #41. No dedicated equipment was in the room (despite Resident #41 being in contact/droplet precautions). When RN F called for an aide to bring a vitals machine, she admitted she did not know how to use it, further explaining that she was going to see if the nurse aides had gotten any vitals on the resident that morning, rather than assess Resident #41 herself after discovering him without humidified air and an obstructed forced air system. When asked, RN F described Resident #41's breath sounds as phlegmy and wet. RN F was asked about suctioning Resident #41 and was unable to locate sterile suction equipment, reaching instead for a package containing a gastrostomy tube cleaner. RN F reported she has worked at the facility for [AGE] years and it's been a long time since she had gotten education about [MEDICAL CONDITION] care and admitted there was a lot she didn't know. Review of an Occurrence Report dated 1/8/18 at 5:25 a.m. reflected RN F was informed by Certified Nurse Aide (CNA) I that Resident #41 had extubated while providing routine care. No attempt was made to replace the [MEDICAL CONDITION] and the Resident was sent to the Emergency Department. Follow-up education was provided to the CNA regarding care with repositioning residents with tracheostomies, but no education was provided to the nurse who did not know how to replace the [MEDICAL CONDITION] in an emergency. During an interview on 05/10/18 08:28 AM, Certified Nurse Aide (CNA) I' reported he was providing care to Resident #41 without a partner working with him the morning of 1/8/18 when Resident #41 decannulated. CNA I reported he ran outside of the room and got the RN F. CNA I reported RN F came into room, checked pulse ox, left on to monitor Resident #41's 02 saturation and asked CNA I to stay with resident while she called 911, and does not recall RN F trying to reinsert the [MEDICAL CONDITION] (contrary to the care plan interventions). CNA I does not recall getting formal education, just told to be careful with providing care. Resident #37 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #37 was an [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #37 was mildly cognitively impaired and required extensive assistance in activities of daily living. On 05/07/18, at approximately 11:55 AM, an interview was completed with Resident #37 in his room. Resident #37 advised that he did not have any teeth and did not know why he wasn't getting dentures but thought someone had told him it would take to long. He denied seeing a dentist recently and stated he had not had teeth for a long time. Resident #37 opened his mouth and was observed to not have any teeth at this time. Review of Resident #37's care plan printed 5/9/2018 did not have any note related to his missing teeth or a goal or plan to provide dental care for Resident #37. A focus area of The resident is at risk for nutritional declines . was documented, but lack of teeth or a need for dental care was not referred to. An intervention of monitor for chewing or swallowing difficulties was documented. A review of Resident #37's admission MDS assessment dated [DATE] and his most recent MDS dated [DATE] revealed in the Dental section that Resident #37 was assessed as having no natural teeth or tooth fragments. A review of facility policy titled Dental Services with a revised date of 11/28/17 revealed that Routine and 24 hour emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .Oral health services are available to meet the resident's individual needs . The facility will promptly or within 3 days refer residents with lost or damaged dentures for dental services. If I referral does not occur within three days the social service staff or designee will document what was done to ensure the resident could still eat and drink adequately while awaiting dental services and describe the extenuating circumstances around the delay. The care plan and Kardex will be updated to reflect interventions .

Based on interview and record review, the facility failed to prevent a fall for 2 of 3 residents (Resident #8 and Resident #62) reviewed for falls, from a total sample of 18 residents, resulting in Resident #8 sustaining a fall with minor injuries and Resident #62 sustaining a fall with major injury. Findings include: Resident #8 A review of Resident #8's admission record, dated 5/8/18, Resident #62 was a [AGE] year old resident admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #8's Minimum Data Set (MDS- a tool used for assessing a resident's care needs), dated 5/1/18, revealed Resident #8 had a Brief Interview for Mental Status (BIMS- a tool used to determine a resident's cognitive status) score of 11 which indicated Resident #8 was moderately cognitively intact. A review of Resident #8's nursing progress note, dated 2/26/18, revealed Resident (Resident #8) returning to facility from [MEDICAL TREATMENT] via (name of transportation company) when the driver stopped the vehicle and the resident fell out of his w/c (wheelchair). Resident (Resident #8) was assisted back into his w/c by transportation CENA (certified nursing assistant) and (name of transportation company) driver. When resident (Resident #8) returned to facility his skin and pain were assessed, abrasions to L (left) forehead and knee were cleansed, opsite (a type of bandage) was applied to knee, to be monitored and changed prn (as needed). Bruising to R (right) hand. Resident (Resident #8) states he has NO pain, the sling he has to use for [MEDICAL TREATMENT] made him slip out of his w/c. Neuro (neurological) checks initiated, wnl (within normal limits). Resident (Resident #8) to wear seat belt system on bus . Mitigating Factors: not wearing the complete seat belt system on (name of transportation company) bus . Interventions: resident to wear complete seat belt system while riding the bus. Staff education. A review of Resident #8's incident report, dated 2/26/18, revealed Resident #8 had fallen out of his wheelchair while on a mass transit vehicle. Resident #8's wheelchair was tied down, but Resident #8 not wearing seatbelt. Resident #8's incident report further revealed TA L was present at the time of the incident and Resident #8 was instructed he must wear seatbelt when on mass transit. Aide (TA L) inserviced on need for seatbelt. During an interview on 05/09/18 at 12:53 PM, transportation aide (TA) L stated, I picked him ( Resident # 8 ) up from [MEDICAL TREATMENT]. We got on the bus. We hooked him (Resident #8) up. We used the anchors in the floor to secure his wheelchair. (Name of Resident #8) doesn't have a seatbelt in his wheelchair. It's just common sense to use one (when transporting on a bus or van). (Name of Resident #8) had ridden (name of transportation company) multiple times before and not had a seatbelt. We didn't always put a seatbelt on him. (Name of transportation company) says it's (seatbelt) an option, but not required. They said they wouldn't make a resident wear one if they refused. We left the hospital and stopped at the yield sign. As we went forward to the stop sign, the driver stopped the bus slower than anticipated. There's a slight decline between the yield sign and the stop sign. (Name of Resident #8) came out of his chair. He's a double [MEDICAL CONDITION], so it threw him off (the quick stop). We got him back in his wheelchair. I asked him if he was hurt. He said no. I told the driver we needed to do an incident report when we got back to the facility. He seemed like he was in a hurry and said he didn't have time. I told him we needed to. When I got (name of Resident #8) into the building, the driver was giving (name of Nursing Home Administrator (NHA) A) a report. I gave them (facility management) a report. This facility has a policy that everyone has to be seatbelted in. No one said anything to me about everyone being seatbelted in before this happened. On 05/09/18 at 02:45 PM, a review of TA L's personnel file with NHA A failed to reveal TA L had been educated (as mentioned in Resident #8's nursing progress note and incident report, both dated 2/26/18) regarding TA L's failure to ensure Resident #8 was wearing a seatbelt while being transported in a bus. During an interview on 05/09/18 at 03:00 PM, NHA A stated, I was told by the driver that the bus wasn't even moving at the time of the incident. The driver told me he (Resident #8) just put his arms up and pitched himself forward out of his wheelchair. I don't have any witness interviews. Our facility did not have a policy for transportation on a bus with a wheelchair with the old company. I just found we had a policy for our new company. I haven't read it, yet. The new company took over on (MONTH) 1st (25 days before the incident). During an interview on 05/09/18 at 04:20 PM, Resident # 8 stated, I remember when I fell out of my wheelchair on the bus (2/26/18). The bus stopped suddenly and I slid out of my wheelchair. I slid out butt first. I wasn't hurt. They never offered to seat belt me in my wheelchair. I never refused to have a seat belt. A review of the facility's transportation policy, undated, revealed All residents and staff must be fastened into the appropriate safety restraint. This includes seat belts, shoulder straps, or a combination thereof. Residents in wheelchairs must wear both a lap belt and shoulder harness. Resident #62 A review of Resident #62's admission record, dated 5/8/18, Resident #62 was a [AGE] year old resident admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #62's Minimum Data Set (MDS- a tool used for assessing a resident's care needs), dated 4/3/18 (5 days prior to the fall), revealed Resident #62 had a Brief Interview for Mental Status (BIMS- a tool used to determine a resident's cognitive status) score of 14 which indicated Resident #62 was cognitively intact. In addition, Resident #62's MDS revealed Resident #62 needed extensive assistance (resident involved in activity with staff providing weight-bearing support) of one person physical assistance for toileting and limited assistance (resident highly involved in activity with staff providing guided maneuvering of limbs or other non-weight bearing assistance) of one person for walking in her room. In addition, Resident #62's MDS revealed Resident #62 did not have any pain. A review of Resident #62's MDS (a significant change in status MDS), dated [DATE], revealed Resident #62 In addition, Resident #62's MDS revealed Resident #62 needed extensive assistance (resident involved in activity with staff providing weight-bearing support) of two persons physical assistance for toileting and Resident #62 did not walk in her room. Resident #62's MDS also revealed Resident #62 had occasional pain of a 5 (on a 0 to 10 scale where 0 indicates no pain and 10 indicates the worse pain you can imagine) that limited daily activities. These were negative changes to Resident #62's status after the fall on 4/8/18. During an interview on 05/09/18 at 09:30 AM, Resident #62 stated, I fell in the bathroom. I don't remember when. I was working with therapy. I had to go to the bathroom. I went in the bathroom and closed the door. The therapist was with me. I took a big step, slipped, and fell . A review of Resident #62's progress notes, dated 4/1/18 to 4/16/18, revealed the following: - Activities note, dated 4/9/2018, revealed New fall with a fracture. Situation (where/when/what/who): (Resident #62) Was ambulating to bathroom from her bed with a CENA (certified nursing assistant), resident (Resident #62) stated that she was dizzy, resident leaned on door and slid to the floor with assist from CENA. Injury/No injury: Fracture to right hip. Factors involved (acute condition/environment, etc.): Was dizzy . Analysis of interventions to implement: x-ray completed, and (Resident #62) sent to ER (emergency room ), admitted to the hospital. - Nursing progress note, dated 4/8/2018, revealed Date of Fall: 04/08/2018. Resident (Resident #62) had fall on 3rd (midnight) shift. (Resident #62) was resting in bed this shift. c/o (complained of) of severe pain with movement. (Resident #62) unable to sit up or transfer . received orders for hip, femur and knee Xrays. Xray returned with displaced femur head fx (fracture) . sent resident to (name of hospital) ER. - Nursing progress note, dated 4/8/2018, revealed Date of Fall: 04/08/2018. Situation Details: resident (Resident #62) being ambulated to bathroom by cena when she (Resident #62) stated she was dizzy and leaned against bathroom door and slide to floor. (Resident #62) assisted back to bed using mechanical lift. Assessment: resident (Resident #62) has c/o pain in right thigh and an abrasion on right knee. A review of Resident #62's incident report, dated 4/8/18 and completed on 4/23/18, revealed on 4/8/18 at 5:30 AM, Resident #62 was walking to bathroom with assist from CENA (CNA O). Res (Resident #62) stated she felt dizzy when they got to bathroom door. (Resident #62) had non-slip socks on, using walker. Res (resident) started to lose balance, CENA (CNA O) put her arm behind res (Resident #62's) back & (and) lowered her to the floor. Res (Resident #62) attempted to get up & got to her knees, CENA has res sit on floor & assisted to bed with lift (lift device). (Resident #62) c/o pain in (R) (right) thigh, later c/o severe pain, sent to ER, admitted c/ (with) (R) [MEDICAL CONDITION]. A review of CNA O's written statement, dated 4/8/18, revealed (CNA O) went in woke her (Resident #62) up. (Resident #62) only used call light once. Asked her if she had to use BR (bathroom). (Resident #62) had gripper socks, 0 (no) gait belt, walker. (Resident #62) doing great. Got into bathroom, (Resident #62) stated felt dizzy, leaned against roommate's bathroom, slid down to floor. My (CNA O) arm was behind her back, (Resident #62) stated I'm ok, got up onto her knees. Had her sit on floor until evaluated by nurse. Assisted to bed c/ lift. A review of Resident #62's x-ray results, dated 4/8/18, revealed Resident #62 had a [MEDICAL CONDITION] femoral neck (hip joint). A review of Resident #62's hospital records, dated 4/9/18, revealed Resident #62 required surgery for [REDACTED]. A review of Resident #62's physician orders, dated 3/1/18 to 4/30/18, revealed Resident #62 had an order for [REDACTED].#62 had a physician's orders [REDACTED]. A review of Resident #62's (MONTH) (YEAR) Medication Administration Record [REDACTED] - Resident #62 received [MEDICATION NAME] (a pain medication) 400 mg daily. - Resident #62 received [MEDICATION NAME] 5/325 mg as needed one to three times a day from 4/14/18 to 4/28/18 for pain that ranged from a 4 to an 8 on a 0 to 10 pain scale (the majority of the time Resident #62 rated the pain as a 6). - Resident #62 received scheduled [MEDICATION NAME] 5/325 mg twice daily from 4/27/18 to 4/30/18.

