Every finding on record at Medilodge of Okemos

This citation pertains to intake 3105587Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL) care (showers and facial shaving) for one dependent resident (#2) of three residents reviewed for ADL care.Findings Included: Resident #2 (R2)Review of the medical record revealed R2 was admitted [DATE] with diagnoses that included cerebral vascular accident (stroke), ulcerative colitis, hypertension, asthma, depression, gastro-esophageal reflux, obsessive-compulsive disorder, vitamin D Deficiency, reduced mobility, lack of coordination, vascular dementia, hyperlipidemia (high fat content in blood), sleep apnea, need for assistance with person care, muscle weakness, and aphasia (brain disorder that makes it hard to speak, understand words, read, and write). Review of R2's Minimum Daa Set (MDS), with an Assessment Reference Date (ARD) of 07/16/2026, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section GG-Functional Abilities of the MDS, with the same ARD, revealed that R2 was dependent to shower/bathe of self.During observation and interview on 08/14/2026 at 09:45 a.m. R2 was observed lying down in bed. R2 was observed to have facial stubble. R2 explained that he had not received his desired shower two times per week. R2 explained that he was to receive his showers on Wednesdays and Saturdays during the daytime. R2 explained that frequently he is provided with a bed bath instead of a shower. R2 explained that he preferred to receive showers and not bed baths. R2 explained that when he is provided with a bed bath, the staff will only wash under his arms. R2 explained that yesterday, during his bed bath, he had requested to have a facial shave. R2 was observed pointing to his facial stubble and stated, looks like that did not get done. R2 explained that he could not recall the last time that he had received a shower.Review of R2's plan of care revealed an intervention which stated Bathing: 2 person assist- Wednesday and Saturday Mornings. The intervention was initiated 01/09/2024. Review of R2's Kardex (computerized document of the medical record that directs care of the resident) revealed, Bathing: 2 person assist- Wednesday and Saturday Mornings. Review of R2's task entitled GG-Shower/bathe Wednesday and Saturday Mornings, for the last 30 days, revealed: 07/15/2026 and 07/28/2026 resident refused. The same documented revealed a bed bathe was completed 07/22/2026, 07/25/2026, 07/29/2026, 08/01/2026, 08/08/2026, and 08/12/2026. The same document revealed shower was completed 08/08/2026.During an interview on 08/13/2026 at 11:03 p.m. Certified Nurse Aide (CNA) K residents were to receive showers or bathes at least twice per week. CNA K explained that a resident's medical record would list when residents are to receive showers or bathes. CNA K explained she would occasionally ask the resident if they preferred a shower or a bed bath. CNA K explained that she frequently will not ask the resident their desire but will perform a bed bath. When CNA K was asked why she would perform a bed bathe instead of a shower she stated, It is easier. CNA K explained that she was responsible for R2's care today but had only assisted with his showers/bathes one time.During an interview on 08/13/2026 at 11:10 a.m. Certified Nurse Aide (CNA) L explained that she worked at the facility full-time and worked most of the time on the Mountain Hall (Hall where R2 resides). CNA L explained that she knew R2 desired to have showers instead of bed baths. CNA L could not recall the last time she had assisted R2 with his shower.During an interview on 08/13/2026 at 11:27 a.m. Nurse Manager (NM) E explained that she was the NM that was responsible for the hall that R2 resided on. NM E explained that it was her expectation that residents were to receive either a shower or bathe at least twice per week. NM E explained that either a shower or bathe would be given based upon the resident's preferences. NM E explained that it was her expectation that the staff follow the plan of care for each resident. NM E explained that if a resident refused a shower or a bathe the nurse was expected to intercede and ask the resident for clarification and document the refusal in the medical record. NM E explained that male residents would be offered facial shaving on those shower days or upon their request. NM E explained that she was aware that R2 preferred a shower instead of bed bathe. NM E was asked if R2's preference of showers was documented in his plan of care. NM E confirmed that R2's preference of showers was not in the plan of care but should have been. NM E confirmed that R2's plan of care stated, stated Bathing: 2 person assist- Wednesday and Saturday Mornings. NM E confirmed that R2's shower/bathe task (for the last 30 days) was documented as bed bathe six times and a shower only one time. NM E could not explain why R2 had not received a shower instead of a bed bathe.During an Interview on 08/13/2026 at 11:46 a.m. Director of Nursing (DON) B explained that it was her expectation that residents were to receive a shower or bathe at least twice per week, as listed in a resident's plan of care. DON B' explained that it was her expectation that if a shower or bathe was refused a bed bathe would be offered. DON B confirmed that R2 had received a bed bathe six times and a shower only one time, in the last 30 days. DON B could not explain why R2 had not received a shower on his care planned days and could not provide explanations in the medical record.

Based on interview and record review, the facility failed to ensure four of 32 Licensed Nurses maintained current cardiopulmonary resuscitation (CPR) certification for Healthcare Providers (HCP), which included a hands-on session, for one (R98) of one reviewed.Findings include: Review of the medical record reflected R98 admitted to the facility on [DATE], with diagnoses that included intraspinal abscess and granuloma, acute respiratory failure with hypoxia, cardiomyopathy, atrial fibrillation, atherosclerotic heart disease, methicillin susceptible staphylococcus aureus and chronic kidney disease. The 5-day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R98 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R98 died in the facility on [DATE] and was a full code (desired CPR efforts). A Progress Note for [DATE] at 6:37 AM, authored by Licensed Practical Nurse (LPN) H, reflected they were informed by the Certified Nurse Aide (CNA), at 4:15 AM, that R98 was unresponsive. R98 was observed face down, between the bed and window. The CNA was directed to obtain the crash cart and call a code. Staff assisted with placing R98 on their back. According to the note, CPR was initiated at 4:20 AM, and 911 was called. The automated external defibrillator (AED) was applied at 4:27 AM, and no shock was advised. Compressions resumed at 4:29 AM. At 4:31 AM, CPR was paused, no shock was advised by the AED, and CPR was resumed. Emergency Medical Services (EMS) arrived at the facility at 4:32 AM. R98 was pronounced deceased in the facility at 5:06 AM. LPN H's personnel file included a Basic Life Support (BLS) CPR/AED/First-Aid certificate of completion, dated [DATE], which reflected it was valid for two years, from cprheartcenter.com. The attached provider card, also dated [DATE] from cprheartcenter.com, reflected the course was administered by the National CPR Foundation. There was no evidence that LPN H had completed a hands-on component to their CPR certification. Attempts were made to contact LPN H via phone on [DATE] at 1:10 PM and [DATE] at 8:10 AM. A return call was not received prior to the exit of the survey. In an interview on [DATE] at 9:09 AM, Director of Nursing (DON) B reported Human Resources and nursing monitored CPR certifications. DON B reported nurses were to be Basic Cardiac Life Support (BCLS) certified and were not allowed to complete their CPR certification online. On [DATE] at 11:50 AM, DON B reported she had left messages with LPN H, in attempt to clarify their CPR certification and determine if there was an in-person component of their class. Review of CPR certifications for the facility's licensed nurses reflected a National CPR Foundation BLS provider card for Registered Nurse (RN) R, dated [DATE], which was valid for two years. In an interview on [DATE] at 12:53 PM, RN R reported their CPR certification course was completed online, and they did not do a hands-on or demonstration component of the course. Record review reflected a BLS HCP CPR/AED/First-Aid certificate of completion for RN Y, dated [DATE], which was valid for two years and provided by the National CPR Foundation. Record review reflected a National CPR Foundation provider card for Healthcare-CPR/AED, for LPN BB, dated [DATE], which was valid for two years. On [DATE] at 12:39 PM, writer called the cell phone for RN Y, voicemail stated she was unable to accept messages at this time. Unable to leave a message due to mailbox being full. During an interview on [DATE] at 12:40 PM, RN BB, stated she took her CPR recertification online and did not perform a hands-on demonstration, just the online education. RN BB stated she had been a nurse for 30 years and confirmed she did not do a hands-on demonstration for her CPR recertification. According to National CPR Foundation, online courses offered include Standard-CPR/AED, Standard-First Aid, Standard-CPR/AED, First Aid, Standard-Bloodborne Pathogens, Healthcare Professional-CPR/AED, and Healthcare Professional-Basic Life Support. According to the Frequent Asked Questions, CPR Foundation does not offer hands-on training and stated, However, if your employer or licensing board requires a hands-on component or a skills check, or a different provider, please visit CPRNearMe.com (https://nationalcprfoundation.com/support/) According to CPR Heart Center, online courses offered include CPR/AED, First Aid, CPR/AED/First Aid, Bloodborne Pathogens, Healthcare CPR/AED, and Basic Life Support (BLS). The Support section of the website revealed CPR Heart Center does not offer hands-on training and stated, For those who are required to complete a hands-on component or a skills-check, please visit cprnearme.com. (https://cprheartcenter.com/) Review of the facility's Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) policy dated [DATE] revealed Obtain and/or maintain certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for Healthcare Providers in an adequate number of key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. This certification will be obtained through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable.

Based on observation, interview and record review, the facility failed to ensure call lights were answered timely for nine residents (R2, R3, R17, R26, R28, R43, R58, R90, R101) in a facility census of 92.Findings include: Resident #3 (R3) Review of the medical record reflected R3 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses of trigeminal neuralgia, multiple sclerosis, chronic pain syndrome, polyneuropathy, muscle weakness and lack of coordination. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2025, revealed R3 had a Brief Interview of Mental Status (BIMS) of 13 out of 15 (cognitively intact) and is dependent of all care. During an observation on 09/02/2025 at 1055 AM, R3 turned her call light on to get someone to put her back to bed after her appointment at the pain clinic. R3 stated she asked staff to make/change her bedding when she left at 900 AM, and it had not been changed, observation of stool smeared on her blue pad that covers her bottom sheet. R3 stated staff would tell her they are too busy, morning and night shifts. R3 stated she has had to wait up to 1.5 hours for somebody to answer her call light and provide care or turn the call light off and tell her they will be back. R3 stated they always had an excuse, she had to end up yelling out for help, the resident next door would yell out for her too. R3 stated the staff call this the yelling hall, because we have to yell for help, because nobody answers our call light and we cannot get out of bed on our own. During an observation on 09/02/2025 at 10:58 AM, 4 other call lights were on as well on the hall 300. No CNA was visible anywhere on the hall. R3 has been waiting in her wheelchair waiting to go back to bed for almost an hour. During an interview on 09/02/2025 at 1109 AM, Licensed Practical Nurse (LPN) CC stated she had 2 CNA's on the 300 hall for 23 residents, she stated she did not know how many residents were a 2-person assist. LPN CC also stated staff would be down to assist R3 when they are done giving another resident a shower. During an observation on 09/05/2025 at 9:25 AM, 300 hall had 3 call lights on, rooms 315, 318 and 323. During an observation on 09/05/2025 at 0940 AM, all 3 lights are still on (315, 318 and 323), plus call light for room [ROOM NUMBER] is on. During an observation and interview on 09/05/2025 at 0940am, CNA DD stated there was 2 CNA's on the 300 hall. Writer asked how many residents on the 300 hall required 2 person assist with care provided. CNA DD stated they have 11 residents that required 2-person assistance with all care and 24 residents in total on the 300 hall. During an observation on 09/05/2025 at 0944 AM- CNA DD walked into room [ROOM NUMBER], carried out a breakfast tray and did not provide any care. room [ROOM NUMBER] call light on. During an observation on 09/05/2025 at 9:47 AM, the call light for 317 was turned off. The other 4 call lights are still on. During an observation on 09/05/2025 at 9:50 AM, room [ROOM NUMBER], the call light was turned off, but they never changed her brief, resident turned light back on once she stated they came in and turned it off saying they would be back. During an observation on 09/05/2025 at 9:51 AM, the call light for room [ROOM NUMBER] turned off and needs are met. During an observation on 09/05/2025 9:53 AM, call light turned off for room [ROOM NUMBER], providing care for her at this time. During an observation on 09/05/2025 at 9:59 AM, call lights were still on for rooms [ROOM NUMBERS]. During an observation on 09/05/2025 at 10:02, room [ROOM NUMBER] light is not on, but CNA DD was in the room providing care but was standing at the door waiting for another CNA to help her transfer resident with the mechanical lift. During an observation on 09/05/2025 at 10:06 AM, room [ROOM NUMBER] and 323 call lights were still on. During an observation on 09/05/2025 at 10:10 AM, CNA EE walked into room [ROOM NUMBER] assisting her back to bed. During an observation on 09/05/2025 at 10:18 AM room [ROOM NUMBER] call light is still on while residents continued to wait for care. During an observation on 09/05/2025 at 11:00 AM, some residents had to wait over an hour and half for care to be provided to them. R28Review of the medical record revealed R28 was admitted to the facility on [DATE] with readmission date of 8/4/25 with diagnoses that included: pain, difficulty walking and anxiety. According to the Minimum Data Set (MDS) assessment dated [DATE], R28 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 9/2/25 at 10:02 AM, R28 was observed sitting up in bed. R28 reported that sometimes it takes over an hour for staff to answer her call light and one time she waited 3 hours. R28 reported that the day she waited 3 hours, her sister spoke with the Director of Nursing (DON) and that she (R28) had spoken to nursing staff about her concerns with long call light response times. R101Review of the medical record revealed R101 was admitted to the facility on [DATE] diagnoses that included: transient ischemic attack and nondisplaced fracture of upper end of humerus. According to the Minimum Data Set (MDS) assessment dated [DATE], R101 scored 15/15 on the Brief Interview for Mental Status (BIMS) exam (which indicated intact cognition). On 9/2/25 at 9:51 AM, R101 was observed sitting up in her bed. R101 reported that it takes anywhere from 5 minutes to an hour and a half for staff to respond to her call light and that certified nursing assistants (CNA) have reported to her that they don't have enough staff to take care of what they need to do each shift. R101 added that she believed that the meals arrive cold due to a lack of staff. R26: Review of the medical record reflected R26 admitted to the facility on [DATE], with diagnoses that included Parkinsonism. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/3/25, reflected R26 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 09/02/2025 at 10:38 AM, R26 was observed in bed, wearing a night gown. R26 stated the facility needed to hire more help so they didn't have to wait so long to go to the bathroom. R26 reported sometimes call lights were answered right away and other times took up to one hour. On 09/02/2025 at 10:43 AM, an observation of a call light system device, located at the nurse's station, reflected the call light for R43 had been on for 19 minutes, while the call light for another room had been on for 42 minutes. R43 had been overheard calling out, hello. Both call lights were turned off at 10:44 AM. R43: Review of the medical record reflected R43 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included heart failure. The Quarterly MDS, with an ARD of 8/21/25, reflected R43 scored 15 out of 15 (cognitively intact) on the BIMS. On 09/02/2025 at 10:58 AM, R43 was observed up in a chair, in their room. R43 reported it took up to two hours for their call light to be answered, at times, but not daily. R43 reported they sometimes had to holler because they were not sure if their light was on. R58: Review of the medical record reflected R58 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral palsy. The Quarterly MDS, with an ARD of 7/2/25, reflected R58 scored 15 out of 15 (cognitively intact) on the BIMS. On 09/02/2025 at 12:01 PM, R58 was observed lying in bed. R58 reported they needed more than two Certified Nurse Aides (CNAs), as a lot of residents required two-person assist for care and mechanical lift transfers. R58 reported at times, they were wet for four to eight hours before being changed. According to R58, it was occurring a couple times per week, including on third shift. R58 reported it was important for them to get changed due to a history of urinary tract infections. R58 reported staff would tell them they were not changed due to her being off the unit or asleep, however, R43 stated they were ok with being awaken or being brought back to the unit to be changed. R2: Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included senile degeneration of the brain and dementia. The Significant Change in Status MDS, with an ARD of 5/30/25, reflected R2 scored two out of 15 (severe cognitive impairment) on the BIMS. During a phone interview with R2's family member on 09/02/2025 at 12:44 PM, they reported using R2's call light for assistance a couple weeks prior. A CNA responded and said they would get the nurse. It then took three hours for the nurse to come. R2's family member did not specifically recall what the need was but stated it may have been for pain medication. R17: Review of the medical record reflected R17 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cholecystitis. The Quarterly MDS, with an ARD of 7/21/25, reflected R17 scored 15 out of 15 (cognitively intact) on the BIMS. On 09/02/2025 at 2:07 PM, R17 was observed seated in a wheelchair, in their doorway. R17 reported they required two-person assist with care and a mechanical lift for transfers. R17 reported when they needed something, they were sometimes told there were five people ahead of them. On 09/05/2025 at 11:17 AM, R58's room door was closed, and their call light was observed to be on. The call light system, at the nurse's station, reflected R58's call light had been on for 25 minutes. The call light was responded to at 11:25 AM. Review of the medical record revealed R90 was admitted to the facility on [DATE] with diagnoses that included vascular dementia without behavioral disturbance/psychotic disturbance/mood disturbance, anxiety, insomnia, major depressive disorder, and psychotic disorder with hallucinations. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/2/25 revealed R90 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), was frequently incontinent of urine and bowel, and was dependent on staff for activities of daily living (ADLs). On 9/2/25 at 10:51 AM, R90 was observed seated in a Broda chair in the dining room on the unit. R90 reported on second shift, they were often left soiled for hours. R90 reported he told staff when he needed to be changed, and staff responds with in a minute or in a second. R90 stated, a second turns into an hour and a minute turns into five hours. R90 reported staff frequently told him they have 25 residents to care for. In an interview on 9/5/25 at 9:51 AM, Director of Nursing (DON) B reported the facility discussed staffing needs in morning stand up meeting, throughout the day, and a the end of the day stand down meeting. DON B reported they reviewed census and acuity of each unit. DON B reported they were unaware of any call light concerns from residents.

Based on observation, interview and record review the facility failed to maintain resident's personal privacy for one resident (resident #6) of one resident reviewed. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis and Type 1 Diabetes Mellitus. According to the Minimum Data Set (MDS) assessment dated [DATE], R6 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 9/2/25 at 2:36 PM, R6 was observed in her room, sitting up in a power wheelchair. When interviewed in her room with the door closed, two staff members (at different times), knocked on the door and entered before R6 was able to provide permission to enter her private room. R6 became upset and stated that this happens routinely (staff not respecting her privacy). R6 added that staff had entered her room in the past, while she was having a private conversation with her attorney and that she had previously had a sign requesting privacy on her door which was ignored by staff. On 9/4/25 at 12:25 PM, during an interview with Director of Nursing B, when asked what the expectation was for staff prior to entering a resident room, DON B stated that staff should knock on the door, announce who they are, ask if they can come in (for people that are able to invite them in) prior to entering a resident room.Nursing Home Administrator (NHA) A was asked for a policy regarding personal privacy and on 9/4/25 at 2:25 PM, responded via email that the facility does not have a policy specifically for personal privacy and provided the facilities Resident Rights policy. A review of the Resident Rights policy provided revealed no mention of personal privacy.

Based on observation, interview, and record review, the facility failed to provide justification for not performing a gradual dose reduction (GDR) for one (R90) of five reviewed. Findings include:Review of the medical record revealed R90 was admitted to the facility on [DATE] with diagnoses that included vascular dementia without behavioral disturbance/psychotic disturbance/mood disturbance, anxiety, insomnia, major depressive disorder, and psychotic disorder with hallucinations. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/2/25 revealed R90 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/2/25 at 10:51 AM, R90 was observed seated in a Broda chair in the dining room on the unit. Review of the Physician's Orders revealed R90 was admitted to the facility with an order for Seroquel 200 milligrams (mg) daily. On 6/2/25, the Seroquel was decreased to 150 mg at bedtime for major depressive disorder with psychotic features. Review of the OBRA assessment dated [DATE] revealed [R90] does appear to be in a depressive episode and has also been presenting with psychotic features such as hallucinations. However, these psychotic features could also be a result of his stroke/neurocognitive changes. Review of the Behavior Management Monthly Note dated 8/20/25 revealed Continue with [name of psychiatric services provider] evaluation for GDR of Seroquel. Cymbalta has been helpful with making statements about pain and how to end things. Possible increase of Cymbalta in the future as we continue to decrease Seroquel may be helpful as well with mood/pain. Review of the Psychiatry Follow up note dated 8/21/25 revealed Social Worker [SW] requested evaluation regarding patient's increased symptoms of ongoing moderate depression, insomnia and anxiety with medication review. Per SW, clinical team [discontinued] his Lexapro and started him on Cymbalta 30 mg daily for depression and to help aid in his pain. A GDR of Seroquel was not implemented as they were adding a new medication and did not want to do multiple med [medication] changes at once .No new or worsening behaviors noted .He denies any a/v [auditory/visual] hallucinations. Nursing staff also deny any behaviors. The note further revealed Seroquel 150 mg nightly, with recommendation for GDR to 125 mg nightly as patient has had no a/v hallucinations and no negative behaviors .A GDR will be attempted with 50 mg dose, total dose of 150 mg will be reduced to 125 mg. Review of R90's behavior documentation for the last 30 days revealed no documentation of any hallucinations or delusions. The medical record revealed R90 remained on Seroquel 150 mg at bedtime. There was no documentation as to why R90's GDR from 150 mg to 125 mg was not implemented. In an interview on 9/5/25 at 8:40 AM, Social Worker (SW) J reported psychiatric services emailed their recommendations to her and the facility conducted behavior management meetings weekly which included discussing psychiatric services recommendations and GDRs. SW J reported R90 was last discussed in the behavior management meeting on 8/20/25. SW J reported they did receive an email from psychiatric services regarding the recommendation to GDR R90's Seroquel to 125 mg. SW J reported usually there was documentation in the medical record if a recommendation was not implemented. SW J was unable to locate documentation. In an interview on 9/5/25 at 9:43 AM, Director of Nursing (DON) B reported behavior management meetings were conducted weekly, with each resident being reviewed monthly. DON B reported if psychiatric services made recommendations, an Interdisciplinary Team meeting was usually conducted. DON B was unable to provide any documentation as to why R90's further GDR was not implemented.

Based on observation, interview, and record review, the facility failed to prevent a fall for one (R5) of two reviewed. Findings include:Review of the medical record revealed R5 admitted to the facility on [DATE] with diagnoses that included epilepsy, and morbid obesity. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/24/25 revealed R5 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was dependent on staff for activities of daily living (ADLs). On 9/2/25 at 10:45 AM, R5 was observed lying in a bariatric bed with a perimeter mattress and a fall mat on the right side of the bed. A Broda chair was observed in R5's room. R5 reported she fell out of her Broda chair and fractured her leg. Review of the Witnessed Fall incident report dated 6/9/25 at 10:45 AM revealed R5 had fallen out of her wheelchair outside of the building in the parking lot. The incident report revealed an Activity Aide was propelling the Broda chair and the chair slid sideways, and he could not straighten it out in time before the wheel got stuck in a crack in the blacktop and the chair tipped to the left and the resident fell out to the side and the chair tipped on top of her. The incident report revealed R5 reported 9 out of 10 right hip/thigh pain and that R5 sustained a fracture. Review of the hospital documentation revealed R5 sustained an acute nondisplaced distal femoral fracture and was discharged with a right knee brace. In a telephone interview on 9/4/25 at 9:02 AM, Certified Nursing Assistant (CNA) T reported they were in the parking lot in their vehicle when they witnessed Activities Aide (AA) U pulling R5 in the Broda chair in the parking lot, using one hand. In an interview on 9/4/25 at 9:58 AM, AA U reported R5 used a Broda chair which was larger and difficult to push. AA U reported pushing Broda chairs on the sidewalk did not seem safe as the Broda chairs almost fell off the sidewalk. AA U reported because of this, they pushed Broda chairs in the parking lot around the building. AA U reported while pushing R5 in her Broda chair, the Broda chair started to swerve right, and he could not get it to go straight. AA U reported as he was trying to straighten out the Broda chair, they hit a big crack in the pavement, the wheel went into the crack and R5's whole chair tipped over. According to a witness statement from Vendor V that was included in the facility's investigation, Vendor V was in their van in the parking lot at the time of the incident. Vendor V witnessed a staff member propelling R5's Broda chair with one hand, hit a bump, and the chair tipped over. In an interview on 9/4/25 at 11:57 AM, Director of Nursing (DON) B reported while AA U propelled R5's Broda chair, they hit a crack in the blacktop where the wheel got stuck and the chair tipped over. DON B reported most Broda chairs in the facility, including R5's, had a green pedal that could be engaged for easier control/movement of the chair. The parking lot was observed with a repaired crack/gap that appeared to be approximately two inches wide. DON B reported the facility had identified noncompliance and implemented corrective actions. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included ad hoc QAPI meeting, all Broda chairs in the facility were inspected, education that only CNAs and nurses are to propel Broda chairs, and weekly audits for compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to ensure staff utilized personal protective equipment (PPE) for one (R70) of one reviewed for Transmission-Based Precautions (TBP). Findings include: Review of the medical record reflected R70 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included Crohn's Disease. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/21/25, reflected R70 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 09/02/2025 at 12:29 PM, a sign was observed, outside R70's room door, which had two STOP signs and read, CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 09/02/2025 at 12:29 PM, Staff Member (SM) C was observed to pass a lunch tray to R70's room, without the use of PPE. When asked about the sign for contact precautions and what it was for, SM C reported the sign indicated if they needed to wear a gown or mask if going in to do care on R70. R70's Physician's Orders reflected contact isolation was implemented for vomiting on 8/30/25 and discontinued 9/3/25. In an interview on 09/04/2025 at 9:38 AM, Infection Preventionist (IP) D reported R70 was placed on contact precautions over the previous weekend, as a precaution, for nausea, vomiting and diarrhea, until they were seen by a provider. IP D reported anyone entering R70's room, for any reason, should have worn a gown, mask and gloves.

Based on interview and record review the facility failed to maintain respect and dignity to one resident (Resident #3) of one resident's care and services.Resident #3 (R3)Review of the medical record reflected R3 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses of trigeminal neuralgia, multiple sclerosis, chronic pain syndrome, polyneuropathy, muscle weakness and lack of coordination.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2025, revealed R3 had a Brief Interview of Mental Status (BIMS) of 13 out of 15 (cognitively intact) and is dependent of all care.During an observation and interview on 09/02/2025 at 11:52 AM, R3 stated some of the staff are not very kind, this writer asked if she has told anyone, and R3 stated no not yet, she was going to wait and see if her attitude got any better. Stated the staff are ruff with repositioning her, due to her chronic pain and Multiple Scleroses. Writer passed this information on to the LNA A.During an interview on 09/05/2025 at 10:10 AM, R3 stated that LNA A came into her room yesterday to talk to her about staff being rude and disrespectful. R3 stated she was concerned about the night staff because they are the problem. R3 stated LNA A left a card for her to call if she had any more concerns. R3 stated that the other night, she called CNA by name, stated she would not change her brief after R3 told her she was wet. R3 stated she had to change herself in the night, because nobody would change her. R3 stated she pulled her brief off from the side and washed herself off with a wet wipe the best she could. R3 pointed to the pack of wet wipes on her over the bed table and a pack of briefs in the corner sitting on her chair. R3 stated that CNA would come into her room, look at the front of her brief and say she was not wet, and leave the room. R3 stated she told her she was soaked underneath, and she would be told she was not wet, and then left the room. She had to pull her own brief off and try to clean herself up 2 times last night. R3 stated her call light was on over an hour last night and they came in and turned it off without providing care. Discussed the need for staff to leave her call light on until care is provided. R3 stated they turn it off all the time without helping her, telling her they would be back.During an interview on 09/05/2025 at 10:56 AM, DON B writer reported R3's concerns about having her call light on and turned off without care provided. This writer reported that this happened twice last night. DON B pulled up the documentation from last night's shift and reported there was documentation throughout the night on check and change. DON B stated she would go down and talk to R3 now.

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in two resident rooms (Resident #38, #86) resulting in the potential for unsafe access to medications. Findings include: Resident #38 (R38) On 09/10/24 at 11:16 AM, a bottle of Flonase Nasal Spray was observed on R38's bedside table. The bottle was dated and contained the initials of R38. R38 reported that the Flonase spray was not normally stored in her room and that she does not have permission to store and/or administer medications to herself. Review of R38's Physician orders revealed that R38 had an active order for Fluticasone Propionate Suspension, 1 spray in each nostril in the morning for Rhinitis. Resident #86 (R86) On 09/10/24 at 1:33 PM, two boxes of Voltaren Gel were observed in R86's room. R86 reported that he does not administer the pain-relieving gel to himself and that the boxes were left in the room on a regular basis. Review of R86's Physician orders revealed that R86 had an active order for Voltaren External Gel 1 % (percent) (Diclofenac Sodium (Topical). In an interview on 09/13/24 at 11:08 AM, Director of Nursing (DON) B verified that R38 and R86 did not have an approved medication self administration assessment and that the medications observed in the resident's room should not have been there.

Based on observation, interview and record review, the facility failed to provide restorative services or enabler bars for three residents (R18, R73 and R75) of three residents reviewed for restorative care, out of a total sample of 19 residents, resulting in the potential for residents to decline in their current highest functioning level losing their independence and leading to withdrawal, depression and complications of immobility. Findings Include: Resident #18 (R18) Medical record revealed Resident #18 (R18) was admitted to the facility on [DATE] and readmitted on [DATE] initially with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, Diabetes, Chronic Kidney Disease, Pressure Ulcer of Sacral Region, stage 3, Obesity, Gastrointestinal Hemorrhage, Other Intervertebral Disc Degeneration Lumbar Region and a Spinal Cord injury. According to R18's Minimum Data Set (MDS) dated [DATE], revealed R18 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. MDS section GG0120 Mobility Devices used by R18 include a manual or electric wheelchair, 2 person transfer using a mechanical lift. Record review of the care plan for R18 had a focus of; resident would benefit from a restorative range of motion program related to decreased strength in upper extremities. Interventions included, observe for verbal and nonverbal signs and symptoms of pain during splint application and removal. Provide range of motion program (ROM). Active ROM and strengthening. Bilateral shoulder/elbow. 2-3 lb hand weights as tolerated. 2 x 10 reps 5x a week on Mon-Fri. Record review also revealed the task sheet for the last 30 days, did not reflect that R18 receive restorative care. Reason for not receiving was marked with response not required, resident not available or resident out of the facility. During an interview on 09/12/24 at 10:35 AM, Physical Therapy Director (PTD) O stated the restorative program can include exercise, bikes, activities to maintain function. PTD O also stated that once the residents are discharged from therapy services, they make recommendations for each resident and then it is handed over to the nursing department. PTD O also stated that if the resident is unable to follow the program, Assistant Director of Nursing (ADON) P will let them know, otherwise therapy does not follow up. During an interview on 09/12/24 at 10:40 AM, ADON P stated physical therapy department would give her a form completed with the recommendations, she would put it on task sheet to be completed. ADON P stated she had 2 Certified Nursing Assistants (CNA) that do this program. This writer asked ADON P if the restorative program was being done on this resident. ADON P stated she needed to look through the task sheet and check on it. ADON P stated R18 just started on a program, and depending on if he is in the mood he may or may not participation. ADON P stated she meets with the 2 CNA'S monthly to discuss who is participating and who is not. Writer asked for the documentation showing R18 did or did not receive restorative treatment. During an interview on 09/12/24 at 10:58 AM, ADON P stated that R18 was not available in the facility for restorative treatment, added that he gets up in his wheelchair late morning and he is busy with activities, or sitting out in the sun. Writer asked if they went back to try at a different time, ADON P stated she did not know. ADON P also stated that the CNA's did not have any documentation to validate the reason the program was not followed, if it was refused or if they reapproached R18 at a different time during the day. ADON P stated she did not know if CNAs could document that in the program or not. Record review revealed the facility did not follow the recommendations from the physical therapy department to maintain R18's highest functional level. Resident #75 (R75) Medical record revealed Resident #75 (R75) was admitted to the facility on [DATE] initially with diagnoses that included Atrial Fibrillation, Chronic Kidney Disease, Chronic Pain Syndrome, Wernicke's Encephalopathy, History of Pulmonary Embolism, History of [NAME] Blood Embolism, Acute Gastric Ulcer with Hemorrhage, Osteoarthritis, Muscle Weakness, Difficulty Walking, and repeated falls. According to R2's Minimum Data Set (MDS) dated [DATE], revealed R75 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. MDS section GG0120 Mobility Devices used by R75 was a walker, manual or electric. Record review revealed a task of Skilled Restorative Nursing: Range of Motion (active): Bilateral Upper Extremities (UE). Care flexion/reach forward, L + R rotation x 15 reps/2 sets as tolerated. 3x/week on M-W-F was on the task sheets. Record review also revealed R75 did not receive Restorative treatment on 09/02/24, 09/04/24, 09/06/24, and 09/09/24. During an interview on 09/12/24 at 10:35 AM, Physical Therapy Director (PTD) O stated the restorative program can include exercise, bikes, activities to maintain function. PTD O also stated that once the residents are discharged from therapy services, they make recommendations for each resident and then it is handed over the nursing department. PTD O also stated that if the resident is unable to follow the program, Assistant Director of Nursing (ADON) P will let them know, otherwise therapy does not follow up. During an interview on 09/12/24 at 10:40 AM, ADON P stated physical therapy department would give her a form completed with the recommendations, she would put it on task sheet to be completed. ADON P stated she had 2 Certified Nursing Assistants (CNA) that do this program. This writer asked ADON P if the restorative program was being done on this resident. ADON P stated she needed to look through the task sheet and check on it. ADON P stated R18 just started on a program, and depending on if he is in the mood he may or may not participation. ADON P stated she meets with the 2 CNA'S monthly to discuss who is participating and who is not. Writer asked for the documentation from August 1, 2024, through August 12, 2024, showing R75 did or did not receive restorative treatment. During an interview on 09/13/24 at 11:35 AM, ADON P stated she would have to go look to see why the treatments were not provided. ADON P did not provide this information prior to exit. Record review revealed the facility did not follow the recommendations from the physical therapy department to maintain R75's highest functional level. 27446 Resident #73 (R73) Per R73's diagnoses list R73 had a left femur fracture and muscle weakness diagnoses dated 7/23/2024. Record review of a Nursing to Therapy Communication note dated 9/3/2024, revealed that a therapy referral was required for the following reasons: Would like to have recommendation for enabler bars to bed to assist with bed mobility and transfers in and out of bed. The symptoms listed were increased difficulty in positioning in bed, increased difficulty getting in and out of bed, increased desired to get out of bed more, increased motivation to maneuver self in bed and/or room. No therapy assessment was noted in R73's electronic medical record (EMR). Observation on 9/12/2024 at 10:10 AM, revealed no enabler bars on R73's bed. In an interview on 9/12/2024 at 11:24 AM, Physical Therapy Assistant (PTA) O who was the Therapy Director said she thought she had received R73's nursing referral. PTA O said it was possible it was missed, but thought she had turned it in. After searching for the referral, PTAO stated she must have missed it because she could not find it. PTA O stated that nursing would give her the Nursing to Therapy Communication note in the morning meeting, and then stated that she did have the communication document for R73, and stated that R73 was already being seen by therapy but she had forgotten to screen R73 for bedrails as requested by nursing. In an interview on 9/12/2024 at 11:35 AM, Director of Nursing (DON) B stated she was the one who put in the therapy communication to see if R73 would benefit from the enabler bars. DON B said she wanted to see if the enabler bars would benefit R73 on getting her back to her status of one person limited assistance, and said now R73 was a two person extensive assistance for bed mobility and transfers. DON B said every morning in the morning meeting PTA O would get a copy of the Nursing to Therapy Communication note, if applicable, would then assess the resident, give their recommendations to nursing, who would then place the enabler bars on the resident's bed.

