Every finding on record at Medilodge of Plymouth

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in eight of fifteen resident bedrooms (#109, 110, 111, 112, 113, 114, 115 and 116) and at least 100 square feet in one of five single bedrooms (room#102), resulting in the potential for inadequate space. Observations of resident rooms made on 7/17/25 at 2 P.M., during the environmental tour and review of the facility bed count information sheet with the Regional Director of Operations, who was familiar with facility room waivers, identified the following: Room # Square feet beds102 81 1 1109 143 2 2110 143 2 2111 143 2 2112 143 2 2113 143 2 2114 143 2 2115 143 2 0116 143 2 2 The health and safety of the residents was not affected by the room size. Interviews with the residents noted no complaints concerning room size.

Based on observation, interview, and record review, the facility failed to provide dignified dining for two residents (R22 and R27) during dining observations, resulting in a staff member standing over the residents during meal assistance which did not resemble the comfortable characteristics of a home. Findings include: On 7/23/24 at 12:34 PM, Resident #27 (R27) was in her room, awake, and sitting in her geriatric chair. Certified Nurse Aide (CNA) G was standing next to R27 while offering the resident spoons of thickened apple juice. When R27 stated she had enough, CNA G stopped. On 7/23/24 at 12:39 PM, Resident #22 (R22) was in her room, awake, and sitting up in her bed. R22's lunch tray was positioned in front of her on an overbed table and had not been touched. Licensed Practical Nurse (LPN) H was observed in the room shared by R22 and R27 and said that sometimes R22 feeds herself, but other times staff feed her. LPN H was sitting next to the roommate of R22 and R27 while feeding the roommate her lunch. On 7/23/24 at 12:50 PM, CNA G was observed standing next to R22's bed while offering the resident bites of food. At the end of the meal, CNA G said R22 consumed the top of her roll, all her dessert and milk, and a small amount of the beef and rice. A review of the Admission Record for R22 documented an initial admitted [DATE] and readmitted [DATE]. R22's diagnoses included chronic obstructive pulmonary disease, diabetes mellitus-type 2, and unspecified dementia. A MDS dated [DATE] documented severe cognitive impairment. Physician orders documented R22 was to receive a regular diet, regular texture, regular fluids, thin consistency. R22's ADL care plan documented to provide supervision to one-person assist, varies on resident's mood/behavior, for eating. A review of the Admission Record for R27 documented an admitted [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis, vascular dementia, and dysphagia. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment. Physician orders documented R27 received bolus feedings of a liquid supplement via a gastrostomy feeding tube and a regular diet, pureed texture, and honey/moderately thick consistency fluids by mouth. A review of R27's nutrition and activity of daily living (ADL) care plans documented to provide assistance with meals as needed and one-person assist for eating. On 7/24/24 at 10:09 AM, Registered Dietitian (RD) B said that staff should be sitting on the same level of the resident when assisting them with feeding because it is respectful. Residents should be treated like family. On 7/25/24 at 3:00 PM, the Director of Nursing (DON) said staff should be at the same level of the resident when offering feeding assistance so you can see the resident's face and it is also an integrity issue. Staff should be sitting down not standing up while feeding residents. The facility policy titled, Resident Rights, dated 10/30/23, documented in part, The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. On 7/25/24 at 4:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information regarding this citation when asked.