Based on observation, interviews, and record review, the facility failed to ensure there was sufficient skilled and competent nursing staff to provide nursing and related services for 3 residents (Resident #41, Resident #29 and Resident #9), out of 18 residents reviewed, resulting in the potential for drug diversion, harm and the potential for serious harm, injury and or death when staff were not educated or competency evaluated according to professional standards for resident specific [DIAGNOSES REDACTED]. Findings include: Review of the facility assessment reflected Each admission is look at individually for level of care, diagnosis, medications, etc. Each admission is then reviewed for acuity and if the [DIAGNOSES REDACTED]. The assessment further indicated the center was .skillfully able to care for .Respiratory System-pneumonia, [MEDICAL CONDITION] [MEDICAL CONDITION] . In addition to being able to skillfully care for conditions affecting the respiratory system, the assessment indicated it was able to skillfully manage Infectious diseases including: Respiratory infections, Urinary Tract Infections [MEDICAL CONDITION], infections with multi-drug resistant organisms, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The facility assessment further indicated it was able to identify and prevent infection, including contact isolation if needed and address Other special care needs such as ostomy care, [MEDICAL CONDITION] care . Staff Training/Education and competencies referenced in the facility assessment indicated .Nurse competencies are completed upon hire, yearly and as needed. Medication pass is reviewed with licensed nurses. Education and training is provided with in house training as warranted for [DIAGNOSES REDACTED]. Return demonstrations by staff are included in these training's. Specific Nursing Competencies in the assessment included: Medication Administration-oral, injectable, subcutaneous and topical, Resident assessment and exam, specialized care-catheter, suctioning, [MEDICAL CONDITION], tube feedings, TPN, [MEDICAL TREATMENT] after care,[MEDICAL CONDITION]/suctioning, caring for residents with disabilities, behaviors, [MEDICAL CONDITION] and history of trauma, non-pharmacological interventions. Resident #41 Review of a facility Admission Record and Minimum Data Set (MDS) Quarterly assessment dated [DATE] reflected Resident # 41 was a [AGE] year-old man originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected that Resident #41 was in a persistent vegetative state and required total assistance from two people for all care. Resident #41 was also in contact/droplet precautions due to a recently diagnosed upper respiratory infection [MEDICAL CONDITION] and pseudomonas A (bacteria). On 5/8/18 at 10:25 a.m., [MEDICAL CONDITION] care was observed being given by RN E. RN E was not able to locate or verbalize what supplies would be needed in the event of an decannulation, was unable to locate an obturator and [MEDICAL CONDITION] in the event of an emergency and did not verbalize or demonstrate competency related to management and monitoring of Resident #41'[MEDICAL CONDITION] device. In addition, Resident #41's [MEDICAL CONDITION] was observed to be partially occluded with partially dried, sticky/gummy brown phlegm that was protruding from the inner canula of the trach, a mask over [MEDICAL CONDITION] attached to blue corrugated tubing intended to deliver forced, humidified air, was soiled with thick phlegm. The water canister on the aerosol compressor was dry. Blue corrugated tubing connected to the compressor led down to the water trap bag that was resting in a puddle of water in a pink wash basin on the floor. Another blue hose led up from the water trap and was connected to Resident #41'[MEDICAL CONDITION]. When asked, RN E explained that there should be water in the canister to provide humidified air to Resident #41, to prevent his secretions from drying out. RN E also explained that the water trap needed to be at the lowest level of the hose to collect condensation and was periodically emptied to prevent water from backing up into the hose, preventing humidified air from reaching Resident #41. RN E also explained that the collection bag was in the wash basin because it was leaking. Upon [MEDICAL CONDITION], RN E did not assess Resident #41, despite obvious copious secretions. RN E was not familiar with the contents of [MEDICAL CONDITION] kit, and was surprised to see peroxide solution was provided, along with pipe-cleaners. RN E had obtained an unopened bottle of peroxide solution and extra sterile gloves when she had left the room to get more water for the humidifier. When the inner canula was removed it was observed with bright red blood and thick brown sputum inside the canula. RN E soaked the inner canula in a peroxide/sterile-water solution and had to use a sterile q-tip and three pipe cleaners to dislodge a chunk of dried sputum that was stuck to the inner canula. When the procedure was complete, RN E did not assess the resident before leaving the room. On 5/9/18 at 11:40 a.m., Resident #41 was observed without a dressing around [MEDICAL CONDITION] the water canister was empty. The aerosol compressor water trap was full, resting in a pool of water with a phlegm-like substance in the water, with water backed up into the proximal tubing, visibly bubbling and inhibiting airflow/mist from the compressor to the resident. RN F said she had been in the room about 45 minutes prior to the observation and said there was about an inch of water in the canister at that time. RN F was unable to find distilled water in the room to refill the canister and could not locate emergency supplies in the event Resident #41 decannulated. RN F said she had never seen an obturator and didn't know if there was one in the building. RN F said that if Resident #41 were to decannulate, she would send him to the Emergency Department. RN F said she [MEDICAL CONDITION] to Resident #41 at 6:30 a.m. that morning and thought maybe one of the nurse aides had taken the dressing off. RN F reported that she usually worked nights and that the nurse aides would change the sponge dressing and clean him up. When asked what supplies were used to [MEDICAL CONDITION], RN F could not locate them and said she would use sterile water and a q-tip to clean around the trach. RN F did not describe cleaning the inner canula. RN F was asked to assess the vital signs for Resident #41. No dedicated equipment was in the room (despite Resident #41 being in contact/droplet precautions). When RN F called for an aide to bring a vitals machine, she admitted she did not know how to use it, further explaining that she was going to see if the nurse aides had gotten any vitals on the resident that morning, rather than assess Resident #41 herself after discovering him without humidified air and an obstructed forced air system. When asked, RN F described Resident #41's breath sounds as phlegmy and wet. RN F was asked about suctioning Resident #41 and was unable to locate sterile suction equipment, reaching instead for a package containing a gastrostomy tube cleaner. RN F reported she has worked at the facility for [AGE] years and it's been a long time since she had gotten education about [MEDICAL CONDITION] care and admitted there was a lot she didn't know. Review of an Occurrence Report dated 1/8/18 at 5:25 a.m. reflected RN F was informed by Certified Nurse Aide (CNA) I that Resident #41 had extubated while providing routine care. No attempt was made to replace the [MEDICAL CONDITION] and the Resident was sent to the Emergency Department. Follow-up education was provided to the CNA regarding care with repositioning residents with tracheostomies, but no education was provided to the nurse who did not know how to replace the [MEDICAL CONDITION] in an emergency. During an interview on 05/10/18 08:28 AM, Certified Nurse Aide (CNA) I' reported he was providing care to Resident #41 without a partner working with him the morning of 1/8/18 when Resident #41 decannulated. CNA I reported he ran outside of the room and got the RN F. CNA I reported RN F came into room, checked pulse ox, left on to monitor Resident #41's 02 saturation and asked CNA I to stay with resident while she called 911, and does not recall RN F trying to reinsert the [MEDICAL CONDITION]. CNA I does not recall getting formal education, just told to be careful with providing care. During an interview on 5/9/18 at 1:20 PM, Staff Development Coordinator and Infection Control Nurse RN D reported she had not educated staff on tracheostomies [MEDICAL CONDITION] including suction. RN D could not describe how to properly set up, monitor and maintain the aerosol compressor. When asked to [MEDICAL CONDITION] using [MEDICAL CONDITION] kit, RN D was unaware of the contents of [MEDICAL CONDITION] kit and did not know how to use all the items in it. Upon opening [MEDICAL CONDITION] kit, RN D said she would not use the peroxide. RN D said she would pour the sterile water into a sterile specimen cup for use and cleaning of the trach. RN D said she has never assisted a nurse with developing competency [MEDICAL CONDITION] at the bedside. Resident #29 and Resident #9 A review of facility provided Occurrence Report # 2 dated 1/17/2018 regarding Resident #29 revealed a conclusion written by former Director of Nursing (DON) W: upon investigation it was found that resident received another resident's [MEDICATION NAME]-however this this (sic) resident is ordered to receive the same medication at the same time. Resident had no ill effects. Nurse to use rights of medication administration. It is documented that Registered Nurse (RN) X would be educated regarding the rights of medication administration (sic). The due date was documented as 1/26/2018 and the status was noted as pending. A review of facility provided Occurrence Report # 5 dated 1/20/2018 regarding Resident #9 revealed a conclusion written by former DON W: upon investigation in error nurse gave resident 100 mg of [MEDICATION NAME] instead of ordered 50mg . It is documented that Registered Nurse (RN) M would be educated on rights of medication administration. The due date was documented as 1/26/2018 and the status was noted as pending. An interview was completed with RN S on 5/10/2018 at 2:35 PM. RN S stated that she had relieved RN M from her shift on 1/20/2018. RN S stated that when they counted the medication cart the count was off and she believed that Resident #9 was given another resident's medication for her noon or 1200 dose and then after talking to the doctor the 6:00 PM or 1800 and midnight or 0000 dose were ordered to be held. RN M could not recall what resident's medication was allegedly used. RN M stated she believed the other nurse did an incident report and stated that no one ever followed up with her regarding the incident. An interview was completed with Resident #9 at 9:50 AM on 5/10/2018. Resident #9 is noted in her most recent MDS to be cognitively intact. Resident #9 denied being aware of receiving a higher or lower dose of her pain medication at any time. Resident #9 stated that she counts all of her pills when she takes them and asks questions if she has too few or too many pills that she is used to. On 5/9/2018 at approximately 12:40 PM, a request was made for further information regarding the medication error incidents as well as proof of educations for RN M and RN X related to these incidences. An interview was completed with Nursing Home Administrator (NHA) A on 5/10/2018 at 7:35 AM. NHA A stated that she had not been made aware of the incidents at the time, and was unsure if former DON W had documented the education of the nurses. The Occurrence Report had been completed in another system the facility no longer uses and may have more information. An additional request was made at 11:15 AM and 3:30 PM on 5/10/2018 and no additional information had been located. As of the time of exit on 5/14/2018 at 5:20 PM, the facility had not provided this information. A review of Resident #9's MAR indicated [REDACTED]. The back of the MAR indicated [REDACTED]. During an interview with NHA A at 3:30 PM the MAR indicated [REDACTED]. NHA A admitted that the charting was incorrect. NHA A was asked if they were aware of what other resident's medication Resident #9 or Resident #29 had received and they were not aware at that time. NHA A was questioned further about the lack of information regarding the incidents and stated they would check with pharmacy and review narcotic count sheets and would initiate a facility reported incident regarding potential diversion. A review of RN X's personnel file revealed a 1:1 In-service from 1/23/2017 regarding narcotics policy. No additional education or disciplines regarding the 1/17/2018 incident was found. A review of RN M personnel file revealed no education or disciplines related to the 1/20/2018 incident.