Based on observation, interview, and record review the facility failed to ensure one out of one residents (Resident #42) received timely dental care to obtain a new set of dentures, resulting in embarrassment and a difficult time eating. Findings Included: In an interview on 9/10/2024 at 2:20 PM, Resident #42 (R42) stated that she had seen the dentist about two months ago, and the dentist told her she needed to get new dentures. R42 said she had not seen the dentist since then and had not had any denture fitting done. R42 was observed to have no visible teeth. R42 stated she wanted dentures as soon as possible because she felt embarrassed having no teeth. Record review of R42's dental notes dated 5/30/2024, revealed the age of R42's dentures was six plus years, the condition of her teeth were poor, had moderate soft plaque/food debris buildup, moderate hard calculus deposits, moderate gingivitis inflammation/swollen bleeding gums. Review of the, Treatment notes: .Patient (R42) has upper complete denture that is very loose and worn. She is having trouble chewing, having also lost her lower partial denture. New dentures will benefit her nutrition and general health .Action Required by Nursing Home Staff, Continue Daily Oral Care; Please have Responsible Party sign Consent for Denture Form. Record review of R42's electronic medical record (EMR) revealed no consent for dentures was signed and in R42's EMR. In an interview on 9/12/2024 at 1:18 PM, Social Worker SW G stated she did receive the dental recommendation for R42's dentures, but said she never got the consent signed by R42's responsible party. SW G said she was the one who would have residents sign consents to be seen by the dentist, but stated she did not have the consent for R42 because it was missed.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when two medication errors were observed from a total of 31 opportunities for two residents (Resident #43, #60), resulting in a medication error rate of 6.67%. Findings include: Resident #43 (R43) Review of the medical record revealed R43 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure. A Physician order dated 10/1/23 included an order for Ayr Saline Nasal Drops Nasal Solution 0.65% (percent) to be administered once a day. Ayr Saline Nasal Drops are used to alleviate the symptoms of dry nostrils. On 9/11/23 at 08:15 AM, Registered Nurse (RN) K reported that she was preparing to administer medications to R43. RN K obtained a cotton tipped swab and Ayr nasal gel from the medication cart. RN K applied AYR nasal gel to the end of the cotton tip swab and assisted R43 with coating both nostrils with the AYR gel. Further review of R43's Physician orders revealed no order for AYR nasal gel. In an interview on 09/13/24 at 11:08 AM, Director of Nursing (DON) B stated that any medication that is administered to a resident must have a Physician order. DON B verified that there was no order for AYR nasal gel for R43. Resident #60 (R60) Review of the medical record revealed R60 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications. Review of the Physician's Order dated 8/30/24 revealed an order for Lantus Solostar Subcutaneous (innermost layer of the skin) Solution Pen-injector 100 unit/ML (milliliter). On 9/11/24 at 8:04 AM, Registered Nurse (RN) K removed the Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) from the medication cart and applied the disposable cap containing the needle to the end of the Insulin Glargine pen-injector. RN K twisted the end of the pen to 60 units and verbally verified that the order for R60 was 60 units. RN K then proceeded to enter the room of R60, donned gloves, and approached R60 to explain that she was giving her Insulin Glargine. R60 lifted her left arm and RN K administered the Insulin Glargine to the subcutaneous tissue on R60's left arm. RN K was not observed priming the insulin pen (process of ensuring the pen is clear and functioning to ensure all ordered units are properly administered) prior to administration or utilizing an alcohol wipe to clean and disinfect the skin at the site of administration on R60's left arm prior to injecting the Insulin Glargine. In an interview on 09/13/24 at 11:08 AM, Director of Nursing (DON) B reported that the procedure for insulin administration would be to prime the pen and use an alcohol wipe to cleanse the site of injection prior to insulin injection.

This citation two DPS statements 1 of 2: DPS 1) Based on observation, interview, and record review, the facility failed to provide services that met the acceptable standards of clinical practice for peripherally inserted central catheter (PICC) line dressings in 2 of 2 sampled resident (R348 and R350) reviewed for PICC lines, from a total sample of 19 resident, resulting in the increased likelihood for infection. Findings include: Resident #348 (R348) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R348 was a [AGE] year old male admitted to the facility on [DATE], with recent diagnosis that included osteomyelitis (infection of the bone) left ankle, diabetes mellitus, atrial fibrillation(irregular heart rhythm), hypertension (high blood pressure), spinal stenosis, chronic pain, anxiety disorder, bipolar disorder and depression. The MDS reflected R348 a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was intact. The MDS reflected R348 had no behaviors including rejection of care. During an observation and interview on 9/10/24 at 10:11 AM, R348 was laying in bed with an external fixator on left ankle and lower leg area., reported he ran out of pain medicine yesterday. R348 appeared calm and able to answer questions without difficulty. R348 reported had long history of issues with left lower leg infection and was currently on Intravenous (IV) antibiotics four times daily. R348 had a single lumen PICC located in the left upper arm with dressing dated 8/31/24. R348 reported was diabetic and blood sugars had not been controlled since admission to the facility. During an observation on 9/10/24 at 1:50 PM, R348 was laying in bed with family present in room. Observed R348 PICC dressing that continued to be dated 8/31/24. Review of the Physician Orders, dated 8/29/24, reflected R348 had an order that included, Transparent dressing change every 7 days and as needed. Document in progress notes any concerns such as changes to site, s/s infection, or complications. every day shift every 7 day(s) Supplementary documentation includes: Arm circumference in cm. (ACC) Catheter Length in cm. (CL) . Review of the Treatment Administration Record(TAR), dated 8/28/24 through 9/10/24, reflected R348 had an order that included, Transparent dressing change every 7 days and as needed. Document in progress notes any concerns such as changes to site, s/s infection, or complications. every day shift every 7 day(s) Supplementary documentation includes: Arm circumference in cm. (ACC) Catheter Length in cm. (CL) . Continued review of the TAR reflected R348 had documentation that reflected R348 did not received scheduled PICC dressing change on 9/5/24 as reflected by, 5, which indicated to see progress notes, with no additional documentation of dressing changes completed, including on 8/31/24. Review of R348 PICC care plan, dated 8/29/24, reflected interventions that included, IV catheter care, maintenance, and dressing changes per orders . During an observation and interview on 9/12/24 at 10:10 AM, R348 was observed in bed with PICC dressing to left upper arm dated 9/11/24 with PICC insertion site covered by gauze border of transparent dressing(within 1 centimeter of edge of dressing). During an observation and interview on 9/12/24 at 10:26 AM, Registered Nurse Unit Manager (RNUM) R reported if residents have PICC line on admission nurse would assess and verify when PICC dressing change was due to be changed and would expect dressing to be changed every seven days or as needed and PICC site to be assessed with each IV medication administration including for signs and symptoms of infection at insertion site. RNUM R reported R348 was admitted [DATE] and staff attempted to change PICC dressing on 9/5/24 with Progress Note that reflected was recently changed and schedule was not adjusted and should have been to ensure dressing was changed every 7 days. RNUM R reported R348 PICC dressing should have been changed every 7 days and reported that nurse on 9/10/24 changed R348's PICC dressing that was dated 8/31/24.(10 days since last dressing change). RNUM R entered R348 room and observed R348's dressing on left upper arm and verified was dated 9/11/24 and insertion site was not visible through dressing. Resident #350 (R350) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R350 was a [AGE] year old female admitted to the facility on [DATE], with recent diagnosis that included osteomyelitis(infection of the bone) right ankle, thrombocytopenia, anemia, and muscle weakness. The MDS reflected R350 a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was intact. The MDS reflected R350 had no behaviors including rejection of care. During an observation and interview on 9/10/24 at 1:14 PM, R350 was observed in room laying in bed and appeared well groomed and able to answer questions without difficulty. R350 reported was recently admitted to the facility for right foot infection with need for IV antibiotics every four hours. R350 had a single lumen PICC with dressing dated 8/31/24 with serosanguinous drainage noted at insertion site through transparent dressing. Review of the Physician orders, dated 8/24/24, for R348, reflected, Transparent dressing change every 7 days and as needed . Review of R350 PICC care plan, dated 8/24/24, reflected interventions that included, IV catheter care, maintenance, and dressing changes per orders . During an interview and record review on 9/12/24 at 10:26 AM RNUM R reported R350's PICC dressing change should be changed every seven days and verified was changed 9/10/24 and had been dated 8/31/24. RNUM R reported R350's TAR reflected PICC dressing was not changed as reflected by a hole (blank) on the TAR (no documentation) on 9/7/24. RNUM R reported R350 had a physician order to change PICC dressing change every 7 days. During an interview on 9/12/24 at 2:15 PM, Director of Nursing (DON) B reported would expect staff to follow PICC policy including PICC dressings should be changed every 7 days and assess daily for signs and symptoms of infection including insertion site for redness that must be visible. According to Clinical Nursing Skills & Techniques, 6th edition, ([NAME], A., [NAME], P. 2006. page 937), A transparent dressing should be changed with annual site rotation and immediately if integrity of the dressing is compromised. Gauze dressings should be changed routinely every 48 hours and immediately if integrity is compromised. Gauze used underneath a transparent dressing is considered a gauze dressing and should be changed every 48 hours. According to the publication American Nurse Today, dated May 2014, volume 9, number 5, under PICC line dressing changes: Change a transparent dressing every 7 days, if the dressing is no longer intact, oozing or has become bloody or contaminated, change it as soon as possible. Review of the facility, Care and Maintenance of Central Venous Catheter, dated12/13/23, reflected, Policy: The facility will adhere to accepted standards of practice regarding the care and maintenance of central venous catheters .5. Assess the central line daily: a. Assess the site for signs of infection: redness, tenderness, pain or swelling at the insertion site .Change dressings routinely using aseptic technique, based on the type of dressing . 46954 DPS 2) Based on observation, interview and record review the facility failed to ensure an as needed narcan order was in place for one (Resident #348) of 19 reviewed for quality of care resulting in the potential to not receive the opioid reversing medication in a timely manner. Resident #348 (R348) Review of an Admission Record revealed Resident #348 (R348) admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome and spinal stenosis. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/3/24, reflected R348 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/10/24 at 10:11 AM, R348 was observed in bed. R348 explained that he had frequent pain and was prescribed medications for pain control. Review of R348's Physician Orders revealed active orders for Morphine Sulfate ER (extended release) oral tablet 15 MG (milligrams), Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen), and Dilaudid Oral Tablet 4 MG (Hydromorphone HCl) which are all medications containing opioids. Further review of the Physician order revealed no PRN (as needed) order for Narcan (medication that can reverse opioid overdose). In a interview on 9/13/24 at 9:57 AM, a confidential nursing staff member reported that she was familiar with R348's care and verified that R348 received multiple opioid containing medications. The staff member confirmed that typically PRN Narcan would be ordered as a safe guard. In an interview on 09/13/24 at 11:08 AM, Director of Nursing (DON) B stated that any medication that is administered to a resident must have a Physician order. In an interview on 9/13/24 at 12:47 PM, Nursing Home Administrator (NHA) A confirmed the facility's policy and stated that Resident R348 should have an active Narcan order. However, NHA A was unable to locate a current Narcan order for R348.

Based on observation, interview, and record review, the facility failed to ensure timely coordination of dental services for one (Resident #22) of one resident reviewed for dental services, resulting in the potential for untreated and unmet dental needs. Findings include: Review of the medical record revealed that Resident #22 (R22) was readmitted to facility 1/25/2021 with diagnoses including cerebral infarction, aphasia, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/23 revealed that R22 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition). Section L of the Annual MDS with an ARD of 10/16/2022 reflected that R22 had obvious or likely cavity or broken natural teeth. In an observation and interview on 7/24/23 at 12:46 PM, R22 stated that she had broken and loose teeth, denied seeing a dentist recently but verbalized need to do so, and although denied any chewing issues did admit to intermittent oral discomfort. Upon smiling, R22 was observed to have two upper front teeth broken off near gum line and black in color and was observed to jiggle loose bottom front teeth with her tongue. Review of R22's medical record completed with the following findings noted: Order dated 1/9/2023 for Amoxicillin Capsule 500 MG (milligrams) with instruction to give 1000 MG one time only and then 500 MG every 8 hours for 3 days for indication of Dental abscess. Order dated 1/9/2023 for Peridex Solution (an oral rinse used to help reduce redness and swelling of gums and to help control any gum bleeding) 0.12% (percent) twice daily for 30 days for indication of poor dentition. No associated physician or nursing note located within medical record to reflect initiation of Peridex Solution. Order dated 1/10/2023 for urgent dental visit due to dental caries/broken teeth, mouth pain. Order dated 1/26/2023 for Amoxicillin-Pot Clavulanate Tablet 875-125 MG every 12 hours for 10 days for indication of Dental caries. Physician Progress Note dated 1/26/2023 included no oral/dental assessment information or mention of restarting antibiotic therapy nor were any nursing progress notes located within R22's medical record until 1/30/2023 to reflect reimplementation of antibiotic therapy. Order dated 4/11/2023 for Augmentin Oral Tablet 875-125 MG every 12 hours for 10 days for indication of Dental caries. Order dated 4/11/2023 for Peridex Mouth/Throat Solution 0.12% twice daily for 30 days for indication of Dental caries. Order dated 6/28/2023 and discontinued 7/4/2023 for Lidocaine Viscous Mouth/Throat Solution (a local anesthetic used to relieve pain and discomfort from a sore mouth/throat) 2% with instruction to place and dissolve 1 application buccally (cheek region) two times a day. No indication for use was noted to be provided within order. Order dated 7/4/2023 and discontinued 7/20/23 for Lidocaine Viscous Mouth/Throat Solution 2% with instruction to place and dissolve 1 application buccally every morning and at bedtime. No indication for use was noted to be provided within order. Order dated 7/20/2023 and discontinued 7/24/2023 for Lidocaine Viscous Mouth/Throat Solution 2% with instruction to give 2.5ml (milliliters) by mouth every morning and at bedtime and to place on cotton tipped swab and swab broken tooth area for indication of pain. Physician Assistant (PA) Progress Noted dated 1/9/2023 stated, .CHIEF COMPLAINT .dental pain .HISTORY OF PRESENT ILLNESS .Patient also with poor dentition, has some dental pain complaints .IMPRESSION AND PLAN .2. Dental abscess .Patient does have dental abscess, poor dentition, tenderness. We will treat with amoxicillin 1 g (gram), then 500 mg (milligrams) q (every) 4h (hours) x (times) three days. Patient to see dentist at next available visit . Pertinent Charting-Infections/Signs Symptoms Note dated 1/11/2023 at 4:17 AM stated, .Site of infection: Dental abscess .edema and pain to gums/teeth .dental consultation in progress . SOC-Infection Note dated 1/11/2023 at 4:52 AM stated, Type of infections/Signs & symptoms: Dental abscess, pain and edema with rotting teeth present, assessed by practitioner . Pertinent Charting-Infections/Signs Symptoms Note dated 1/13/2023 at 10:40 AM stated, .At dentist currently having an extraction. Antibiotic complete at this time. No additional progress notes located in R22's medical record on or in the days following the 1/13/2023 entry to reflect tooth extraction and no consultation note located within R22's medical record from 1/13/2023 to reflect that dental appointment was completed. Physician Progress Note dated 1/16/23 at 2:38 PM stated, Late Entry .IMPRESSION AND PLAN .2. Dental caries .Continue Augmentin for 10 days for improvement of same. Awaiting dental evaluation . Review of both physician and nursing progress notes from 1/16/2023 through 1/29/2023 were not noted to include documentation regarding R22's oral/dental status. Pertinent Charting-Infections/Signs Symptoms Note dated 1/30/2023 at 10:17 AM stated, Event Date: 1/27/2023 .Site of Infection: Dental Infection .Reason on antibiotics/new signs & symptoms: Poor dentition. Has dental infection with swelling and mouth pain .Augmentin 875-125mg PO (by mouth) BID (twice daily) x 10 days . Review of both physician and nursing progress notes from 2/6/2023 through 4/10/2023 were not noted to include documentation regarding R22's oral/dental status. PA Encounter Note dated 4/11/2023 at 1:00 AM stated, .Problem .dental pain .patient complains of dental pain nursing requesting evaluation. Patient with poor dentition awaiting dental appointment .Physical Exam .Poor dentition with multiple caries redness swelling .Plan .Patient with poor dentition and multiple dental caries we will order Augmentin twice daily for 10 days .patient to be sent to dental for further evaluation extractions as indicated . Pertinent Charting-Infections/Signs Symptoms Note not noted until 4/13/2023 at 1:17 PM (although antibiotic therapy was restarted 4/11/2023) stated, Event Date: 4/11/2023 .Site of Infection: Dental caries .Augmentin BID (twice daily) x 10 days .Awaiting oral surgeon consultation for teeth extractions. Review of both physician and nursing progress notes from 4/25/2023 through 6/22/2023 reflected no documentation regarding R22's oral/dental status. Nurse Practitioner (NP) Encounter Note dated 6/28/2023 at 1:00 AM stated, .History of Present Illness .Seen today for cracked and missing teeth in the front top. She has many cracked teeth. States she has pain as well. She does not know how long this has been there. Makes it difficult to eat. Many dental caries noted .Physical Exam .multiple cracked teeth and dental caries, no signs of abscess .Assessment .Cracked tooth .Stat (immediate) referral to oral surgery for removal. Lidocaine swish and spit for pain . Nursing Evaluation Summary dated 7/15/2023 at 12:31 AM stated, .Res (resident) has several broken teeth and is awaiting an appt. (appointment) to have them removed. Continue on Lidocaine Viscous swish and spit for mouth discomfort . Appointment/Transportation Note dated 1/11/2023 at 10:44 AM stated, .Called (name of dental school) and they are able to get resident in on [DATE] at 9:30am. Appointment/Transportation Note dated 1/31/2023 at 8:27 AM stated, .Called the oral surgery department at (name of dental school) and was told that there had not been a referral sent to them. I was then transferred to the dental school. Asked them what the next steps were for resident and they said that she needed to be assigned a dental student yet. She was reaching out to that department and the student would be calling me to schedule an appointment. Appointment/Transportation Note dated 2/3/2023 at 12:04 PM stated, Received a call from (name of dental school) to schedule a follow-up appointment. Scheduled for 2/14 at 2pm. Appointment/Transportation Note dated 2/14/2023 at 12:55 PM stated, (Name of transportation company) called and canceled transport this morning .(Name of employee from transportation company) has been trying to reschedule the appointment but when he finally talked to the dental school they said at this time they did not have an available day/time for make up . Appointment/Transportation Note dated 2/14/2023 at 4:13 PM stated, .Dental school student called to scheduled appt for 2/22 at 9am . Appointment/Transportation Note dated 2/20/2023 at 11:47 AM stated, (Name of dental school) called .canceling all appointments this week. Resident's appointment was scheduled for 2/22. They said they would call back with a new appointment at a later date. Appointment/Transportation Note dated 3/16/2023 at 12:00 PM stated, (Name of dental school) called to schedule an appointment for resident. Scheduled for 4/3 at 9am. Appointment/Transportation Note dated 3/28/2023 at 8:17 AM stated, (Name of dental school) reached out yesterday to see if resident could come in on 3/31 instead of 4/3 .New appointment will be 3/31 at 9am . No additional progress notes located in R22's medical record on or in the days following the scheduled 3/31/23 appointment to reflect appointment completion and no consultation note located within R22's medical record from 3/31/2023 to reflect that dental appointment was completed. No appointment/transportation notes, physician notes or nursing notes located in R22's medical record from 3/28/23 (the date of the last Appointment/Transportation Note) through 7/25/2023 to reflect ongoing efforts to coordinate a dental appointment for R22 despite completion of 3 courses of antibiotic therapy (1/10/23-1/13/23, 1/26/23-2/5/23, 4/11/23-4/21/23), 2 courses of Peridex Solution (1/9/23-2/8/23, 4/11/23-5/11/23), and Lidocaine Viscous Mouth/Throat Solution treatment (6/26/23-7/24/23). Alert Note dated 7/25/2023 at 7:35 PM stated, Resident called to show me her loose tooth nurse notified. Resident has an appointment scheduled for 7/27/23 for her teeth to be removed. Review of consult note scanned into R22's medical record completed with the facility's ancillary dental group dated 6/14/23 indicated, .Patent needs restorations of teeth #6, 10, 11. Tooth #8 is fractured and not restorable. Teeth #23 and 26 are extremely mobile and being retained with calculus. Extraction can be performed in facility. Will need consent . A second ancillary dental group consult dated 6/28/23, and scanned into R22's medical record, reflected routine dental prophylaxis and pending teeth extraction. Review of ancillary dental services Consent for Extraction, dated 6/19/23, indicated R22's approval for recommended extractions. In an interview on 7/26/23 at 11:51 AM, Social Services (SS) I confirmed familiarity with R22, stated that she coordinated ancillary services (vision, dental, podiatry, audiology) within the facility, as well as assisted with coordination of outside appointments. Per SS I, the facility had transitioned to a new company for the provision of ancillary services in January 2023 with the prior company ending services mid November 2022. SS I stated that although some of the ancillary services with the new company began in January of 2023, the dental services did not start until June of 2023 and therefore the facility had no ancillary dental services from mid November 2022 (when the prior company ended all services, including dental) until June 2023 (when dental services were started with the current ancillary company). SS I stated that as R22 had received ancillary dental services from the prior company (last consult note was dated 5/2022) and as she was aware of R22's ongoing dental concerns, she facilitated dental services with the facility's new ancillary services. Upon reviewing R22's recent 6/14/23 and 6/28/23 ancillary dental consult notes as well as R22's 6/19/23 consent for extractions, SS I stated that she would be following up as, to her knowledge, no date had yet been scheduled for R22's extractions through the facility's ancillary dental company as she would have been the one to coordinate. Although SS I confirmed that she did assist with coordination of outside appointments, SS I denied knowledge as to whether R22 attended the scheduled 1/13/23 and 3/31/23 outside dental appointments and could not provide additional information as to why follow up had not been completed regarding these appointments or on the scheduling of any subsequent dental appointments at that time. Additionally, SS I denied knowledge of R22's pending 7/27/23 appointment for extractions as indicated within the Alert Note dated 7/25/23 at 7:35 PM. In an interview on 7/26/23 at 12:48 PM, Director of Nursing (DON) B stated that the Interdisciplinary Team had been working together to schedule resident appointments since the resignation of the prior facility scheduler on May 1, 2023. Upon review of R22's medical record, DON B confirmed that the chart contained no scanned consult notes from the scheduled 1/13/23 and 3/31/23 community dental appointments, acknowledged that since 3/28/23 no documentation contained within chart to reflect ongoing efforts to coordinate dental appointments despite recurrent antibiotic treatment for dental abscesses, verbalized surprise that the facility's ancillary dental services would complete extractions at the facility, and denied knowledge of R22's 7/27/23 dental appointment as indicated within 7/25/23 Alert Note. Upon referencing the facility's transportation log, DON B stated that the log reflected that R22 had a 7/27/23 8:00 AM appointment for oral surgery but denied knowledge of additional details surrounding appointment and verbalized plan to follow up to obtain additional details regarding both the 7/27/23 appointment and previously scheduled 1/13/23 and 3/31/23 appointments. On 7/26/23 at 4:04 PM, emailed correspondence received from DON B with indication that facility staff had contacted transportation company indicated on log for R22's oral surgery appointment scheduled for 7/27/23 and were informed that the facility's previous nursing staff scheduler had coordinated transportation services on 6/14/23 for the 7/27/23 appointment. DON B provided no additional details regarding facility efforts to coordinate R22's dental appointments between 3/28/23 and 6/14/23 nor were consult notes from the 1/13/23 or 3/31/23 outside dental appointments provided prior to survey end.

Based on observation, interview and record review, the facility failed to ensure that prescribed medications were given on time and per physician's orders for one resident (R6) of one reviewed for significant medication error, resulting in several missed doses of Physician ordered prescription eye drops, inaccurate dosing and the potential for preventable decline and/or loss of vision. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R6 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, schizoeffective disorder, chronic obstructive pulmonary disease, end stage renal disease with dialysis, anxiety, and depression. The MDS reflected R6 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required one person physical assist with transfers, dressing, hygiene, and bathing. During an observation and interview on 7/24/23 at 12:53 PM, R6 was sitting in 100 hall dining room in a wheel chair eating lunch with one other resident. R6 appeared well groomed, calm, pleasant and well developed eating independently. R6 requested this surveyor return after meal to room to discuss care concerns. During an interview and observation on 7/24/23 at 1:11 PM, R6 requested this surveyor enter room to discuss care concerns. R6 appeared mildly anxious but able to answer questions without difficulty. R6 reported planned to call family member to help resident report concerns. R6 reported family member was R6 advocate. R6 family N and R6 reported R6 had recent issue with right eye and reported was sent for eye consult. R6 family N and R6 reported on 6/30/23 was seen for eye consult and given eye drops for right eye to be given 2 drops every 4 hours and was given 14 vials. Reported facility administered eye drops 6/30/23 through 7/7/23 with no eye drops on 7/8/23 through 7/14/23(7 missed days). R6 family N reported spoke with the Director of Nursing (DON) B on 7/3/23 who reported would order more drops. R6 family N reported R6 had follow up eye consult 7/14/23 and was provided additional eye drops to re-start as originally directed and reported physician was no happy that eye drops had not been given for last 7 days. R6 reported right pain was painful by the time of follow up appointment 7/14/23. Review of the Electronic Medical Record(EMR), dated 6/1/23 through current, reflected no evidence of R6's eye Consult visit. Review of the Physician Orders, dated 6/30/23, reflected R6 had an order for Oxervate Ophthalmic Solution 0.002% Instill 1 drop in right eye every 2 hours for Corneal tear for 14 Days. Review of the Medication Administration Record(MAR), dated 6/30/23 through current(7/25/23), reflected R6 was given Oxervate Ophthalmic Solution one drop in right eye every two hours 6/30/23 through 7/8/23 around the clock(12 doses per day). The Record reflected R6 missed Oxervate every 2 hour eye drops 7/8/23 through 7/14/23 as evidenced by 9 documented on MAR as see documentation. Review of the Nursing Progress Notes, dated 7/1/23 through 7/14/23, reflected no evidence R6's eye consult physician had been contacted about missed doses of physician ordered prescription eye drops. During an interview on 7/26/23 at 2:20 PM, Unit Manager E reported R6 was prescribed specialty eye drops by eye specialist named Oxervate on 6/30/23 that cost $10,000. During a telephone interview on 7/26/23 at 4:30 PM, Accredo Pharmacy verified three shipments of 14 days each of Oxervate were sent for R6 of three 6/28/23, 7/11/23, and 7/21/23. During an telephone interview on 7/26/23 at 4:41 PM, Specialty Eye Clinic staff O reported facility had just called for R6 consult notes and were faxing at that time. During an interview on 7/26/23 at 5:05 PM, Assistant Director of Nursing (ADON) D verified was unable to located R6 Specialty Eye Consult visit notes in the EMR and requested copies. ADON D reported was unsure why facility did not have records in EMR and should be. During a telephone interview on 7/27/23 at 8:07 AM, Specialty Eye Clinic Manager P reported R6 was given physician order on 6/30/23 for Oxervate 1 drop right eye six times daily for eight weeks and was provided 14 days supply. During an interview on 7/27/23 at 8:36 AM, DON B and ADON D provided R6 Eye Consult notes. DON B reported did not receive records of visits until today and reported received two page document from R6 Eye Specialist on 6/30/23 that including next visit and medication orders that facility had not been able to locate. DON B verified R6 Oxervate was ordered as 6 times daily per consult note and verified they gave every 2 hours (12 times daily). During an interview on 7/27/23 at 9:08 AM DON B reported facility should have followed up to obtain consult notes. DON B reported it was expected that night shift prior to resident appointments prepare packets for consults that include page for notes to be written by consult office and if they do not write facility assumes no orders. DON B reported prior transportation staff used to follow up to obtain consult notes but had been gone since May.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when three medication errors were observed from a total of twenty-five opportunities for two residents (Resident #11 and #64) of six reviewed for medication administration, resulting in a medication error rate of 12% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: Resident #11 On 7/25/23 at 8:29 AM, Registered Nurse (RN) C was observed preparing multiple medications for Resident #11 (R11) including four oral medications as well as an Albuterol Sulfate (Ventolin) and a Symbicort Inhaler. After entering R11's room and administering oral medications, RN C was observed to shake and then hand Albuterol Inhaler to R11 with R11 observed to place inhaler to and close lips around inhaler mouthpiece and self-administer 2 consecutive puffs prior to handing inhaler back to RN C. RN C proceeded to immediately shake and hand Symbicort Inhaler to R11 with R11 observed to place inhaler to and close lips around inhaler mouthpiece and self-administer 2 consecutive puffs and then immediately completed swish and spit mouth rinse with water provided by RN C. RN C then proceeded to document the medications as given in the electronic medical record. Throughout the administration of both the Albuterol and Symbicort Inhalers, R11 was not observed to exhale fully in preparation to breathe in medication, was not observed to hold breath after inhalations, and was not observed to wait prior to administration of second inhalation. In an interview following R11's medication administration, RN C initially stated that she had never really instructed anybody on Albuterol or Symbicort Inhaler usage, then stated that she couldn't think of what instruction she usually provided, and then stated that she knew she had forgotten but usually provided R11 with instruction to hold his breath for a few seconds after each inhalation. RN C confirmed that she generally provided inhalers to R11 so that he could self-administer, stated that he usually administered them rapidly, one puff after the other, so that she did not have time to remind him to wait between puffs but that, I would think he should wait at least 1 minute. Resident #64 On 7/25/23 at 8:50 AM, RN C was observed preparing multiple medications for Resident #64 (R64) including ten oral medications, an insulin injection, and Fluticasone Propionate Nasal Spray. After entering R64's room and administering oral medications, RN C was observed to shake and then hand Fluticasone Propionate Nasal Spray to R64 with instruction to go ahead and spray in each nostril. R64 was observed to place tip of Fluticasone Nasal Spray to base of right nostril, instill 1 spray and then to base of left nostril and instill one spray prior to handing back to RN C. RN C was then observed to administer R64's insulin injection prior to exiting room and documenting the medications as given in the electronic medical record. Throughout nasal spray administration, R64's head was observed to be positioned upright with R64 not observed to close opposite nostril with finger, inhale slowly through nostril with mouth closed or to breathe out slowly through mouth during administration or to tilt head back after administration of the nasal spray in either the right or left nostril. In an interview following R64's medication administration, RN C confirmed that she generally handed R64 his nasal spray for self-administration and stated, I usually tell him how many sprays to do in each nostril and after a short pause stated, I'm drawing a blank in reference to any additional instructions provided upon administration of R64's Fluticasone Propionate Nasal Spray. In an interview on 7/25/23 at 3:16 PM, Director of Nursing (DON) B stated that the expectation would be for the nurse to administer and provide instruction for inhalation techniques with both inhaler and nasal spray administration and that an assessment would be completed for self-administration with associated documentation within a resident specific medical record if the resident was going to be handed an inhaler or nasal spray for self-administration. Review of a facility policy titled Medication-Inhaler with a reviewed/revised date of 1/1/22 stated, Policy: Medications are administered as prescribed, in accordance with current nursing principles and practices and only by persons legally authorized to do so .Policy Explanation and Compliance Guidelines .6. Explain the procedure to the resident and answer any questions .7. Instruct resident to exhale away from device .8. Instruct resident to seal lips around the mouthpiece .9. Instruct resident to press down on canister while breathing in slowly and deeply .10. Instruct to hold breath for as long as possible to ensure deep instillation of medication .11. Remove inhaler from mouth and instruct to breathe out gently .12. Allow 1-2 minutes between inhalations . Review of facility policy titled Medication-Nasal Spray Administration with a reviewed/revised dated of 1/1/22 stated, Policy: Nasal spray medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .2. Procedure .g. Occlude opposite nostril with your finger and insert tip of medication container into desired nostril .h. Spray medication into nostril while instructing resident to inhale with mouth closed. Instruct resident to exhale through the mouth .j. Instruct resident to tilt head back for several minutes, breathing through his or her nose. Instruct to not blow nose for several minutes .