Based on interview and record review, the facility failed to immediately report a Resident-to-Resident incident for two residents (R3 and R40) of three residents reviewed for abuse, resulting in allegations of abuse that were not reported to the State Agency timely and the potential for feeling of not being protected or unsafe within the facility, and for abuse to continue without being reported. Findings include: R3 Review of an Admission Record revealed, R3 admitted to the facility on [DATE] and with pertinent diagnosis which included Schizophrenia and Bipolar Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R3 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 6 out of 15. Review of a nurses note with a date of 4/28/24 at 10:27 p.m. revealed, . Resident did not appear to be upset. A resident was in his bed and had to be redirected out of (R3's) bed. While the resident was being redirected out of the area (R3) spontaneously hit him in the face . R40 Review of an Admission Record revealed, R40 admitted to the facility on [DATE] and discharged on [DATE] with pertinent diagnoses which Dementia and Alzheimer's Disease. Review of a MDS assessment dated [DATE] revealed R40 had cognitive impairment with a BIMS score of 6 out of 15. Review of a nurses note with a date of 4/28/24 at 9:32 p.m. revealed, . Resident has been wandering through out the unit and has to be redirected. Resident was observed in another resident's bed, resident was redirected by staff out of the bed and back into his wheelchair. When staff member turned around to attend to another resident, a resident spontaneously hit (R40) in the face. (R40) was taken out of the area and placed in his bedroom. The residents' nose was bleeding, and the writer placed an ice pack on the nose and stopped the bleeding. A head-to-toe assessment and a pain assessment was completed. Prn pain medication was given. The family the on call Physician, DON (Director of Nursing), and the Administrator were notified. Review of a nurses note with a date of 4/30/24 at 1:23 p.m. revealed, . resident noted picking at scabs on arms and face, bruise noted on right side of nose where glasses sit notified md ordered x-ray of the nose. encouraged family to bring long sleeve shirts lotion applied. safety maintained . In an interview on 7/24/24 at 11:16 a.m., the DON reported the resident-to-resident incident was not reported to the state agency. In an interview on 7/24/24 at 3:18 p.m., the Nursing Home Administrator (NHA) reported the incident should have been reported to the state agency within two hours if there is an injury. The NHA then confirmed the incident involving R3 and R40 should have been reported to the state agency. Review of the Abuse, Neglect and Exploitation policy revised 10/24/22 documented, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific timeframes: a. Immediately, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Based on observation, interview and record review, the facility failed to implement effective skin care for one resident (R16) of two residents reviewed for skin care, resulting in dry, scaly skin and resident dissatisfaction. Findings include: On 7/23/24 at 10:02 AM, Resident #16 (R16) was observed awake and lying in bed. R16 stated, They are supposed to put salve on my legs and feet, but nothing is being done about it. R16 granted permission for the Surveyor to look at her feet. The bottoms of R16's feet were very dry, scaly, with peeling skin. The Admission Record for R16 documented an admitted [DATE] with diagnoses that included endometrium (uterus) cancer, chronic obstructive pulmonary disease, obesity, and congestive heart failure. A Minimum Data Set assessment dated [DATE] documented intact cognition. On 7/24/24 at 9:29 AM, Registered Nurse (RN) D reviewed R16's clinical record for orders related to foot care. There were none. RN D said R16 does not have the physical ability to apply lotion to her feet. R16 was dependent upon staff to do that for her. RN D admitted that she had not examined R16's feet lately. On 7/24/24 at 9:38 AM, after examining R16's feet, RN D stated, She really needs lotion for dry skin. I'm going to call the doctor for the order. RN D said the skin on the bottom of R16's feet was dry and scaly, and when you rub the bottom of R16's feet, skin would come off. RN D noted discoloration of dark brown spots on the top of both feet. RN D indicated that the condition of R16's feet did not recently happen. This should have been noted and brought to her attention. Nursing progress note of 7/24/24 at 9:58 AM documented in part: Resident both feet assess today, both feet are dry scaly skin on palm of the feet, dark brown skin noted on top of both feet, NP (nurse practitioner) on call notified of dry scaly peeling skin. stated I will put the order in now for (lac-hydrin) lotion. On 7/25/24 at 2:49 PM, the Director of Nursing said R16's skin should have been moisturized with lotion. R16's skin was extremely dry and should have been attended to on a regular basis. The facility policy titled, Activities of Daily Living (ADLs), dated 12/28/23, documented in part: A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. On 7/25/24 at 4:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information regarding this citation when asked.