This citation is in regards to MI 167 Based on interview and record review, the facility failed to prevent an avoidable fall for one resident (Resident #101) out of 2 residents reviewed for falls from a total sample of 3 residents resulting in a fall with a hematoma and pain requiring hospitalization . Findings include: According to a facility face sheet dated 5/6/14 (no time noted), Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].(stroke with delusions and hallucinations), [DIAGNOSES REDACTED] with status [REDACTED]. During an interview with Administrator "A" and Director of Nursing (DON) "B" on 8/1/14 at 10:30 a.m., DON "B" stated Resident #101 experienced a fall on 4/15/14. A facility document titled, "Resident Incident" dated 4/15/14 reflected that Resident #101 had a fall on 4/15/14 at 1:00 a.m. The report reflected, "Resident (#101) states that he went to stand up to go to the bathroom. Barefoot on one foot and regular stocking on the other foot, he said the sock slid and he leaned on the overbed table to try and keep himself from falling. Overbed table broke and resident (#101) landed on the floor on his knees. (Resident #101) was able to stand up on his own..." During the interview with DON "B" on 8/1/14 at 10:30 a.m., DON "B" confirmed this is what had occurred with Resident #101. DON "B" stated that the intervention implemented was for Resident #101 to wear non slip foot wear (gripper socks) to prevent another fall. DON "B" confirmed that Resident #101 didn't appear to have any injuries from this 4/15/14 fall. DON "B" stated Resident #101 required to be up with assist of one person with a walker and a gait belt. There was no indication in the investigation that Resident #101 had called for assistance. Director of Nursing (DON) "B" stated during an interview on 8/1/14 at 9:50 a.m., that there is no fall assessment such as a fall risk score. The Fall/Injury Assessment is used. A physical therapy tool titled, "Tinetti Assessment" dated, 4/17/14 was reviewed with Physical Therapist (PT) "D " on 8/1/14 at 9:50 a.m. PT "D" revealed that the balance score and the gait score give you a fall risk score. According to this assessment on 4/17/14, Resident #101 was at moderate risk for a fall Review of a consulting physician document on 4/17/14 (no time noted) reflected that Resident #101 was noted to have a "Large hematoma of the right anterior (front) thigh (top of leg). Tenderness with ecchymosis." This document also reflected that Resident #101 ws on Lovenox, an injectable blood thinner. According to Lexicomps Drug Reference Handbook, Edition 21, copywrite 2012, page 589 reflects that Lovenox adverse reactions, "as with any anticoagulants, bleeding is the major adverse effect of enoxaparin (Lovenox). Hemorrhage may occur at virtually any site." According to a facility document titled, "Resident Incident" dated 5/2/14 for Resident #101 reflected that on 5/2/14 at 9:45 a.m., "(A) loud crash came from Residents (#101) room, upon entering, resident (#101) observed kneeling on the floor on right knee with left foot on the ground and hands bracing self on floor. (The) breakfast tray was spilled all over the floor and all over resident (#101). Resident (#101) had regular socks on...Resident (#101) states he was walking to the bathroom and slipped. Upon skin assessment, resident (#101) was observed to have a 3.5 cm (centimeter) by 3 cm red area to right knee, also a 3 cm by 2 cm scrape to right back by arm." Investigation summaries with a summary of investigator findings on this facility document reflected, "Upon investigation, it was found that the Resident (#101) slipped on his way to the bathroom and was found on the floor in a kneeling position with his food tray also on the floor. He was wearing regular type socks. (A) small red mark and abrasion noted, no complaints of discomfort. He (Resident #101) has a BIM's (Brief Interview for Mental Status) score of 13 (out of 15 indicating good cognitive function). During the evening, Resident (#101) began to complain of right hip pain at a severe level and was noted to have bruising to the hip area. He (Resident #101) requested that he be sent to the ER (emergency room ) for evaluation at which time showed no rotation or shortening of the leg. Resident (#101) had no complaints earlier in the day of any complaints of pain to that hip and had worked with (physical) therapy also that day following the fall. Examination in the ER showed a lobular heterogenous collection (a hematoma, a leakage of blood into the soft tissues) within the soft tissues laterally (outside) and anterior (front) to the proximal right femur (large bone of the leg), no fracture noted..." During the interview with DON "B" on 8/1/14 at 10:30 a.m., DON "B" stated that the intervention of gripper socks (which had already been implemented and not used during this fall) and a tolieting program was added to Resident #101's care plan to prevent another fall. The intervention of gripper socks had not been on Resident #101 during this fall on 5/2/14 to prevent this fall. There was no indication on this investigation that Resident #101 had called for assistance. A local acute care facility document titled, "Consultation Report" dated 5/3/14 (no time noted) reflected, "This [AGE] year old Caucasian gentleman who is well known to me with multiple medical problems including recent hemorrhagic cerebrovascular accident (stroke), as well as history of thyroid [DIAGNOSES REDACTED], history of Crohn's disease (an [DIAGNOSES REDACTED] bowel disease) and a history of peripheral vascular diease, was in his usual state of health at his nursing home and hew was ambulating and fell on his right hip. He (Resident #101) started having some deformity and ecchymosis of this area and significant pain. He (Resident #101) was unable to be controlled (Pain) and was then brought into the emergency department. He was evaluated from the hematoma standpoint..." A facility document titled, "Resident Incident" dated 5/11/14 for Resident #101 reflected that on 5/11/14 at 7:30 a.m., Resident #101 was noted, "sitting on his bottom with his back to the window. He had his gripper socks on and was dry." Resident #101 stated that he was going to look for a Mother's Day card. This document reflects that Resident #101 was "re educated on the use of his call light and asking for help." Corrective action: "continue with therapy, he (Resident #101) has a BIM'S score of 15 (out of 15 indicating Resident was cognitively intact)." Review of a document from a local acute care facility dated 5/11/14 at 2:33 p.m. reflected, "[AGE] year old male with pain in her (sic) right hip. He fell this morning at (name of long term care facility) at 9:00 a.m.. He (Resident #101's pain) did not begin until this afternoon. He has a history of a large right inguinal/femoral /hip hematoma. He was admitted to the hospital earlier this month for pain control. He was evaluated by orthopedics and surgery at that time and also had a CAT scan that showed a hematoma to be subcu(taneous) (in the tissues)....He's (Resident #101) been taking Lovenox (an injectable blood thinner) for his DVT (deep vein thrombosis or blood clot) his last dose was yesterday." "Comments: He (Resident #101) has a large hematoma extending from the lateral right hip across the inguinal area approximately 10 cm by 20 cms. There is ecchymosis (bruising) up into the right flank. He is exquisitely tender to palpation (touch) of the hematoma...." Resident #101 continued to have pain from his hematoma from his falls. The facility document titled, "Care Delivery Guide" dated 8/1/14 for Resident #101 was reviewed. A "Care Delivery Guide" dated before 4/15/14 for Resident #101 was requested from DON "B" during an interview on 8/1/14 at 10:30 a.m.. DON "B" and Administrator "A" stated resident "Care Delivery Guides" (kept in resident's rooms) from Resident #101's room "frequently came up missing". DON "B" was asked how Certifiied Nurses Aids know how to care for Resident #101 if the care guide is missing. DON "B" states that when one is noted missing, it is replaced with a new care guide. The Care Delivery Guide dated 8/1/14 (date of interview with DON "B") reflected Resident #101 required a walker for ambulation, assist with transfer of one person, and the use of a gait belt. The Care Delivery Guide for Resident #101 dated 8/1/14 does not reflect the need for the use of gripper socks, the need for a tolieting program or the need to re educate the resident to use the call light for assistance. ( )