Based on observation, interview and record review, the facility failed to provide physician ordered services and assistance to restore bowel and bladder continence for one Resident (R54) of one reviewed for bowel and bladder, resulting in decrease quality of life, lost sleep, frustration and the potential worsening incontinence. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R54 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included peripheral neuropathy, diabetes mellitus, benign prostatic hyperplasia, anxiety, and depression. The MDS reflected R54 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required set up assist with all activities of daily living and occasional assistance with bathing and hygiene. R54's MDS reflected frequent incontinence(more than 7 episodes of incontinence). During an observation and interview on 7/24/23 at 3:05 PM, R54 was observed in hall self propelling in wheelchair. R54 entered his room and gave permission for this surveyor to enter room to discuss care concerns . R54 appeared well groomed, calm and pleasant mood and able to answer questions without difficulty. R54 reported had been having increased problems with urinary incontinence over past several months that was not present on admission the the facility and staff and physicians aware with no follow-up. R54 reported loss of sleep and unable to recall last time he had good night sleep related to frequent need to urinate during the night. R54 reported often needs frequent staff assistance toileting including incontinence care related to long call light response times at night. R54 reported very frustrating because he did not used to be incontinent. R54 reported was diagnosed with overactive bladder with medication for treatment that were not effective and recently missed a urology appointment and unsure if it had been rescheduled. Review of the Electronic Medical Record(EMR), reflected no evidence R54 had urology consult over the past twelve months. During an interview on 7/25/23 at 2:32 PM, Director of Nursing (DON) B reported physician consults were located in Miscellaneous tab of the EMR. During an interview on 7/25/23 at 3:20 PM, Medical Record staff (MR) L reported physician consults scanned into the EMR and verified was unable to locate R54's urology consult. Review of the Physician Provider note, dated 3/09/2023, for R54, reflected, Visit Type: Acute .Chief Complaint / Nature of Presenting Problem: Chronic urinary complaints History Of Present Illness: [AGE] year-old male here for long-term care patient with chronic urinary complaints requesting to see urologist. Patient having overactive bladder patient currently on oxybutynin 5 mg daily. Patient denies any dysuria or other urinary complaints .Plan: Patient continues to have urinary complaints we will hold sending to urology for the time being patient can increase oxybutynin to 10 mg and reevaluate in 2 weeks. Will order PSA and other labs and follow-up at that time as well. Patient on Flomax we will continue current dose .Follow-up 2 to 4 weeks or sooner as needed . Review of the Physician Provider note, dated 4/11/2023, for R54, reflected, Visit Type: Follow Up .Chief Complaint/ Nature of Presenting Problem: Urinary complaints History Of Present Illness: [AGE] year-old male here for long-term care patient with history of urinary spasms recently increased oxybutynin no relief of symptoms. Patient would like consult to urology has seen urology in the past .Plan: Patient with chronic urinary complaints no relief with oxybutynin no signs or symptoms of UTI at this time will monitor closely consider urine culture and sensitivity as indicated . Review of the Progress Notes, dated 4/19/2023, for R54, reflected, Appointment/Transportation Note Note Text: Referral sent to (name of) Urology with appointment scheduled on 5/24 at 1pm (name of) Urology . Review of the Nursing Progress Note, 4/23/2023 at 4:36 p.m., reflected, [named R54] returns via EMS with a new order for an antibiotic for a UTI . Review of the Progress note, dated 5/24/2023, for R54, reflected, Appointment/Transportation Note Note Text: Cystoscopy scheduled for 6/12 at 2:45pm at (name of) Urology . Review of the Physician Orders, dated 5/26/23, reflected R54 had order for follow up appointment with Urology for Cystoscopy. Review of the Physician Provider note, 6/13/2023, for R54, reflected, Visit Type: Follow Up .Chief Complaint / Nature of Presenting Problem: Pain evaluation, urology complaints .Patient also with urinary complaints desires to see a urologist had one scheduled and was sent out to the hospital .Plan .Patient also continue ongoing evaluation with physical med and rehab here. Patient with urology complaints has urology appointment pending. Reviewed medications will continue as directed. Continue 24-hour care and assist with ADLs as indicated. Follow-up 2 to 4 weeks or sooner as needed . Review of the Physician Provider note, dated 7/10/2023, for R54, reflected, Visit Type: Regulatory .his chronic urinary symptoms for which he is seeing urology in the next few days . Review of the facility, Urinary Continence Evaluation, dated 4/30/23, reflected R54 was continent of urine upon admission and had occasional incontinence(less than 7 days) that the time of the evaluation. Review of the Care Plans, dated 9/9/21 through current, reflected no mention of individualized continence treatment or services offered/provided for R54. The bladder incontinence care plan included two intervention that included, BRIEF USE: The resident uses disposable briefs. Check q 2 hours and change prn .Encourage fluids during the day to promote prompted voiding responses . During a telephone interview on 7/25/23 at 3:34 PM, R54's Urology staff M reported R54 was seen at Urology office on 5/24/23 and then scheduled for Cystoscopy 6/12/23. Urology staff M reported R54 and facility were called to reschedule procedure for 7/12/23. Urology staff reported R54 did not show up for scheduled appointment on 7/12/23 and had not heard from facility until today, just prior to this call, to reschedule R54's procedure for August 2023(Two months after original scheduled procedure). Review of the Nursing Progress Notes, dated 7/25/23 at 3:08 p.m.(30 minutes after this surveyor requested R54's 5/24/23 Urology consult), DON B entered note that reflected, This writer spoke with [named] urology in regards to obtaining notes on the previous appts. Office is faxing over the notes for 5/24/23, states that the physician had an emergency and canceled the Cystoscopy scheduled for 6/12/23 and that the resident was a no show on 7/12/23. This writer stated to staff there that they had called resident himself and confirmed the appt and when he arrived there on 7/12 they told him he had no appt and sent him home. This writer is attempting to reschedule cystoscopy that has been cancelled twice. During an interview on 7/25/23 at 5:05 PM, DON B reported had contacted R54 urology office and was told was seen 5/24 and provided with consult note. DON B reported would expect staff to obtain consult note at the time the the visit. DON B verified had scheduled cyctoscope at the time for 6/12/23 and urology office rescheduled to 7/12/23. DON B reported R54 went to consult appointment and office sent him back and DON B verified no documentation was located to support. DON B reported was told by urology office that R54 was a no show on 7/12/23 and reported would expect staff to follow up either way and reschedule ordered cystoscope for R54. DON B verified was unable to locate evidence appointment had been rescheduled and requested appointment and was rescheduled for 8/23/23. Review of the Urology Consult, faxed to the facility 7/25/23, as evidence of time stamp, reflected R54 was seen of Urology consult on 5/24/23. The Consult reflected R54 reported up at least five times during night to urinate and R54 reported quality of life was, Terrible if he had to continue with urinary symptoms as they were currently. The Consult reflected to schedule cystoscope in office. According to the Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, manual, each resident who was incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. The same source indicated many incontinent residents (including those with dementia) respond to a toileting program, especially during the day.

Based on observation, interview, and record review, the facility failed to revise the care plan in 2 of 18 residents reviewed for care plans (R29 and R54), resulting in unmet needs. Findings include: Resident # 54 (R54) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R54 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included peripheral neuropathy, diabetes mellitus, benign prostatic hyperplasia, anxiety, and depression. The MDS reflected R54 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required set up assist with all activities of daily living and occasional assistance with bathing and hygiene. R54's MDS reflected frequent incontinence(more than 7 episodes of incontinence). During an observation and interview on 7/24/23 at 3:05 PM, R54 was observed in hall self propelling in wheelchair. R54 entered his room and gave permission for this surveyor to enter room to discuss care concerns . R54 appeared well groomed, calm and pleasant mood and able to answer questions without difficulty. R54 reported had been having increased problems with urinary incontinence over past several months that was not present on admission the the facility and staff and physicians aware with no follow-up. R54 reported loss of sleep and unable to recall last time he had good night sleep related to frequent need to urinate during the night. R54 reported often needs frequent staff assistance toileting including incontinence care related to long call light response times at night. R54 reported very frustrating because he did not used to be incontinent. R54 reported was diagnosed with overactive bladder with medication for treatment that were not effective and recently missed a urology appointment and unsure if it had been rescheduled. Review of the Electronic Medical Record(EMR), reflected no evidence R54 had urology consult over the past twelve months. During an interview on 7/25/23 at 2:32 PM, Director of Nursing (DON) B reported physician consults were located in Miscellaneous tab of the EMR. During an interview on 7/25/23 at 3:20 PM, Medical Record staff (MR) L reported physician consults scanned into the EMR and verified was unable to locate R54's urology consult. Review of the Physician Provider note, dated 3/09/2023, for R54, reflected, Visit Type: Acute .Chief Complaint / Nature of Presenting Problem: Chronic urinary complaints History Of Present Illness: [AGE] year-old male here for long-term care patient with chronic urinary complaints requesting to see urologist. Patient having overactive bladder patient currently on oxybutynin 5 mg daily. Patient denies any dysuria or other urinary complaints .Plan: Patient continues to have urinary complaints we will hold sending to urology for the time being patient can increase oxybutynin to 10 mg and reevaluate in 2 weeks. Will order PSA and other labs and follow-up at that time as well. Patient on Flomax we will continue current dose .Follow-up 2 to 4 weeks or sooner as needed . Review of the Progress Notes, dated 4/19/2023, for R54, reflected, Appointment/Transportation Note Note Text: Referral sent to (name of) Urology with appointment scheduled on 5/24 at 1pm (name of ) Urology . Review of the Nursing Progress Note, 4/23/2023 at 4:36 p.m., reflected, [named R54] returns via EMS with a new order for an antibiotic for a UTI . Review of the facility, Urinary Continence Evaluation, dated 4/30/23, reflected R54 was continent of urine upon admission and had occasional incontinence(less than 7 days) that the time of the evaluation. Review of the Care Plans, dated 9/9/21 through current, reflected no mention of individualized continence treatment or services offered/provided for R54. The bladder incontinence care plan included two intervention that included, BRIEF USE: The resident uses disposable briefs. Check q 2 hours and change prn .Encourage fluids during the day to promote prompted voiding responses . No evidence of individualized continence treatment or services offered/provided for R54. 30337 Resident #29 (R29) R29 was observed in his room lying in bed on 7/26/23 at 10:46 AM and stated during an interview, that he goes to dialysis twice a week. R29's Minimum Data Set (MDS) assessment dated [DATE], revealed he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short cognitive screener for nursing home residents, score of 14 (13-15 Cognitively Intact). The same MDS revealed R29 had the diagnoses of end stage renal failure (ESRD, kidney failure) with renal dialysis, high blood pressure and heart failure. In review of R29's hemodialysis care plan, revised 12/29/22, he required hemodialysis and often refused dialysis, especially due to the holidays. In review of R29's nutritional care plan, revised 4/18/23, he had dialysis on Tuesday and Saturday. In review of R29's potential for fluid deficit care plan, revised on 7/11/23, the focus statement indicated he had dialysis on Tuesday, Thursday and Saturday morning. On the same care plan, under intervention, R29 had dialysis twice a week on Tuesday and Saturday's. In review of the Care Planning Dialysis Special Needs policy, reviewed on 1/01/22, the care plan would be reviewed routinely and as needed for effectiveness and revised as needed. In review of physician orders dated 7/08/23, R29's dialysis communication form was to be completed every Tuesday and Saturday. R29's physician orders dated 6/24/23, revealed Ranolazine 500 milligrams (mg) (heart medication, can be used to treat chronic chest pain) was to be administered on Monday, Wednesday, Thursday, Friday and Sunday for angina (a type of chest pain caused by reduced blood flow to the heart). R29 also had an order for Norvasc 2.5 mg (used to treat high blood pressure and chest pain) to be administered on Monday, Wednesday, Thursday, Friday and Sunday. There were no instructions in R29's care plan or in the physician's orders to hold Ranolazine and Norvasc on Thursday if he went to dialysis. R29's Physician order dated 7/26/23 indicated Metoprolol Tartrate (Beta Blocker, used to treat high blood pressure) 50 MG twice a day every Monday, Wednesday, Friday, and Sunday. R29's physician's orders and care plans did not instruct the nurse to administer Metoprolol Tartrate on days he did not receive dialysis. In review of R29's July 2023 Medication Administration Record (MAR) and physician orders, dialysis was on Tuesday, Thursday, and Saturday, the start date was 7/13/23. Nurses note dated 7/13/23 at 10:28 AM indicated R29 refused dialysis and stated he was only going to go to dialysis twice a week. The Director of Nursing (DON) B was interviewed on 07/26/23 at 10:55 AM and stated R29 goes to dialysis twice a week. DON B stated R29 refused to go to dialysis three times a week for treatment in the past. DON B stated in the same interview R29 must have refused to go to dialysis on Thursday's, and would call the dialysis center for clarification. Progress note dated 7/26/23 at 11:29 AM revealed R29's order for Ranolazine extended release was changed to give one tablet every Monday, Wednesday, Thursday, Friday, and Sunday morning's; Hold on Thursday if goes to dialysis.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for two (Resident #22, #30) of 18 residents reviewed for MDS, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: Resident #22 Review of the medical record revealed that Resident #22 (R22) was readmitted to facility 1/25/2021 with diagnoses including cerebral infarction, unsteadiness on feet, and muscle weakness. Review of the MDS with an Assessment Reference Date (ARD) of 4/18/23 revealed that R22 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition). Section G of the same MDS reflected that R22 had functional limitations in upper and lower extremity range of motion (ROM) on one side. Annual MDS with an ARD of 10/16/2022 reflected that R22 had no functional limitation in ROM with assessments prior to (Quarterly MDS with ARD of 7/16/22) and after (Quarterly MDS with ARD of 1/6/23) reflecting that R22 had functional limitations in upper and lower extremity ROM on one side. In an observation and interview on 7/24/23 at 12:37 PM, R22 was observed sitting in wheelchair, in room, playing a game positioned on over the bed table directly in front of her. R22 stated that she had a stroke and did not have use of her right arm with R22's right upper arm observed to be positioned at her right side, bent at elbow, with right forearm and hand observed to rest on her right thigh. R22 observed to use left hand/arm to pick up and move right arm and then to open fingers on right hand with use of left hand/fingers. R22 also stated that although she had limited use of her right leg, she could walk with staff help. R22's Physician Progress Notes dated 9/28/22 stated, .PHYSICAL EXAMINATION .Neurovascular .hemiplegia (paralysis on one side of the body) . and 9/12/22, PHYSICAL EXAMINATION .Neurologic: Patient has motor deficits related to CVA (Cerebral Vascular Accident) with hemiparesis . In an interview on 7/26/23 at 11:29 AM, Licensed Practical Nurse/Minimum Data Set Nurse (LPN/MDS Nurse) G confirmed familiarity with R22 and stated that she was admitted to facility with right sided hemiplegia. Upon review of Section G of R22's Annual MDS with an ARD of 10/16/2022, LPN/MDS Nurse G acknowledged that the coding was incorrect as reflected that R22 had no functional limitation in ROM when she indeed did have limitation in both right upper and lower extremity ROM. In an interview on 7/26/23 at 11:38 AM, Senior MDS Coordinator J agreed that R22's Annual MDS with an ARD of 10/16/2022 was not coded correctly, stated that she was unsure if she was able to complete a modification that far back, verbalized plan to check with Regional MDS Coordinator K and if acceptable, would complete a modification to the Annual MDS with an ARD of 10/16/2022 to reflect R22's functional limitations in upper and lower extremity ROM on one side. Resident #30 Review of the medical record revealed that Resident #30 (R30) was admitted to facility on 1/4/23 with diagnoses including dependence on wheelchair, cerebral palsy, generalized muscle weakness, and history of falling. Review of the Quarterly MDS with an ARD of 4/12/23 revealed that R30 had a BIMS of 15 (cognitively intact). Section P of the same MDS indicated that R30 used a trunk restraint less than daily. In an observation and interview on 7/24/23 at 1:30 PM, R30 was observed sitting in a motorized wheelchair in her room. R30 stated that she had the motorized chair prior to her 1/4/23 facility admission, had a seat belt on the chair at some point but did not believe that the seat belt was still in place and if it was, had not used since prior to facility admission. A seat belt was observed to be in place on R22's motorized chair with each side tucked between the back and arm rest of the chair and visible from back of chair only. R22 confirmed that she could not reach the seat belt, had not used it, and did not even realize that it was still attached to her wheelchair. In an interview on 7/25/23 at 1:08 PM, LPN/MDS Nurse G stated that no resident in the facility currently had a restraint and that, from what she could recall, she had never coded anyone as having a restraint. LPN/MDS Nurse G confirmed familiarity with R30, stated that she did not currently, nor had she ever had a restraint, and that her MDS did not reflect restraint usage. Upon review of R30's Quarterly MDS with an ARD of 4/12/23, LPN/MDS Nurse G confirmed that she had completed, acknowledged that Section G of the MDS reflected Trunk restraint usage less than daily, stated that was coded in error and should reflect Not used and would be completing a modification to the Quarterly MDS with an ARD of 4/12/23 to correct. In an interview on 7/25/23 at 1:42 PM, Regional MDS Coordinator K confirmed that although R22's motorized wheelchair had a seat belt in place, as it had not been used, would not be considered a restraint and therefore should not have been coded as a restraint on the MDS. Regional MDS Coordinator K confirmed that the restraint was coded in error and stated that a modification would need to be completed for the Quarterly MDS with an ARD of 4/12/23.

Based on interview and record review, the facility failed to complete a timely Significant Change Minimum Data Set (MDS) assessment for one (Resident #5) of 18 residents reviewed for MDS assessments, resulting in the potential for untimely/inaccurate care plans and unmet care needs. Findings include: Review of the medical record revealed that Resident #5 (R5) was readmitted to facility 6/26/22 with diagnoses including chronic obstructive pulmonary disease and cerebrovascular disease. Review of the MDS with an Assessment Reference Date (ARD) of 6/24/23 revealed that R5 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) of 13 (cognitively intact). Section O of same the MDS indicated that R5 was receiving hospice care. Review of the Significant Change MDS with an ARD of 12/22/22 indicated that R5 received hospice care within the last 14 days. R5's Physician's Order dated 1/23/2023 stated, Admit to (name of hospice company) effective 12/6/22 . In an interview on 7/25/23 at 1:08 PM, Licensed Practical Nurse/Minimum Data Set Nurse (LPN/MDS Nurse) G stated that a Significant Change MDS Assessment was completed when either a significant improvement or decline in resident health status was noted in at least 2 areas or when a resident enrolled or disenrolled from hospice services. In the same interview, upon review of R5's medical record LPN/MDS Nurse G confirmed that R5 was admitted to hospice services on 12/6/22 and therefore the Significant Change MDS Assessment and Care Area Assessments should have been completed within14 days of that date. LPN/MDS Nurse G stated that she would have anticipated that the ARD date for the Significant Change MDS be set for 12/19/22 and not for 12/22/22 as that would have fallen outside of the assessment period and therefore completed late. In an interview on 7/25/23 at 1:42 PM, Regional MDS Coordinator K stated that when a resident was enrolled or disenrolled from hospice services, the MDS Assessment should be scheduled and completed by the 14th day of the resident signing on or off services. Regional MDS Coordinator K further stated that as R5 enrolled in hospice on 12/6/22, the Significant Change MDS assessment should have been completed by 12/19/22 and that the assessment and CAAs should have been signed as completed by that date, as well. However, the MDS Assessment was not signed as completed until 1/2/23 and the CAAs were not signed as completed until 1/4/23.

This citation pertains to Intake MI 1538 and MI 1784. Based on interview and record review the facility failed to prevent the development and worsening of pressure ulcers and failed to assess and treat pressure ulcers for two residents (Resident #1 and #5) of six residents reviewed, resulting in Immediate Jeopardy when Resident #1 was admitted to the facility with a stage 4 (full thickness tissue loss with exposed bone, muscle or tendon) sacral pressure ulcer without treatment interventions in place for 22 days, had a worsening of the pressure ulcer, without timely physician notification or physician evaluation of the worsening wound, and developed an unstageable pressure ulcer to the heel, resulting in the likelihood for serious harm, serious injury, serious impairment or death and the potential for new and worsening pressure ulcers for R5. Findings include: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/22/21 revealed R1 was admitted to the facility with a stage 4 pressure ulcer, two venous/arterial ulcers, and moisture associated skin damage (MASD). The MDS revealed R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required extensive assistance for bed mobility. Review of the hospital Operative Report dated 6/10/21 revealed R1 had sacral and ischial decubitus wounds and a developing decubitus wound on the left heel. Review of the hospital Discharge Summary dated 6/15/21 revealed Patient should continue to follow up with the wound clinic .patient should follow up with wound care, infectious disease . Review of the Nursing Admission assessment dated [DATE] revealed R1 had a stage 4 pressure ulcer to the sacrum and vascular wounds to the right and left lower legs. (The sacral pressure ulcer was also referred to as a coccyx pressure ulcer throughout interviews and record reviews.) Review of the pressure ulcer care plan initiated 6/16/21 and revised 6/25/21 revealed The resident has a pressure ulcer stage 4 to the following areas [coccyx]. Interventions dated 6/16/21 included administer treatments as ordered and evaluate for effectiveness, monitor/document/report PRN [as needed] any changes in skin status: appearance, color, wound healing, s/sx [signs/symptoms] of infection, wound size (length x width x depth), stage, skin inspections by CNA [Certified Nursing Assistant] during cares and showers/baths. Report changes to licensed nurse immediately. The Activities of Daily Living care plan revealed prafo boots while up in the chair was implemented on 6/22/21. There was no indication of interventions taken for R1's heels while in bed. There was no indication of a turning and repositioning program or a pressure reduction mattress upon admission. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Occupational Therapy Evaluation & Plan of Treatment dated 6/17/21 revealed pt with hx [patient with history] chronic LE [lower extremity] wounds; has current developing wounds also sacral, ischial, and left heel . Review of the Physical Therapy Evaluation & Plan of Treatment dated 6/17/21 revealed pt with hx chronic LE wounds; has current developing wounds also sacral, ischial, and left heel . Review of the Skin & Wound Evaluation dated 6/18/21 revealed the assessment was in progress. There was no assessment of R1's sacral pressure ulcer to include measurements and description. Review of the Skin assessment dated [DATE] revealed R1 had MASD to the sacrum. Review of the Nurse's Note dated 6/22/21 revealed sacral dressing applied to top of gluteal cleft for what appears to be MASD. Review of the Physical Therapy (PT) Progress Report dated 6/24/21 through 6/29/21 revealed pain/wounds-buttocks/sacral .prolonged bed rest. The PT Progress reported dated 6/30/21 through 7/5/21 revealed wounds-sacral, medial left thigh, bilateral lower legs, left heel. Review of PT's Summary of Skilled Services dated 6/28/21 revealed substantial sacral drainage with green staining on blanket and strong odor present-information communicated to unit nurse. There was no indication that the physician was notified. Review of the Skin assessment dated [DATE] revealed R1 had MASD to the sacrum. The Skin assessment dated [DATE] revealed R1 had a worsening pressure ulcer to the sacrum. Review of the Nurse's Note dated 7/8/21 revealed Dressings to bilateral lower legs changed. Foul odor and heavy exudate noted. NP [Nurse Practitioner] notified and came to room to visualize wounds. Orders for wound cultures for sacral and BLEs [bilateral lower extremities] obtained. Xray to rule out [CONDITION(S)] to sacral wound was called to [name of x-ray provider]. Sacral wound is deteriorating, large amount of slough present, tunneling noted, foul odor and copious exudate. Dakins solution will be ordered from pharmacy as well. Review of the Physician's Progress Note dated 7/8/21 revealed wound cultures done to coccyx .pending. Consult order for wound services .POSITIVE SACRAL WOUND. There was no documentation prior to this date that the Physician or Nurse Practitioner acknowledged or assessed R1's sacral/coccyx wound. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the coccyx wound culture results collected on 7/8/21 and reported 7/10/21 revealed pseudomonas aeruginosa (bacteria) and [MEDICATION(S)]. [MEDICATION(S)] (which R1 was already receiving for leg wound infections) was not listed on the bacterial susceptibility panel. There was no documentation that R1's physician was made aware of these results nor acknowledged the laboratory report. Review of R1's sacrum/coccyx Radiology Report dated 7/8/21 revealed Cannot exclude [CONDITION(S)], recommend MRI workup. Review of the Orders Administration Note dated 7/9/21 revealed R1's sacral wound treatment was not completed because Dakins solution was not available at this time. R1's pressure ulcer care plan revealed it was not until 7/12/21 that repositioned with 2 people [every 2 hours] and PRN was implemented. Review of the Skin assessment dated [DATE] revealed R1 had an unstageable pressure ulcer to the sacrum. Review of the Wound Care & Hyperbaric Center's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .dakins rinse and pack with dakins soaked gauze, cover with abd pad, secure with [MEDICATION(S)] tape, change dressing every day. Please order wound vac to run at 125 mmhg continuous suction, secure with drape, change dressing every Monday, Wednesday, Friday. Wound #5 Left Heel .santyl ointment to cover eschar on heel, cover with abd pad, secure with conforming gauze and [MEDICATION(S)] tape, change dressing daily, off load heels at all times .turn patient every 2 hours keeping patient off coccyx area .bed/mattress pressure relief-group 2 mattress. According to R1's ADL and skin integrity care plans, a low air loss mattress was not implemented until 7/20/21. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 8/5/21 at 10:35 AM, Registered Nurse (RN) C reported she did R1's admission assessment. RN C stated upon admission, R1 had horrible wounds to his legs and coccyx and old wounds, eschar to his heels. RN C reported R1 had a stage 4 pressure ulcer to his coccyx with purulent drainage. When asked how she would know what wound care orders to put in place on admission, RN C reported she did not know because she was not a wound nurse. RN C reported if the orders were not listed on the hospital paperwork, she would notify the Director of Nursing (DON B) and the Unit Manager (UM D) either at the time of admission or the next day in morning meeting. RN C reported she did not measure R1's pressure ulcer on admission, but she knew it was the expectation. RN C reported she never saw R1 get out of bed. RN C reported during R1's stay at the facility, the coccyx pressure ulcer worsened by getting deeper, tunneling, worsened odor, and infection. In an interview on 8/5/21 at 10:58 AM, UM D reported he was the unit manager for the whole building, usually worked the floor two to three times a week and was responsible for performing wound assessments. UM D reported the facility had a wound program which involved photographing pressure ulcers each week and then entering a progress note. UM D reported R1 had a coccyx pressure ulcer on admission, but UM D could not recall the appearance or characteristics of R1's pressure ulcer on admission, nor could he recall if any treatments were in place. UM D reviewed R1's medical record and reported there were no treatments put in place for R1's coccyx pressure ulcer until 7/9/21. UM D stated Had I seen it sooner, I would have entered something. That was 3 weeks after he was here already. UM D reported before R1 was sent to the wound clinic, the coccyx pressure ulcer was unstageable with a lot of slough, drainage, and pretty deep like 6 to 6.5 to 7 centimeters (cm) with tunneling. In a telephone interview on 8/5/21 at 12:45 PM, CNA F reported R1 was admitted to the facility with a really bad open sore on his bottom. CNA F reported never witnessing R1 out of bed. In an interview on 8/5/21 at 1:07 PM, PT K reported R1 was essentially bed bound and transferred out of bed on a couple of occasions. PT K reported he believed R1 had a coccyx pressure ulcer upon admission. PT K reported there was a day (6/28/21) when he reported drainage and a foul odor to the nurse. In an interview on 8/5/21 at 1:58 PM, Nurse Practitioner (NP) M reported he was not aware R1 had a pressure ulcer on admission. NP M reported he first observed R1's pressure ulcer on the day he ordered the x-ray and culture on 7/8/21. NP M reported he assumed the wound clinic had been managing R1's wounds. In a telephone interview on 8/9/21 at 8:53 AM, Wound Clinic RN J reported R1 had been followed by the wound clinic in the past, but R1 was first sent to the wound clinic by the facility on 7/15/21. RN J stated His sacral wound was really bad. We ordered off-loading for heels, ROHO cushion, and a group 2 mattress. When he came in [to the wound clinic], they said none of that was done, wounds were getting worse. RN J reported on 7/15/21, R1's sacral pressure ulcer was a stage 4 and measured 6 cm x 6 cm x 3.5 cm and at that time, R1 also had an unstageable left heel pressure ulcer with black eschar that measured 6 cm x 5.4 cm. RN J reported when R1 arrived to the wound clinic on 7/22/21, he was absolutely saturated and was sent to the hospital because he was not getting good care. RN J reported on 7/22/21, R1's sacral pressure ulcer measured 9 cm x 6 cm x 2.8 cm and the left heel pressure ulcer measured 6 cm x 5.4 cm. RN J reported R1 also had a new scrotal wound that was really broken down .with soft tissue necrosis which may be from being wet. RN J reported that wound measured 3.2 cm x 1.8 cm. Review of the Nurses' Note dated 7/22/21 revealed R1 went to the wound clinic appointment and the wound clinic transferred R1 to the hospital. In an interview on 8/9/21 at 9:26 AM, DON B reported R1's hospital discharge paperwork reflected he was to follow-up with the wound clinic and infectious disease. DON B was not able to find where that had been ordered prior to 7/8/21. DON B reported upon admission, R1 had leg wounds and a coccyx wound that UM D was following. DON B reported 7/9/21 was the first time she spoke with the Wound Clinic Case Manager. DON B reported R1's medical record reflected turning and repositioning was implemented on 7/12/21, off-loading heels was implemented on 7/16/21, and an air mattress was implemented on 7/20/21. When asked why this was not done earlier, DON B reported she was not sure. When asked what treatment order was in place for R1's coccyx pressure ulcer upon admission, DON B stated I'm not finding it. DON B reported the first treatment order was implemented on 7/9/21. In a telephone interview on 8/9/21 at 1:44 PM, Physician/Medical Director (MD) T reported he did not believe he ever assessed R1's sacral/coccyx pressure ulcer. MD T reported he saw R1 on admission, but R1 was agitated and did not want to show his bottom. MD T was not aware that a treatment order was not in place for 22 days after admission. MD T reported he was not notified of the green drainage and foul odor from R1's pressure ulcer on 6/28/21. Review of the facility's Pressure Injury Prevention and Management Policy and Procedure dated 1/1/21 revealed The facility shall establish and utilize a systemic 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 .Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .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 .The attending physician will be notified of: i. The presence of a new pressure injury upon identification. ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. iii. Any complications (such as infection, development of a [MEDICATION(S)] tract, etc.) as needed. On 8/9/21 at 2:01 PM, Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that began on 6/16/21 and was identified on 8/9/21 when the facility failed to implement treatments and interventions to prevent the development and worsening of pressure ulcers. On 8/11/21 it was verified that the facility implemented the following to remove the Immediate Jeopardy: 1. Total of 64 current residents had a Skin Assessment conducted by Director of Nursing and/or designee on 8/10/2021 2. Skin assessments were compared to current orders and treatments and validated as appropriate on 8/10/2021 3. Total of 7 current residents with pressure wounds have validated appropriate orders and treatment plans are in place as of 8/9/2021 4. Immediate re-education with licensed nurses effective 8/9/2021 on Pressure Injury Prevention and Management policy, to ensure new wounds, including admissions, have been assessed to include orders and care plans by Staff Development Coordinator and MDS Coordinator. 18 out of 23 nurses have received education. Any licensed nurse not completing education will be re-educated prior to next scheduled shift. CNAs were not educated on Wound Management whereas it is not in their scope of practice. CNAs were re-educated by Staff Development Coordinator on Routine Resident Checks policy. Education includes reporting changes in the resident's condition and medical needs that cannot be performed by the person conducting the routine check must be reported to the Nurse Supervisor/Charge Nurse at once. 21 out of 35 CNAs have been educated. Any CNA not completing education will be re-educated prior to next scheduled shift. 5. Effective 8/9/2021, new Wound Care nurse has been designated 6. Adhoc QAPI was completed on 8/9/2021 Although the Immediate Jeopardy was removed on 8/10/21, the facility remained out of compliance at a scope of isolated and a 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. Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 6/5/21 revealed R5 scored 15 out of 15 (cognitively intact) on the BIMS and had an unhealed facility acquired stage 2 pressure ulcer. Review of the Skin assessment dated [DATE] revealed R5 had open and excoriated areas on buttocks with a treatment in place. There was no Skin assessment dated [DATE]. Review of the wound clinic note dated 7/22/21 revealed R5 was having buttock pain today and reports that she may have a wound there. R5 had bilateral buttocks stage 3 pressure ulcers identified. Review of the wound clinic orders dated 7/22/21 revealed bilateral sacral ulcers: [MEDICATION(S)] ointment, then small piece of xeroform, then duoderm thin. Change every 2-3 days. Off load wounds. Resume use of alternating pressure mattress overlay ASAP. Review of R5's medical records revealed the treatment order was not put in place. Review of the Treatment Administration Record (TAR) dated July 2021, revealed no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Skin assessment dated [DATE] revealed no documentation that pertained to R5's sacral ulcers. Review of the wound clinic notes dated 8/3/21 revealed R5 reported the facility was using barrier cream on her sacral wounds rather than the dressing that I ordered 2 weeks ago. The wound clinic ordered the same treatment they ordered on 7/22/21. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/21 a request was made to observed R5's skin, however R5 was out of the facility for [CONDITION(S)]. In an interview on 8/10/21 at 12:12 PM, DON B reported she was not aware the wound clinic ordered a treatment on 7/22/21 that was not implemented until 8/4/21.