Based on observation, interview, and record review, the facility failed to change oxygen tubing in a timely manner for one resident (R16), out of one resident reviewed for oxygen therapy, resulting in the potential for cross contamination and respiratory infection. Findings include: On 7/23/24 at 11:20 AM, Resident #16 (R16) was awake and lying in her bed. R16 said staff do not change her tubing like they are supposed to. The tape on R16's oxygen tubing was dated 7/19/24. On 7/24/24 at 9:21 AM, the date on R16's oxygen tubing remained 7/19/24. The Admission Record for R16 documented an admitted [DATE] with diagnoses that included endometrium (uterus) cancer, chronic obstructive pulmonary disease, obesity, and congestive heart failure. A Minimum Data Set assessment date 6/27/24 documented intact cognition. Physician orders documented to date and change resident's oxygen tubing every three days. Order date: 12/29/23. On 7/25/24 at 2:36 PM, the Director of Nursing (DON) said R16's oxygen tubing should be changed every three days. The tubing dated 7/19/24 should have been changed to a clean one on 7/22/24. The DON said R16 drops her tubing on the floor and would need it changed more often than weekly. The DON indicated that physician orders supersede facility policies. A review of the policy titled, Oxygen Administration, dated 10/26/23, documented in part the following: change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. On 7/25/24 at 4:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information regarding this citation when asked.

Based on observation, interview, and record review, the facility failed to ensure resident food preference was honored for one resident R16) out of six residents reviewed for food preferences, resulting in resident meal dissatisfaction. Findings include: On 7/24/24 at 8:05 AM, the breakfast served to Resident #16 (R16) included a bowl of bran flake cereal, one boiled egg, one muffin, a glass of milk, and a glass of orange juice. R16 said to Certified Nurse Aide (CNA) G that she wanted another boiled egg. On 7/24/24 at 8:06 AM, R16 stated, This (breakfast) is not going to be enough to hold me until lunch. On 7/24/24 at 8:14 AM, CNA G informed R16 that the kitchen indicated they did not have any more boiled eggs. On 7/24/24 at 8:18 AM, Dietary Manager (DM) A stated, We gave out all the boiled eggs we cooked. When queried if there were more eggs in the kitchen, DM A stated, We have plenty of eggs. I can boil some more. On 7/24/24 at 10:09 AM, Registered Dietitian (RD) B said they use resident food preferences to adjust what the residents receive. RD B indicated it was important to honor resident food preferences because this was their home. They should get what they want, with what's available, and based upon their diet. We do our best to give them what they like. Regarding R16's request, RD B stated, They should have served her another egg. The Admission Record for R16 documented an admitted [DATE] with diagnoses that included endometrium (uterus) cancer, chronic obstructive pulmonary disease, obesity, and congestive heart failure. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of R16's breakfast meal ticket for 7/24/24 documented, Diet Order: Regular Diet. Notes: prefers boiled eggs. On 7/25/24 at 3:25 PM, the Nursing Home Administrator (NHA) stated it was unacceptable that R16 did not receive her request and added, They should have stopped to make her a boiled egg. If they (the residents) want two boiled eggs, they should have it. The facility policy titled, Resident Rights, dated 10/30/23, documented in part, The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. On 7/25/24 at 4:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information regarding this citation when asked.

Based on observation, interview, and record review, the facility failed to provide at least 80 square/feet per resident in eight of fifteen resident bedrooms (# 109, 110, 111, 112, 113, 114, 115 and 116) and at least 100 square feet in one of five single bedrooms (room # 102), resulting in the potential for inadequate space. Findings Include: Observations of resident rooms made on 7/23/24 at 1:49 PM during the environmental tour and review of the facility bed count information sheet with the Maintenance Director identified the following: Room # Square feet Beds 102 81 1 109 143 2 110 143 2 111 143 2 112 143 2 113 143 2 114 143 2 115 143 2 116 143 2 The health and safety of the residents was not affected by the room size. Interviews with the residents noted no complaints concerning the room size.