Based on observation, interview and record review, the facility failed to develop, implement, and monitor interventions to prevent significant weight loss for 1 resident (Resident #5) out of 3 residents reviewed for weight loss from a total sample of 16 residents resulting in avoidable weight loss and possible malnutrition. Findings include: According to a facility face sheet dated 2/7/14 (no time noted), Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with the Diagnoses: [REDACTED]. According to a facility document titled, " Weights Detail Report ", Resident #5 weighed 125 lbs. (pounds) on 8/6/13 and on 5/5/13 Resident #5 ' s weight was 110 lbs. Resident #5 had lost 15 lbs in 9 months. An interview on 5/8/14 at 12:25 p.m. with Registered Dietician (RD) " D " and Corporate Registered Dietician "C" , RD "D" stated she had been employed with the facility for 2 months and that Corporate RD " C " had been the RD for the facility before that. RD " C " and RD "D" made a timeline of Resident #5 ' s weight loss and this was reviewed with them: 9/23/13 Resident #5's weight loss was stable but food intake was down. RD "C " confirmed no new interventions to prevent weight loss were added. 11/13/13 Resident #5's weight was reviewed by the interdisciplinary team and intake was up to 58%, no new interventions were placed. 1/8/14 Resident #5 had a weight loss. Resident was changed to the assisted dining room for supervision and cueing her to eat. 2/5/14 There was a weight loss in January 2014 for Resident #5. RD "C" noted staff monitoring and cueing Resident #5. Resident #5 was back in the main dining room. RD "C" can not explain why this has occurred. An observation of Resident #5 dining in the main dining room on 5/7/14 at 8:25 a.m. was made. Resident #5 was seated at a table with 2 other female residents. Resident #5 had a tray of breakfast foods in front of her including a fried egg and toast. Resident #5 had a small glass of pink looking milky liquid, a clear red liquid and a mug. Resident #5 took an occasional drink of the pink liquid but kept picking up the mug, looked into it and sat it down. She looked into this mug 5 times before she lifted it to her mouth and not received any liquid. While Resident #5 was at the table, it was noted that both of her table mates received refills on their hot liquids but Resident #5 was never asked if she would like a hot liquid refill. Once during her breakfast meal, Certified Nurses Aid "Y" picked up the pink drink and offered it to her twice during the observation. Once, CNA "X" asked Resident #5 if she would like her egg cut up and she said, "Yes" but CNA " X " never encouraged her to eat. Two staff members stood at Resident #5's table and spoke with her tablemates but no one encouraged her to eat her meal. It was observed that no one encouraged Resident #5 to eat any of her meal during the 35 minute meal observation. Another observation of Resident #5 was made during a meal in the main dining room on 5/7/14 at 12:41 p.m. It was noted Resident #5 ate 1/3 of her fish patty and seemed to enjoy her soup. No staff members were noted encouraging Resident #5 to eat. Resident #5' s intervention to encourage oral intake and eat in the assisted dining area was not being implemented. Review of Resident #5's Minimum Data Set, an annual evaluation dated 8/9/13 reflected that Resident #5 required supervision of one staff and set up help for eating. Review of Resident #5's Minimum Data Set, a quarterly evaluation reflected that Resident #5 now required supervision of one staff and assist of one staff for eating. 4/4/14 Resident #5 was again reviewed by the Interdisciplinary Team (IDT) due to weight loss. An intervention to increase her Ready Care 2 calories to 90 cc (cubic centimeters) three times a day was implemented and Resident #5 was placed on weekly weights. During an interview on 5/8/14 at 12:25 p.m. with Registered Dietician (RD) "D" and Corporate Registered Dietician "C", both were asked who administers the Ready Care Supplement. RD "C" and "D" confirmed nursing gave the Ready Care 2.0 cal. RD "C" and " D " were asked how they were able to monitor Resident #5 ' s intake of the supplement. RD "C" stated that the nurses documented the percentage taken in by Resident #5 on the Medication Administration Record [REDACTED]. RD "C" and "D" confirmed that they could not assess the effectiveness of the Ready Care if they were not informed of Resident #5's intake of the supplement. 4/14/14 Resident #5 was reviewed again by RD " D " due to weight loss. "No additional recommendations" were made to intervene in Resident #5' s gradual weight loss. Review of a facility document titled, " Nutrition Risk Data Collection and Assessment " reflected that in the review on 11/13/14 Resident #5 was consuming 58% of her meals. During the 2/6/14 RD assessment, Resident #5 was consuming 62% of her meals. During the 4/30/14 RD assessment, Resident #5 was consuming 49% of her meals. During an interview on 5/8/14 at 12:25 p.m. with Registered Dietician (RD) " D " and Corporate Registered Dietician " C " , both were asked how they assessed what type of intake Resident #5 was having. RD " C " and " D " confirmed that staff only noted percentage of the meal eaten not the type of foods such as proteins, starches, vegetables. RD "C" and "D" agreed it was difficult to assess her nutritional intake when they could not assess what Resident #5 was actually consuming. Review of a facility policy dated revised July 2010, titled "Clinical Algorithm for Weight Loss Interventions" reflects: Step 1) IDT to determine interventions, discuss possible weight loss causes and update care plan. Step 2) IDT to determine interventions, review effectiveness of intervention. Utilize food interventions (i.e. whole milk, pudding, ice cream, peanut butter, etc), update care plan. Step 3 IDT to determine interventions, review effectiveness of intervention. Utilize enhanced foods/fortified foods program (i.e. super cereal, super spuds, super pudding, super milk, etc) update care plan. Step 4) IDT to determine interventions, review effectiveness of intervention. Utilize med pass program (supplemental drink) and update care plan. Step 5) IDT to determine interventions, review effectiveness of intervention. Utilize house supplements (normal serving size 4 to 6 ounces), update care plan. Step 6) IDT to determine interventions, review effectiveness of intervention. Utilize high calorie enhanced house supplement. Discontinue other supplement usage as indicated. Update care plan. Step 7) IDT to determine interventions, review effectiveness of intervention. Utilize specialty supplement. Discontinue other supplement usage as indicated. Update care plan. It was not noted that the IDT was not following their facility's step by step policy and Algorithm for Weight loss. Resident #5 had a significant, unplanned weight loss that compromised the resident's overall physical condition and health status. ( )( )

This citation pertains to MI# 971 Based on observation, interview, and record review, the facility failed to supervise and prevent a fall in 1 (#101) of 4 sampled residents from a total sample of 4, resulting in resident #101 being found by staff on the floor with a left hip dislocation and fracture. Findings include: Record review of resident #101's minimum data set ((MDS) dated [DATE] revealed a [AGE] year old male with a [DIAGNOSES REDACTED]. Record review of the facility reported incident/accident report dated 11/9/11 at 8:00 PM revealed that the resident was found by staff on the floor in his room doorway. The resident was noted to have been either trying to get up from his wheelchair by himself or he was leaning too far forward in the wheelchair. The incident/accident report forms second sheet revealed that the resident was unable to give a clear answer on whether he was self transferring or leaning too far forward in wheelchair. The resident was found on floor in bedroom doorway and had hit his head on the left side on the door frame as he fell . The resident was sent to the hospital. Record review of hospital x-rays dated 11/9/11 revealed resident #101 had a left hip dislocation with suspicion of periacetubular fracture. Record review of the facility Fall/Injury Assessment: Prevention and Management Plan of Care policy dated 1/2009, revealed Extendicare Health services revises the residents plan of care and or center practices to reduce the likelihood of another fall. Determining causal factors leading to a resident fall is necessary to provide consistent intervention to help prevent future occurrences. Causal factors may include, but are not limited to: Leaning, Poor weight bearing, Osteoarthritis, Record review of Resident #101's cognitive assessment/care plan dated 2/16/11 noted that the resident's mental function varies over the course of the day. Record review of Resident #101's safety device plan of care dated 1/20/11 and re-written on 5/23/11 revealed that the resident had mobility bars on his bed. There were no further safety devices listed on the care plan. Record review of resident #101's fall/injury assessment: prevention and management plan of care dated 7/1/09 and re-written 5/23/11 revealed that the resident was at risk for falls due to osteoarthritis, stiffness and unsteadiness. The care plan noted a [DIAGNOSES REDACTED]. Interventions on the care plan included a chair alarm sensor and a bed alarm sensor. It was noted that the wife had a history of [REDACTED]. The resident had a history of [REDACTED]. Nurse notes dated 11/8/11 at 4:30 PM for Resident #101 revealed that the resident was leaning to the right when sitting in his wheelchair and that occupational therapy was to evaluate. Record review of resident #101's physical therapy notes dated 11/7/11 through 11/10/11 revealed that the resident was being seen for upright seating in wheelchair with trunk ext. (extension), instructing the resident to sit up with constant verbal cues. Resident #101 was noted to be leaning forward and to the right. There were no new recommendations for safety devices or increased supervision by therapy noted. Record review of the quarterly nursing data collection and assessment form dated 10/30/11 revealed that the resident used a wheelchair, was unsteady and had impairments on both sides of extremities. The data collection assessment revealed that the resident needed supervision with locomotion on and off the unit. Record review of the multi-disciplinary therapy screening tool dated 11/7/11 revealed that Resident #101 was assessed for wheelchair positioning and propulsion with a change noted of leaning to the right in wheelchair. Observation on 12/1/11 of Resident #101 revealed the resident to be confused and bed bound with a left leg brace that cupped the hips and left thigh area. In an interview on 12/1/11 at 2:55 PM, Registered Nurse (RN) #3 who found Resident #101 on the floor revealed that the resident's pressure pad sensor was sounding. RN #3 stated that the resident had been known to lean forward in his wheelchair while propelling. RN #3 stated that the resident did not have a pull string alarm in place or other safety device such a Velcro seat belt to alert when he leaned to far forward. In an interview on 12/1/11 at 3:10 PM, CNA #4 stated that resident #101 had been leaning forward in his wheelchair and that she attempted to help him sit back. CNA #4 then went to assist another resident in a room to get ready for bed. CNA #4 stated that resident #101 was confused and that she left him sitting in the hallway. CNA #4 stated that the resident did not have a Velcro seat belt or pull/string alarm to let staff know when he was leaning forward, that he only had a pressure sensor alarm that sounded when the resident gets up. CNA #4 stated that she did not see the fall because she was with another resident who had an alarm. In an interview on 12/1/11 at 3:17 PM, via phone with Licensed Practical (LPN) nurse #5 revealed that he was Resident #101's nurse, but that he was in the north side of the building when the fall occurred. LPN #5 stated that he had the resident's hall but that the facility still wants that nurse position to float when needed. LPN #5 stated that he was assisting with an admission on the north unit when he was called back to his unit and resident #101 was lying on the floor. LPN #5 stated that he thinks that the resident leaned too far forward in his wheelchair and fell . LPN #5 stated that there was no safety device in place to alert staff when the resident was leaning forward or a safety seat belt to prevent the resident from falling. #