This citation is related to intake MI 497 This citation has two deficient practice statements (DPS), DPS A and DPS B. DPS A: Based on observation, interview and record review, an Immediate Jeopardy was identified when the facility failed to ensure staff exited the premises after reporting signs and symptoms of COVID-19; failed to screen all staff at the beginning of their shift for fever, signs/symptoms of illness, and if advised to self-quarantine; and failed to review staff and visitor screening logs; resulting in increased risk of spreading infection, in a census of 62 residents, staff and visitors. Findings include: In review of the Visitor Vitals Log dated 6/08/20, nurse assistant (NA) A1 had a cough and indicated they had community or travel exposure in the last 14 days. Director of Nursing (DON) B was interviewed on 9/23/20 at 11:36 AM and stated office support staff XX did not report NA A1 had symptoms on 6/08/20. DON B stated NA A1 tested positive for COVID-19 on 6/09/20. DON B stated NA A1's son was in the emergency roiagnom on [DATE] and tested positive for COVID-19 on 6/07/20. During an interview on 9/23/20 at 11:36 AM, Director of Nursing (DON) B stated staff screening duties included passing resident meal trays. DON B stated the facility had seven staff test positive for COVID-19 since April 27, 2020. During the same interview, DON B stated there were eight staff, not seven that tested positive for COVID-19. Staff-Vendor Vitals Log dated 6/29/20, indicated x-ray tech was written in the space for the staff name. The same form did not indicate the x-ray tech was screened in or out of the facility, and they did not answer questions related to signs and symptoms of COVID-19. The bottom of the same form instructed the following: non symptomatic employees who have been exposed to COVID or suspected COVID may continue to work with mask while in facility. Visitor Vitals/Log dated 7/08/20, revealed a visitor's first name and last initial, no temperature on entrance was documented, no answer was documented for signs and symptoms of COVID-19, and the staff screener signature was left blank, indicating they were not checked in or out of the building. In review of office support staff XX payroll time sheet from 7/13/20 to 7/31/20, on Monday, 7/13/20 she punched in at 6:27 AM and out at 2:33 PM. The same document indicated on Thursday 7/16/20, office support staff XX punched in at 6:26 AM and out at 9:02 AM. In review of office support staff XX physician progress notes [REDACTED]. The same fax indicated office support staff XX reported a few exposures in the last 14 days. The same fax indicated office support staff XX had tested positive for [MEDICAL CONDITION]. Office support staff XX was interviewed on 9/24/20 at 11:34 AM, and stated she had signs and symptoms of COVID-19 since 7/13/20, and last worked on 7/16/20. Office support staff XX stated she had signs and symptoms of COVID-19 prior to entering the facility and did not call in because after three call-in's the policy was to terminate employment. Office support staff XX stated she reported her symptoms on 7/16/20 to DON B and was not allowed to punch out until a replacement was found. Office support staff XX stated in the same interview a nurse worked with COVID-19 symptoms and DON B would not let her leave either. In review of the Visitor Vitals Log dated 7/16/20, office support staff member XX, indicated she had symptoms of loss of smell, congestion, sore throat, cough, loss of taste, muscle aches, headache, and fever. On 9/24/20 at 12:45 PM, Central Supply/NA YY stated she had signed out office support staff XX on 7/16/20 and was aware of her symptoms. Central Supply/NA YY stated she reported office support staff XX's symptoms to DON B, and she continued to work. Review of the facility's screening log for the date of 9/11/2020, at 6:30 AM, revealed RN CC reported that she had a sore throat. Review of another facility screening log dated 9/12/2020, at 7:30 AM, revealed RN CC reported that she had a runny nose and a sore throat. Review of RN CC's time clock record revealed that on 9/11/2020 she punched in at 6:34 AM and punched out at 6:45 PM, with a total of 11.6 hours worked on 9/11/2020. Another time clock record, dated 9/12/2020, revealed RN CC punched in on 9/12/2020 at 6:49 AM, and punched out at 6:49 PM, with a total of 11.5 hours worked on 9/12/2020. Review of the facility's screening log for the date of 9/11/2020, at 2:00 PM, revealed Certified Nurse Aid (CNA) RR reported she had a cough and stuffy nose. Review of CNA RR's time clock record revealed that on 9/11/2020 she punched in at 2:25 PM and punched out at 10:30 PM, with a total of 7.6 hours worked on 9/11/2020. Review of the facility's screening log for the date of 9/13/2020 revealed CNA SS reported yes under signs and symptoms on the screening log, however the log did not reveal what CNA SS's signs and symptoms were. Another screening log date 9/15/2020, at 10:25 PM, revealed CNA SS reported she had a sore throat, and on 9/16/2020, at 10:00 PM, the screening log revealed CNA SS reported she had a sore throat. Review of CNA SS time clock record revealed CNA SS punched in on 9/13/2020 at 10:30 PM and punched out at 10:48 AM, with a total of 11.9 hours worked. Another time clock record revealed CNA SS punched in on 9/15/2020 at 10:35 PM and punched out at 6:59 AM, with a total of 7.9 hours worked. Another time clock record, dated 9/16/2020 revealed CNA SS punched in at 10:31 PM and punched out at 6:49 AM, with a total of 7.8 hours worked. Review of the facility's screening log for the date of 9/13/2020 revealed CNA DD reported yes to signs and symptoms, however no signs and symptoms were listed on the log. Another screening log dated 9/15/2020, not timed, revealed CNA DD reported that he had a cough. Review of CNA DD's time clock record revealed he punched in on 9/13/2020 at 2:34 PM and punched out at 10:29 PM, with a total of 7.4 hours worked. Another time clock record revealed CNA DD punch in on 9/15/2020 at 6:26 AM and punched out at 2:47 PM, with a total of 7.9 hours worked. Review of the facility's screening log, dated 9/17/2020 at 6:00 AM, revealed Dietary Aid (DA) TT reported he had a sore throat. Review of DA TT time clock record revealed he punched in on 9/17/2020 at 5:23 AM and punched out at 1:37 PM, with a total of 7.7 hours worked. Review of the facility's screening log, dated 9/17/2020 at 6:00 AM, revealed DA UU reported that she had a sore throat. Review of DA UU's time clock record revealed she punched in on 9/17/2020 at 6:19 AM and punched out at 2:40 PM, with a total of 7.9 hours worked. Review of the facility's screening log, dated 9/17/2020 at 6:00 AM, revealed DA VV reported that she had a sore throat. Review of DA VV's time clock record revealed she punched in on 9/17/2020 at 6:34 AM and punched out at 2:56 PM, with a total of 7.5 hours worked. Review of the facility's screening log listed signs and symptoms revealed staff were to answer the question: Do you have any of the following: Fever, new onset cough, new onset shortness of breath or difficult breathing, Chills, muscle or body aches, headache, sore throat, new loss of taste/smell, repeated shaking with chills, Congestion/runny nose, nausea/vomiting/diarrhea, New production of sputum, or hemoptysis (couging up of blood)? The log revealed that on 9/24/2020, 37 staff members were screened in to work and the signs and symptoms section was blank. Further review of the facility's screening log revealed the questions of, Do you work at another facility, and Community or Travel Exposure in the last 14 days. Review of the log revealed that on 9/24/2020, 37 staff members were screened for work, and this section was blank. Review of the facility's screening log revealed two separate sections that revealed, Temp. (temperature) on entrance (fever= (equal too) 100.0 or greater), and Temp on exit (fever= 100.0 or greater. Review of the screening log revealed that on 9/24/2020, 37 staff members were screened for work, and both sections were blank. Review of the facility policy and procedure titled, Coronavirus Surveillance, dated 3/11/2020, revealed under, Policy Explanation and Compliance Guidelines, #3 Screening for visitors and staff : a. Signs or symptoms of a respiratory infection, such as fever, cough, new onset or unusual shortness of breath, or sore throat, b. In the last 14 days, has had contact with someone with a confirmed [DIAGNOSES REDACTED]. c. International travel within the last 14 days (or as state recommends) to countries with sustained community transmission (i.e. China, Iran, South Korea, Italy, and Japan) . d. Residing in a community where community-based spread of COVID-19 is occurring. Further review of the policy revealed under #5, Staff who have signs and symptoms of a respiratory infection shall not report to work. In an interview on 9/24/2020, at 11:43 AM, Director of Nursing (DON) B stated that the expectation was for the staff member who performed the screening to contact her right away related to any staff member with reported signs and symptoms related to Covid-19. DON B stated the staff who screen employees at the door had been educated on calling her right away when a staff member was screened at the door with any sign and symptoms related to Covid-19. DON B said she was not aware that RN CC was on antibiotics nor that she had been ill on 9/11 and 9/12/2020. DON BS said she was not made aware that CNA RR had a cough and stuffy nose when she was screened in for work on 9/11/2020. DON B said she had received a lot of phone calls from staff who performed the screenings as the door, but stated it was not happening consistently. During the interview DON B was asked to provide the documented education provided to the staff in regards to contacting her when a staff member was screened at the door with any signs and symptoms of Covid-19. Upon exit from the facility on 9/25/2020 no documented education was received. In an interview on 9/24/2020, at 12:10 PM, Activities Aid (AA) JJ, who was also a screener of staff at the door, stated that she was supposed to go get a nurse, Administrator, or DON if a staff member lists one sign and symptom of Covid-19 on the screen log, and was to hold the staff member back from entering the facility until the nurse, DON, or Administrator was notified. AA JJ stated that the staff member would be allowed to work with listed symptoms as long as they did not have a fever. AA JJ further stated that she had not been educated on the process for screening a staff member. In another interview on 9/24/2020, at 1:00 PM, AA JJ stated that she did notify DON B that RN CC had documented signs and symptoms on 9/11/2020 on the screening form. In an interview on 9/24/2020, at 1:58 PM, CNA KK, who performed screening of staff duties, stated that she would just ask staff if they had a temperature, and said DON B said only if the staff member did not have a fever then they could work. CNA KK further stated that she had not been instructed to contact DON B for signs and symptoms, but only had been instructed to contact DON B if a staff member had a temperature. It was confirmed on 9/25/20 that 3 office staff, that shared an office, tested positive for COVID-19 on 9/14/20. During an interview with DON B on 9/23/20, she stated the office staff did not have interactions with residents, and did not always wear their masks while working in the office. On 9/25/20 DON B stated the most recent staff to test positive was a housekeeper on 9/18/20. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy (IJ) on 9/24/20 with deficient practice that had the potential to affect a census of 62 residents, staff, and visitors. Immediate Jeopardy began on 7/16/20, identified on 9/24/20, removed on 9/25/20. The Immediate Jeopardy was removed on 9/25/20 when the facility had the following in place: On 9/24/20 at 3:40 PM Medical Director Y, County Medical Director ZZ were contacted by facility regarding current screening practice. Both physicians validated the questions and screening process were appropriate. On 9/24/20 at 4:00 PM, Re-education started to all staff if they have any current symptoms listed below will notify the Director of Nursing and/or Charge nurse prior to entering the building. Symptoms: Fever, cough, shortness of breath or difficult breathing, chills, muscle pain, headache, sore throat, new loss of taste/smell, repeated shaking with chills, congestion/runny nose, nausea/vomiting, and diarrhea. Fever 100.0 or greater. Re-education provided to all staff if they develop symptoms during their shift they will report to the Director of Nursing and/or Charge nurse, don a mask, and exit the facility. All staff currently working in the facility have been interviewed for current symptoms. No staff reported that they have any current symptoms. Residents have been tested on [DATE] with all negative results and will be retested per guidelines on 9/25/20. On 9/24/20 at 5:00 PM, DON B and Regional Director of Clinical reviewed the current COVID log to ensure all current test results for staff were negative. Current screener has been re-educated to notify the Director of Nursing or Charge Nurse Immediately if staff reports to work and has any symptoms listed on the COVID screening tool. All screeners will be re-educated prior to the beginning of their next shift to notify the Director of Nursing and/or Charge Nurse immediately if any staff reports to work and has any symptoms listed on the COVID screening tool. On 9/25/20, the screening logs were updated to include a column regarding who they notified of the symptoms and at what time. Although the immediate jeopardy was removed on 9/25/20, the facility remained out of compliance at the scope of isolated and the severity of no actual harm with potential for no more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the state agency. DPS B Based on observation, interview and record review, the facility failed to sanitize equipment per manufactures instructions, failed to don recommended personal protective equipment (PPE) when collecting samples to test for COVID-19; failed to monitor resident's temperature daily in one (Resident #63) of 3 residents reviewed for COVID-19 survey; resulting in increased risk of spreading infection, in a census of 62 residents, staff and visitors. Findings include: During an interview on 9/18/20 at 2:44 PM with Staff Development (SD) Nurse K, she stated she completed all the COVID-19 testing for residents and staff. SD K stated she did not don a gown when completing COVID-19 testing, she stated she asked the infection control preventionist (ICP) if she needed to wear a gown for tests and was instructed that she did not need to don a gown. SD K stated she did not monitor staff and visitor logs. On 9/18/20 at 3:19 PM, Director of Nursing (DON) B/ICP was interviewed and stated a gown was not required during COVID-19 testing because they were screening. Source for information for practice was requested and not provided. In review of the Centers for Disease Control (CDC) website at <https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html>, Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19), Updated July 8, 2020, For providers collecting specimens or within 6 feet of patients suspected to be infected with [DIAGNOSES REDACTED]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. Resident #63 (R63) On 9/23/20 at 9:30 AM, R63 was observed in bed with a cell phone in hand, and stated she was in the process of making a follow-up appointment with her surgeon that performed a skin graft on her left heel. R63's admission Minimum Data Set (MDS) assessment, dated 9/02/20, revealed she was admitted to the facility on [DATE] from an acute hospital; and had the [DIAGNOSES REDACTED]. The same MDS assessment introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, and R63's score was 15 (Scale: 13-15 Cognitively Intact). R63's Discharge Summary, admitted [DATE] and discharge date [DATE], revealed she was [AGE] years old, had a diabetic ulcer on her heel, ulcers to both lower extremities; and was advised by the wound clinic, seen for a scheduled routine appointment, to go to the emergency room for further evaluation and intravenous (IV) antibiotics. On 7/22/20 R63 had surgery to her left foot to remove dead tissue, wet gangrene (bacterial infection) and application of a skin graft. The same summary indicated R63 received [MEDICAL TREATMENT] three times weekly. R63's hospital records dated 7/17/20 to 8/27/20, revealed she had [MEDICAL CONDITION] stents (small tubes inserted into the ureter to treat or prevent a blockage that prevent the flow of urine from the kidney to the bladder) that were placed November of 2019 due to kidney stones and were removed on 7/24/20 followed [MEDICAL CONDITION], in which urology believed was secondary to the stent removal. Hospital records indicated R63 received a blood transfusion during her stay due to a hemoglobin (protein responsible for transporting oxygen in the blood) of 6.5 grams (g)/ deciliter (dL),(normal range for female: 12 to 16 g/dL). In review of R63's temperature summary in the electronic medical record, no temperatures were documented on 8/27/20, 8/29/20, 8/31/20, 9/01/20, 9/08/20, 9/09/20, 9/16/20, and 9/18/20. During an interview on 9/23/20 at 11:36 AM, Director of Nursing (DON) B stated residents had their temperature taken daily to screen for COVID-19; and did not explain why R63 did not have a record of daily temperatures. In review of the CDC website at <https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html>, Testing Guidelines for Nursing Homes, Interim [DIAGNOSES REDACTED]-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel, Updated July 21, 2020; instructed to At least daily, take the temperature of all residents and ask them if they have any COVID-19 symptoms. During an observation/interview, on 09/17/20 at 3:34 PM, Licensed Practical Nurse (LPN) LPN K stated she oversaw the facility's Restorative program and Staff Development. LPN K placed a glucometer and an insulin pen directly on the med cart, then carried them into a resident's room, put a one ply tissue on the tray table and then placed the glucometer and pen on the tissue. After administering the insulin, LPN K carried the insulin pen and the glucometer to the sink and placed them directly on the sink counter while she washed her hands. LPN K then carried them to the med cart and set them on top the med cart. LPN K sprayed liquid hand sanitizer directly on the glucometer. wiped the entire glucometer off with the sanitizer that she sprayed on earlier. I don't know if the hand sanitizer is recommended by the manufacturer, it's just something I like to do. After discussing what chemicals were in the hand sanitizer (hand sanitizers contain alcohol, not bleach), LPN K said, They used to have these wipes . bleach wipes. LPN K then found a container of EPA-registered germicidal bleach wipes on a different cart, grabbed a bleach wipe and quickly wiped the glucometer and set it on directly the top of the med cart. Then, she put the insulin back in the med cart. When querried, LPN K said, It (the glucometer) has to be wet for 5 minutes. LPN K said, I don't always put it on a barrier, I put in on a barrier in the room . Correct, I put them on the sink and didn't clean them and then put them on the med cart . I shouldn't have done that. According to the glucometer's manufacturer's instructions, Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe . Take extreme care not to get liquid in the test strip and key code ports of the meter . According to the Centers for Disease Control (CDC), March 2, 2011, Infection Prevention during Blood Glucose Monitoring and Insulin Administration: .An underappreciated risk of blood glucose testing is the opportunity for exposure to [MEDICAL CONDITION] (HBV, [MEDICAL CONDITION] virus, [MEDICAL CONDITION].through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. In the last [AGE] years, alone, there have been at least 15 outbreaks of HBV infection associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring . Whenever possible, blood glucose meters should be assigned to an individual person and not be shared . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html During an observation/interview on 9/17/20 at 8:12 AM, LPN E walked into a resident's room without a face shield or goggles on. When querried, LPN E said a face shield or goggles were required when in a residents' room. When LPN E was missing a medication, he walked to a different hall, went to the med room. opened the door, then cupboards, then to a different cart, opened it and touched bottles and did not sanitize hands. There was no hand sanitizer on his med carts. LPN E donned gloves, and opened capsule of lactobacillus, crushed the other meds placed them all in cup and put pudding in them. LPN E then doffed the gloves, did not sanitize hands, poured water into a cup, shut the cart, went into room, then washed his hands with soap and water in the resident's room. LPN E stated the facility did not supply hand sanitizer for staff to keep on their person, and he had to go to a hand sanitizer dispensers found in the hallways if he wanted to use hand sanitizer. During an observation/interview on 9/17/20 at 8:56 AM Unit Manager/Registered Nurse/RN D placed plastic spoon directly on the med cart, then used it to administer medications to the resident in her room. RN D did not put on the goggles that were resting on the top of her head. RN D donned gloves, put [MEDICATION NAME] on the resident's low back, took off gloves, opened door by touching the handle, then went to cart and sanitized hands. According to the Centers for Disease Control, (CDC), 2019, Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. During Routine Patient Care: During Routine Patient Care, Two Methods for Hand Hygiene: Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient; Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices; Before moving from work on a soiled body site to a clean body site on the same patient; After touching a patient or the patient's immediate environment; After contact with blood, body fluids or contaminated surfaces; and Immediately after glove removal. Wash with Soap and Water: When hands are visibly soiled; After caring for a person with known or suspected infectious diarrhea; After known or suspected exposure to spores (e.g. B. anthracis,[DIAGNOSES REDACTED]icile outbreaks); and After known or suspected exposure to spores (e.g. B. anthracis,[DIAGNOSES REDACTED]icile outbreaks). https://www.cdc.gov/handhygiene/providers/index.html

This citation includes intake MI 081. Based on interview and record review, the facility failed to ensure two of five resident reviewed for significant medication errors were free from significant medication errors (Resident #370 and Resident #64), resulting in unmanaged cranial swelling and R370 not maintaining/achieving her highest practicable physical, emotional and psycho-social well-being, and the potential for negative outcomes for Resident #64. Finding include: Resident #370 (R370) According to the Intake Information, dated [DATE], [DATE]th will be a day I will never forget, mainly because it was the last time, I got to hold my mother's hand and hug her. While my mother was at the (facility), everything seemed okay, until the first incident occurred. [DATE]st was her first night there, she was doing well and had no complaints of anything. Then about 2 weeks later, she stopped talking, couldn't use her one good hand to eat, was forgetting she had food in her mouth, forgetting a lot in general. Nobody knew why, and it was breaking a lot of hearts. Miraculously, . an absolutely wonderful nurse named (LPN/Licensed Practical Nurse L) was looking thru records and noticed she wasn't taking her [MEDICATION NAME] like she was supposed to. [MEDICATION NAME] was the medication that controlled the swelling on my mother's brain. Somehow, some way, either in her transport to the facility, that [MEDICATION NAME] script was re-written PRN as needed. Confused as to why it would be 'as needed' since she was STEADILY taking it ,[DATE] times DAILY for months. My mother knew what was going on, but she physically couldn't tell us . According to the Minimum Data Set, dated dated [DATE], R370 was admitted to the facility on [DATE], had moderate cognitive impairment, was able to make herself understood, needed extensive assistance with bed mobility, was totally dependent for transfers and had [DIAGNOSES REDACTED]. Review of R370's medical record revealed she signed a Do Not Resuscitate Order on [DATE] and she expired at the facility on [DATE]. R370's Death Certificate revealed, Cause of Death - [MEDICAL CONDITION]. Review of R370's Hospital Physician Discharge Summary, dated [DATE], revealed (R370) is a 51 y.o. (year old) with . ([MEDICAL CONDITION]) s/p (status [REDACTED]. CT (imaging scan) Head in the ED (emergency department) shows progression of vasogenic [MEDICAL CONDITION] (excessive accumulation of fluid in the brain). Neurosurgery evaluated her in the ED (emergency department) and did not recommend acute intervention . continue home [MEDICATION NAME] (steroid -see below) . Discharge was completed however family felt she was unsafe for home and agreed w(with)/palliative input. She is continued on [MEDICATION NAME] ([MEDICATION NAME]), and [MEDICATION NAME] for the headache . pain remains ,[DATE] at all times but functionally able to do more w (with)/current [MEDICATION NAME] dosing . Family has decided on discharge to SAR (subacute rehabilitation) at (facility). Page 14 of R370's hospital Discharge Orders, dated [DATE], revealed Continue these medications which have CHANGED . [MEDICATION NAME] ([MEDICATION NAME]) 4mg tablet. Take 1 tablet (4 mg) by mouth every 8 hours for 14 days. Use of [MEDICATION NAME] (steroid) for vasogenic [MEDICAL CONDITION]. Vasogenic [MEDICAL CONDITION] is a result of a disruption of the blood brain barrier that is frequently related to tumors. The [MEDICAL CONDITION] can lead to increased intracranial pressure in addition to tissue shifts and brain displacement . [MEDICATION NAME] is a potent, long-acting glucocorticoid . Glucocorticoids have a number of mechanisms for how they reduce inflammation in the body . Reduction of symptoms may begin within a few hours after starting [MEDICATION NAME] . <http://www.hughesmedicine.com/,[DATE]/use-of-[MEDICATION NAME]-for-vasogenic-[MEDICAL CONDITION].html> Review of R370's admission orders [REDACTED]. Give 1 tablet by mouth every 8 hours as needed (prn) for preventative/steroid treatment. Review of R370's Medication Administration Record [REDACTED]. The prn [MEDICATION NAME] was ordered on [DATE] at 7:30 PM by Nurse Practitioner N (who no longer worked at the facility at the time of the survey) and it was discontinued on [DATE] when [MEDICATION NAME] Tablet 4 MG - Give 4 mg by mouth every morning and at bedtime for cerebral [MEDICAL CONDITION] (bid) was ordered to begin on [DATE]. Review of Nursing Progress Notes, dated [DATE] at 5:26 PM, revealed, Nursing Evaluation Summary. Late Entry: Note Text: 51 y/o (year-old) female admitted to facility . Reason for hospitalization and admission to (facility) is for generalized weakness due to malignant [DIAGNOSES REDACTED]. PMH (past medical history) of depression, anxiety, craniotomy, [MEDICAL CONDITION] and hypertension. Resident is here for rehab due to generalized weakness secondary to recent hospitalization for malignant [DIAGNOSES REDACTED]. Resident orders verified with (Nurse Practitioner N) and faxed to pharmacy. Resident is alert and oriented x ,[DATE], able to make all needs known . This late entry was documented by LPN P [DATE] at 7:26 PM. Review of R370's Medical Record revealed no Nursing or physician progress notes [REDACTED]. A Pharmacy Medication Review Progress Note, documented by Pharmacy Consultant M, dated [DATE], revealed, Monthly MMR Performed - No recommendation. In a telephone interview, on [DATE] at 2:37 PM, Pharmacy Consultant M was queried about the prn [MEDICATION NAME] 4 mg prn admission order ([DATE]) and the subsequent Pharmacy review on [DATE]. Pharmacy Consultant M said [MEDICATION NAME] was not typically prescribed as PRN and said, We must have missed it on admission review. That's something we should have caught. You just assume they (the nurses) transcribed it correctly . Unfortunately, yes, it is a significant med error. Pharmacy Consultant M agreed that [MEDICATION NAME] would decrease brain swelling and decrease pain and he reported the Pharmacy gets copies of Medication Error reports from the facility and he attends their Quality Assurance Performance Improvement meetings but he did not remember a Medication Error report for R370's [MEDICATION NAME] or it being discussed at QA. Pharmacy Consultant M said, Yes, we get the med error report but that wouldn't have been until it was caught. In an interview, on [DATE] at 3:52 PM, Director of Nursing (DON) B reported she was aware of the [MEDICATION NAME] error back in January when the nurse found it - probably the next day. However, she gave no explanation as to why she didn't fill out a Medication Error Report or whether she reported it to the Administrator (at that time the Administrator was MM). According to a Progress Note for R370, dated and signed by NP O (who no longer worked at the facility), dated [DATE] at 11:20 PM, PROGRESS NOTE: seen and examined ,[DATE] at 5pm. CHIEF COMPLAINT: follow up labs. HISTORY OF PRESENT ILLNESS: asked to see by nursing staff for labs. WBC 2.1. Has been 2 to 3. Pt with glio[DIAGNOSES REDACTED], cerebral [MEDICAL CONDITION]- was previously on scheduled [MEDICATION NAME]. resting in bed. nonverbal for me- appears to be sleeping. ANC 1617. Discussed with dietician r/t protein levels. MEDICAL/SURGICAL HISTORY: glio[DIAGNOSES REDACTED], cerebral [MEDICAL CONDITION], gastric bypass, craniotomy, right [MEDICAL CONDITION]. medications: [REDACTED]. ASSESSMENT: glio[DIAGNOSES REDACTED] ([MEDICAL CONDITION]) with [MEDICAL CONDITION] (swelling) . -clarify [MEDICATION NAME] with oncology . -continue current treatment plan, diagnosis, medications. -medications reviewed in detail . (sic). Review of R370's medical record revealed no evidence that NP O sought clarification from the oncologist or rectified any concerns she may have had at the time regarding the [MEDICATION NAME] prn order. In a telephone interview, on [DATE] at 2:54 PM, NP O reported she had no recollection of R370, the [MEDICATION NAME] order, or her note to clarify the order with oncology. Review of a Social Services Progress Note for R370, dated [DATE] at 4:54 PM, revealed . met with resident and her spouse . resident gave the thumbs up to wanting CPR. She attempted to initial POA papers, appeared to have difficulty writing her initials . Resident spouse at her bed, read each section of the POA papers out loud. He would stop and explain, what it meant would happen. Resident reiterate using the thumbs up sign for her way of communicating . Review of an IDT-Interdisciplinary Progress Note, dated [DATE] at 11:23 AM revealed, . total dependence for everything . medically declining . Review of an IDT-Interdisciplinary Progress Note, dated [DATE] at 2:46 PM (a week after [MEDICATION NAME] was being regularly administered) revealed, . Resident is now verbal, and able to speak fluently considering she was non-verbal . In an interview, on [DATE] at 11:06 AM, LPN P said, In my defense, I'm guessing this call is in regard to a med error. They gave me three admissions back to back with no help. The night nurse and unit manager are supposed to check the admission orders [REDACTED]. I got a write up 30 days later. That is bull crap in my opinion. When I read those orders, I don't remember scheduled three times a day, I thought it was prn. It breaks my heart. Yes, I was blamed for a negative outcome. (R370) had an altered mental status. The problem was it could have improved her quality of life. Yes, she was less talkative with her family and she started improving when the medication was put in place. Her husband and one of the nurses, (LPN L) who worked that day ([DATE]) and she was passing meds and saw the med in the cart and asked the husband why she took it prn. He said, she's supposed to be getting it scheduled. The nurse who followed me was nurse NN I think, and the Unit Manger was OO - I don't remember her last name and no longer works there. It is a hot mess over there. In the last three and a half years we've had the worst management. Admission, admission after admission, two hours late on an IV (I can't remember the resident's name) all management leaves the building at 6:00 PM and I had to stay until 10:30 PM trying to get everything done. (Corporate Manger PP) offered me a transfer when I quit. We were way past due for a State Survey, you keep them on their toes. You should have come in a long time ago. I worked the day (R370) died and I cried with the family. She was a beautiful woman and the family is amazing. The guilt I feel about the error is horrible. Why didn't anyone check my order? On [DATE] at 2:12 PM, all Medication Error Reports for R370 were requested from the facility, but no Medication Error Reports for the [MEDICATION NAME] error were presented to the survey team. In an interview, on [DATE] at 12:10 PM, Nurse Educator, LPN K said, Admissions and transcribing orders? (Nurses) get educated when they come (upon hire). In an interview with Medical Director R on [DATE] 02:02 PM, he stated, I do the administrative record. (Physician S) is in charge of medical. Medical Director R said Medication Error Reports go to QA, but he didn't recall anything regarding a [MEDICATION NAME] error for R370 having been discussed in QA (Quality Assurance Performance Improvement meetings). In an interview with Administrator A on [DATE] at 02:16 PM, he said, Yes, we take med error reports and incident reports to the QA meetings so we can look for trending. On [DATE] at 2:16 PM, this Surveyor requested any discipline or education reports for LPN P from Human Resources Manager X, but she found no reports related to a medication error in LPN P's Human Resource file. In an interview, on [DATE] at 2:20 PM, DON B said she had been the Director of Nursing since [DATE] but a [MEDICATION NAME] error for R370, does not ring a bell. What my system was. I am going to look and see if I have a med error report. When I first started their system, I've had them in my little um . let me look and see if it is in another place. It might be uploaded in QA (quality assurance) reader . and if (LPN P) got a write up there would have been a med error report to go along with that. The people responsible should have been held accountable and there should have been a med error report. DON B then began looking through her desk filing cabinet but was unable to locate a Medication Error Report or a discipline report for LPN P. In an interview, on [DATE] at 10:23 AM, LPN L reported, I've worked here five years and used to be a Unit Manager years ago. I remember (Resident # 370) very well. I noticed she should have been on [MEDICATION NAME]. I called and spoke with (Nurse Practitioner/NP O) and said, 'Correct me if I'm, wrong; [MEDICATION NAME] is for reducing swelling in the brain?', and she said, 'It is one of the most comforting medications you can give.' (R370) would complain of headache and NP O said that she would be more comfortable to reduce the swelling . It would be protocol to make out a med error report; they are used to teach people to pay attention . I was not aware they go to QA (Quality Assurance meetings). NP (O) is the only one I discussed it with. I never see those reports (Pharmacy Medication Reviews) from the pharmacy. I don't get them. I don't know who does. When we had (name of pharmacy) they were faxed to us and we put them in the doc box. (Facility contracted pharmacy) must do it different. I don't get those (Pharmacy Medication Reviews). (R370) was non-verbal just thumbs up or thumbs down, but it was not very long, a few days after she started receiving [MEDICATION NAME] 4 mg three times a day, there was a huge change in her ability to talk. It was early morning, about 6:30 AM, and she was in her chair at the desk and she said, 'I like your hair (named her by her name). I am so thankful I can talk. I wanted to tell you that you are pretty.' Regarding the admission process, LPN L reported, We receive a discharge summary and as a Unit Manager, I always told the nurses, you only take the orders from the discharge summary. You call the physician and read all of the medications, check everything and if it doesn't look right talk to the doctor, you sign the discharge summary with the date and time you spoke to the physician, enter the meds into PCC (electronic medical record), and have another nurse verify you orders before any medications are administered. (R370's hospital discharge summary) was not signed and dated - somebody didn't follow the process. If you don't call a provider to verify the medications, how do you know if that attending physician is in agreement. Yes, a med error report should have been made out. Resident #64 (R64) R64's admission Minimum Data Set (MDS), dated [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 15 (Scale: ,[DATE] Cognitively intact). The same MDS assessment revealed R64 had active [DIAGNOSES REDACTED]. R64's Discharge Summary, dated [DATE], revealed an order for [REDACTED]. R64's [DATE] Medication Administration Record [REDACTED]. Director of Nursing (DON) B was interviewed on [DATE] and verified R64's Gluophage dosage was a medication error, that was not identified until surveyor review. DON B stated admission orders [REDACTED]. DON B stated she would write the error on a medication error report and stated R64 was discharged home on [DATE]. DON B was interviewed on [DATE] at 12:00 PM and verified she had completed a medication error report but did not notify R64 of the medication error, and attempted to call her following the interview, but the line was busy. DON B stated she planned to notify R64 as soon as possible.