Based on interview and record review, the facility failed to demonstrate professional standards of practice by not obtaining vitals per physician's orders for one resident (R39) out of one resident reviewed that died in the facility, resulting in an incomplete gauge of the resident's general health and well-being. Findings include: A review of the Admission Record for Resident #39 (R39) documented an initial admitted [DATE], readmitted [DATE], and death in the facility on [DATE]. R39's diagnoses included venous insufficiency, severe protein-calorie malnutrition, and hypertension. A Minimum Data Set assessment dated [DATE] documented intact cognition. Nursing note on [DATE] at 10:53 PM documented in part, Resident in bed, no audible apical heartbeat (pulse point on the chest), or no palpable pulse or no respirations. Verified by RN (Registered Nurse) on duty. Notified on call team .for notification of passing. Release of body form completed. On [DATE] at 2:15 PM, R39's clinical record was reviewed with the Director of Nursing (DON). Physician orders documented the following: 1. Vital signs every evening shift every Friday. Started on [DATE]. 2. Vital signs every night shift. Started on [DATE]. The DON said nursing should have contacted the physician to confirm the vital sign orders. The DON said that normally vitals include obtaining a resident's blood pressure, temperature, pulse, respiration, and oxygen level. R39's [DATE] Medication Administration Record (MAR), reviewed with the DON, revealed that nurses signed off that they completed vitals on R39 nightly. R39's clinical record provided the following documentation of vitals obtained during the month of [DATE]: Blood Pressure: [DATE] at 9:38 PM ,d+[DATE] [DATE] at 9:41 AM ,d+[DATE] [DATE] at 9:33 PM ,d+[DATE] [DATE] at 2:01 PM ,d+[DATE] [DATE] at 6:30 PM ,d+[DATE] Temperature: [DATE] at 9:38 PM 98.4 F (Fahrenheit) [DATE] at 9:41 AM 97.7 F [DATE] at 9:33 PM 98.6 F [DATE] at 2:01 PM 97.8 F [DATE] at 6:30 PM 98.2 F Pulse: [DATE] at 9:38 PM 72 bpm (beats per minute) [DATE] at 9:41 AM 63 bpm [DATE] at 9:33 PM 70 bpm [DATE] at 2:01 PM 69 bpm [DATE] at 6:30 PM 74 bpm Respiration: [DATE] at 9:38 PM 15 Breaths/min [DATE] at 9:41 AM 14 Breaths/min [DATE] at 9:33 PM 16 Breaths/min [DATE] at 2:01 PM 15 Breaths/min [DATE] at 6:30 PM 16 Breaths/min Oxygen level: [DATE] at 9:38 PM 98.0% Room Air [DATE] at 9:41 AM 92.0% Room Air [DATE] at 9:33 PM 98.0% Room Air [DATE] at 2:01 PM 95.0% Room Air [DATE] at 6:30 PM 96.0% Room Air The DON stated a resident's vital signs should be documented because that gives you an accurate picture of the resident's condition. On [DATE] at 4:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information regarding this citation when asked.

Based on observation, interview, and record review, the facility failed to properly dispose of refuge and maintain cleanliness of the outside garbage area, resulting in the potential for harborage of pests. This deficient practice had the potential to affect all 34 residents that resided in the facility. Findings include: On 4/19/23 at approximately 2:00 PM, during an observation of the outside dumpster area with the Dietary Manager A, two carts were observed in the dumpster area. The contents of a blue cart, approximately a quarter full of garbage, was described by Dietary Manager (DM) A as Soiled gloves, masks, and pill cups. A black cart was observed containing approximately three quarters full of dark, murky water that contained debris including tree branches. DM A stated, These carts have been here in this condition since January. It's an eyesore for residents. During an interview on 4/20/23 at 10:45 AM, the facility Administrator stated, No one should be leaving trash inside those bins (carts). They are for transportation of garbage from the facility to the dumpster only. They should be empty when not in use. The 2013 FDA Food Code was reviewed and revealed the following: - 5-501.110 Storing Refuse, Recyclables, and Returnables: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. - 6-501.114 Maintaining Premises, Unnecessary Items and Litter: The premises shall be free of: (B) Litter.