This citation pertains to intake #MI 954 and MI 023. Based on observation, interview, and record review, the Facility failed to prevent staff to Resident physical and emotional abuse (held roughly against his will) in 1 of 4 sampled Residents (#701) from a total sample of 4 residents resulting in Resident #701 sustaining multiple bruises while being showered and emotional turmoil regarding the abuse. Findings include: An observation on 8/29/11 at 9:45 AM revealed Resident #701 lying on his back, in bed, in his room. Resident #101's tray table, that held his water, tissues and remote control for his television, were not within his reach but over 3 feet away from his bed. Resident #701 was a thin, frail looking, soft spoken man who had oxygen on per nasal canula. Resident #701 had bruises on both of his forearms. Two bruises were noted on Resident #701's left forearm that were red and purple in color and approximately 3 centimeters by 3 centimeters. The two bruises on Resident #701's right arm were purple and approximately 1 centimeters by 1 centimeters in size. All bruises were noted on the posterior aspect of his forearms. When asked how the bruises occurred Resident #701 said, "A girl done it to me. First she took all my clothes off and then she took me to the shower. I couldn't get out." When asked what the girl's name was Resident #701 said, "Can't think of what her name is". Resident #701 said the abuse occurred in the morning but did not say what day. Resident #701 said, "she took me out of here". Resident #701 became upset talking about the situation. There was a bandage on his nose and his nose was swollen and not in alignment. During the observation, Visitor #1 (Resident #701's daughter and responsible party), entered the room. Visitor #1 explained the bruises occurred when her father was forced to have a shower. When asked how it made him feel Resident #701 said, "feels like your not in this world." Visitor #1 explained that he felt like what he wanted didn't matter. When asked what happened to Resident #701's nose Visitor #1 said, "Saturday night (8/27/11), an aide had him in the wheelchair and didn't use footrest. She was going too fast and he flipped out of the wheelchair onto his face and broke his nose". Resident #701 showed no signs of aggression during the interview and observation. Review of the clinical record revealed Resident #701 was a [AGE] year old man admitted to the facility on [DATE]. Review of the MDS dated [DATE] revealed Resident #701 had [DIAGNOSES REDACTED]. Review of the Facility's "Care Delivery Guide" for Nurse aides to follow, (dated 6/30/11 as last revised), revealed Resident #701's shower schedule was for Tuesday and Friday mornings. There were no specific instructions for nursing to follow regarding Resident #701's shower. Under Behavior instructions revealed instructions to "allow Resident to set pace" and "speak softly". Review of the Facility's Accident report dated 8/23/11 at (time not legible), revealed Visitor #1 reported bruises on both of Resident#701's forearms and said the bruises occurred during the shower. Review of the nurse's notes (called progress notes) dated 8/22/11 at 1:20 PM, revealed Visitor #1 was in to visit Resident #701 and had no complaints noted. The progress notes dated 8/23/11 at 6:00 PM revealed the Physician was notified of Resident #701's bruises to bilateral forearms. Progress notes dated 8/25/11 at 3:30 PM revealed that a meeting was held to discuss the bruises to Resident #701's bilateral forearms with Resident #701,Visitor #1, and her husband. According to the notes the Unit Manager (Registered Nurse (RN) "I"), the Facility Social Worker (SW), the Director of Nursing (DON), and the Hospice Nurse RN "D" were at the meeting also. According to the notes Resident #701 was taken across the hall covered with a bath blanket to the shower room and had no complaints until the shower was half way done. At that time he became angry and crossed his own arms and held them down himself, according to the notes. The family stated that if he were angry he would not hold his own arms down and cross them. Resident #701 stated at the meeting, according to the notes, that he was "very angry" because he was forced to take a shower and not given a choice. The Family wondered why he was undressed in his room and taken across the hall naked. Resident #701 said he wants a choice of whether he takes a shower or not. RN "D" said she did not observe Resident #701 in the shower, according to the meeting minutes, written in the Facility's progress notes. According to the notes, RN "D" said she did see staff hold Resident #701's arms. A line was drawn across the word hold and changed to "touching" resident's arms. Review of the progress notes signed by SW dated 8/25/11 at 4:30 PM revealed Resident #701 and the Family wanted to meet privately with SW because they were so upset about what the DON had summarized regarding the Facility's investigation of the bruises that occurred during the shower of Resident #701 in the morning on 8/23/11. Certified Nurse Aide (CNA) "E", in an interview on 8/29/11 at 11:25 AM, said she was Resident #701's aide on Tuesday 8/23/11 and that she covered him with a bath blanket, took him across the hall to the shower room and he exploded during his shower. CNA "E" said she put the shower call light on and no one came. She then said she yelled for help and no one came. She said she then flagged CNA "B" to come into the shower room and help her finish dressing Resident #701. CNA "E" said Resident #701 kept trying to swing his arms at her so she stopped his hands to protect herself. CNA "E" said Resident #701 was upset because he wanted to leave, so she crossed his hands over each other and he thought he was grabbing her. CNA "E" said he pressed down onto his own arms as they were crossed. CNA "E" said RN "D" stopped in because she heard yelling but we were all done by then. CNA "B", in an interview on 8/28/11 at 11:55 AM, said on 8/23/11 at approximately 10:00 AM, CNA "E" was in the shower room with Resident #701 and flagged her down to help. CNA "B" said Resident #701 was "very agitated and upset". CNA "B" said Resident #701 was dressed with everything on except his pants and shoes. CNA "B" said Resident #701 was swinging his arm and she grabbed his hands and held them down because she didn't want to get hit. CNA "B" said she saw some bruises on his arm about the size of a quarter. CNA"B" said she did not see or hear that the shower call light was on the morning of 8/23/11. During an interview on 8/29/11 at 11:00 AM, RN "D" said she heard yelling coming from the shower room on 8/23/11 at approximately 10:00 AM. RN "D" said she stuck her head in the shower room and saw Resident #701 flailing his arms and legs and was very agitated because he didn't want a shower. RN "D" said she asked CNA "E" and CNA "B" if everything was OK and CNA "E" told her they were done now and everything was "good" and RN "D" said she did not go into the shower room to assess Resident #701 to determine if he was injured. RN "D" said she did not see or hear that the shower call light was on the morning of 8/23/11. CNA "G" (a Hospice nurse aide), in an interview on 8/30/11 at 11:25 AM, said she was on a different hall and was asked by RN "D" to sit with Resident #701 on 8/23/11 at about 10:00 AM. CNA "G" said that RN "I" told her to keep an eye on Resident #701 because he just had a shower. CNA "G" said she thought that was an odd request at first but went right over and saw Resident #701 in the hall and he was "really mad". CNA "G" said his feet were moving really fast, eyes were squinted, and he was frowning. CNA "G" took Resident #701 to his room and she said, "he showed me his bruises" and told her "these girls did this to me." CNA "G" said the bruises were dark purple and they were on top of both of his forearms. CNA "G" said Resident #701 did not name the CNA's but she knew CNA "B" and CNA "E" had taken care of him that morning. CNA "G" said she tried to divert his attention because it was so upsetting to him. CNA "G" said, "I knew he enjoyed his past military experiences so I turned on a Military movie and he began to relax a little. CNA "G" said she had taken care of Resident #701 several times before and "never saw him so upset to this extent before". When asked if she wrote a witness statement CNA "G" said "no". CNA "G" offered and wrote a statement for the Surveyor on 8/30/11 regarding her observations of Resident #701 on 8/23/11. RN "F", in an interview on 8/30/11 at 10:30 AM said she was the Charge nurse on 8/23/11 during the day shift. RN "F" said that at about 12:30 PM (over 2 hours after the incident occurred), CNA "E" reported to her that she had "deflected some punches" Resident #701 had attempted in the shower room. RN "F" said that the shower call light was not on that morning. RN "F" stated she was passing medications at 10:00 AM and she did not hear yelling. RN "F" said she gave Resident #701 his medications earlier that day (prior to 10:00 AM on 8/23/11), and he smiled and took them nicely. RN "F" said she also saw Resident #701 at about 11:30 AM on 8/23/11 while CNA "G" was sitting with him and he had a straight face, "no smiles". RN "F" said she was not aware of the incident in the shower that morning because she was not notified until the afternoon, after lunch sometime (approximately 12:30 PM). RN "F" said she had taken care of Resident #701 several times in the past and never saw him flailing his arms or get "that upset". When asked if she had noticed any bruises on Resident #701's arms RN "F" said "No" and said she thought he had on a red plaid long sleeve shirt on that day. RN "F" reviewed Resident #701's entire care plan and said, "it doesn't say he doesn't like showers". RN "F" reviewed Resident #701's Physician orders [REDACTED]. In an interview on 8/30/11 at 12:00 PM, the SW said she saw Resident #701 on 8/23/11 at 10:00 AM, sitting in a wheelchair, in the hall and she asked Resident #701 if he had a shower. SW said Resident #701 said to her "Oh you people make me do things I don't want to". SW said Resident #701 was upset and attempted to grab people as they walked by so she said she waited for CNA "G" to come because RN "I" told her that she called and asked CNA "G" to sit with Resident #701. SW said, at a care conference about 3 months ago, the daughter said to be firm about the showers because they had been giving him bed baths and not giving him showers. SW said this is the first time there was such a catastrophic reaction, that she was aware of. SW reviewed Resident #701's care plan and said there was no specific interventions related to Resident #701 not wanting showers. SW indicated that Resident #701 was not on a "behavior medication". SW said she did not keep behavior tracking in Resident #701's record. Review of the skin assessment sheet done following the shower incident on 8/23/11 (no time documented), revealed Resident #701 had multiple bruises. Left posterior arm bruises; Bruise #1 was 10 CM x 4 CM reddish purple in color and 8 CM up from wrist. Bruise #2 was 10 CM up from wrist and measured 4 CM x 3 CM and was red. Right posterior arm Bruise #3 on the hand/wrist area had a 1 CM x 1 CM red bruise over center knuckle. Bruise #4, scattered bruises, 10 CM up from wrist had scattered red bruises. 