This Citation Pertains to Intake MI 388 and MI 088. Based on observation, interview, and record review the facility failed to ensure 2 residents (#25 and #71) were free from abuse of 14 reviewed for abuse, from a total sample of 20. Resulting in Resident 25 crying and not being able to sleep and Resident 71 being physically restrained against their will. Findings include: Resident 25 According to the clinical record, including the Minimum (MDS) data set [DATE], revealed Resident # 25 (R25) was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R25 scored a 15 out of 15 (cognitively intact ) on the Brief Interview for Mental Status. During a bedside interview with Resident #25 on 09/18/20 at 10:15 AM, she reported receiving her oral medication and a pain patch between 5:00 and 6:00 am, which is the normal daily routine and then she goes back to sleep, except for one night approximately a month ago. R25 went on to say that Licensed Practical Nurse LPN U administered the oral medication only, R25 stated he had done this a few times before despite her asking to receive both medications at the same time. R25 stated she asked him for the pain patch and he stated he forgot and would be right back. R25 stated it was about 5:00 am and she had stayed awake awaiting his return, turned on the call light and asked the certified Nurses Aide to get LPN U for her pain patch. R25 reported shortly after the request was made LPN U came in the room flipped on the overhead bright lights and started to talk to her in a rough tone of voice You think you are more important than everyone else? R25 reported she just reiterated to please administer the oral medication and her pain patch at the same time, like the other nurses do. R25 then reported LPN U approached the bed and yelled at her not to tell him how to do his job. R25 stated this occurred on a Saturday morning and reported it to Administrator A and Director of Nursing (DON) B on Monday morning. R25 further reported I was so upset, I felt like he had no right to yell at me like that, I cried and cried and could not go back to sleep. R25 reported when she reported the incident to DON B, DON 'B was not responsive as a DON and allegedly told R25 What do you want me to do fire him? R25 reported LPN U gave a forced quick and lame apology and was no longer assigned to her per her request. On 09/18/20 at 12:14 PM, during a telephone interview with LPN U he recalled the incident and reported he gave the oral medication around 5:00 am and the phone kept ringing so he did not administer R25 pain patch, he left the room to answer the phone then got side tracked for about 45 minutes until the CNA (unknown) told him R25 was complaining of pain and wanted her pain patch. LPN U stated he returned to R25's room about 6:00am, LPN U denied yelling , stated he turned on the bright lights so he could talk to R25. LPN U stated the more he tried to explain that he got busy with other residents and the phone the more upset R25 became. LPN U did acknowledge that he asked R25 if she thought she was more important than everybody else, LPN U also acknowledged that he did tell Resident # 25 You can't tell me how to do my job, you are not a nurse. When queried if he thought those comments were verbally abusive, disparaging, or demeaning, LPN U stated that he said that because Resident # 25 was not understanding his point of view and she needed to. LPNU further acknowledged he was aware the incident caused her to cry. According to the facility policy titled Abuse Prevention Program dated 2/22/2018 Abuse - The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the 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. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Resident #71(R71) A Facility Reported Incident (FRI) of abuse was reported to the state agency by the facility on 02/10/20 at 01:35 PM, and a complaint of restraints, abuse and neglect was submitted to the state agency on 02/11/20 at 09:49 AM. The Electronic Medical Record (EMR) on 09/18/20 at 09:13 AM reflected R71 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. The 5 day modified Minimum Data Set (MDS: resident assessment tool) with and Assessment Reference Date (ARD) of 2/1/20 reflected R71 was cognitively intact, required extensive assistance of 1 person for transfers, required supervision of 1 person for bed mobility, limited assistance of 1 person for dressing/hygiene, and experienced moderate pain frequently. Nurses' Notes, documented by Registered Nurse (RN I) dated 02/10/20 at 02:58 AM, in the facility's EMR reflected the following: Note Text: Resident stated several times in the late evening of Sun 2/9/2020 that her husband was on his way to pick her up, and that they were moving to Florida. Resident had been collecting her belongings for several hours, and had reported to at least one employee that she was leaving this facility. It was decided to place a WanderGuard on this resident. The number is (wanderguard number), and it is on her left ankle. The resident was very angry that this was placed on her person. She began kicking her feet at the nurse placing the device, and tried to lean over and stop that nurse from placing the WanderGuard. This writer intervened by holding the resident's arm while the WanderGuard was being placed, which led to the resident attempting several times to strike this writer. Those attempts failed. Resident stated several times that she would report us, that we were taking away her rights, and that this is what they do to people in prison. An incident report was completed by former unit manager RN OO, reflecting the incident occurred on 02/10/20 timed at 02:58 AM. The brief description reflected: Was reported to this writer a wanderguard was placed on resident and resident was objective to this placement. The report reflected R71's Nurse Practitioner (NP M1) but not her physician was notified on 02/10/20, however no time was indicated. Also, the report reflected R71's responsible party was notified on 02/10/20, with no time indicated, and that it was signed by Administrator (ADM MM) on 02/10/20 with no time indicated. The skilled daily charting for R71 completed on 02/10/20 at 01:57 AM reflected R71 as interviewable, and alert to person, place and date. R71's skin assessment initiated on 02/10/20 at 04:46 PM and completed on 02/11/20 at 09:53 AM reflected, R71 had a 35.5 centimeter purplish with green around the outside of the bruise, at her left elbow. A pain assessment dated [DATE] at 04:54 PM and completed on 2/11/20 at 10:02 AM reflected R71 had pain frequently, which was impacted by day to day activities. R71's acceptable level of pain was noted as 2 (little pain) out of 10 (intense severe pain). Pain intensity was noted at an 8 (severe) out of 10, severe at her lower back. R71 was unable to explain what made pain worse, but that it was managed with pain medication. The facility initiated an Elopement/Wandering assessment on 02/09/20 at 10:34 PM and completed the form on 02/10/20 at 08:07 AM. The assessment reflected R71 did not have a elopement history, and that a physician's orders [REDACTED]. Yet, record review concluded no order existed for R71 in the EMR by a physician, for wanderguard placement. Also, the facility had not obtained a signed consent from R71, for the wanderguard restraint device prior to placement on 02/10/20, whereby R71 verbally and non-verbally expressed her refusal of placement. R71's consent for the wanderguard restraint device was not obtained until 02/11/20. The facility's incident investigation file, reflected the facility reported the concern to the local authorities, and that a police report was filed. A statement was taken by ADM MM, from R71 on 02/10/20 (not timed) that reflected: I don't know why they put that thing on me. I was packing my clothes for my trip to Florida and I was waiting for my husband. They assumed I was going to walk out and leave or something. I don't like the fact they put the thing on me. I'm okay now and I really don't understand what happened . On 09/18/20 at 10:43 AM RN I was interviewed by phone, and asked to recall the day of the incident with R71 on 02/09/20 to 02/10/20. RN I revealed, he came in to work at 03:00 PM and was scheduled to leave at 11:00 PM. At the beginning of the shift he noticed R71 was folding her clothes and stacking them, saying her boyfriend was coming to pick her up, they were going to Florida throughout his shift and after he was supposed to leave. RN I revealed he was at the facility late charting. RN I expressed the other nurse (RN H) was becoming nervous, that R71 would be alone without a sufficient number of Certified Nursing Assistants (CNA's) that should be on the floor, and be by herself until the morning. RN I revealed, he believed it was RN H's idea to put the wanderguard on R71 who was a flight risk, and he agreed. R71 revealed, R71 was there because she had a stroke with cognitive deficits, she could walk pretty well, could have potentially exit the building and trigger alarm. RN H found a wanderguard, and they went in R71's room to put it on her. R71 was facing RN H, who was crouched down to put the wanderguard on one of her ankles, R71 starting hitting RN H telling her to stop, and that she did not want it. After R71 hit RN H, RN I revealed he held R71's arms, to prevent her from hitting RN H. It took a few more seconds for RN H to get the wanderguard on R71, he stayed for a while and after a couple minutes left to finish charting. RN I was asked if RN H had an order for [REDACTED]. When asked if R71 stated she did not want the wanderguard device RN I revealed, Yes, she said she did not want it, and that they we were treating her like a prisoner. When asked if he reported the incident to the administrator RN I revealed, he did not know. RN I revealed the facility called him the next morning (02/10/20), and told him he was suspended for several days pending the outcome of an investigation. Also, that he received a call, that per corporate abuse occurred, and they had to let him go. RN I was asked if he was educated to grab a resident's arm if they were combative? RN I replied, I know not to do that again. The administrator told him, in the event of someone needing to be watched or kept safe, they should just redistribute staff. RN I revealed, honestly staffing was his and his colleagues, most common complaint to facility management. On 09/18/20 at 11:13 AM the Director Of Nursing (DON B) was interviewed, and was asked to recall the incident related to R71 on 02/09/20-02/10/20. DON B revealed, the incident occurred on midnight shift, she discovered it in the morning when reviewing notes and notified ADM MM. DON B revealed, they had called her and told her that R71 was continually exit seeking, and they were afraid she was going to go out the door on midnight shift, because staff were in rooms caring for other residents. When asked if she gave the nurses any direction DON replied, I advised them she (R71) could be a 1:1 (provide continuous observation for an individual patient) if they could do that, tag team her, have her follow them around, or have someone be in sight. DON B revealed they had enough staff to do that on the days in question. DON B was asked what nursing staff should do when a patient is combative. DON B revealed re-approach, some residents prefer different care givers, if re-approaching does not work, they should try having another care giver assist. DON B was asked if nursing staff had been educated to hold residents arms? DON B revealed No, they are to make sure the resident is safe, leave them or get back out of striking distance, depending on the situation. If combative DON B revealed, staff were to make sure the resident is safe, stand back, leave the room and re-approach. DON B also revealed she could not recall if the nurses who worked the night of concern had complained of being short staffed. When asked if the nurses were terminated DON B revealed, there was a conference call and the decision of the cooperation was to terminate them. DON B was asked, prior to wanderguard placement, what steps were to be taken. DON B revealed, nursing staff were to get an order and do an elopement assessment before applying a wanderguard. DON B was then asked, if a resident becomes combative and verbalizes they do not want a wanderguard, were nursing staff to still apply it? DON B replied, No. DON B revealed, nursing staff never called her, to inform her that a wanderguard had been applied to R71. On 09/18/20 at 04:16 PM RN H was interviewed by phone, and asked to recall the day of the incident with R71 on 02/09/20 to 02/10/20. RN H revealed, she believed it was on a Sunday night, she was working with another nurse, and that he was getting ready to leave. RN H was unfamiliar with R71, R71's room was near an exit, she had increased confusion at night, a fall history, had poor decision making, was packing her belongings stating her husband was coming to get her, and that she was going to Florida that night. RN H revealed she wanted to keep R71 safe, and asked the CNA if she had a wanderguard on. RN H revealed she was not aware R71 was her own person, she had found a wanderguard, and had another nurse enter R71's room with her. RN H revealed, she applied the wanderguard to R71's lower leg on one of her ankles, and the other nurse had taken care of the documentation, which she was not aware of until the following day. RN H was asked if R71 had an order for [REDACTED]. RN H replied, I had thought, looking back now there wasn't an order for [REDACTED]. When asked how R71 reacted to the wanderguard placement RN H revealed, R71 was hostile and that was why she had the other nurse in there for assistance. RN I had stood next to R71 when she applied the wanderguard device, she heard R71 hit RN I, but did not see it. RN H denied R71 kicked or moved her legs, or complained of being treated like a prisoner, but keep still. Also, that R71 said nothing to her while applying the wanderguard, but told RN I about what her job was like as an attorney. RN H revealed she filled out a elopement risk form, but did not have a clear picture of what to fill out. In the morning she told nurse manager RN OO what occurred. RN OO helped RN H fill out the correct documentation, and she had left thinking she had completed all the steps. RN H revealed, she told RN OO she put the wanderguard on R71 at night for safety, because R71 was not in her right mind. RN H denied being aware that RN I had held R71's arm down, revealed the wanderguard was hard to latch, and that she had only applied a wanderguard once before. When asked if RN OO was objective to her placing the wanderguard on R71 RN H revealed, she walked through the process of it with RN OO. RN H revealed on 02/10/20 she was interviewed by ADM MM, put on suspension until the investigation was completed, but was never officially terminated. However the statement written by ADM MM by RN H on 02/10/20 at 02:45 PM reflected, .I went into her room and explained that the device was for safety. She immediately became upset and started hitting RN I. I proceeded to put the device on her leg . On 02/10/20 the Human Resource Coordinator (HRC X) completed a Michigan Health Professionals-Report of Change in Staff Privileges form for both RN H and RN I. The form reflected the nurses were suspended from 02/10/20 to 02/13/20 related to, Abuse substantiated during investigation. In addition, according to the facility's investigation dated 02/17/20 RN H was educated on the Abuse Prevention Policy June 2019 and RN I in March 2019. The facility's Abuse Prevention Program policy dated February 2018 reflected: Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptom. (Collectively, hereinafter abuse). 7. To help with identification of incidents of abuse, the following definitions of abuse are provided: Abuse - The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the 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. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview and record review, the facility failed to implement effective interventions to prevent falls and follow the care plan for hot liquid safety in two of five residents reviewed for accidents (Resident #42 and Resident #49), resulting in a [MEDICAL CONDITION] (Resident #42) and the potential for burn injuries (Resident #49). Findings include: Resident #42 (R42) On 3/11/19 at approximately 9:15 AM, R42 was observed lying in bed with the over-the-bed table away from the bed, a bell was observed on the over-the-bed table that was not in R42's reach. There was no other call light available to request assistance. During the same observation, a urine collection catheter bag was observed hanging on top of R42's foot board on her bed, above the level of her bladder. In a document titled Frequently Asked Questions about Catheter-Associated Urinary Tract Infection, from website at https://www.cdc.gov/hai/pdfs/uti/CA-UTI_tagged.pdf, it was recommended to keep the catheter bag lower than the bladder to prevent urine from backflowing to the bladder, in which could lead to a urinary tract infection [MEDICAL CONDITION]. R42's risk for falls care plan dated 8/17/17 indicated to ensure the call light was within reach at all times. The same care plan revealed R42 had the [DIAGNOSES REDACTED]. R42's Minimum Data Set (MDS) annual assessment dated [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 00 (Scale: 00-07 Severe Impairment). The same MDS assessment indicated R42 was admitted to the facility on [DATE], had no functional limitations in range of motion (ROM, joint mobility that affected functional ability or placed resident at risk for injury). The same MDS indicated R42 did not receive as needed (PRN) pain medications during the 5-day look-back period and was able to walk in her room and in the corridor with limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight-bearing assistance). The same MDS assessment indicated R42 had a history of [REDACTED]. The same MDS assessment indicated R42 was frequently incontinent of of bowel (2 or more episodes of bowel incontinence, but at least one continent bowel moment during the 7-day look-back period) and was not currently in a toileting program to manage R42's bowel continence. Staff witness statement attached to R42's fall investigation report, dated 10/5/18, indicated the physical therapy assistant heard R42 call out for help at 11:15 AM and R42 was observed sitting on the floor in her room with her walker in front of her. Incident Report (titled facility name), dated 10/5/18 at 11:15 AM revealed R42 fell in her room while walking to the bathroom. The Fall Investigation Report signed 10/8/18, revealed R42 got up without help to use the bathroom and the conclusion was to assist her to the bathroom before meals. Statement of Witness, attached to the Fall investigation Report signed 10/8/18, indicated 2 staff were in another room providing care at the time of R42's fall. Statement of Witness dated 10/5/18 revealed a certified nurse assistant was at lunch at the time of R42's fall. R42's risk for falls care plan dated 8/17/17 indicated to offer and encourage toileting every two hours, initiated 3/26/18 and to toilet R42 before meals, initiated 10/9/2018 (implemented 4 days after the above fall). Incident Report (titled facility name), dated 10/6/18 at 12:30 PM and attached Fall Investigation Report revealed a CNA observed R42 on the floor by the bathroom when she was walking by her room to help another resident. The Fall Investigation Report attached to the Incident Report dated 10/6/18 at 12:30 PM indicated R42 stated I have to go to the bathroom and was last toileted at 8:00 AM. Statement of Witness dated 10/6/18 at 12:30 PM revealed at the time of R42's fall, she was helping another resident. Statement of Witness dated 10/6/18 (no time) indicated she was helping in the dining room when R42's fall occurred. R42's risk for falls care plan dated 8/17/17 indicated to offer and encourage toileting every two hours, initiated 3/26/18 and to toilet R42 before meals, initiated 10/9/2018 (implemented 3 days after the above fall). The same fall investigation indicated R42 was barefoot at the time of her fall and a new order for gripper socks at all times was implemented. In review of R42's Fall Risk care plan, gripper socks at all time was already initiated on 8/08/2018. Incident Report (titled facility name), dated 10/7/18 at 7:40 AM revealed a loud noise was heard from R42's room and help me; R42 was found on the floor in her room, tray table was knocked over, water and a fruit cup was noted on the floor. Statement of Witness dated 10/7/19 at 7:40 AM revealed statements from three staff members that they were with assisting other residents and the nurse was passing medications at the time of R42's fall. Incident Report (titled facility name), dated 10/30/18 at 9:15 AM revealed R42 was observed sitting on the floor near the end of her bed. The Fall Investigation Report attached to the 10/30/18 incident report indicated R42 was up most of the night and confused. Witness statements titled Statement of Witness dated 10/30/18 at 9:15 AM, indicated the nurse was passing medications at the time of R42's fall, two staff members were with another resident at the time of the fall, and one staff member responded to R42's call bell and found her sitting on the floor. Incident Report (titled facility name) and Statement of Witness dated 11/2/18 at 5:10 PM indicated R42 was observed sitting on the floor mat attempting to put her shoes on. Quality Assessment & Assurance Investigation Report dated 11/2/18 at 5:10 PM indicated R42 was observed .sitting on mat putting shoes on, second time this week . Incident Report (titled facility name), and Statement of Witness dated 11/29/18 at 10:30 AM, revealed R42 was found by the housekeeper on the floor on her knees with her head lying on the floor mat in her room. The attached Fall Investigation Report indicated R42's breakfast tray was spilled all over the floor and the floor was wet. The same report revealed R42 was last toileted between 7:00 AM and 7:30 AM and she needed to use the bathroom. The same fall investigation indicated R42 had been up all night, confused, thinking people were coming to pick her up . 3/13/19 at 9:09 AM, UM O were interviewed and verified a sleep/wake assessment was not considered after R42's fall. R42's risk for falls care plan dated 8/17/17 indicated to offer and encourage toileting every two hours, initiated 3/26/18 and to toilet R42 before meals, initiated 10/9/2018. Incident Report (titled facility name),Fall Investigation Report and Statement of Witness, dated 12/17/18 at 12:30 PM indicated R42 was found on her floor mat in her room by her daughter, was last toileted at 10:00 AM. The same report indicated R42 was deaf, blind, had poor balance, and wanted to pull her pants up. The were no new interventions included on the fall investigation report for R42. 3/13/19 at 9:09 AM, Unit Manager (UM) O was interviewed and confirmed no interventions were put into place following R42's fall on 12/17/18. UM O stated in the same interview, a soundless motion sensor that activated the call light system was not considered for R42 because the former DON was against alarms. R42's risk for falls care plan dated 8/17/17 indicated to offer and encourage toileting every two hours, initiated 3/26/18 and to toilet R42 before meals, initiated 10/9/2018. Incident Report (titled facility name), dated 12/22/18 at 12:10 AM indicated R42 .screamed 'help! help! help! I fell ' . and was found next to the bed on her floor mat. Fall Investigation Report attached to the same incident report indicated R42 was last toileted at 8:00 PM and the root cause of the fall was .seemed to attempt toileting self without asking for help. Incident Report (titled facility name) and Fall Investigation Report, dated 12/22/18 at 8:20 PM revealed R42 was found on the floor in her room and contributing factors indicated toileting status. The same report indicated nurse assistant education regarding timely removal of meal tray and to initiate bladder tacking for 7 days were planned. Incident Report (titled facility name), dated 1/11/19 4:22 AM, revealed a nurse assistant responded to R42's call for help, found her on the floor, lying next to her bed, partially on the floor mat and R42 stated she had to use the bathroom. Incident Report (titled facility name) and Fall Investigation Report dated 1/15/19 at 6:00 PM the nurse indicated she heard a loud crash and then R42 calling for help. The same report revealed the nurse observed R42 lying on her back on the fall mat. The same investigation report indicated R42 was last toileted at 3:30 PM. Incident Report (titled facility name) and Fall Investigation Report dated 1/21/19 at 6:40 AM indicated staff responded to R42 calling out for help from her room and was observed sitting on her buttocks. The same report included the amount of assistance in effect and footwear were contributing factors of R42's fall. Incident Report (titled facility name) and Fall Investigation Report dated 1/21/19 at 6:50 AM revealed staff heard R42 yell ouch and crying, and observed her lying face first on the floor with blood under her head from a laceration. Incident Report (titled facility name) and Fall Investigation Report dated 2/14/19 at 5:30 PM R42 was observed in her room sitting on the floor. Incident Report (titled facility name) and Fall Investigation Report dated 2/16/19 at 11:45 AM R42 was found sitting on the floor in her room. The same report indicated R42 stated she was walking to the toilet and was last toileted at 8:00 AM. R42's risk for falls care plan dated 8/17/17 indicated to offer and encourage toileting every two hours, initiated 3/26/18 and to toilet R42 before meals, initiated 10/9/2018. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.16, (MONTH) (YEAR), indicated a previous fall, especially a recent fall, recurrent falls, and fall with significant injury were the most important predictors of risk for future falls and injurious falls. The same source advised to evaluate toileting and staffing needs for residents who are at risk for falls. The same source indicated many incontinent residents (including those with dementia) respond to a toileting program, especially during the day. The same source indicated an individualized, resident-centered toileting program should include observations of at least three days of toileting patterns with prompting to toilet (using a schedule and prompting the resident to toilet) and recording results in a bladder record. The same source revealed voiding patterns (frequency, volume, duration, nighttime or daytime, quality of stream) help detect urinary patterns or intervals between incontinence episodes. The same RAI manual, under section H, included simply tracking continence status using a bladder record or voiding diary should not be considered a trial of an individualized, resident-centered toileting program. Incident Report (titled facility name) and Fall Investigation Report dated 2/20/19 at 3:00 PM revealed R42 was seen standing in her room holding a blanket and then fell on to her left knee, then to her left side on the floor. The same report indicated a hematoma (localized bleeding outside of blood vessels)/bruise as noted to R42's left knee. The same report indicated interventions to prevent future falls included one to one observation. X-ray report sign by the physician 2/20/19 at 11:36 PM revealed R42 sustained a left [MEDICAL CONDITION] following her fall. Discharge Summary from hospital stay dated 2/27/19 indicated R42 was admitted for surgical repair of the left [MEDICAL CONDITION] had [DIAGNOSES REDACTED]. R42's MDS significant change assessment dated [DATE] revealed she had moderately impaired cognition (decisions poor; cues/supervision required); had no physical, verbal or other behaviors, and did not wander or reject care during a 7-day look-back period. The same MDS assessment indicated R42 did not walk in her room or in the corridor over the entire 7-day period. The same MDS assessment revealed R42 had a functional limitation in range of motion on one side in the lower extremity (hip, knee, ankle, foot) and received or was offered as needed pain medication during the 5 day look-back observation period. 3/13/19 at 9:09 AM, UM O and Director of Nursing (DON) B were interviewed and stated R42 last bowel and bladder assessment/patterning was in (MONTH) (YEAR). UM O stated in the same interview, hourly or every two hour checks for incontinence/toileting need during the bladder assessment period in (MONTH) (YEAR) were not assessed. R42's Bladder Report dated 12/16/18 through 12/31/18 was reviewed and included continence and incontinence charted one to three times in a day, did not record bladder activity every two hours and before meals. The same report did not include urine volume, duration, or quality of stream for R42. The same report did not provide enough data to determine a bladder pattern for R42. R49 According to the facility's admission record, R49 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], reflected that R49 had severe cognitive impairment received hospice services. On 3/12/19 at 9:40 a.m., R49 was observed in her wheelchair, next to the desk in the 300-hall drinking a hot beverage in a brown, insulated mug with no lid. Her hands were shakey and the liquid in the cup was moving. Certified Nurse Assistant (CNA) T was in the area chatting with R49 and other residents also seated there. A review of the care plans for R49, initiated on 1/24/19, reflected a plan for risk for injury related to hot liquids. The goal was to reduce risk of serious injury in the event of accidental spillage, and the intervention was encourage resident to use cup with lid when handling hot liquids. On 3/12/19 at 3:30 p.m., R49 was observed holding a mug of coffee without a lid, complaining that it was cold. CNA S brought her a fresh mug, removed the lid (which resembled a lid like that put on a cup of soda, not a coffee-type lid) and handed it to her. The liquid in the cup was steaming some, and R49 held the mug at an angle so the liquid nearly spilled out. When questioned, CNAS said that she didn't need a lid, I don't thing she's ever burned herself. Besides, he said, We don't have lids that fit on those mugs. At 3/12/19 at 3:45 p.m., Director of Nurses (DON) B was interviewed. When asked when hot liquid assessments are done, DON B answered on admission, quarterly and with an accident or change of condition. DON B offered that R39 was care planned for lids on hot beverages. At 3/12/19 at 4:00 p.m., R49 was observed in her usual spot, drinking from a green, 2-handled sippy cup with a spout lid. At 3/12/19 4:51 p.m., DON B reported that there were , indeed, no lids for the brown mugs and they were now on order. Someone just went to buy some as we speak, DON B said, The current lids are not considered safety lids for hot beverages.

This citation is related to intake MI 878 Based on interview and record review the facility failed to address Resident #3's request for pain medication in a timely manner, resulting in untreated pain, delayed medication for pain relief and feelings of frustration. Findings Include: Resident (R) #3 was admitted to the facility on [DATE] and discharged on [DATE] according to the Electronic Medical Record (EMR). R3's admitting [DIAGNOSES REDACTED]. The facility reported to the state agency on 8/24/18 that R3 did not receive a narcotic dose of medication. Also, that R3's daughter alleged upon discharge 8/24/18 that a dose of narcotic medication was never given to R3 as signed out on the record. The facility had no documentation to reflect the above concern was identified prior to R3's daughter notifying them of reported missed medication. On 9/27/18 at 4:23 PM R3 was called and asked about her stay at the facility following her left knee surgical procedure. R3 revealed, I had to get up and was in dire pain, and rung my bell for about an hour. I needed my pain pill. I walked down three halls looking for nursing staff. I saw a girl and asked her did she know where the nurses were. The girl said, 'No, I don't know where they are at'. It was about 2:00 AM. Every-time I needed my pain medication, I would push my button and have to wait. Three other people's call lights were on. I would tell an aide I needed my pain pill, and she went and did something and forgot. I asked her again if she told the nurse after a while and she said she forgot and would tell and the nurse. The nurse finally came in and asked me if I was in pain, she apologized for the wait and said they were short staffed. She went and got it and brought it back to me. I did not receive my medicine on time the whole time I was there. R3 described the pain while at the facility and R3 stated, The first time was about a 10 right after I had gotten there and after about a few days .I had total left knee replacement. The pain was aching, throbbing and shooting pain at the knee. R3 revealed her daughter had words with the nursing director, it was not fair how she was treated, she did not like it at all and that she would like for the facility staff to have gone through the pain she went through related to her leg. The ProHealth (YEAR) online health reference reflected: 0 = no pain, 5 = distressing pain and 10 = unimaginable/unbearable pain. physician's orders [REDACTED]. The narcotic sheet for R3's [MEDICATION NAME] reflected she was medicated the following dates with (1) tablet: 8/19/18 at 01:00 AM 8/20/18 at 08:55 PM 8/23/18 at 08:00 AM 8/23/18 at 08:40 PM However the Medication Administration Record (MAR) for R3's [MEDICATION NAME] reflected she was medicated the following dates with (1) tablet: 8/19/18 = No doses given 8/20/18 at 01:00 AM 8/23/18 at 8:44 PM only Based on the above information there were several errors: 1. 8/19/18 [MEDICATION NAME] documented given on the narcotic sheet but not the MAR at 01:00 AM. 2. 8/20/18 [MEDICATION NAME] signed out given at 08:55 PM on the narcotic sheet, yet signed out given on the [DATE] hours later at 01:00 AM. 3. 8/23/18 (2) doses of [MEDICATION NAME] signed out on the narcotic sheet at 08:00 AM and 08:40 PM, however it was only documented given once on the MAR at 20:44 PM. During the survey between 9/26/18 and 10/2/18 staff who cared for R3 were interviewed, each staff member desired to remain anonymous. The first staff person was interviewed and asked if he/she recalled R3 and her issues with receiving her [MEDICATION NAME] medication timely. The staff person revealed, I remember giving it to her and signing it out. The staff person revealed that was the only night he/she had worked with R3, R3 had complained of waiting for her medication. The staff person revealed, There was a combined total of 35 residents and as a result half the residents had to wait over an hour or 2 hours. I quit my job because of the shortage. The facility called and offered my job back with better staffing, promising the patient/nurse ratio would be better. That was the only pain pill I gave her. She shortly discharged after that because she had to wait so long for her pain pills I was told and that she was pretty upset. The second staff person was interviewed and asked if he/she recalled R3 and her issues with receiving her [MEDICATION NAME] medication timely. The staff person revealed, It's harder to get to them at night with an admission, there could be a delay maybe 30 minutes. The staff person revealed that he/she would be overwhelmed with the amount of people he/she had to care for. He/she knew the Certified Nursing Assistants (CNA's) told him/her about R3 wanting pain medication and he/she told the CNA's that R3 would be medicated but was overwhelmed and R3 received it late. Some units had over possibly 35 residents, at different shifts 3 nursing staff could be working and it was overwhelming. R3 was upset for waiting for so long for her pain medication. Also, that there were times when there were not enough CNA's in the building, there was a huge problem with staff calling out, the facility was running short on staff a lot and that although the census had dropped some, staff are still overwhelmed. The third staff person was interviewed and asked if he/she recalled R3 and her issues with receiving her [MEDICATION NAME] medication timely. The staff person revealed that he/she had never given R3 her medication late, but was aware R3 had complained or had not gotten her medications at night before. When asked what was the standard ratio for nurses to residents, the staff person revealed usually 23. When asked if he/she felt 35 residents was a lot for (1) nurse the staff person stated, Yeah it would be. When asked if there were any issues with staffing, the staff person revealed, I know the facility was filling up with residents and at the time there weren't many nurses on a unit and they had to bring in nurses to fill it up. The investigation packet was provided and observed to contain audits, interviews, in-service educational material and medication error reports. Prior to leaving the building on 9/28/18 the Director Of Nursing (DON) was interviewed about the reported incident. The DON revealed they had determined that the narcotic sheet for R3 was accurate but errors were noted on R3's MAR and that education and audits were done to address the issue.