Based on observation, interview, and record review, the facility failed to ensure a qualified Certified Dietary Manager, Certified Food Service Manager, and/or full time Registered Dietitian was in place to lead the dietary department as required, resulting in operational failures which have the potential affect all 33 of the nursing home residents that eat out of the kitchen. Findings include: During an interview on 4/18/23 at 1:36 PM, Assistant Director of Nursing (ADON), Registered Nurse E said,The facility's registered dietitian was coming once a week but went on maternity leave about two to three weeks ago. ADON E said, No one has covered for her during her absence. During an interview on 4/19/23 at approximately 2:00 PM, Dietary Manager (DM) A denied she was certified as a dietary manager or food service manager. DM A said, I am just beginning the process to become a certified dietary manager. When DM A was asked to provide production sheets she stated, I do not have any production sheets. DM A was unable to provide a cleaning schedule when asked. During an interview on 4/20/2023 at 11:03 AM when the Regional Registered Dietitian (RD) B was queried if kitchen operations could be adequately performed by one person, she stated, I don't know. I don't work here. RD B stated the purpose of production sheets was To make sure we have on hand what is needed. (Without production sheets) we don't know what the kitchen needs or has used. According to regulation: If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. (i) The director of food and nutrition services must at a minimum meet one of the following qualifications- (A) A certified dietary manager; or (B) A certified food service manager 34901

Based on observation, interview, and record review, the facility failed to ensure the kitchen was adequately staffed in order to prepare and serve meals in a timely manner and manage and operate the kitchen properly, resulting in resident dissatisfaction, untimely meal service, and standard kitchen operations not being performed affecting all residents eating meals from the kitchen. Findings include: A review of a facility provided document revealed meals were to be served at the following times: breakfast at 8 AM, lunch at 12 noon, and dinner at 6 PM. During an observation on 4/18/23 at 2:00 PM, Resident #141 (R141) had not been served lunch. During observations on 4/19/23, R141 was served breakfast at 8:37 AM and lunch at 12:30 PM. During an interview on 4/19/23 at approximately 2:00 PM, Dietary Manager (DM) A stated On Monday (4/17/2023) I worked breakfast and lunch by myself (cooking and serving both meals and washing dishes, pots, and pans afterwards). There should be a cook and an aide every shift. There should be two people working every shift. I was supposed to obtain the temperature of the dish machine, and I did not. DM A further added, As a manager, I can't educate, take trainings, complete invoices, supervise, and prepare work schedules because I'm too busy working as a staff member because we don't have enough staff. A review of the April 2023 kitchen staff schedule revealed DM A was scheduled to work as the AM cook 14 out of 30 days. During an interview on 4/19/23 at 2:04 PM, the Nursing Home Administrator (NHA) said if breakfast was 30 minutes late it was related to system problems in the kitchen, probably related to staffing. Starting meal service (passing trays to residents) 15 minutes late was more reasonable. The NHA stated that meals should be served close to (established) mealtimes within 15 minutes tops (at the latest) realistically. During an interview on 4/20/23 at 10:04 AM, Resident #19 (R19) stated, Meals are usually a half hour late. R19 said sometimes he gets hungry waiting for meals to be served. During an interview on 4/20/2023 at 11:03 AM when Regional Registered Dietitian (RD) B was queried if kitchen operations could be adequately performed by one person, she stated, I don't know. I don't work here. RD B then stated she recommended that kitchen staffing should include one cook and two aides for the size of this building. A review of the facility policy titled, Resident Meal Service, dated 1/1/2021, revealed in part the following: Each resident shall receive the correct diet .and shall receive prompt meal service . 47964