0.4 CM x 0.5 cm, 0.6 CM x 0.4 CM directly down, 1 CM x 1.4 CM towards thumb, 1.4 CM x 1 CM toward pinky, 0.8 CM x 1 CM toward wrist. Bruises #5 was located on anterior of his right arm, 8 CM up from his left wrist Review of the skin assessment sheet done most recently prior to the shower incident that occurred on 8/23/11, dated 8/17/11 and signed by RN "J", revealed no bruises or any skin problems. Resident #701's assessment was checked as "no areas of skin impairment". In an interview on 8/30/11 at 11:10 AM, when asked if he liked showers, Resident #701 said, "it depends". When asked what it depended on Resident #701 said, "on the water temperature. A lot of times its cold". Review of the Facility's investigation summary, dated 8/29/11 and signed by the Administrator, revealed that they concluded their investigation and determined that it was possible the bruising could have occurred during the shower but were not sure if Resident #701 inflicted the bruises on himself or if staff unintentionally inflicted them during care to ensure safety. Review of the Facility's Procedure for Prevention of Abuse dated as last revised on February 2011 under the section titled, "Physical Abuse" was written, "Physical abuse includes hitting, slapping, pinching, scratching, spitting, "holding roughly"...etc." (# )

This citation pertains to intake # MI 04 and MI 892 Based on observation, interview and record review, the Facility failed to provide adequate supervision and assistive devices (wheelchair footrests and bed bolsters) in 2 of 4 sampled Residents (#701 and #702), from a total sample of 4 residents, resulting in: 1.) Resident #701 being pushed in a wheelchair without footrests under his feet where he flipped out of the wheelchair and fell forward, face first, onto the tiled floor sustaining a fractured nose and facial laceration, and 2.) Resident #702, who had a known history of rolling out of bed, rolled out of bed and sustained facial injuries with a serious laceration on her face with possible fractures. Findings include: Resident #702 Review of the clinical record revealed Resident #702 was a [AGE] year old woman admitted to the facility on [DATE]. Review of the MDS dated [DATE] revealed Resident #702 had [DIAGNOSES REDACTED]. An observation on 8/29/11 at 2:15 PM revealed Resident #702 with her eyes closed, in a gerichair, which was reclined. She was not able to be awakened to be interviewed. Review of the physician progress notes [REDACTED]. The note indicated the Physician would increase the Depakote to see if it would help stabilize her mood and decrease aggressive behavior. Review of the Physician orders [REDACTED].#702's Depakote from 250 mg twice daily to three times daily. Review of the Physician order [REDACTED]. Ativan (anti-anxiety agent) gel was also prescribed on 8/17/11 if Resident #702 refused oral Ativan. Review of the nurses notes dated 8/17/11 revealed Resident #702 was administered Roxanol. The medications listed above had a potential for adverse reactions which included in increased confusion and lethargy and increased the risk of Resident #702 falling. Review of the Facility accident report dated 8/18/11 at 2:30 PM revealed Resident #702 was found on the floor. Review of the Facility's progress note dated 8/18/11 at (time written as 6-2), revealed Resident #702 was "observed on the floor mat next to her bed." A purple bruise was noted as an injury on Resident #702's left elbow. Under the section titled, "Immediate action taken to prevent further incidents" was written, "assess pt full ROM UE and LE" (assess patient full range of motion upper extremity and lower extremity). There were no new interventions put in place to assist in the prevention of Resident #702 from rolling out of bed again. Under the section titled, "Answer all questions" were blanks. None of the questions were answered such as "Exhibiting behavior symptoms just before the incident?, Does the Resident know what caused the incident?, Activity when incident occurred?, Assistive devices?, Bed type or Specialty mattress? and Compliant with prescribed assistive devices?" were all blank and not answered by the Facility staff. Review of the Facility's accident report dated 8/19/11 at 10:45 AM revealed Resident #702 was found on landing strips (a thin, smaller than a twin mattress, plastic-like rectangular shaped pad) on the floor, next to her bed. There was a laceration on her nose and forehead and a skin tear on her right forearm. Under the section titled "Specialty mattress type" was a blank space. Review of the care plan for Resident #702, titled "falls" and dated 7/17/2008, under interventions revealed no new interventions were implemented such as bed bolsters or a mattress with raised foam edges after Resident #702 was found on the floor next to her bed on 8/18/11. Review of the "Care Delivery Guide" revealed Resident #702 had an air mattress that was used which potentially increased the risk of her falling out of bed. During an interview on 8/29/11 at 3:00 PM, an Occupational Therapist (OT), said she heard an alarm sounding and went to Resident #702's room because she heard an alarm sounding and observed Resident #702 lying on her right side with her head on the tiled floor and a pool of bright red blood was near her head. OT said no one else was in the room at that time so she called for a Nurse. In an interview on 8/29/11 at 3:25 PM, Registered Nurse (RN) "A" said on 8/19/11 at approximately 10:45 AM, she was called to Resident #702's room by RN "I" (the Unit Manager). RN "A" said when she entered the room, Resident #702 was on her right side and her head was not on the mat. RN "A" said the bed was low and the alarm was not sounding. RN "A" said there was a moderate amount of blood on the floor near her head. RN "A" said, "it looked like she rolled out of bed". An interview on 8/31/11 at 11:25 AM with RN "I" revealed that she worked on 8/19/11 and went to Resident #702's room and observed blood coming from the bridge of her nose and a skin tear on her forehead. RN "I" said she called 9-11, but the family did not want her sent to the Hospital. Her wound was cleaned and bandaged and neurological assessments were done. An observation on 8/31/11 at 11:25 AM revealed one side of Resident #702's bed was against the wall. Landing strips were observed as thin (approximately 1 inch thick). An interview, at the time of the observation, with RN "I", revealed that she worked on 8/19/11 and went to Resident #702's room after she fell at approximately 10:45 AM. RN "I" said she had a landing strip next to her bed and she was on it after the fall. RN "I" said Resident #702 also had an air mattress. When asked why she didn't have bed bolsters to help prevent her from rolling out of bed RN "I" said, "I don't know". Resident #701 An observation on 8/29/11 at 9:45 AM revealed Resident #701 lying on his back, in bed. His tray table was not within his reach but over 3 feet away from his bed. Resident #701 was not able to reach his remote control of his TV, nor was he able to reach his water or his tissues placing him at high risk for falls if he wanted the items mentioned above. There was no mat on the floor next to the left (window) side of his bed; the mat was leaning up against the wall in Resident #701's room. There was a bandage on his nose and his nose was swollen and not in alignment. During the observation, Visitor #1 (Resident #701's daughter and responsible party), entered the room. When asked what happened to Resident #701's nose Visitor #1 said, "Saturday night (8/27/11), an aide had him in the wheelchair and didn't use footrest. She was going too fast and he flipped out of the wheelchair onto his face and broke his nose". Visitor #1 said she had just left the Facility and was called by RN "D" who told her he fell out of the wheelchair but was "OK" and had no serious injuries so Visitor #1 said she did not think it was necessary to return to the Facility until the next day. Visitor #1 said when she came back on Sunday (8/28/11), Resident #701's nose was swollen so she requested an x-ray be taken of his nose. In an interview on 8/30/11 at 2:30 PM, Certified Nurse Aide (CNA) "K' said Resident #701's alarm went off so she transferred him from his bed to his wheelchair. CNA "K" said she started wheeling Resident #701 in the hall, stopped briefly so RN "J" could give him his medicine,then pushed his wheelchair down the hall, and he came forward and fell on his face. CNA "K" said, "when I got him up (from the bed) I should have put the foot rests on. They were in his room. It was my mistake". Review of the clinical record revealed Resident #701 was a [AGE] year old man admitted to the facility on [DATE]. Review of the MDS dated [DATE] revealed Resident #701 had [DIAGNOSES REDACTED]. Review of the "fall prevention" care plan dated 3/16/09 revealed an intervention that included placing mats on the floor next to both sides of Resident #701's bed to provide a cushion if he were to fall. Another intervention dated 5/29/11 revealed instructions for nursing to "keep bedside table within reach". Both interventions were not implemented as observed by this surveyor on 8/29/11 at 9:45 AM. RN "F", in an interview on 8/30/11 at 10:30 AM, said Resident #701 is a high risk for falls and that is why he is suppose to have mats on each side of his bed. In an interview on 8/29/11 at 10:10 AM, Licensed Practical Nurse (LPN "C") said Resident #701 is supposed to have mats on both sides of his bed. LPN "C" took the mat that was leaning against the wall in Resident #701's room and placed it next to Resident #701's bed, while he was lying in the bed. LPN "C" also said Resident #701 should have his tray table within his reach. Review of the nurse's notes dated 8/27/11 at (no time), revealed RN "D" noted that Resident #701 fell from the wheelchair and sustained approximately 1/8 inch skin tear on bridge of nose. RN "D" did not document that she notified the Physician, but wrote that Resident #701 was transferred to bed and had no other injuries. Review of the nurse's notes dated 8/27/11 at (2-10), and signed as written by RN "J" revealed Resident #701 "fell from his wheelchair while being pushed down the hall". Nurse's notes dated 8/28/11 at 12:30 AM revealed Resident #701 complained about his nose being sore and was swollen. According to the nurse's notes Visitor #1 arrived at 12:30 PM on 8/28/11 and requested an x-ray of his nose be obtained. Review of the Facility accident report dated 8/27/11 at 5:45 PM revealed Resident #701 was being pushed in a wheelchair down a hallway and fell forward onto his face causing bruising and a skin tear to his nose. The report indicated that the immediate action to prevent further accidents was to use foot pedals on the wheelchair and tilt the wheelchair. Review of the Hospital X-Ray report dated 8/28/11 revealed Resident #701 had a 2 millimeter Depressed Nasal Bone Fracture. In an interview, on 8/30/11 at 2:45 PM, RN "J" said she was the Charge Nurse on 8/27/11 and Resident #701 was being pushed while in his wheelchair by CNA "K". RN "J" said when CNA "K" stopped in the hallway on her way to the dining room, she administered Resident #701 his medication. When asked if she told CNA "K" she needed to use foot rests when she pushed Resident #701 in the wheelchair, RN "J" said, "yes I did as soon as the accident happened". When asked why she didn't instruct CNA "K" to use foot rests on the wheelchair prior to the accident happening, RN "J" said, "I did not notice before the accident that he did not have foot rests on. I only looked at his face". ( )