This citation pertains to MI 104 Based on interview and record review, the facility failed to implement interventions to prevent a fall with major injury for 1 (Resident #507) of 2 reviewed for falls, resulting in Resident #507 sustaining a fall while in the direct care of staff resulting in a right ankle fracture and a significant decrease in the ability to perform Activities of Daily Living (ADLs Findings include: Review of the Admission Record and Minimum Data Set ((MDS) dated [DATE], revealed Resident #507 (R507) was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed R507 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating she was cognitively intact and required limited assistance of 1 person for bed mobility, transfers, walking in her room, and toilet use. The MDS revealed R507 had 1 fall with major injury since admission or prior assessment. Review of the Fall Risk Evaluation dated 2/16/18, revealed R507 scored 16 and interventions were required. The Fall Risk Evaluation revealed R507 ambulates with problems and with devices (gait is unsteady, slow, lurching) Review of the Activities of Daily Living (ADL) care plan initiated 2/16/18, revealed R507 transferred using stand and pivot with 1PA and required assistance by 1 staff to move between surfaces. R507 also had an at risk for falls care plan initiated 2/16/18. Review of the Incident Report dated 2/22/18 at 1:00 AM, revealed Resident (R507) fell in bathroom while accompanied by aid (sic). Aid (sic) helped resident down to ground, but resident still hurt right ankle .send to ER. Review of the Statement of Witness dated 2/23/18, revealed CNA S stated I was assisting (R507) to the bathroom. She didn't have the gaitbelt around her. I was standing behind her and she was in front of me, using her walker. I didn't have my hands on her but they were close to her in case she needed me. We got to the bathroom door and as she started to walk in, her knees buckled, I put my hands at her side and attempted to pull her up as she was going down and then I just help (sic) her slide down and she landed with the right foot under the left foot. (R507) complained of her right ankle hurting right after this incident . The surveyor attempted to contact Certified Nursing Assistant (CNA) S on 7/13/18 at 9:33 AM, voicemail was not available and a return call was not received prior to the exit of survey. Further, on 7/13/18 at 10:38 AM, Scheduler T reported she texted CNA S and asked that she call the surveyor. A return call was not received prior to the exit of survey. Review of the hospital Consult dated 2/22/18, revealed R507 .had a fall when attempting to walk to the bathroom when she fell and her ankle rolled under her. She had sudden pain and inability to ambulate. Review of R507's right ankle x-ray dated 2/22/18, revealed oblique mildly comminuted fractures of the distal tibial and fibular daphyses with one-half shaft width lateral displacement and shortening approximately 1.4 cm. There is question of subsegmental fracture fragment of the distal fibula . The hospital records dated 2/22/18 at 8:24 AM, revealed R507 was screaming in pain. Review of R507's Progress Notes dated 2/27/18 and 2/28/18, revealed she was readmitted to the facility on [DATE] after surgery for [REDACTED]. Review of R507's admission MDS dated [DATE], revealed she required extensive assist of 2+ persons for bed mobility, transfers, toilet use, and did not walk. This was a significant change in status from the MDS dated [DATE]. In an interview on 7/13/18 at 3:35 PM Director of Nursing (DON) B reported she was not employed by the facility at the time of R507's fall with fracture. DON B reported CNA S as well as other staff received education regarding gait belt use with transfers following the resident fall with fracture while in the direct care of staff.

This citation includes intake MI 601. Based on observation, interview and record review the facility failed to ensure three sampled residents (#4, #8 and #25 ) and two non sampled residents (#55 & #29), were free from abuse of eight residents that were reviewed for abuse from a total sample of 28 resulting in abuse to continue with the potential to affect all 84 residents that reside in the facility. Findings include: Resident #55 According to the electronic health record resident #55 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum (MDS) data set [DATE] resident #55 had a Brief Interview for Mental Status (BIMS) of 15, on a scale of 0 to 15, indicating resident #55 was cognitively intact and had no cognitive impairment. 01/11/18 at 10:19 AM during a bedside Interview with Resident #55, she stated name of resident #8 was neglected, yells out at night and is ignored by staff . Further stating , They are relentless at mocking her. When queried who They were, she reported the Aides. When queried if she reported this to the Nurses she stated nurses ignored and mocked resident #8 too. Resident #55 further stated that resident #4 was ignored and told by staff We don't like you. Resident #55 detailed that resident #4 was the frequent target of being teased, mocked and ignored by staff. Resident #55 stated she had many times observed resident #4 sit by the Nurses desk and asked to be changed but Sits for hours at nursing and not be changed. When queried if she had spoken to administration about this, resident #55 laughed and stated Yes. They ignore me, I am treated like I am a disgruntled employee. When queried which staff played a role in the mocking and allegations of neglect she stated she was fearful of being kicked out of the facility and did not want to answer. Resident #8 The record review for Resident #8 reflected she was a [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. Resident #8 Minimum (MDS) data set [DATE] reflected long and short term memory impairment. An attempt was made to interview resident #8 regarding the incidents described by resident #55 on 1-11-2018 but due to her cognition the interview was unable to be conducted. Resident #4 Per the facility face sheet Resident #4 was a [AGE] year old female admitted on [DATE]. [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) , resident #4 had a Brief Interview for Mental Status score of 7, indicating severe cognitive impairment. Resident #29 Resident #29 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] reflected a Brief Interview of Mental Status (BIMS) of 15, on a scale of 0 to 15, indicating resident #29 was cognitively intact and had no cognitive impairment. During an interview with Resident #29 on 01/11/18 at 10:58 AM she reported resident #4 and resident #8 were ignored by staff when they asked for help, and on multiple occasions have overheard staff tell resident #4 I cant stand you. Resident #29 stated she had reported her concerns to staff, but nothing has changed. According to the facility policy titled Abuse Prevention Program dated 9-27-2017 page 5. Verbal abuse is defined as any use of language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, to describe resdients, regardless of their age, ability to comprehend, or disability. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or witholding of treatment or services. Resident #25 Resident #25 was observed on 1/17/18 at approximately 9:40 AM sitting in front of the nurses desk in a broda (specialty wheelchair) chair. Resident #25's Admission Record dated 11/18/17, revealed he was an [AGE] year old, admitted to the facility on [DATE], and had the [DIAGNOSES REDACTED]. In review of Resident #25's hospice care plan, dated 1/13/18, he received long-term hospice services. In review of the facility investigation summary titled Date of Incident: (MONTH) 10, (YEAR); Resident #25 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 00 (00-07 indicated a severe impairment). The same summary revealed Housekeeper CC notified the nursing home Administrator that she heard a Certified Nursing Assistant (CNA) say to Resident #25 take your teeth, take your 'f*cking teeth now. The same summary indicated the facility was also investigating discoloration of skin on Resident #25's hands. In an interview with nursing home Administrator (NHA) A on 1/18/18 at 2:19 PM, she stated Housekeeper CC reported on 1/8/17, in the morning, that a CNA had talked to Resident #25 in a raised voice, not that he had said take your teeth, take your f*ucking teeth now. NHA A stated during the same interview that she didn't get the whole story regarding a CNA using the language F*ucking. until bruises were observed, on 11/10/17. During an interview with Housekeeper CC on 1/19/18 at 9:15 AM, she stated on 11/8/17 that she was new on the job, with only her second or third day working, and she heard CNA DD screaming at Resident #25 take your f .ing teeth now and shoved his teeth into his mouth. Housekeeper CC stated she could see Resident #25 directly from the hall, and the door to his room was open. Housekeeper CC stated during the same interview, she heard Resident #25 mumble to CNA DD that he didn't want them, and it seemed to her that Resident #25 didn't understand. During the same interview, Housekeeper CC' stated prior to CNA DD yelling at Resident #25, CNA DD seemed frustrated, because a different resident had requested his assistance multiple times throughout the shift. Housekeeper CC stated in the same interview, that when CNA DD yelled at Resident #25, the nurse was not near the room. Housekeeper CC stated that following the incident, she went off the unit and reported the incident to both a co-worker and then to her supervisor. Housekeeper CC stated in the same interview that her and her supervisor, that was no longer employed at the facility during this interview, both went to the NHA's office to report the event. During the same interview, Housekeeper CC stated the NHA typed up her statement, and that she signed it. During the same interview, Housekeeper CC stated two days later, she was asked to come in and signed another statement with NHA A. Housekeeper CC stated in the same interview, that both statements she signed on 11/8/17 and 11/10/17 were the same. 1/19/18 at 12:04 PM, NHA A was interviewed and stated she did not type up a statement from Housekeeper CC on 11/8/17 because Housekeeper CC reported CNA talked to Resident #25 in a raised voice, she did not report CNA DD stuffing Resident #25's teeth in his mouth and using the F word. During the same interview, NHA A stated she reported the incident to the Director of Nursing (DON). During the same interview, NHA A stated the DON did not investigate CNA DD using a raised voice during Resident #25's care; and she did not initiate an investigation because it wasn't reported until Friday (11/10/17) that CNA DD used the F word while providing care with Resident #25. NHA stated CNA DD was suspended pending investigation on 11/10/17 and then terminated because he failed to report an arrest. During the same interview, NHA A stated she was not aware of any bruises of unknown origin that have occurred since 11/10/17 with Resident #25. On 1/19/18 at 12:33 PM DON B stated on 11/8/17 she was asked by NHA A to look into another resident falling four times on the night shift ending on 1/8/17. During the same interview, DON B stated she did not investigate CNA DD yelling at Resident #25, because she would had reported the occurrence as an abuse allegation and it would had been investigated. Resident #25's Incident Report, no title, dated 11/10/17 at 8:00 AM, revealed bruises were noted on the left wrist, left forearm, and right hand. In review of the facility investigation summary titled Date of Incident: (MONTH) 10, (YEAR); Resident #25's bruising was unknown etiology, quite possibly related to transferring resident or on occasion resident hit his hands on chair per staff, therefore may be self inflicted. The same document, under Witness Statements revealed, Housekeeper CC .reported that on 11/8/17 at approximately 5:53 AM, she heard (CNA DD), yelling at resident to take your teeth, take your f*cking teeth now. The same document revealed on 11/10/17, staff reported Resident #25 had bruises on the top of his hands that weren't there the day before. Attached to the investigation summary titled Date of Incident: (MONTH) 10, (YEAR); Resident #25's was a copy of the submission of the incident to the State Agency, reported on 11/10/17 at 6:53 PM. In review of the Tuesday (MONTH) 7, (YEAR) staff assignment sheet, there was a call-in on the 10:30 PM to 6:30 AM shift (11/7/17 to 11/8/17) on the unit Resident #25 resided on. Merriam-Webster (https://www.merriam-webster.com/legal/reasonable%20), defined a reasonable person as a person with an ordinary degree of reason, prudence, care, foresight, or intelligence whose conduct, conclusion, or expectation in relation to a particular circumstance or fact is used as an objective standard by which to measure or determine something. A reasonable person would potentially suffer mental anguish resulting from the abuse as described.

Based on interview and record review the facility failed to assess and treat 1 of 4 total sampled residents (#42) in a timely manner for nausea, vomiting and decreased food and fluid intake resulting in Resident #42 having a fall with minor injury and developing mental status changes and kidney failure requiring hospitalization for emergency [MEDICAL TREATMENT] and hydration with subsequent death. Findings include: Based on the Minimum Data Set (MDS) assessment, dated [DATE], Resident #42 was an alert and oriented [AGE] year old female whose [DIAGNOSES REDACTED]. The Resident's Brief Interview for Mental Status (BIMS) score from the above MDS was ,[DATE] indicating intact cognitive functioning. The above MDS reflected Resident #42 required minimal assistance with transfers, ambulation, bathing and dressing and was independent with eating. Based on the electronic medical record (EMR) Resident #42 was admitted to the facility on [DATE] after a hospital stay for surgery to remove part of the large bowel and creation of an [MEDICAL CONDITION] (opening of the large bowel onto the abdomen) related to [MEDICAL CONDITION] tumor. Based on the Medication Administration Record [REDACTED]. An anti-nausea medication ([MEDICATION NAME] 4 mg) was prescribed every eight hours as needed. Based on the EMR Resident #42 was discharged to the hospital on [DATE] at 6:30 PM after laboratory data revealed critical high values for potassium and blood urea nitrogen (BUN) and a critical low values for sodium and kidney function. In addition, Resident #42 had dry oral mucus membranes, confusion and increased weakness, all symptoms of dehydration. Based on the hospital emergency department records, dated [DATE], Resident #42 was diagnosed with [REDACTED]. Acute tubular necrosis (ATN) is severe damage to the filtration cells of the kidney resulting in severely decreased or no kidney function. ATN is primarily caused by low circulating blood volume such as in dehydration, low heart function,[MEDICAL CONDITION] (blood infection), exposure of the kidney to toxic substances such as contrast dye used for diagnostic studies and some antibiotics and blood clotting defects. ATN causes high blood concentrations of potassium, low concentrations of sodium and calcium and low to zero urine production. The survival rate is ,[DATE]% (Medscape, Acute Tubular Necrosis, Nikil Shah, MBBS, NNB, Vicihi Batumon, MD, FASN, Meshindar Agrohoka, MD, MBBS, FACP, FASN, Brent Kelly, MD, and Edgar V. Lerma, MD, FACP, FASN, FAWN, FASH, FNLA, FNKF. Based on the same records Resident #42 required emergency [MEDICAL TREATMENT] to treat the excess potassium and replace the damaged kidney function, intravenous fluid support to maintain blood pressure and antibiotic therapy to treat the infection. Based on the face sheet in the hospital record Resident #42 died on [DATE]. Review of the CBC, CMP and estimated GFR (eGFR) dated [DATE], 2 days after it was initially ordered, reflected critical high values of potassium at 7.9 mEq/L (normal range 3XXX,[DATE].9 mEq/L) and blood urea nitrogen (BUN) at 118 mg/dl (normal range-,[DATE] mg/dl). Elevated white blood count (WBC) at 15.9 K/ul (normal range-,[DATE]) and [DIAGNOSES REDACTED]s (wbcs produced during an infection) at 89.5% indicated the presence of an infection. A critically low level of sodium at 125 mEq/L (normal-,[DATE] mEq/L) and a eGFR of 4ml/min (normal->90 ml/min) indicating severe kidney failure. During the two day delay in obtaining the above laboratory tests Resident #42 continued to receive a potassium supplement 10 meq twice daily and a urinary tract infection remained undiagnosed or treated. This put Resident #42 at greater risk for heart rhythm problems and muscle weakness related to the elevated potassium and dehydration related to the infection. On [DATE] at 5:11 PM a telephone interview was conducted with Confidential Interviewee (CI) P. CI P stated Resident #42 had not been eating well at the facility and was vomiting. CI P stated the Resident had a decreased food and fluid intake for the last week she was at the facility, was getting weaker and had developed tremors in her hands so feeding herself was difficult. In addition, CI P stated Resident #42 had a fall with abrasions on her nose during the last week at the facility and laboratory studies that had been ordered had not been completed. CI P stated that on [DATE] Resident #42 was not tracking well, not as alert as usual, looked gaunt and cheeks were sunken, eyes looked haunted and starry. The Nursing Evaluation Data-V5 assessment completed on admission for Resident #42 reflected the following; a small amount of [MEDICAL CONDITION] (swelling related to fluid under the skin) in both legs/feet, intact cognition (mental abilities), a height of 5 feet 3 inches, weight of 220.2 pounds, independent transferring capability and administration limited assistance was required for ambulation. The admission history and physical exam by Physician C, dated [DATE] at 12:02 PM, reflected Resident #42 denied any nausea, vomiting, abdominal pain or diarrhea. The first documentation of nausea was a care conference progress note by Social Worker (SW) D, dated [DATE] at 12:54 PM, which reflected .Resident is receiving PT (physical therapy/OT (occupational therapy). Her progress was limited by nausea last week . On [DATE] at 4:40 AM the nursing progress note reflected Patient states she has not voided (urinated) since yesterday morning. Says she has tried multiple times. Bladder scan done 3 times and was 118,99,and 52ml. The progress note by Nurse Practitioner (NP) E, dated [DATE] at 1:11 PM, reflected Resident #42 was diagnosed with [REDACTED]. On [DATE] at 11:04 AM the progress note from NP E reflected Resident #42 was assessed for nausea without vomiting and suprapubic (lower abdomen) pain. The follow up abdominal X-ray was negative for any acute issues and the post void bladder scan reflected a residual urine amount of 27 ml (nursing progress note dated [DATE] at 10:56 PM) indicating the Resident was emptying her bladder adequately. A urinalysis with culture and sensitivity was also ordered. Physician F saw Resident #42 on the same day according to the progress note dated [DATE] at 11:58 AM and agreed with the assessment and plan of care initiated by NP E. There was no nursing documentation related to Resident #42's nausea between the [DATE] SW note and the NP and Physician notes on [DATE]. On [DATE] at 11:19 AM the progress note written by Physician F reflected Resident #42 was seen for a surgical wound assessment and assessment of her bowel sounds/abdomen/nausea. The plan was to evaluate the bladder scans for possible [MEDICAL CONDITION] and wait for the results of the urinalysis. On [DATE] NP E's progress note reflected .She is sitting upright in wheelchair in no acute distress of any chest pain, shortness of breath, significant nausea and vomiting. She does c/o (complain of) suprapubic discomfort which has been persistent now for ,[DATE] days .I will order an abdominal ultrasound for further diagnostic assessment and monitor . The lack of urinalysis results 3 days after it was ordered was not addressed. On [DATE] at 4:22 PM Licensed Practical Nurse Unit Manager G documented a SOC-Skin note in the EMR which reflected Contributing deficits: Resident complains of severe nausea since admit, has poor PO (oral) intake. Resident also reports some difficulty in swallowing pills at times. PT reports that resident does not have stamina to complete all of PT sessions daily . On [DATE] at 1:18 PM NP E documented Resident #42 .does not appear to be in distress but does exhibit increased confusion . and the abdominal ultrasound showed no evidence of an acute process .Check laboratory studies including urine culture and sensitivity for further diagnostic assessment, resident is appearing nontoxic and has remained afebrile . Based on the physician orders [REDACTED]. On [DATE] at 9:26 AM Physician F's progress note reflected Resident #42 continued to have nausea without vomiting of unknown cause and the physician would check the urinalysis and bladder scan results (ordered on [DATE]). On [DATE] at 9:45 AM NP E's progress note reflected Resident #42 was assessed after an early morning fall with discomfort in her left knee and shoulder and small abrasions to her scalp and bridge of her nose. The plan of care was to order stat (immediate) laboratory blood studies and a urinalysis with culture and sensitivity, shoulder and knee X-rays, vital signs (blood pressure, pulse, respirations and temperature) every shift for five days related to an increased heart rate and a Speech Therapy (ST) evaluation related to swallowing. The urinalysis and culture with sensitivity ordered on [DATE], 8 days ago, had still not been obtained or addressed. On [DATE] at 9:56 PM the nursing progress notes reflected Resident #42 had been nauseated and received medication to decrease the nausea. On [DATE] at 12:47 PM the progress note by NP E reflected Resident #42 was seen for weakness, confusion, fatigue and one bout of emesis (vomiting). The note reflected .Laboratory studies were ordered on [DATE] and have yet to be performed .Resident feels she has had minimal oral hydration as of late, I discussed options in relation to IV (intravenous) hydration and awaiting laboratory studies versus hospital assessment. Resident and daughter elect for IV hydration placement now, await laboratory studies which were reordered STAT for further assessment. Resident is afebrile . The next nursing progress note was at 4:28 PM on [DATE] and reflected Resident transferred out to ER at appox. (approximately) 1830 (6:30 PM) . NP E was interviewed on [DATE] at 1:30 PM. NP E stated that when she saw Resident #42 on [DATE] she changed the laboratory tests ordered for [DATE] to a STAT drawn for [DATE] based on the Resident's fall earlier that morning. NP E stated she did not see Resident #42 on [DATE] but did ask about the laboratory results and was told they had not been done. NP E stated LPN UM G stated they would be reordered. NP E stated physician Q would have been on call on [DATE] and would have been informed of the laboratory results by the nursing staff. NP E stated she was notified of any laboratory results on [DATE] during the time she was on call. NP E stated she was not aware of any weight loss issues for Resident #42 and didn't notice any changes in her body size. On [DATE] at 11:17 AM Director of Nursing (DON) B confirmed the above laboratory tests originally ordered to be drawn on [DATE] were not obtained were not obtained until [DATE] when they were reordered by the facility. DON B stated the facility discovered a problem with the interface of the facility and laboratory provider's computer systems that put the laboratory tests ordered on [DATE] in a pending file rather than an active file. In addition, DON B stated the nurses caring for Resident #42 on [DATE] and [DATE] should have been looking for the laboratory results and making sure the tests were done. On [DATE] at 5:19 PM DON B stated she was first alerted to Resident #42's decline in health when the Resident had two falls ([DATE] and [DATE]) before she was transferred to the hospital. Review of the Skilled Daily-V3 nursing notes, used for the once daily required assessment documentation for residents receiving Medicare reimbursed services, between [DATE]-[DATE], reflected no documentation of Resident #42's nausea or any problems with eating or drinking. There were no Skilled Daily-V3 nursing notes for [DATE] and [DATE]. In addition, there was no documentation related to Resident #42's nausea, vomiting, oral food and fluid intake or problems with swallowing in the progress note section of the EMR between [DATE]-[DATE]. The Follow Up Question Report [DATE]-[DATE] in the EMR reflected Resident #42's meal intake from [DATE] at 9:00 AM-[DATE] at 6:01 PM. Between [DATE]-[DATE] Resident #42 ate an average of 72% of her meals. Between [DATE]-[DATE] her average intake decreased to 41% with 8 of 27 meals at 25% or less and 5 meals with zero intake. Review of the Fluids report for each meal in the EMR for the same time period reflected and average fluid intake of 797 ml/day between [DATE]-[DATE] (not including 3 days when less than three meals were documented) and 511 ml/day between [DATE]-[DATE]. Review of the Nutrition Data Collection/Evaluation-V2, dated [DATE] and completed by Registered Dietitian (RD) H, reflected estimated calorie needs of ,[DATE] daily and estimated fluid needs of 2895 ml daily. A comment under both assessments reflected needs likely overestimated r/t (related to) obesity. The Nutritional Summary section reflected .Res (resident) reports that her appetite is improving since the antibiotics have completed and she no longer has been experiencing nausea . Based on the Medication Administration Record [REDACTED]. There was no documentation of additional fluid intake on a daily basis although Resident #42 would have had water or other liquids available at the bedside. On [DATE] at 1:55 PM LPN I stated Resident #42 normally took two 6 oz cups of water (360 ml) to get her pills down on the day shift. Based on the MAR indicated [REDACTED]. Adding the fluid intake with the medication pass to the average meal intake would give Resident #42 a fluid intake of ,[DATE] ml, [PHONE NUMBER] ml less than her estimated needs between [DATE]-[DATE] and [PHONE NUMBER] ml less from [DATE]-[DATE] with a fluid intake between ,[DATE] daily. This would put Resident #42 at risk for dehydration. Review of Resident #42 ' s vital signs between [DATE]-[DATE] reflected a decrease in blood pressure measurements beginning on [DATE] from 130-,[DATE]-80 mmHg to 115-,[DATE]-80 mmHg and a more significant decrease on [DATE] to 103-,[DATE]-72 mmHg. Between [DATE]-[DATE] Resident #42 ' s pulse rate increased to ,[DATE] beats/min with 8 of 11 readings greater than 100 beats/min ([MEDICAL CONDITION]. The Resident ' s pulse rate prior to [DATE] was ,[DATE] beats/min with only 6 of 34 readings greater than 100 beats/min. The increase in pulse rate and decrease in blood pressure are associated with infection and dehydration related to a decrease in circulating blood volume causing the heart to beat faster to maintain blood flow and oxygen to the body. A Stop and Watch Early Warning Tool was completed by therapy staff on [DATE] and [DATE]. The [DATE] tool reflected increased nausea and fatigue effects therapy participation and the [DATE] tool reflected did not eat breakfast left knee buckles increased confusion decreased stability decreased transfers and the following words were circled; tired, weak, confused or drowsy and help with walking, transferring, toileting more than usual. The [DATE] tool was given to LPN UM G and the [DATE] tool was given to LPN J. Neither tool had a response written on it and there was no documentation in the nursing progress notes on those dates related to the information on the tool. On [DATE] at 2:04 PM LPN UM G stated she had received the stop and watch tool for Resident #42 on [DATE] and knew the information was an ongoing issue. LPN UM G stated she may have communicated the information to the physician or the NP or put a note in the physicians' book. LPN UM G stated there was not always documentation in the progress notes related to the stop and watch forms. LPN J was not available during the survey. On [DATE] at 5:19 PM DON B stated the stop and watch system was available to all staff to complete for any resident and was to be given to the appropriate nurse. DON B stated the receiving nurse should evaluate the issue, document in the progress notes and notify the physician if necessary. DON B stated there was no formal follow up with the stop and watch form. Multiple staff reported Resident #42 demonstrated a decline in eating, drinking, energy and an increase in weakness over the time she was in the facility particularly in the week before her transfer to the hospital. On [DATE] at 9:45 AM SW D stated she was aware of Resident #42's declining health over the weeks she was at the facility from reports in the morning meeting. SW D also stated the Therapy Department staff had been frustrated that they were not being listened to with their concerns about the Resident not being able to participate fully in her treatment. At 10:10 AM on the same day LPN UM G stated Resident #42 had poor food and fluid intake throughout her whole stay at the facility and was on scheduled nausea medication when LPN UM G had provided care for the Resident. LPN UM G stated the Resident was lethargic and hard to motivate for therapy. LPN UM G did not recall Resident #42 having any vomiting. On [DATE] at 12:23 PM CNA (Certified Nursing Aide) K stated in a telephone interview that Resident #42 initially ate meals ok then about a week later was eating less and got weaker. CNA K stated the only time she saw any vomiting for the Resident was either [DATE] or [DATE]. On the same date at 2:35 PM OT L stated Resident #42 declined physically and mentally in the last week she was in the facility and required a mechanical lift for transfers prompting OT L to fill out a stop and watch form for the nursing staff. During the same interview Physical Therapy Assistant (PTA) M agreed with OT L's assessment of Resident #42. On [DATE] at 8:39 AM during a telephone interview CNA N stated that some time later in her stay at the facility Resident #42 was confused and was barely eating and would say I'm sick, I' m dying, I don't feel good . CNA N stated one night the Resident was taken to the bathroom but was not able to urinate. On the same date at 9:11 AM during a telephone interview Registered Nurse (RN) N stated Resident #42 was always saying she was nauseous. On the same date at 11:55 AM during a telephone interview LPN I stated Resident #42 had nausea and vomiting on and off and swallowing pills started to trigger vomiting later in her stay. ( )