Complaint Intake Number: MI 672 Based on observations, interviews and records review the Facility failed to provide adequate and appropriate supervision to prevent accidents (falls) for 4 of 5 residents who had fallen in the sample of 5 (#101, #102, #104 & #105) resulting in actual harm for Resident #101 (head laceration with sutures) and in minor injuries (skin tear and bruises) for Resident #104 and in the potential for injury for Residents #102 and #105. Findings include: Resident #101 Review of the investigation file revealed an Incident Report dated 2/28/11 at 19:00 (7:00 p.m.) which stated Resident #101 was found "laying on abdomen" on the floor in her room "with pool of blood under head." Page 3 of the Incident Report dated 2/28/11 stated the personal fall alarm was not found in Resident #101's room during a search conducted after the incident. Page 3 further stated Resident #101 was sent to the emergency room via ambulance and returned with 10 sutures in her forehead. In a telephone interview on 3/16/11 at 4:08 p.m. Nurse Aide #15 stated she was assigned to care for Resident #101 on 2/28/11. Nurse Aide #15 stated she assisted Resident #101 out of bed and into her wheelchair "for supper" at approximately 5:45-5:50 p.m. on 2/28/11. Nurse Aide #15 stated she left Resident #101 in her wheelchair in the corridor and did not apply a personal fall alarm. Nurse Aide #15 admitted that at no time on 2/28/11 did she apply or activate any type of fall alarm to Resident #101, her wheelchair or her bed. Nurse Aide #15 stated she did not see any type of fall alarm device in Resident #101's room on 2/28/11. Nurse Aide #15 stated she applied fall alarms if she saw them on a resident's wheelchair or bed and assumed since there was no alarm visible, Resident #101's care plan had changed and an alarm was no longer needed. Nurse Aide #15 stated she had not been assigned to care for Resident #101 for "quite a few days" and did not review Resident #101's care plan before providing care on 2/28/11. Nurse Aide #15 said, "When I looked at that care plan it was dated back to October. It (the use of fall alarms) was on there." Review of the Care Delivery Guide found on the inside of Resident #101's bedroom door revealed "bed alarm" and "fall alarm" in the "Safety Device" section were both checked and the words "sensor alarm" were written next to both. The Care Delivery Guide was dated 10/4/10 and 3/1/11 however, each individual item was not dated. Review of Resident #101's Fall Risk Care Plan revealed a chair alarm was added to the care plan on 10/11/10 and staff were further instructed "Do not leave in room after meals up in wheelchair. Leave resident at desk or put to bed right away. 10/11/10" In the interview on 3/16/11 at 4:08 p.m. Nurse Aide #15 stated on 2/28/11 she served Resident #101's supper tray in her bedroom and Nurse Aide #15 "stayed in the room to feed her roommate. Right after they got done I took the trays out. It was about 6:30-6:45. I left her in her wheelchair in her room with the over-the-bed table in front. The next time I saw her she was laying on the floor. There were 3 or 4 people there. She was face down and her head was injured. There was a pool of blood under her head..." In an observation on 3/16/11 at 9:35 a.m. Resident #101 was observed in bed with steri-strips on her left forehead; the wound appeared healed. When asked if she had fallen Resident #101 said, "I guess I did." When asked how the fall occurred Resident #101 said, "I don't know." Per the Physician's Progress Note dated 3/8/11 Resident #101 was diagnosed with [REDACTED]." The packet of information regarding Resident #101's fall and injury provided by the Assistant Director of Nursing on 3/16/11 at approximately 10:30 a.m. included documents labeled "Pass (sic) Non Compliance" which consisted of a plan of action implemented by the Facility prior to this investigation to avoid a citation for Resident #101's fall under the "Past Non-Compliance" regulations. The packet included a "One-on-One In-service" dated 3/2/11 which instructed the Nurse Aides "within the first 15 minutes of starting their shift the CNA must 'eyeball' each resident to ensure that they are in a safe location, their alarms are on and functioning and that all other safety equipment is properly in use and in working order...they MUST 'eyeball' their residents within the last 15 minutes (of their shift) before leaving to ensure that they are safe and that all alarms and other safety equipment is on and functioning properly..." Nurse Aide #17's signature was written next to his typed name on the "Enrollment" sheet for the "One-on-One" inservice. Resident #105 In an observation on 3/16/11 at 2:10 p.m. Resident #105 was sitting on the edge of her bed with her feet on the mat. She was leaning forward. This Surveyor stopped Nurse Aide #16 who was walking by and asked if Resident #105 was supposed to be sitting like that. Nurse Aide #16 said, "No" and we both entered the room. This Surveyor did not see a bed alarm on the right side of Resident #105's bed and Nurse Aide #16 said there was no alarm on the bed on the left side of the bed (where she was standing). No alarm was sounding. Nurse Aide #16 assisted Resident #105 from the bed and into her wheelchair. No alarm sounded during the transfer. Nurse Aide #17 was interviewed on 3/16/11 at 2:16 p.m. Nurse Aide #17 was called out of another resident's room to speak with this Surveyor. Nurse Aide #17 stated he came on duty at 2:00 p.m. and immediately answered a resident's call light. Nurse Aide #17 said immediately after providing care to the first resident, a second call light sounded and he was still in the process of providing the care the second resident required. Nurse Aide #17 admitted he did not make any rounds in his first 15 minutes on duty and admitted he did not check any residents' fall alarms as of yet that shift. On 3/17/11 at approximately 8:00 a.m. the Administrator stated a sensor alarm was on Resident #105's bed on 3/16/11 at 2:10 p.m. and both this Surveyor and Nurse Aide #16 failed to see it. On 3/17/11 at 5:03 p.m. Nurse Aide #16 said in a telephone interview that on 3/16/11 she did not see a sensor pad alarm on Resident #105's bed however, if the alarm was there it did not activate when she assisted Resident #105 from the bed. Nurse Aide #16 emphatically stated she did not turn off any type of alarm when she and this Surveyor were in Resident #105's room on 3/16/11 either before or after she assisted Resident #105 out of the bed. On 3/16/11 at 9:47 a.m. Resident #105 was observed propelling herself in her wheelchair in the corridor on the East Hall of North Unit. A fall alarm was attached to her wheelchair. Resident #105 had a scab on her left forehead. Review of Resident #105's Nurses' Notes revealed she had a history of [REDACTED]. Resident #104 Per the Incident Report dated 2/18/11 Resident #104 was "found on floor by CENA (nurse aide) walking past room. Sitting on buttocks facing bathroom. Resident states she had gone to BR (bathroom) was going back to bed. Now facing toward BR. Has skin tear to right upper arm area. She bumped it on book case. Resident also has 2 bruises to right upper arm. Skin tear is "7" shaped 1.0 cm x 1.0 cm...also had crock shoes on." In answer to the form's question "Does the Resident know what caused the incident?" the nurse wrote "tripped. fell on buttocks." In an observation on 3/16/11 at 12:17 p.m. Resident #104 was lying on her bed dressed in street clothes reading a book. Resident #014's shoes were on the floor next to the side of her bed. Resident #104 stated she had fallen at 4:00 a.m. "coming out the bathroom. I had my shoes on. I'm all healed up. In my opinion they had given me a new sleeping pill" which contributed to the fall. Review of Resident #104's physician's orders [REDACTED]. Review of Resident #104's February 2011 Medication Administration Record revealed she received the Melatonin at bedtime on 2/16/11 and 2/17/11; her last dose of Ambien was documented on 2/6/11 at 21:00 (9:00 p.m.). Review of Resident #104's Fall Risk Care Plan and Resident #104's Care Delivery Guide revealed no instructions for extra supervision or any other fall prevention instructions were added after the Melatonin was prescribed on 2/16/11. The Fall Risk Care Plan was revised after she fell on [DATE]. Per Resident #104's Care Delivery Guide (dated 3/28/08, 10/18/10 and 3/3/11) Resident #104 was "Fully ambulatory," independent with transfers, alert and oriented, and used the bathroom. Resident #102 Review of the Accident/Incident Report dated 3/13/11 revealed at 10:10 a.m. the staff heard Resident #102's sensor alarm sounding and found him sitting on the floor between his wheelchair and bed. "The Immediate Action Taken to Prevent Further Incidents" was "will lay resident down after meals." Page 3 of the Accident/Incident Report for the incident of 3/13/11 at 10:10 a.m. stated "Resident observed on floor between bed and wheelchair, no injury noted. Resident will be layed down immediately after meals to avoid self-transfers." Per the Fall Risk Care Plan Resident #102's fall on the morning of 3/13/11 was not included in the list of 4 falls and a second fall which occurred on 3/13/11 at 12:00 p.m. (per the Accident/Incident Report dated 3/13/11) when he slid off his bed while trying to reach his shoes was attributed to 3/14/11. The Falls Risk Care Plan was updated on 3/14/11 with instructions to the staff to put Resident #102 to bed for a "nap after meal (sic)." Review of the Accident/Incident Report dated 3/14/11 revealed Resident #102's "Alarm sensor sounding. Observed resident sitting on floor. Right hand on mobility bar (on the bed) left hand on wheelchair. States was trying to get into bed." Page 3 of the Accident/Incident Report dated 3/14/11 stated "Resident slow eater and just finished eating in north dining room. Resident just returned from north dining room." The time of the incident was "19:55" (7:55 p.m.). In an interview on 3/16/11 at 11:20 a.m. Nurse #12 stated the incident on 3/14/11 occurred at "five minutes to eight" in the evening. Nurse #12 stated Resident #102 was a "slow eater" and he "just came down" to his room from the dining room when the incident occurred. Nurse #12 admitted the instructions on the 3/13/11 Accident/Incident Report to prevent another fall (put Resident #102 into bed "immediately after meals") were not followed. In an observation on 3/16/11 Resident #102 was eating his noon meal in the north dining room at 12:26 p.m. At 1:14 p.m. Resident #102 was still sitting at the table in the north dining room with a glass in his hand and with a small dab of green vegetable on his plate. At 1:45 p.m. Resident #102 was observed alone in his room seated in his wheelchair facing his bed. At 1:55 p.m. Resident #102 was again observed alone in his room still seated in his wheelchair reaching towards his bedside stand and then reaching to his bed. At 2:16 p.m. Resident #102 was observed still alone in his room sitting in his wheelchair which was positioned between his bed and the window wall; he was reading a book. ( )