Based on observation, interview, and record review, the facility failed to investigate and report to all approriate parties, including the state agency, sexual abuse of 2 of 10 Residents, reviewed for abuse, (Resident #24 and #25), from a total of 10 sampled Residents, resulting in the lack of investigation and care planning, ongoing, unauthorized consent (via proxy/Responsible Parties) to engage in sexual contact for both Residents, and the potential for physical, mental and psychological harm. Findings include: According to the facility Abuse and Neglect - Clinical Protocol, dated 9/20/12, 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment (bleeding, bruising .swelling, etc.) .d. Vital signs; e. Behavior over last 24 hours .4. The physician and staff will help identify risk factors for abuse .5. along with other staff and management, the Medical Director will help identify situations .inappropriate management of problematic behavior .a. As needed, the physician will evaluate the resident or have them sent for evaluation; for example, to rule out sexual assault .Cause Identification: 1. The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes . Treatment/Protect/Management: 1. The facility management and staff will institute measures to protect and address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 3. The physician will order measures required to address the consequences of an abuse situation, such as s psychological evaluation .Monitoring and Follow-up: 1. The staff and physician will monitor individuals who have been abused at least until their medical condition, mood, and function have stabilized, and periodically thereafter .3. The Medical Director will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process . According to the facility's Abuse Prevention Program Policy and Procedure, dated 10/2012, Our residents have the right to be free from abuse . Timely and thorough investigations of all reports and allegations of abuse. g. The reporting and filing of accurate documents relative to incidents of abuse . According to the facility's Abuse Investigations Policy and Procedure, dated 10/2012, All reports of resident abuse .shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum: a. review the resident's medical record to determine events leading up to the incident; b Interview the person(s) reporting the incident; c. Interview any witnesses to the incident .Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function .f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the resident's roommate, family members .i. Review all events leading up to the alleged incident .4. Witnesses will be required to sign and date any witness report they make .8. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 9. The results of the investigation will be recorded in a report form. 10. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required .within five (5) working days of the reported incident . According to the facility's Reporting Abuse to Facility Management Policy and Procedure, dated 10/2012, .2. All personnel, residents, family members .are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff .Employees .must immediately report any suspected abuse or incidents of abuse to the Administrator .c. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault .Upon receiving reports of physical .abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. (note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident's clothing or linen. Do not take items for the area in which the incident occurred. Call the police immediately) .The person performing the examination must complete a Report Form and obtain a written, signed, and dated statement .Upon receiving information concerning a report of abuse, the Director of Nursing Services will request that a representative of the Social Services Department monitor the resident's reactions to and statements regarding the incident and his/her involvement in the investigation .Unless the resident requests otherwise, the social service representative will give the Administrator and Director of Nursing Services a written report of his/her findings .Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment abuse, neglect, or any other criminal offense shall immediately report .Failure to report such an incident may result in legal/criminal action against the individual(s) withholding such information .Staff members and persons affiliated with this facility shall not knowingly .induce another to fail to report an incident of mistreatment or other offense .Failure to report an incident of mistreatment or other offense .screen reports or withhold information to reporting agencies . Resident #24 resided on the 300 Hall and Resident #25 resided on the 100 Hall at the time of the Survey. Review of Resident #24's MDS/Minimum Data Set, dated dated [DATE], revealed he was an [AGE] year old man, who was admitted to the facility on [DATE], had severe cognitive impairment but no behaviors, did not wander, had no range of motion impairments but needed assistance with transfers and dressing, had a urinary catheter, and [DIAGNOSES REDACTED]. Review of Resident #24's Letters of Guardianship, dated 7/31/15, revealed the court granted RP/Responsible Party H the care, custody, and control of (Resident #24) .with all authority and responsibilities granted and imposed by law on that date. Review of Resident #24's Care Plans revealed he had no Care Plan for behaviors, wandering, or history of intimate and/or sexual contact with other residents. Review of Resident #24's entire Medical Record, including Nursing Notes, Social Service Notes, and Physician Notes, revealed no history of behaviors, wandering, inappropriate, intimate and/or sexual contact with other residents. In an interview, on 12/20/16 at 4:41 PM, DON/Director of Nursing B reported Resident #24 hallucinates. On 12/21/16 at 9:40 AM, this Surveyor observed Resident #24 sitting in his wheelchair alone in the dark, in his room. Resident #24 told this Surveyor, I'm going to breakfast (breakfast was served almost 2 hours earlier). It's about 2 miles from here. My friend went home yesterday. The restaurant is open. I see it out there (pointed out his window). It is full of tables. In a few minutes I'll be going. This Surveyor observed a snow covered courtyard outside his window. Review of Resident #25's MDS, dated [DATE], revealed she was an [AGE] year old woman, who was admitted to the facility on [DATE], with severe cognitive impairment, no behaviors other than wandering, no range of motion impairment but needed assistance with transfers and dressing, and [DIAGNOSES REDACTED]. Review of Resident #25's Determination of Inability to Participate in Medical Treatment Decisions, was signed and dated by 2 physicians by 10/06/16, indicating she was unable to make decisions for herself. And, Resident #25's Designation of Patient Advocate Form, dated 9/28/13, revealed RP G was her Patient Advocate/Responsible Party. Review of Resident #25's Care Plans revealed she had no Care Plan for behaviors, or history of inappropriate, intimate and/or sexual contact with other residents. Review of Resident #25's entire Medical Record, including Nursing Notes, Social Service Notes, and Physician Notes, revealed no history of behaviors, wandering, inappropriate, intimate and/or sexual contact with other residents. Review of a Progress Note, documented 12/02/16 by PA/Physician Assistant P, revealed she was being assessed for a urinary tract infection due to urinary frequency. On 12/21/16 at 9:31 AM, this Surveyor observed Resident #25 come out of her room in her wheelchair, cross the hall, briskly slap LPN/Licensed Practical Nurse N on the buttock, then she smiled and winked at LPN N and said, Hi, Sweetie. LPN N looked at Resident #25 with a puzzled look as Resident #25 quickly went away down the hall. LPN N told this Surveyor she had just started at the facility and had never been assigned to Resident #25 before. On 12/21/16, a Resident who asked to remain anonymous, told this Surveyor she had heard noises in the middle of the night coming from Resident #25's room, that sounded sexual, and had seen Resident #24 coming out of Resident #25's room with his pants down. The anonymous Resident said the man had a catheter, and said she knew Resident #24 and Resident #25 visited each others in each others' rooms during the middle of the night. The anonymous Resident said she told a Nurse Aide (could not remember the name of the Nurse Aide) all about what she told this Surveyor, but the Nurse Aide told her to keep quiet and not to say anything more about it. This anonymous Resident requested her name not be revealed because she was afraid of what would happen, since she was told not to tell anyone what she knew. Review of this anonymous Resident's most recent MDS, revealed she was cognitively intact. On 12/21/16 at 9:55 AM, this Surveyor told Administrator A about the anonymous report above. Administrator A said, That (the male Resident involved) would be (Resident #24). They (Resident #24 and Resident #25) have become fast friends. They are encouraged to be in common areas. They like to hold hands. Administrator A said she had called both guardians and told them about Resident #24 and Resident #25 kissing and holding hands, and They were both ok with it. When asked if she had documented the conversations with the guardians, she said she had not, and wasn't sure of the exact day she had alerted them. Administrator A said there was no need for an Incident Report or to report to the State Agency because both Residents consented to the relationship, and therefore, there was no abuse. In an interview, on 12/21/16 at 10:10 AM, Nurse Aide E reported Resident #24 and Resident #25 are often in the hallway and Activities together, and she heard they supposedly kissed .I did not see him go into her room, but I heard about it one or one and a half weeks ago. He was found with his pants down. When asked if there was anything on the Kardex (Nurse Aide Care Guide) to guide her on how to manage their behaviors, Nurse Aide E said, I don't know. I think it (guidance) was verbal. When asked what she was instructed to do and by whom, she said she was not sure. In an interview, on 12/21/16 at 10:30 AM, Nurse Aide F reported, A Resident (the anonymous Resident) told me (Resident #24 and Resident #25) had sex last week .I told her not to tell people. I went to the Nurse (could not remember which Nurse) and asked what was going on. The Nurse confirmed how we were taking care of it. When asked if she had been instructed to write a witness statement regarding the allegation that she heard, she said no one asked her to write a witness statement. When asked about what instruction was given to her, Nurse Aide F said she was told Resident #24 and Resident #25 had the right to be together and have a relationship. In an interview, on 12/21/16 at 11:09 AM, Nurse Aide M reported, (Resident #25 and Resident #24) recently became friendly. (Resident #25) slapped a Nurse's butt this morning. (Resident #25) is overly friendly. She loves to hug and touch other Residents. I saw them holding hands in the lobby, and the same day I heard they kissed .A little while later (Nurse Aide K) found (Resident #25 and Resident #24) in Resident #25's bathroom .I think he had his pants down. I don't think the Kardex is updated .I was told they are allowed to be together, but keep an eye on them if they are in a room together, and keep the door open. I went directly to (Administrator A) and told her, and she nodded like she already knew. When asked if Residents with severe dementia could make the decision to have an intimate relationship with another Resident for themselves, Nurse Aide M said, It's a very touchy gray area. I was told, just because they have dementia, doesn't mean they can't consent. I didn't think they could. But that's what (Administrator A) told me. I didn't think it was right. Nurse Aide M said she had not heard that Resident #24 had been in Resident #25's room at night, but said They both self-propel (their wheelchairs). Both can stand on their own. (Resident #24) calls (Resident #25) his 'better half'. (Resident #25) calls everyone 'Sweetie'. In an interview, on 12/21/16 at 11:30 AM, Administrator A said, I believe (Resident #24 and Resident #25) have the ability to consent (to their relationship). On 12/21/16 at 12:02 PM, this Surveyor attempted to contact Resident #25's Responsible Party G via phone. A message was left to return the call, but the call was not returned by the end of the Survey. On 12/21/16 at 12:11 PM, Administrator A reported there was no record of the behaviors in either Resident #24 or Resident #25's Medical Records, and neither of the Residents had any Social Work Notes for the past 1 1/2 months. Administrator A was asked if she conducted an investigation to ascertain whether other Residents had been adversely affected by either Resident #24 or Resident #25's behaviors, and she said no such investigation had been conducted. On 12/21/16 at approximately 12:50 PM, Administrator A restated she did not have and Incident/Accident or Unusual Occurrence Report, and denied that anyone had told her Resident #24 was found with his pants down in the presence of Resident #25. At 11:58 AM, Administrator A said ( Resident #24 and Resident #25), as of right now, are being supervised. On 12/21/16 at 12:17 PM, DON B said I remember it being reported to me - kissing. I didn't document. I Immediately reported it to (Administrator A), who is the Abuse Coordinator. At that time it was reported (Resident #24) was witnessed kissing (Resident #25) and she allowed it to happen. A (Nurse Aide - couldn't remember which one) told me. No, I did not ask her to write a Witness Statement because I handed it to (Administrator A). (Nurse Aide K), came to me on a separate day and said we wanted to know if we knew (Resident #24) was visiting (Resident #25). I told her 'Yes, (Administrator A) is aware of it, it was investigated, and they ae allowed to have that relationship. Both families were notified. (Nurse Aide K) was disgusted. She told me someone found them in the bathroom after the kissing. I told her to take her concerns to (Administrator A). I was told the families were consenting to the relationship, but there is no evidence the families consented. DON stated it was the responsibility of Nursing and Social Services to develop a Care Plan and Kardex for the incidents. DON B also stated she was aware they were found in the bathroom and Resident #25's pants were down. When asked if a physical assessment was done on either Resident after they were found alone in the bathroom, DON B said, I don't know .(Administrator A) said they were allowed to have sexual relations . When asked if she told Administrator A Resident #24 was found with his pants down, DON B said, Yes, she was aware. I believe she interviewed both Residents. I believe it needed to be reported accordingly, but there was a decision made that they were ok to have relations. When asked if the situation had been discussed at a Team Meeting, DON B said we talked about what happened in one Morning Meeting. DON B said no plan was formulated at the Team Meeting, and denied any knowledge of Resident #24 and Resident #25 meeting in each others' rooms during the night. In an interview, on 12/21/16 at 11:56 AM, Activities Director O said there had been some situations where they (Resident #24 and Resident #25) had to be separated during Activities because of their behaviors together. In an interview, on 12/21/16 at 2:02 PM, Activities Aide I reported, During a Childrens' concert (on 12/14/16 at 10:30 AM) .I did not document . I talked to (Administrator A), (Resident #24 and Resident #25) were kissing and holding hands. The kiss was closed mouthed for about 5 seconds. They were talking sweet-talk; tenderness in a romantic way. They want to go to her room all the time and want me to close the door. The next incident was the next day (12/15/16). Resident #24 was talking loudly during the Activity and I needed to take him out. (Resident #25) got very upset that they were being separated. I took them together. She wanted to go into her bathroom and so did he. I told them (Resident #24) 'can't'. That upset her. I helped them sit together (in the Lobby). They wanted to be alone in her room and have the door shut. They are very romantic. They have a romantic relationship. When asked if their relationship was sexual, Activities Aide I said, Yes, and he calls her his girlfriend . When asked if 2 Resident with severe dementia can give consent for a sexual relationship, Activities Aide I said, No, they cannot consent. I think you should use your own judgement. I think it is inappropriate for them to be alone in their room. There is a real potential for them to have sexual relations. They can't be alone together at night or with the door shut. When asked if she had been asked to write a witness statement, she said, (Administrator A) did not ask for one. I think it is important for us to know what to do. Is it ok to let them kiss? Monitoring/chaperoning seems like what should be done. I found them alone in her room that afternoon. This Monday (12/19/16) they were alone holding hands in her room and asked me to close the door. I did not report that. On 12/21/16 at 1:53 PM, this Surveyor attempted to interview Nurse Aide J via phone, and left a voice message. The call was returned at 2:30 PM. During the interview, Nurse Aide J said, Last week, I knocked on (Resident #25's) door, walked in, and they (Resident #24 and Resident #25) were together with door closed. I told them they were not supposed to be alone in the room together doing fooling around stuff. Both were in the bathroom standing up. His shirt was unbuttoned. His pants were zipped down (had his adult brief on). She was exposed from her waist down. I took them out of the room. (Resident #25) said 'I want him out. I don't want to see him again'. She said she felt attacked, and said, He was touching me and I didn't like that. I told (Nurse Aide M) and the Nurse - I don't know her name; it was the first time she had been on the Hall. No one asked me to write a witness statement. I told (DON B) the whole thing and she went to (Administrator A). I asked (DON B) if it was ok for them to do that, but I haven't gotten ay answer back. When asked if a Nurse came to examine either Resident #24 or Resident #25, Nurse Aide J said no one came to examine them, and added, (Resident #24) was seeking (Resident #25) out for the next couple of days. We CNAs (Nurse Aides) decided to try to keep them apart. We didn't get any instruction. Another day (could not remember which day), I walked in on them, and (Resident #24's) brief was actually down that day. In an interview, on 12/21/16 at 2:41 PM, Nurse Aide K reported, On 12/08/16, I think about 6:15 PM, the door was closed and I opened it just a little. I peeked in and listened to what was happening. I saw Resident #24 with his jeans down to his ankles. Resident #25 was saying, 'Let me help you put your clothes back on. My kids might be coming up. I left them alone together, and told the Nurse (not sure which Nurse). Earlier in the day, I witnessed them kissing in the hallway on the lips. They smiled like kids in a candy store .No one asked for a witness statement. In an interview, on 12/21/16, SW/Social Worker D reported the relationship between Resident #24 and Resident #25 was described to her as a romantic friendship, 'Maybe in a morning meeting by (Administrator A). Today is the first time I heard it went further. When asked if 2 Residents with severe dementia could consent to a romantic, physical relationship, SW D said, You must take feelings into account. If (Resident #25) didn't want (Resident #24) in her room, she would have kicked him out .If the guardians are ok, we have to follow their wishes. I was told (Resident #25's) son said it was ok they were friendly. On 12/21/16 at 12:12 PM, this Surveyor attempted to interview Resident #24's RP H via phone, and left a voice message. The call was returned at 3:08 PM. During the interview, RP H said he was told, about a week and a half ago, during a meeting at the facility, that Resident #24 had walked into a female Resident's room back in November, 2016. RP H denied that anyone at the facility reported to him Resident #24 had been holding hands or kissing another Resident, and said, There was no discussion about kissing. RP H said he was not totally shocked that Resident #24 had been kissing a female Resident because Resident #24 had a history of [REDACTED]. RP H said he had no knowledge of Resident #24 going into Resident #25's room and exposing himself or touching any female residents in a sexual manner. RP H said, Now, about that, I'm shocked. What am I supposed to do? Should I call the facility? In a telephone interview, on 12/21/16 at 3:34 PM, Resident #24 and Resident #25's facility physician/MD/Medical Director L reported he had no knowledge of the relationship between Resident #24 and Resident #25 until it was brought to his attention that morning by his PA/Physician Assistant P. When asked what his understanding was regarding 2 Residents with severe dementia being able to consent to a romantic/sexual relationship, he said, You have to get the guardians involved. Keep the patients separate for their own protection. Implement the facility Policies and Procedures. If appropriate, make a plan for them to be able to be alone. Discuss and involve the Plan of Care with the families and Care Givers. Make sure no one has been abused. It is a collaborative with all parties. Make a plan and limit their time alone. When the above interviews were shared with MD L, he said, We have an issue. I will be at the facility next week, and will talk with them (staff). Due to time constraints, all facility video surveillance could not be reviewed, but on 12/21/16 at 3:47 PM, in the presence of Maintenance Director C, this Surveyor observed Resident #24 and Resident #25 entering Resident #25's room and remained there unattended on 12/08/16 from 6:44 PM - 6:58 PM (14 minutes) and on 12/19/16 from 1:47 PM - 2:09 PM (22 minutes). In an interview, on 12/21/16 at 5:24 PM, Administrator A looked puzzled when asked if she had reported or discussed the issues with Residents #24 and #25 with MD L. Administrator A said she had discussed the issues all day, with Regional Director of Operations Q, but had not discussed it with the MD L. Administrator A said today she learned she should document everything, but it was, still a gray area for what we can allow them (Resident #24 and Resident #25) to do. ( )

Based on observation, interview, and record review, the facility failed to protect from mistreatment and neglect for 1 of 15 residents (Resident #10) reviewed for abuse, from a total of 15 Sampled Residents, resulting in anxiety, fear, anger, and the potential for [MEDICATION NAME] psychological and physical harm. Findings include: According to the facility's Abuse Prevention Program Policy and Procedure, dated 10/2012, Our residents have the right to be free from abuse, neglect .Employees .must immediately report any suspected abuse or incidents of abuse to the Administrator .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Verbal abuse is defined as any use of oral .or gestured language that willfully includes disparaging and derogatory terms to residents .to describe residents .Involuntary seclusion is defined as separation of a resident .or confinement to his or her room .against the resident's will .Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . According to the MDS/Minimum Data Set, dated dated [DATE], Resident #10 was admitted to the facility on [DATE], was a cognitively intact [AGE] year old woman with [DIAGNOSES REDACTED]. According to a Nursing Progress Note, dated 10/17/16 at 7:26 PM, Resident mood very down, sad and tearful. Expressing feelings of futility and anger over her situation . According to a Wound Center report, dated 10/20/16 (not timed), Resident #10 was a 20 yo (year old) female who for some reason sustained a gun shot late April to where she was left paralyzed. She has a permanent foley catheter, [MEDICAL CONDITION] bag, [MEDICAL CONDITION] and PICC line for antibiotics. She has a stage IV wound on her sacrum which is being treated with a wound vac. According to the mother she has been at (another facility, then the hospital, then another facility) for rehabilitation .She was pregnant when shot and the baby was delivered early and is 5 months old. Her mental status is intact . According to eDoctors, Wound Care Centers, 2016, a wound vac/vacuum is a vacuum-assisted drainage to remove blood or serous fluid from a wound or operation site .Vacuum-assisted closure is a closed system that requires a change of dressing only every 48 hours. Limiting exposure to the wound results in a lower risk of infection and reduces the need for materials and qualified personnel. <http://www.woundcarecenters.org/article/wound-therapies/vacuumassisted-closure> Review of Resident #10's Physician Orders, dated 10/03/16, revealed an active order for [MEDICATION NAME] (antibiotic) HCL in [MEDICATION NAME] Solution 750 mg/150 mL to be infused two times a day for Infection since 10/03/16, and Piper-Taz 3.375 gm/100ml NS (IV antibiotic) at 3:00 AM, 9:00 AM, 3:00 PM, and 9:00 PM since 9/29/16 for her sacral pressure ulcer, and review of her October 2016 TAR/Treatment Administration Record revealed she was to have the wound vac dressing changed and reapplied on Monday, Wednesday, and Saturday, but it was not documented as being changed/applied between 10/11/16 - 10/27/16. Review of Resident #10's October 2016 electronic TAR/Treatment Administration Record revealed she had an order for [REDACTED]. On 10/17/16 at 8:08 AM, this Surveyor observed Resident #10 laying in bed with her eyes open, but her affect was very flat. Resident #10 refused breakfast and juice that was offered by Nurse Aide P. This Surveyor asked Resident #10 if she slept last night, and she replied, Only a little, then closed her sad eyes. This Surveyor noted Resident #10 had a puff operated call light near her mouth, and did not move any of her limbs, only her eyes and mouth. After the above observation, review of Resident #10's Nursing Progress Notes, a Note dated 10/24/16 at 7:18 AM revealed LPN/Licensed Practical Nurse I documented, .Since resident has been moved to (name of provider group), she has been loud, disrespectful to other residents and staff; calling out HELP for changing her TV station. When writer asked her why she doesn't use her call light, she told me to shut the f*ck up! Resident plays games to get what she wants when she wants it. If she has medication due, she will tell staff to scratch her head, wipe her eyes, etc .then she will take her medication. Everything resident asks for is common care for someone that cannot do it themselves. Resident has lied and told CNA's (Nurse Aides) that writer would not change her head/neck pillow when writer did. Resident telling staff that I touched my name tag and voiced, Nurses don't do that. This writer had never refused a resident care and have never touched my name tag .Attempted to talk to resident in regard to using call light without success, closed door 1/2 way as other residents were in the lobby talking about her behavior. As writer attempted to enter room to flush PICC line, she voiced, get the f*ck out of here and don't come back in.Resident needs to be moved back to Beaches Unit as she does not want this writer in her room. In an interview, on 10/27/16 at approximately 10:00 AM, Administrator A reported she was aware of potential abuse regarding LPN I's interaction with Resident #10 on 10/25/16, said she had begun an investigation, and had reported to the State agency, but had not spoken to/interviewed Resident #10 about the incident. Review of the investigative file revealed the following witness statement from Nurse Aide P: On the morning of 10/24/16, I heard (Resident #10) yelling from her bed and was visibly upset. I asked (Resident #10) what was wrong and she stated that (LPN I) heard her yelling for help and came into her room, told her she didn't need help and to shut up. (Resident #10) then stated (LPN I) tried to shut the door instead of helping her. (Resident #10) stated she wanted to talk with the administrator and did not want (LPN I) back in her room again. I told (Resident #10) that that was her right and I would see to it that she didn't come back in her room and when the administrator came in for the day, I would tell her what happened and that she wanted to talk to her. When I went to walk out of the room, (LPN I) walked in. I told (LPN I) that (Resident #10) had stated she did not want her in her room anymore and to please leave (LPN I) put a smile on her face and walked around me, toward (Resident #10). (LPN I) asked (Resident #10), with the smile on her face, 'You don't want me in your room?!? Why?!?' (Resident #10) started yelling at (LPN I), saying Because you tried to shut the door on me!! (LPN I) then turned back around and was laughing under her breath while walking out of (Resident #10's) room. I asked (Resident #10) what she originally needed, ans she stated she needed to be suctioned and couldn't breathe. I told the other nurse, (LPN G) that she needed to be suctioned, then I checked her oxygen level which it was at an 88% (sic). According to Mayo Clinic, 2016, Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath .Hypoxemia is determined by measuring the oxygen level in a blood sample taken from an artery (arterial blood gas). It can also be estimated by measuring the oxygen saturation of your blood using a pulse oximeter - a small device that clips to your finger .Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low.<http://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/SYM- 930> According to John(NAME)Medicine, 2016, Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. Suctioning should be considered: · Any time the patient feels or hears mucus rattling in the tube or airway · In the morning when the patient first wakes up · When there is an increased respiratory rate (working hard to breathe) · Before meals · Before going outdoors · Before going to sleep · <http://www.hopkinsmedicine.org/[MEDICAL CONDITION]/living/suctioning.html> In an interview, on 10/27/16 at 12:06 AM, Nurse Aide P reported she wrote the above witness statement just that morning (10/27/16) upon Administrator A's request that morning (10/27/16). When asked about the incident on 10/24/16, Nurse Aide P said, I heard (Resident #10) yelling .she doesn't like the puffer (call light) .(Resident #10) told me 'I don't know who that nurse is, but I don't want her in here; she told me to shut up and then closed the door, I don't want her back in my room. (Resident #10) was all ramped up, she said she wanted to talk to the Administrator. (Resident #10) said, 'I need to be suctioned, I can't breathe. (LPN I) walked in. I told her not to come in. I stopped her .said, 'Please leave'. LPN I got a really weird smile on her face and went to (Resident #10's) bed. (Resident #10) started cussing at (LPN I), 'You shut the door on me. I needed help.' (LPN I) started laughing. I told her, 'Please leave'. (LPN I) said, 'I didn't shut the door, it didn't latch'. I was very upset. When asked if she ever knew Resident #10 to make false statements or exaggerate, Nurse Aide P said, I have never known her to exaggerate. She can't move anything, except, sometimes her head. She can't even blow her nose. When asked about her experience with LPN I, Nurse Aide P stated, She is not a very good nurse. No one likes her. Earlier in the shift, another Nurse Aide (BB) asked her to help her with patient care, and she told her no. (Nurse Aide BB) told me LPN I told her she didn't like (Resident #10's) real name because it sounded ghetto, and refused to call her by her real name In an interview, on 10/27/16 at 2:10 PM, SW/Social Worker D reported she was Resident #10's assigned Social Worker, but had not talked to Resident #10 about the incident to assess her emotional well-being because she didn't know about it. SW D said, (Administrator A) asked me to interview other residents to see if they had any complaints of abuse by the night shift staff. In a telephone interview, on 10/27/16 at 3:10 PM, LPN I denied making any derogatory statements about Resident #10, denied refusing to suction Resident #10, denied shutting the door on Resident #10, denied that Resident #10 told her to get out, denied that Nurse Aide P told her to leave Resident #10's room, and said she was never in Resident #10's room with Nurse Aide P at any time. When further queried, LPN I told this Surveyor Resident #10 asked to be suctioned but she told her she did not, because she had [AGE] years experience, and I know when someone needs to be suctioned. LPN I said she told Resident #10 it was important not to be suctioned too often. When asked how many times Resident #10 had asked to be suctioned that shift, LPN I said, That was the first time she asked me to suction her. In a telephone interview, on 10/27/16 at 2:35 PM, LPN G reported she was in the hallway passing medications when, I heard the whole exchange .I heard (Nurse Aide P) tell (LPN I) 'You don't shut the door on the residents .You tried to shut the door on her'. I heard (Nurse Aide P) tell (LPN I) to get out. When asked if she went in and stopped LPN I, LPN G said, No, I went in when I was done with passing the meds. I did not go in right away. I wanted (LPN I) to get what was coming to her. She is not a nice person. She was calling (Resident #10) a b*tch and saying what an awful person she was in report. I worked with (Resident #10) before and never had a problem and never heard of anyone else having a problem with her. It was wrong what (LPN I) did. (Resident #10) was upset when I went in, I apologized for (LPN I's) behavior. I was trying to make it up to her. She asked me to call her mother. I was there when she spoke to her mother and told her what happened. She told her mother, 'I was coughing and I told the nurse I needed to be suctioned . LPN G said, The night shift nurse CC told me she's had a lot of (resident) complaints about (LPN I). When asked if LPN I had abused Resident #10, LPN G said, Yes, seclusion, verbal, emotional, and neglect. (LPN I) never put Resident #10's wound vac on. LPN I worked Saturday and Sunday, and the wound vac was supposed to be put on Saturday (10/22/16). It was still off when I got her on Monday (10/24/16). The wound was bleeding a lot. LPN I said she didn't have enough time to do it (put the wound vac on). In an interview, on 10/27/16 at 4:49 PM, Nurse Aide T reported she was assigned to Resident #10 over the weekend (10/22/16 and 10/23/16), knew Resident #10 was supposed to have her wound vac on Saturday and Sunday, but did not. Nurse Aide I said, (LPN I said she did not have time. She told me that right in front of (Resident #10), and (Resident #10) said she needed it back on. Nurse Aide T said she knew Resident #10 was being neglected, but she did not recognize that as abuse, and did not think it was her place to call DON/Director of Nursing B. This Surveyor attempted to interview the other 12 hour shift nurse that was assigned to Resident #10 the weekend of 10/22-10/23/16, but was unable to do so because she was on a medical leave of absence. This Surveyor attempted to interview Resident #10 on 10/27/16 at approximately 12:00 PM, but she was out to the Wound Center, and attempted again at 2:06 PM, 4:00 PM, 5:03 PM but was unable to do so because she was sleeping soundly. In addition, during an Abuse Prevention interview, on 10/26/16 at 11:19 AM, DON/Director of Nursing B was asked if she knew what a Catastrophic Reaction was, and stated she did not know what a Catastrophic Reaction was. ( )

Based on observation, interview, and record review, the facility failed to protect from involuntary seclusion, and verbal, emotional, and psychological abuse for 1 of 15 residents (Resident #10) reviewed for abuse, from a total of 15 Sampled Residents, resulting in anxiety, fear, anger, and the potential for [MEDICATION NAME] psychological harm. Findings include: According to the facility's Abuse Prevention Program Policy and Procedure, dated 10/2012, Our residents have the right to be free from abuse .and involuntary seclusion . Employees .must immediately report any suspected abuse or incidents of abuse to the Administrator .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Verbal abuse is defined as any use of oral .or gestured language that willfully includes disparaging and derogatory terms to residents .to describe residents .Involuntary seclusion is defined as separation of a resident .or confinement to his or her room .against the resident's will .Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services According to the MDS/Minimum Data Set, dated dated [DATE], Resident #10 was admitted to the facility on [DATE], was a cognitively intact [AGE] year old woman with [DIAGNOSES REDACTED]. According to a Nursing Progress Note, dated 10/17/16 at 7:26 PM, Resident mood very down, sad and tearful. Expressing feelings of futility and anger over her situation . According to a Wound Center report, dated 10/20/16 (not timed), Resident #10 was a 20 yo (year old) female who for some reason sustained a gun shot late April to where she was left paralyzed. She has a permanent foley catheter, [MEDICAL CONDITION] bag, [MEDICAL CONDITION] and PICC line for antibiotics. She has a stage IV wound on her sacrum which is being treated with a wound vac. According to the mother she has been at (another facility, then the hospital, then another facility) for rehabilitation .She was pregnant when shot and the baby was delivered early and is 5 months old. Her mental status is intact . According to eDoctors, Wound Care Centers, 2016, a wound vac/vacuum is a vacuum-assisted drainage to remove blood or serous fluid from a wound or operation site .Vacuum-assisted closure is a closed system that requires a change of dressing only every 48 hours. Limiting exposure to the wound results in a lower risk of infection and reduces the need for materials and qualified personnel. <http://www.woundcarecenters.org/article/wound-therapies/vacuumassisted-closure> On 10/17/16 at 8:08 AM, this Surveyor observed Resident #10 laying in bed with her eyes open, but her affect was very flat. Resident #10 refused breakfast and juice that was offered by Nurse Aide P. This Surveyor asked Resident #10 if she slept last night, and she replied, Only a little, then closed her sad eyes. This Surveyor noted Resident #10 had a puff operated call light near her mouth, and did not move any of her limbs, only her eyes and mouth. After the above observation, review of Resident #10's Nursing Progress Notes, a Note dated 10/24/16 at 7:18 AM revealed LPN/Licensed Practical Nurse I documented, .Since resident has been moved to (name of provider group), she has been loud, disrespectful to other residents and staff; calling out HELP for changing her TV station. When writer asked her why she doesn't use her call light, she told me to shut the f*ck up! Resident plays games to get what she wants when she wants it. If she has medication due, she will tell staff to scratch her head, wipe her eyes, etc .then she will take her medication. Everything resident asks for is common care for someone that cannot do it themselves. Resident has lied and told CNA's that writer would not change her head/neck pillow when writer did. Resident telling staff that I touched my name tag and voiced, Nurses don't do that. This writer had never refused a resident care and have never touched my name tag .Attempted to talk to resident in regard to using call light without success, closed door 1/2 way as other residents were in the lobby talking about her behavior. As writer attempted to enter room to flush PICC line, she voiced, get the f*ck out of here and don't come back in.Resident needs to be moved back to Beaches Unit as she does not want this writer in her room. In an interview, on 10/27/16 at approximately 10:00 AM, Administrator A reported she was aware of potential abuse regarding LPN I's interaction with Resident #10 on 10/25/16, said she had begun an investigation, and had reported to the State agency, but had not spoken to/interviewed Resident #10 about the incident. Review of the investigative file revealed the following witness statement from Nurse Aide P: On the morning of 10/24/16, I heard (Resident #10) yelling from her bed and was visibly upset. I asked (Resident #10) what was wrong and she stated that (LPN I) heard her yelling for help and came into her room, told her she didn't need help and to shut up. (Resident #10) then stated (LPN I) tried to shut the door instead of helping her. (Resident #10) stated she wanted to talk with the administrator and did not want (LPN I) back in her room again. I told (Resident #10) that that was her right and I would see to it that she didn't come back in her room and when the administrator came in for the day, I would tell her what happened and that she wanted to talk to her. When I went to walk out of the room, (LPN I) walked in. I told (LPN I) that (Resident #10) had stated she did not want her in her room anymore and to please leave (LPN I) put a smile on her face and walked around me, toward (Resident #10). (LPN I) asked (Resident #10), with the smile on her face, 'You don't want me in your room?!? Why?!?' (Resident #10) started yelling at (LPN I), saying Because you tried to shut the door on me!! (LPN I) then turned back around and was laughing under her breath while walking out of (Resident #10's) room. I asked (Resident #10) what she originally needed, ans she stated she needed to be suctioned and couldn't breathe. I told the other nurse, (LPN G) that she needed to be suctioned, then I checked her oxygen level which it was at an 88% (sic). In an interview, on 10/27/16 at 12:06 AM, Nurse Aide P reported she wrote the above witness statement just that morning (10/27/16) upon Administrator A's request that morning (10/27/16). When asked about the incident on 10/24/16, Nurse Aide P said, I heard (Resident #10) yelling .she doesn't like the puffer (call light) .(Resident #10) told me 'I don't know who that nurse is, but I don't want her in here; she told me to shut up and then closed the door, I don't want her back in my room. (Resident #10) was all ramped up, she said she wanted to talk to the Administrator. (Resident #10) said, 'I need to be suctioned, I can't breathe. (LPN I) walked in. I told her not to come in. I stopped her .said, 'Please leave'. LPN I got a really weird smile on her face and went to (Resident #10's) bed. (Resident #10) started cussing at (LPN I), 'You shut the door on me. I needed help.' (LPN I) started laughing. I told her, 'Please leave'. (LPN I) said, 'I didn't shut the door, it didn't latch'. I was very upset. When asked if she ever knew Resident #10 to make false statements or exaggerate, Nurse Aide P said, I have never known her to exaggerate. She can't move anything, except, sometimes her head. She can't even blow her nose. When asked about her experience with LPN I, Nurse Aide P stated, She is not a very good nurse. No one likes her. Earlier in the shift, another Nurse Aide (BB) asked her to help her with patient care, and she told her no. (Nurse Aide BB) told me LPN I told her she didn't like (Resident #10's) real name because it sounded ghetto, and refused to call her by her real name In an interview, on 10/27/16 at 2:10 PM, SW/Social Worker D reported she was Resident #10's assigned Social Worker, but had not talked to Resident #10 about the incident to assess her emotional well-being because she didn't know about it. SW D said, (Administrator A) asked me to interview other residents to see if they had any complaints of abuse by the night shift staff. In a telephone interview, on 10/27/16 at 3:10 PM, LPN I denied making any derogatory statements about Resident #10, denied refusing to suction Resident #10, denied shutting the door on Resident #10, denied that Resident #10 told her to get out, denied that Nurse Aide P told her to leave Resident #10's room, and said she was never in Resident #10's room with Nurse Aide P at any time. When further queried, LPN I told this Surveyor Resident #10 asked to be suctioned but she told her she did not, because she had [AGE] years experience, and I know when someone needs to be suctioned. LPN I said she told Resident #10 it was important not to be suctioned too often. When asked how many times Resident #10 had asked to be suctioned that shift, LPN I said, That was the first time she asked me to suction her. In a telephone interview, on 10/27/16 at 2:35 PM, LPN G reported she was in the hallway passing medications when, I heard the whole exchange .I heard (Nurse Aide P) tell (LPN I) 'You don't shut the door on the residents .You tried to shut the door on her'. I heard (Nurse Aide P) tell (LPN I) to get out. When asked if she went in and stopped LPN I, LPN G said, No, I went in when I was done with passing the meds. I did not go in right away. I wanted (LPN I) to get what was coming to her. She is not a nice person. She was calling (Resident #10) a b*tch and saying what an awful person she was in report. I worked with (Resident #10) before and never had a problem and never heard of anyone else having a problem with her. It was wrong what (LPN I) did. (Resident #10) was upset when I went in, I apologized for (LPN I's) behavior. I was trying to make it up to her. She asked me to call her mother. I was there when she spoke to her mother and told her what happened. She told her mother, 'I was coughing and I told the nurse I needed to be suctioned . LPN G said, The night shift nurse CC told me she's had a lot of (resident) complaints about (LPN I). When asked if LPN I had abused Resident #10, LPN G said, Yes, seclusion, verbal, emotional, and neglect. (LPN I) never put Resident #10's wound vac on. LPN I worked Saturday and Sunday, and the wound vac was supposed to be put on Saturday (10/22/16). It was still off when I got her on Monday (10/24/16). The wound was bleeding a lot. LPN I said she didn't have enough time to do it (put the wound vac on). This Surveyor attempted to interview the other 12 hour shift nurse that was assigned to Resident #10 the weekend of 10/22-10/23/16, but was unable to do so because she was on a medical leave of absence. This Surveyor attempted to interview Resident #10 on 10/27/16 at approximately 12:00 PM, but she was out to the Wound Center, and attempted again at 2:06 PM, 4:00 PM, 5:03 PM but was unable to do so because she was sleeping soundly. ( )

Based on observation, interview, and record review, the facility failed to prevent a fall with injury for 1 (#7) of 7 residents reviewed with falls and failed to assess range of motion following a fall in 1 (#21) supplemental resident, in a total sample of 17 residents, resulting in a fracture (#7) and the potential for injury (#21). Findings include: The nurse practicer's Progress Note dated 7/10/15 revealed Resident #7 had worsening Alzheimer's and needs a lot of supervision, very forgetful and past medical history included depression, begin prostate hyperplasia (BPH), osteoarthritis, and anemia. The same note, under Analysis/Plan indicated to monitor for safety. Resident #7's cognition was moderately impaired and required extensive assist (staff provided weight bearing support) for transfers and dressing, as assessed in the most recent Minimum Data Set (MDS), dated [DATE]. In the fall investigation titled Falls Checklist dated 2/26/15, indicated Resident #7 fell on [DATE] at 1:50 a.m. and under recreation of last three hours before fall and the witness investigation statement the CNA assigned to Resident #7 documented Resident #7 called for assistance concerning his IV (intravenous therapy, catheter placed within a vein for infusion of liquids that may be used for hydration) 2 times prior to the fall and the CNA indicated that Resident #7 requested that his IV be unhooked; the CNA explained to Resident #7 that he still had some fluids left in the IV bag and the nurse would take care of it. The CNA's note continued to reveal Resident #7 became agitated and laid down in his while the CNA went to get the nurse. The same note indicated that the CNA heard a noise and found Resident #7 in his room on the floor with the IV pulled out. The Witness Investigation Statement dated 2/26/15 at 1:50 a.m. written by the Registered Nurse revealed Resident #7 was observed lying on the floor next to the bed with the IV pulled out of his left hand, blood was noted all over the bed, Resident #7, the floor and bedside table. The same statement indicated Resident #7 had a goose egg on the left side of his head that was bleeding, that he seemed confused and stated he was trying to get up. In the fall investigation, under Root Cause of Fall, Resident #7 had increased confusion from baseline. The Progress Notes dated 2/27/15 (no time), in an interdisplinary team note (IDT), indicated the root cause of Resident #7's fall was agitation with the IV and impulsive behaviors, the intervention was to discontinue the IV. The same note did not reveal any consideration to encourge Resident #7 to increase his fluid intake or to monitor intake and output. The fall investigation titled Falls Checklist dated 2/26/15 did not indicate any consideration to encourge Resident #7 to increase his fluid intake or to monitor intake and output. According to the Interdisciplinary Team's Progress Notes dated 4/2/15 (no time), Resident #7 was found of the floor in his room hanging on the the enabler bars, Resident #7 had attempted to self transfer from his wheelchair to his bed. The same note indicated the root cause of the fall was the resident's continued non-compliance with his call light due to his dementia, impulsivity and attention seeking behaviors. The Falls Investigation dated 6/19/15 at 8:40 a.m., revealed Resident #7 was in the laundry room and according to the Certified Nurse Assistant's (CNA) statement, Resident #7 stated his shirt had become wet during breakfast so he put it in the dryer, when he stood up he did not have his wheelchair locked and he fell . The progress notes dated 6/22/15, revealed the fall team updated the care plan to reflect re-education of the resident to ask for assistance with his laundry needs. The was no indications that an anti-roll back device for the wheel chair had been considered. Resident education had previously been found to be ineffective due to dementia. According to a Witness Investigation Statement, Resident #7 fell on [DATE] at 1:10 p.m. The same investigation indicated Resident #7 was ambulating in the hallway looking for someone to empty his catheter bag and staff turned resident to go back to his room and lowered Resident #7 to the floor. According to the Interdisciplinary falls note dated 6/25/15, Resident #7's walker was removed from his room and he was re-educated on his ambulatory status. Re-education has been shown to be an ineffective fall prevention intervention for Resident #7. The incident report (no title) dated 7/10/15 at 6:50 p.m., indicated Resident #7 fell in front of the toilet when attempting to transfer self from the toilet to the wheelchair and sustained a laceration to his head. The attached investigation titled Quality Assessment & Assurance Investigation Report revealed Resident #7 hit his head on his wheelchair following the fall and resulted in a laceration to the head and right elbow. The same report indicated a stop sign to ask for assistance would be placed on Resident #7's bathroom door. The incident report (no title) and attached investigation dated 9/30/15, at 9:00 p.m. revealed Resident #7 fell in the bathroom after being left alone on the toilet by staff. The same attached investigation included a witness statement from the CNA assigned to Resident #7, indicating she had transferred Resident #7 to the toilet and went to answer another light and when she came back to Resident #7 he was in a sitting position with back against the toilet on the floor. The same statement indicated the CNA whom initially helped transfer Resident #7 to the toilet had went home sick. The same fall investigation indicated Resident (#7) should not have been left alone in bathroom. According to the incident report (no title) date of incident 10/8/15 at 10:10 a.m., Resident #7 was found face down on the floor in his room with blood spurting from forehead laceration and was transferred to the hospital. The same report indicated Resident #7 stated he had been trying to take his shoes off and in the attached investigation report under Statement of Witness Continued, Resident #7 reported his head and neck hurt. The fall investigation attached to the incident report (no title) date of incident 10/8/15, under the title Recreation of Last Three Hours Before Fall, revealed Resident #7's CNA emptied Resident #7's catheter in his room at 9:00 a.m. and Resident #7 was messing with his shoes. The fall investigation attached to the incident report (no title) date of incident 10/8/15, under statement of witness continued indicated Resident #7 had red gripper socks on and stated he was taking his shoes off and leaned over to far in his wheelchair prior to the fall. Review of chart and time line of falls for Resident (Resident #7's name), attached to the incident report (no title) date of incident 10/8/15 at 10:10 a.m.; Resident #7 fell 14 times between 8/7/14 to 10/9/15, and 11 falls had occurred in resident's room while alone. The same review revealed all falls have occurred because it appears that resident does not lock wheel chair locks and all falls occurred because resident was attempting to do self-care and either would not or could not remember to use call light and wait for assistance. The same review indicated that upon return from hospital resident will be re-assessed for any and all appropriate intervention . The Admission History and Physical dated 10/18/15, revealed Resident #7's fall on 10/8/15 resulted in an inoperable C 1 cervical (neck) fracture and was placed in a Miami J collar (neck brace for immobilization, purpose is to keep the neck and spine straight for healing by supporting the neck bones). The same assessment indicated Resident #7 had worsening dysphagia because of the neck collar and required an nasogastric tube (plastic tube inserted through the nose to the stomach) for nutrition, but had advanced to a dysphasia 1 (pureed food) diet prior to readmission to the facility. The same History and Physical indicated Resident #7 had some head and neck pain and complained of discomfort from the catheter (urinary) .but this is a usual complaint for him. Nurse's Notes dated 10/16/15, revealed Resident #7 must remain in a Miami J collar brace at all times. Fall/Injury Assessment: Prevention and Management Care Plan with due date of 1/16/16, indicated Resident #7 required non-skid socks and anti-tip bars on the wheelchair. The same care plan, under Resident Supervision close visual supervision was not checked as a necessary intervention. The same fall care plan did not indicate an anti-roll back device for Resident #7's wheelchair, as this was not checked. The Director of Nursing (DON) B, was interviewed in the DON office on 11/5/15 at 8:30 a.m. and stated they had never tried using an alarm or one to one supervision for Resident #7's fall prevention interventions. Staff B was asked if the fall team considered if Resident #7's feet were possibly to hot with both gripper socks and shoes on at the same time, following the fall on 10/8/15 and Staff B said no. Staff B stated Resident #7 had an anti-roll back device and anti-tip bars on his wheelchair. Following the interview, staff B and this writer observed Resident #7 in his room and sitting in his wheelchair and Staff B confirmed there were no anti-tip bars or anti-roll back devices on Resident #7's wheelchair. ( ) Resident #21 According to Resident #21's MDS/Minimum Data Set, dated dated [DATE], she was admitted to the facility on [DATE] from the hospital, was cognitively intact, weighed 278 pounds, and had [DIAGNOSES REDACTED]. According to the nursing Admission Assessment, dated 10/17/15, Resident #21 had a history of [REDACTED]. During a tour of the facility with Maintenance Director C on 11/05/15 at approximately 9:10 AM, Resident #21 was heard yelling for help and was observed next to her bed, on the floor on her back with her head resting on the lower rung of her walker. Resident #21 stated, I just kind of bumped my head. I fell . I slipped right off my walker .I didn't have my breaks locked . There was a sign taped on the handle bars of Resident #21's walker that read, Reminder to lock breaks. This Surveyor observed nursing staff assess vital signs and neuro checks prior to moving Resident #21 with a mechanical lift to from the floor to bed. ADON/Assistant Director of Nursing M was present and this Surveyor asked ADON about whether it was protocol for nursing staff to perform range of motion on a resident that had fallen prior to moving them. ADON M said, No, they didn't do range of motion. Well, (Resident #21) not complaining of any pain. This Surveyor asked LPN/Licensed Practical Nurse LL (the nurse who assessed Resident #21) if she knew what Resident #21's admitting [DIAGNOSES REDACTED].#21 had been admitted with a fracture or for rehab after an orthopedic surgical procedure, and LPN LL stated, I don't know what she was admitted for . When asked why she had not performed range of motion before moving Resident #21, LPN LL stated, (Resident #21) didn't complain of pain. There was no apparent injury. In an interview, on 11/05/15 at 9:44 AM, DON/Director of Nursing B reported, Yes, they (licensed nurses) are supposed to do range of motion after a fall before moving them. In an interview, on 11/05/15 at 11:35 AM, ETD/Director of Education and Training J was asked if he educated licensed nurses to perform range of motion on residents who had fallen prior to moving them, and ETD J said, If in pain or there is obvious injury . ETD J stated he did not specifically educate nurses to perform range of motion after a fall. Review of the facility's Accident/Incident reporting form, dated 2012) revealed range of motion was not listed as a task to be completed after a fall. In an interview, on 11/05/15 at 10:50 AM, ADON M reported the facility did not have a Policy and Procedure for fall prevention and/or post fall protocol. ( )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR 1 OF 1 CLOSED RECORDS THAT WERE REVIEWED FOR FALLS (#15) FROM A TOTAL SAMPLE OF 17 RESIDENTS RESULTING IN RESIDENT #15 FALLING AND SUSTAINING A FRACTURED LEFT HIP THAT REQUIRED SURGICAL REPAIRS. FINDINGS INCLUDE: ACCORDING TO THE MEDICATION ADMINISTRATION RECORD DATED 12/08/2011 RESIDENT #15 WAS AN [AGE] year OLD MALE admitted on 12/08/2011 WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE] THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE TO TRANSFER AND AMBULATE WITH ASSISTANCE OF ONE PERSON. THE BRIEF INTERVIEW MENTAL STATUS SCORE WAS CODED AS A 7, INDICATING THERE WAS COGNITIVE IMPAIRMENT. THE INTERDISCIPLINARY TEAM NOTE DATED 12/08/2012 IDENTIFIED RESIDENT #15 AS A FALL RISK. ACCORDING TO THE CARE DELIVERY GUIDE DATED 12/08/2012, A BED AND CHAIR ALARM HAD BEEN IMPLEMENTED. THE FACILITY FORM TITLED "ACCIDENT / INCIDENT REPORT" DATED 12/15/2011 REFLECTED, RESIDENT #15 WAS FOUND ON THE BATHROOM FLOOR ON 12/15/2011 AT 1:30 A.M.; IT WAS UNCLEAR WHETHER THE RESIDENT HAD BEEN ASSISTED IN TOILETING PRIOR TO BED. THE RESIDENT WAS FOUND TO HAVE AN ABRASION ON LEFT POSTERIOR SCALP AND COMPLAINED OF SEVERE LEFT HIP PAIN. THE ACCIDENT/INCIDENT REPORT REVEALED THE BED ALARM DID NOT SOUND. THERE WAS NO DOCUMENTATION TO SUPPORT WHETHER THE RESIDENT HAD BEEN EDUCATED ON HOW TO USE THE CALL LIGHT. HOWEVER, THE INCIDENT /ACCIDENT REPORT REFLECTED THE RESIDENT DID NOT USE THE CALL LIGHT. RESIDENT #15 WAS TRANSFERRED TO THE HOSPITAL AND UNDERWENT SURGERY TO REPAIR THE FRACTURED LEFT HIP AND DID NOT RETURN TO THE FACILITY. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING STAFF "B" AND THE ASSISTANT DIRECTOR OF NURSING STAFF "C" BOTH REPORTED THAT THEIR INVESTIGATION CONCLUDED THAT THE BED ALARM DID NOT SOUND OFF WHEN THE RESIDENT GOT OUT OF BED. STAFF "B" REPORTED SHE HAD SENT THE ALARM TO THE MANUFACTURER TO VERIFY THE MALFUNCTION, HOWEVER THE MANUFACTURER OF THE ALARM INFORMED THE FACILITY THAT THE ALARM WAS NOT DEFECTIVE. ( )

This citation pertains to MI# 027 Based on observation, interviews, and record review, the facility failed to provide the correct dosage of medication (Roxinal) per physician order [REDACTED].#101, who experienced a decreased respiratory rate, decreased blood sugars, and decreased blood pressure. This deficient practice placed resident #101 and other residents with orders for Roxinal medication at high risk of serious physical harm or death. Findings: Record review of facility 5 day investigation report dated 10/6/10 revealed: On 10/3/10 at 6:00 PM resident #101 complained of shortness of breath and nurse #6 gave Albuteral nebulizer treatment. Resident #101 continued to complain of difficulty in breathing and nurse #6 gave resident #101 Roxinal ([MEDICATION NAME] sulfate) 2.5 milliliters oral for dyspnea (labored or difficulty breathing, Miller-Keane encyclopedia & dictionary of Medicine, Nursing & Allied Health, 6th edition. Pg. 493) per physician order [REDACTED]. Further review of the facility 5 day report revealed that Resident #101 was noted to have blood sugar of 38, respirations of 6 and required [MEDICATION NAME] IM and [MEDICATION NAME] (Narcotic antagonist/overdose reversal) two separate times. Review of resident #101's physician order [REDACTED]. Directions: 2.5 to 5 ml, PO (oral) every 4 hours PRN (as needed) for dyspnea/pain. Quantity: 240 ml. Refills: 2. The physician order [REDACTED]. Record review of resident #101's minimum data set ((MDS) dated [DATE] revealed an [AGE] year old male with cognitive skills for daily decision making as independent, decisions consistent and reasonable. Medical disease [DIAGNOSES REDACTED]. Special treatments, procedures and program section of the MDS revealed that resident #101 was receiving IV medication, monitoring of acute medical condition and oxygen therapy. Record review of the resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of the facility narcotic medication log book revealed resident #101's name, the prescription number, date of 10/3/10, medication Roxinal, strength 20mg/ml, the nurse receiving medication (nurse #6), Directions 2.5 ml (5mg) q 4 hours. On 10/3/10 at 19:00 2.5 ml was signed out by nurse #6, remaining 27.5 ml (within the bottle). Review of the "2011 Lippincott's Nursing Drug Guide" written by Amy M. Kartch, book located on the facility Forest unit nursing station pg. 827-830, revealed dosages adult oral of 10-30 mg every 4 hours. Record review of resident #101's nurse note dated 10/3/10 at 2:00 AM written by nurse #6 revealed that the resident had oxygen therapy in place. Record review of resident #101's nurse note dated 10/3/10 at 6:00 PM written by nurse #6 revealed: Resident had no complaint of pain. Oxygen therapy, family into visit. Gave PRN neb treatment every 2 hours PRN. Gave PRN Roxinal 6:00 PM for SOB (shortness of breath) will continue to monitor. Record review of resident #101's nurse note dated 10/4/10 at 3:00 AM written by nurse #6 revealed: Resident had no s/s of pain, no s/s of distress. Resident is having Cheyne-Stokes respiration (breathing of deeply for short time and then breathes very slightly or stops breathing altogether, Miller-Keane encyclopedia & dictionary of Medicine, Nursing & Allied Health, 6th edition. Pg. 310.), 02 (oxygen) therapy in place. Call light in reach. Resident asleep at this time. Will continue to monitor. On 10/3/10 between 3:00 AM and 6:30 AM, there were no further nurse notes of continued monitoring by nurse #6 of resident #101's irregular respirations. Record review of the facility post acute/change of condition monitoring policy dated 10/09, revealed that ESI (facility) requires residents with a change of condition to have the post acute/change of condition monitoring record initiated with documentation every shift for a minimum of 72 hours or until the resident ' s condition is stabilized or the situation is otherwise resolved. An interview on 10/25/10 at 2:11 PM with nurse #6 stated: "(Resident #101) was short of breath, breathing real shallow, fast, used accessory muscles. New med order for Roxinal, to relax his airway, asked if he wanted to try it, and he said, "yes". I went to the med cart pulled out Albuteral neb treatment and the Roxinal bottle/box had not been opened yet. I looked, read the pharmacy label on the box, and compared it to the MAR (medication administration record). I questioned the dose; I had never given Roxinal before. I grabbed (nurse #8), asked her to read the script on the bottle and the MAR. We agreed 2.5 ml instead of 5 ml. I wanted start with a low dose because script said 2.5 ml or 5 ml. I measured it in a plastic med cup, clear plastic graduated dose cup. Measured 2.5 ml and took it and Albuteral to resident #101. I gave him the medication and neb treatment. He seemed to calm down; resp (respiration) relaxed and went to sleep. ... " Further interview with nurse #6 revealed that "I did look at the (Roxinal bottle) syringe, and I thought why such a small syringe, if give 2.5 ml and syringe is only 1 ml, it's similar to an insulin syringe. Why was it so small, I wondered"? On 10/25/10 during the interview, Nurse #6 demonstrated for the state surveyor how resident #101 was observed breathing (Cheyne-Stoke) at 3:00 AM on 10/4/10 with taking a breath and held it/stopped breathing for a few moments then took another breath. Nurse #6 stated that (demonstrated) breathing was different for resident #101. During the interview on 10/25/10 nurse #6 stated that she had worked the night shift on 10/2/10 till 10/3/10 at 6:30 AM and came back to work on 10/3/10 at 2:00 PM and worked a 16 hour shift till 10/4/10 at 6:30 AM. An interview on 10/20/10 at 12:30 PM with nurse #7 who received report on 10/4/10 at the start of her day shift at 6:30 AM from nurse #6 who was going off shift revealed: I worked days 10/4/10, 6:30 AM to 3:30 PM, got report from (nurse #6). She said that resident #101 was a hospice resident, questioned current meds continued. She was unclear on what to do. Nurse #6 said that he had a new order for [MEDICATION NAME] from Physician #3, and that she gave a dose. I asked her about the dosing. She said the bottle only came with a 1 ml measuring syringe, so she measured it up in a plastic med cup. She said that she used two and a half syringes. She finished report; I asked about blood sugars, she said were OK. She said he slept for her all night. I went in to check on him after med count because it seemed like a lot of [MEDICATION NAME]. At 7:00 AM, resident #101 awoke to verbal stimuli, respirations 18, unlabored. I did my med pass. I talked to unit manager and the unit manager said that the order was wrong. I checked him and he seemed lethargic. Checked his blood sugar 35. He was conscious, I squeezed gel glucose into his mouth, he wouldn't ' t swallow it, he would fall back to sleep, ended up giving IM glycogen for blood sugar. The blood sugar increased to 54, I listed them on the back of his MAR indicated [REDACTED]. Unit manager thought that he had cheyne-stoke respirations, lungs clear, and respirations 6. When the [MEDICATION NAME] hit him it was fast, like a ton of bricks. Rechecked his blood sugar, decreased to 60, more IM glycogen given. The nurse practioner got an order for [REDACTED]. Record review of resident #101 ' s nurse note dated 10/4/10 at 9:30 AM written by the unit manager revealed that the residents ' respirations were not labored and that he appeared sedated. The resident was noted not being able to eat on his own, not swallowing food, or meds. The nurse note stated: This writer upon arrival this AM at 7:00 AM discovered that resident had received an incorrect dose of Roxinal, Order from history and physical does not match order written by physician. At 8:30 AM physician notified. Clarification obtained. Faxed to pharmacy and corrected. Nurse note dated 10/4/10 at 11:15 AM written by the corporate nurse consultant revealed: Resident noted to have increased lethargy. BP (blood pressure) 72/40, P (pulse) 80 pacer, oxygen sat 92%, respirations 6, order obtained for [MEDICATION NAME] (narcotic antagonist) 0.4 mg IM now at 11:27 AM. An interview on 10/27/10 at 1:30 PM via phone with the corporate nurse consultant revealed: " On Monday 10/4/10 around 10 AM, I was at the regional office then to Capital facility, then to Okemos. The director of nursing told me about the med error, so I looked into what dose was actually given. As I was doing this the unit manager came in and said he ' s (resident #101) was acting different. So I went down and assessed the resident and he had respirations of 6, blood pressure low, he would open his eyes but not responsive, with pin point pupils, sluggish, sedated. The nurse manager called the physician half way through for the [MEDICATION NAME] order. And the nurse practitioner was in the building " . An interview on 10/27/10 at 1:35 PM with the nurse practioner revealed, "Monday is office day, I ' m on call. The facility kept paging me, so I came to the facility. I went to see the resident around 10ish, between 10:00 AM and 11:00 AM. He (resident #101) could wake-up, but fall back asleep. Very lethargic. Vital signs OK. He ' s over sedated, had to shake him to get him to open his eyes. Poor lung function, dim, slow and shallow respirations of 6. [MEDICATION NAME] given to stabilize the decreased respirations, decreased blood sugar and decreased responsiveness. [MEDICATION NAME] half life is shorter than the [MEDICATION NAME]. Told them (facility staff) to monitor him. The blood sugar, he couldn't ' t swallow, blood sugar of 38, so I choose [MEDICATION NAME] 50 IVP as quickest route. Yes, I had to shake his arm to arouse him that was different for him. Staff were very excited/upset over med error". Observation on 10/20/10 of the facility photocopied medication box front with pharmacy labeling revealed: [MEDICATION NAME] Concentrate (immediate release) concentrated oral solution. Labeled Resident #101's name, [MEDICATION NAME] 20 mg/ml. Give 2.5 ml (5mg) by mouth every 4 hours as needed, Give 5 ml (10 mg) by mouth every 4 hours as needed. Observation on 10/20/10 of the [MEDICATION NAME] sulfate bottle located in the Forrest unit medication cart-B revealed [MEDICATION NAME] 20mg/ml. Review of the pharmacy medication packing slip/invoice dated 10/3/10 at 1:45 revealed that nurse #6 signed the packing slip/invoice and accepted the [MEDICATION NAME] 20 mg/ml. Further review of the packing slip/invoice revealed a note at the bottom of the page the stated: Note discrepancies and fax immediately to specialized pharmacy services. There was no documentation of nurse #6 reporting any discrepancies. An interview and observation on 10/20/10 at 8:50 AM of resident #101 revealed the resident to be sitting up in a wheelchair watching television and eating breakfast in his pajamas. The resident was observed with oxygen via nasal canula at 2 liters. The resident stated, "I've lived here since May 15th of 2008. Come back and we'll talk after I've eaten and dressed". The resident was noted to feed self and swallowed with ease. The resident consumed 90% of the meal. A second interview on 10/20/10 at 11:05 AM with resident #101 revealed: "Yes, I was having trouble breathing periodically. I have problems; sometimes feel like I'm not breathing well. I have [MEDICAL CONDITIONS] with shortness of breath and occasionally have problems". The resident was asked about the medication [MEDICATION NAME] and he acknowledged that he did take a liquid medication, but was not sure what it was for. Review of facility medication administration policy dated 5/2010 received from the director of nursing revealed the procedures related to general dose preparation and medication administration. Listed under procedure step #4 at 4.1.1 facility staff should: verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Step 4.1.2, Confirm that the MAR indicated [REDACTED] Record review of nurse #6 employee file revealed that the nurse began employment in 4/10 with the facility. Review of nurse #6 Medication Pass Guidelines dated 4/10 revealed that on #3 medication administrations #1) Nurse verifies medication, strength, and labeled directions for use against the MAR. Review of nurse #6's Clinical Skills Development post test of handling medication orders (undated) revealed a score of 50%. A retest of the Clinical Skills Development post test of handling medication orders dated 4/12/10 revealed 100%. Observations on 10/26/10 of a medication administration pass of sampled resident #203 revealed the resident to receive [MEDICATION NAME] 5/500 one tablet (PRN) as needed. The nurse administered the medication and recorded the medication on the PRN medication administration record. Close observation of the PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. At the bottom of the PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pertinent resident information was blank. An interview on 10/26/10 with the Mountains unit nurse #5 revealed that the resident #203 had been getting [MEDICATION NAME] 5/500 all through October 2010, and had been signing the medication out on the PRN MAR. The nurse #5 and the unit manager nurse #9 were notified of the pertinent resident information was blank on the PRN MAR. The administrator was notified on 10/26/10 at 1:14 PM of the immediate jeopardy that began on 10/3/10 at 6:00 PM. The immediate jeopardy is the result of the facility's failure to provide the correct dosage of medication (Roxinal) per physician order [REDACTED]. On 10/27/10, the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: 1. On 10/4/10 at 9:30 AM, the following measures were initiated related to the physician writing the order: Nurse manager notified physician #3 regarding med administration per physician order. New order received: Roxinal 20 mg/ml p.o. q4 hours prn=0.125 mg for mod. Dyspnea. Roxinal 20 mg/ml 5 mg p.o. q 4 hours prn= 0.25 mg for severe dyspnea. 2. On 10/4/10 at 11:00 AM, quality performance improvement action plan was implemented. 3. On 10/4/10 at 1:00 PM, clinical records were reviewed for oral class II medications to ensure accuracy. 4. On 10/4/10 at 2:00 PM, nurse #6 was called back for education and suspended at the time pending investigation. 5. On 10/4/10 at 4:00 PM, the director of nursing notified the medical director of medication error. Medical director contacted the physician #3 to follow-up and educate the physician. 6. On 10/4/10 at (untimed), physician #3 assessed resident #101. 7. On 10/5/10 at 8:00 AM, the director of nursing spoke with the pharmacist regarding error. 8. On 10/5/10 (untimed), the nurse practitioner assessed resident #101. 9. On 10/6/10 at 7:00 AM, 2:00 PM, and 3:00 PM, 34 of 47 nurses were re-educated on 1) the medication administration process. 2) the need to be familiar with medications prior to administration. 3) the medication pass checklist. On 10/12/10 at 11:00 AM, the remaining 13 licensed nurses completed the in-service education. While the immediate jeopardy was removed on 10/6/10 at 11:00 AM, the facility remained out of compliance at a pattern scope and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance has not been verified by the state agency. #

This citation pertains to #MI 027 Based on observation, interview and record review, the facility failed provide pharmaceutical services of accurately acquiring, receiving, dispensing and administering medication to a resident in 1 (#101) of 9 sampled residents, resulting in the facility nurse #6 receiving the medication shipped, failing to checking the pharmaceutical shipping invoice medication strength against the physician order [REDACTED]. Record review of facility 5 day investigation report dated 10/6/10 revealed: On 10/3/10 at 6:00 PM resident #101 complained of shortness of breath and nurse #6 gave Albuterol nebulizer treatment. The resident #101 continued to complain of difficulty in breathing and nurse #6 gave resident #101 Roxinal (morphine sulfate) 2.5 milliliters oral for dyspnea (labored or difficulty breathing, Miller-Keane encyclopedia & dictionary of Medicine, Nursing & Allied Health, 6th edition. Pg. 493) per physician order [REDACTED]. Review of resident #101's physician order [REDACTED]. Directions: 2.5 to 5 ml, PO (oral) every 4 hours PRN (as needed) for dyspnea/pain. Quantity: 240 ml. Refills: 2. The physician order [REDACTED]. Record review of pharmacy delivery receipt dated 10/3/10 at 1:45 AM revealed that the pharmacy company sent Morphine Sulfate 20 mg/ml solution in 30 ml bottle. The delivery receipt was signed by nurse #6. On 10/20/10 the surveyor compared the written physician order [REDACTED]. The pharmacy delivery of Roxinal/Morphine Sulfate acquired by the facility did not match what the physician had ordered. Record review of pharmacy delivery receipt dated 10/3/10 at 1:45 AM revealed that the pharmacy company sent morphine sulfate 20 mg/ml solution in 30 ml bottle. The delivery receipt was signed by nurse #6. At the bottom of the delivery receipt it was noted: Note discrepancies and fax immediately to pharmacy services. There were no discrepancies notes on the invoice by nurse #6 or any facility staff personnel. Observation on 10/20/10 of the Roxinal medication bottle revealed there to be 1 ml syringe style measuring devices used to measure and dispense the medication. An interview on 10/25/10 at 2:11 PM with nurse #6 revealed that she did receive the medication (Roxinal/Morphine Sulfate) on 10/3/10 from the pharmacy and that she did sign the delivery receipt. Nurse #6 stated that she placed the medication in the narcotic lock-up box located on the medication cart so that it could be used. Nurse #6 stated that she did not notice any thing wrong with the medication (strength/concentrated) or the instructions on the label. An interview on 10/25/10 at 2:11 PM with nurse #6 stated: " (Resident #101) was short of breath, breathing real shallow, fast, used assessory muscles. New med order for Roxinal, to relax his airway, asked if he wanted to try it, said 'yes' . I went to the med cart pulled out albuterol neb treatment and the Roxinal bottle/box had not been opened yet. I looked, read the pharmacy label on the box, and compared it to the MAR (medication administration record). I questioned the dose; I had never given Roxinal before. I grabbed (nurse #8), asked her to read the script on the bottle and the MAR. We agreed 2.5 ml instead of 5 ml. I wanted start with a low dose because script said 2.5 ml or 5 ml. I measured it in a plastic med cup, clear plastic graduated dose cup. Measured 2.5 ml and took it and albuterol to resident #101. I gave him the medication and neb treatment. He seemed to calm down; resp (respiration) relaxed and went to sleep. ... " Further interview with nurse #6 revealed that "I did look at the (Roxinal bottle) syringe, and I thought why such a small syringe, if give 2.5 ml and syringe is only 1 ml, it's similar to an insulin syringe. Why was it so small, I wondered"? Record review of facility medication error reports for 6 months revealed that nurse #6 was reported on 3 separate incidents of medication errors: 5/3/10 of an extra dose and a missed dose of medications. 7/11/10 wrong dose of Morphine Sulfate ER of 30 mg tablet was given in place of Lonesta 3 mg tablet. 10/3/10 wrong dose of Roxinal, nurse administered per order on box, did not check dosage on bottle. #

This citation pertains to MI# 027 Based on observation, interview and record review, the facility failed to provide accurate labeling to facilitate safe administration of medication (Morphine Sulfate concentrate) and to ensure safe and secure storage of medication carts on 3 of 4 resident care units (medication carts on the Forest, Mountain, Ocean Units), resulting in resident #101 being over medicated with Morphine Sulfate and the state surveyor finding 3 unlocked medication carts on 3 different resident care units with residents, visitors and non medical facility staff located within the hallways. Findings: Observation of resident #101 ' s medication box/bottle labeled Roxinal/Morphine Sulfate concentrate, 20 mg/ml solution. The box administration instructions: Give 2.5 ml (5 mg) by mouth every 4 hours as needed ...Give 5 ml (10 mg) by mouth every 4 hours as needed. These instructions when calculated for dosing to the resident 2.5 ml=50 mg dose, 5 ml=100 mg dose. Review of the ' 2011 Lippincott ' s Nursing Drug Guide ' written by Amy M. Karch, book located on the facility Forest unit nursing station pg. 827-830, revealed dosages adult oral of 10-30 mg every 4 hours. Review of resident #101's physician order [REDACTED]. Directions: 2.5 to 5 ml, PO (oral) every 4 hours PRN (as needed) for dyspnea/pain. Quantity: 240 ml. Refills: 2. The physician order [REDACTED]. On 10/3/10 at 6:00 PM, nurse #6 administered Roxinal/Morphine Sulfate concentrate as the box administration instructions: Give 2.5 ml (5 mg) by mouth every 4 hours as needed to resident #101, resulting in decreased respiratory rate of 6, blood sugar of 38, and blood pressure of 70/40. Observation while walking down hallway on 10/20/10 at 12:00 PM of the Forest resident care unit revealed medication cart B to be located outside of resident room [ROOM NUMBER], left unlocked. This surveyor was able to access all medication drawers. The nurse #10 the assistant director of nursing (ADON) was walking in hallway and approached state surveyor while standing at the medication cart. This surveyor demonstrated to the ADON that the medication cart was left unattended and unlocked. Further observation revealed nurse #7 to be in room [ROOM NUMBER] behind a room dividing curtain out of sight on other side of room wall. The ADON locked the medication cart and explained to nurse #7 that medication cart has to be in arms reach and sight when unlocked. Observation on 10/25/10 at 1:52 PM of the Mountains resident care unit revealed a medication cart to be unlocked and unattended. Surveyor was able to access all drawers, which contained resident medications. The state surveyor had 3 (#11. #12, #13) certified nurse assistant (CNA) check the resident care unit hallways for the nurse on duty. Each CNA reported to the surveyor that they could not find the nurse on duty on the resident care unit. At 2:08 on 10/25/10 the facility administrator walked up the hallway from the direction of the Forest care unit. The state surveyor asked the administrator why medication cart was unlocked and unattended. The facility administrator did not know why the medication cart was left unlocked or unattended. The facility administrator locked the medication cart by hitting the button with his fist. As the surveyor and administrator where discussing the unlocked medication cart, nurse #6 approached from the Forest care unit direction. On 10/25/10 at 2:10 PM nurse #6 stated, "I was on break. I ran home for a few minutes. I need to get my (medication cart) keys from the other unit. I'll be back. I forgot something at home this morning and I needed to leave to go get it. The Forest unit nurse #7 was covering for me". Nurse #6 left the medication cart unlocked and unattended, and left the building to going home. There were visitors, physical therapy staff, environmental services staff and CNA ' s noted within the hallway. Observation on 10/27/10 at 1:10 PM of the Great Lakes resident care unit revealed medication cart A to be unlocked and unattended. Nurse #14 stated, "I'm so good about locking it usually. I was down the hall giving a med to a resident". Nurse #14 proceeded to lock the med cart in front of the surveyor. The facility administrator was on the unit and notified of unlocked medication cart in hallway. State surveyor noted that families of residents were in the hallway along with physical therapy staff, other residents, CNA's, and environmental services staff. #