Complaint Intake Number: MI- 652 Based on observations, interviews and records review, the facility failed to provide adequate supervision to prevent elopement for 1 of 10 residents in the sample who had the physical ability to exit the facility without assistance (#101), resulting in immediate jeopardy when resident #101 left the facility without the knowledge of staff and was stopped at the edge of the street by an employee who happened to be passing by, placing the resident at high risk for serious harm or injury. Findings include: Per the Incident Report dated 8/3/10, Resident #101 was seen self-propelling his wheelchair outside the facility; he had exited through the front door. During all entrances/exits through the Facility's front door, this surveyor set off a loud alarm unless this surveyor or a facility employee entered a code on a keypad attached to the wall on the inside of the front lobby at the front door's upper right corner or pressed a button located on the wall on the inside of the small enclosed area between the exterior front doors and the front doors that opened into the Facility's front lobby. In an interview on 9/1/10 at 2:26 p.m., Nurse Aide #14 said on 8/3/10 she was driving on the street approaching the facility when she saw Resident #101 self-propelling his wheelchair about half way down the right arm of the horseshoe shaped driveway in front of the facility. Nurse aide #14 said she recognized Resident #101 and knew he was not supposed to be outside unattended. Nurse aide #14 said she slowed her car and looked towards the facility's front double doors and noticed one door was propped open. Nurse aide #14 said she could see an unknown person in a wheelchair under the front portico but did not see any staff member. Nurse aide #14 said she quickly drove past the facility and entered the left arm of the horseshoe shaped drive and abandoned her car in the driveway. Nurse aide #14 said, "I took off running, calling his name. By the time I got to him he was at the edge (of the drive) about to go into the road. (Resident #101) said, 'I'm getting the hell out of this place.' (nurse aide #23) came out just as I grabbed him. She said, 'Oh my god! Thank god you drove by!" Nobody knew he got out of the building." Nurse aide #14 said Resident #101 continued to propel his wheelchair forward and she had to forcefully pull him back from the road. In an interview on 9/2/10 at 4:26 p.m., nurse aide #23 said sometime between 5:00 p.m. and 5:30 p.m. on 8/3/10 as she walked up the corridor facing the front lobby and the front door Visitor #26 approached her and "said he saw a resident outside and 'I'm not sure he's supposed to be there.' I said, 'OK-I'll go double check.' There was no one in the lobby area and no one at the desk. The AIT (Administrator In Training) and ADON (the Assistant Director of Nursing) or maybe it was (Human Resources staff #22) and a man and a woman visitor were in the accountant's office (which opened onto the front lobby near the front door). I punched the code and opened the door. The outer door was open. A resident and his family-the man who said there was a man outside-were sitting (outside next to the front door). (Nurse aide #14)'s car was parked funny. She was running. She said, '(Name of Resident #101) wait!' I took off running towards her. (Resident #101) was at the very end of the drive within a foot of the street. (Nurse aide #14) had to pull him backwards. He was still trying to go forward. (Resident #101) said, 'What? I wasn't doing nothin'. I wasn't hurting nobody. I was going home.' (We brought Resident #101 inside) and immediately stopped at the office. The (male and female) visitors were still there. (The AIT) said she turned off the alarm and didn't see anybody when she looked. Nobody else said they heard the door alarm..." In an interview on 9/3/10 at 9:00 a.m., visitor #26 said, "I did not see (Resident #101) go out the door. Me and my Dad (also a visitor) were coming in from smoking a cigarette. One door was open anyway. We went over to our car half-way down the driveway. I turned my Dad around (in his wheelchair) and (Resident #101) was totally out the door. I was setting there watching him. After (Resident #101) got outside he unhooked his chair alarm and tossed it on the ground. Sometimes the (inner) door sticks open. Maybe when I took my Dad out he hurried up and got out the door. I have to open it real far for my Dad to go through. I have to push it real hard to get it to shut." Visitor #26 said he and his Dad returned to his Mother's room in the facility after he alerted nurse aide #23 and he did not have any further information. Immediately after this interview, this surveyor tested the front door. The inner door stayed against the wall when pushed firmly open as far as it would go. Although it stayed open for a few minutes, it shut without any pressure applied, and the alarm sounded the whole time it was open until silenced by the button on the wall. The alarm began sounding again while the door was open after a 15 second delay. In an interview on 9/1/10 at 2:12 p.m., the AIT said on 8/3/10 "at about 5:00 p.m. the (front door) alarm went off. I went outside. A family member had gone out. The outside doors were propped open." The AIT said her daughter (#16) was the visitor in the office with her when nurse aide #14 brought Resident #101 back inside. The AIT said her daughter (#16) then told her that she saw Resident #101 go outside but the door alarm did not sound as the door was already partially open when Resident #101 pushed on it. In a telephone interview on 9/1/10 at 3:35 p.m., visitor #16 said she was "standing outside" the accountant's office in the front lobby and saw Resident #101 "scurrying towards the door. He pushed on the door. The alarm sounded. He shut the door partway and the sound stopped. Then he opened the door again and it did not ring. He went out. He stopped by the bench. Another person was there. I thought they were visitors. About 5 minutes later a woman brought him back in." Visitor #16 insisted that no one silenced the door alarm activated by Resident #101 but rather the alarm stopped ringing when he pulled the door partially shut. Immediately after this telephone interview, this surveyor tested the front door. The alarm did not silence itself after the door was opened no matter what position was tried. In an interview on 9/2/10 at 4:00 p.m. HR #22 said she recalled being in an office off the front lobby on 8/3/10 "after 5:00 p.m." with the AIT and "her daughter and a male friend). HR #22 said she recalled the AIT "went and checked on one alarm but she didn't say anything that sticks in my mind." HR #22 said she could not recall if the door alarm sounded again before Resident #101 was returned to the building. Resident #101 was observed seated in a wheelchair at the intersection of the front lobby and the North Unit east/west corridor on 9/1/10 at 11:25 a.m. When asked his name, he said his first and last name and then spelled his last name. He then said, "Now give me 50 dollars." When asked if he had gone outside alone recently, he said, "Oh yeah. I'm by myself most of the time. I was just monkeying around." When asked if he remembered anything about going out, he said, "A little bit. It was probably to eat." Per the Minimum (MDS) data set [DATE], Resident #101 was diagnosed with [REDACTED]." The diagnosis "Dementia" was not checked. However, since 2/9/09, he was prescribed the drug Namenda which was used in the treatment of [REDACTED]. Per the Minimum (MDS) data set [DATE] (which was the most recent found in the clinical record despite repeated requests for a newer one), Resident #101 had identified short and long term memory loss and moderately impaired ability to make decisions. He had not exhibited wandering in the past 7 days. He required extensive assistance with transfers, but he required only limited assistance to walk in his room. He required extensive assistance with wheelchair self-sufficiency in his room. However, he scored "0-Independent" with wheelchair self-sufficiency (ability to move to and from distant area on the floor and moving to and returning from off unit locations such as the dining room). The Administrator was notified on 9/2/10 at 1:15 p.m. of the Immediate Jeopardy that began on 8/3/10 as a result of failure to provide adequate and appropriate supervision to Resident #101 who made an unauthorized exit from the facility through the alarmed doors in the front lobby and reaching the edge of the street from the facility driveway and was found by a staff member who was driving past which placed other mobile residents at risk of serious harm from elopement. On 9/9/10, the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. On 8/3/10, Resident #101 was returned uninjured to the facility, reassessed for elopement risk, a Sondergaard bracelet was applied, and his care plan was updated. 2. On 8/4/10, 106 of 106 residents were assessed for elopement risk, and 49 residents were identified as having the physical ability to elope. 22 of the 49 residents were determined to be a potential elopement risk and Sondergaard bracelets were applied and their care plans were updated. The care plans for the remaining 27 residents were reviewed. 3. On 8/3/10, alarms on all exit doors were evaluated and found functional. 4. On 8/3/10, the Elopement Prevention and Management Policy and Procedure was reviewed and verified as appropriate. 6. By 8/5/10, 85 of 85 facility employees were re-educated on the Elopement Prevention and Management Policy and Procedure. 7. On 9/2/10, a plan for 1:1 door sitter was created and set in action. 8. On 9/2/10, a Front Door Sitter's Log was developed to record activity at the front door and functionality of the door alarm. A sign-in sheet to designate and confirm the staff members were assigned as Front Door Sitter and a plan to ensure staff members assigned this duty will be trained prior to the assignment was developed. 9. On 9/2/10, a plan for the Administrator/Designee to review the Front Door Sitter's Log for patterns or trends of resident exit attempts and alarm functionality was devised. Immediate Jeopardy was removed on 9/2/10 at 5:00 p.m. The facility remained out of compliance at a scope and severity of pattern with no actual harm but potential for more than minimal harm but not immediate jeopardy due to the facility had not come to a conclusion as to how Resident #101 was able to exit through an alarmed door and how they planned to prevent unauthorized exits so they could discontinue the 1:1 door sitter and sustained compliance had not been verified by the State Agency. ( )