Based on observation, interview, and record review, the facility failed to follow the established planned menu for all residents eating from the kitchen, resulting in the residents not being informed of what was being served in advance and the potential for unmet resident nutritional needs. Findings include: The facility provided a menu for Tuesday, 4/18/2023 which indicated the following was to be served for lunch: pork chop with sour cream, herbed rice, green beans, wheat bread, fresh apple slices, and garnish parsley sprig. The facility served the following for lunch on 4/18/2023: sweet and sour chicken, rice, green beans, mixed corn, pineapples, and rolls. During an interview and observation on 4/18/23 at 12:51 PM, Resident #141 (R141), who was alert and able to clearly express herself, had not been served lunch. R141 stated, I'm vegetarian, but I eat chicken, fish, and eggs. R141 indicated she previously informed the Nursing Home Administrator (NHA) that she did not eat meat and that the NHA would get her a salad, fruit, and apple juice. When R141 was informed about what was served at lunch, she stated, I could have had that. They don't have a menu to give you. During an observation on 4/18/23 at 2:46 PM, Dietary Manager (DM) A returned to the facility with some grocery bags. DM A said she went to purchase food for a resident that requested a salad. During an interview on 4/19/23 at approximately 2:00 PM when Dietary Manager DM A was asked to provide production sheets for the last seven days in order to assess the nutritional adequacy of meals previously served to the residents, she stated I do not have any production sheets, but I can tell you what was served. We haven't had a menu to follow because we haven't had a working freezer and I'm too busy running to the store to get food to prepare a menu. During an interview on 4/20/23 at 10:04 AM, Resident #19, who was alert and able to clearly express himself, stated, I don't know what is being served. They don't tell us in advance, sometimes I'll go to the kitchen and ask. During an interview on 4/20/23 at 11:03 AM, Regional Registered Dietitian (RD) B indicated the facility's menus are developed by a national food service distribution company. RD B stated that menus should be followed To make sure people are getting what they are supposed to be getting and nutritionally sound. 34901

Based on observation, interview, and record review, the facility failed to (1) effectively clean food service equipment, (2) properly date-label food in the cooler, (3) ensure staff food was stored separately from resident food, (4) consistently test the dish machine operating temperature, and (5) correctly obtain steam table food temperatures. These deficient practices have the potential to affect all residents who eat food out of the kitchen resulting in the increased potential for cross-contamination, bacterial harborage, and increased potential for resident foodborne illness. Findings include: During the initial tour of the kitchen on 4/18/23 at 8:55 AM with Dietary Manager (DM) A the following was observed: - the stove food trap was half full of grease and food debris from the flat grill - the panel below stove door was soiled with dirt and grease - the stock cupboard doors were soiled - in the clean pot and pan area, two full-size pans were soiled with food debris. DM A acknowledged the pans were soiled. - the racks where the clean pots and pans were stored were rusted - the spice rack doors did not close completely and were held closed by towels soiled with food debris. - the shelf under the prep table was rusted and contained food debris. The following was observed in cooler number two: - the shelves were soiled and rusted. DM A stated, I know it's rusty and dirty; it needs to be cleaned. - the following staff food was stored with resident food: coffee creamer and a protein shake - an opened container of whipped cream was not marked with a used-by-date - an undated bag of diced potatoes appeared pink and moldy. A review of the dish machine temperature log revealed temperatures were not obtained on 4/17/23. DM A said, I operated the dish machine yesterday and did not obtain temperatures. During a kitchen observation on 4/18/23 at 11:50 AM, AM Cook C was observed obtaining the temperatures of food from the steam table. AM Cook C did not clean and sanitize the metal-stem thermometer between testing the mashed potatoes and pureed chicken. During an interview on 4/19/23 at approximately 2:00 PM, DM A did not provide a cleaning schedule when asked. DM A stated, We do not have a cleaning schedule due to a lack of staff. The 2013 FDA Food Code was reviewed and revealed the following: - 3-101.11, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. - 501.11, Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. - 4-602.11, Equipment Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be cleaned (5) at any time during the operation when contamination may have occurred. - 4-602.13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on observation, interview, and record review, the facility failed to provide adequate backflow protection for the ice machine resulting in the potential for contamination. This deficient practice had the potential to affect all residents that consume ice from the kitchen. Findings include: During an observation on 4/18/23 at 8:55 AM of the kitchen with the Dietary Manager A, the two drain lines from the ice machine were observed to lack the required one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). During an interview on 4/20/23 at 11:03 AM, Regional Registered Dietitian stated the purpose of an air gap was, To make sure that there is no backflow of dirty (water) into the clean (water). The 2013 FDA Food Code was reviewed and revealed the following in Section 5-202.13 Backflow Prevention, Air Gap: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.

Based on observation, interview, and record review, the facility failed to perform a timely nutrition assessment and implement nutrition interventions for two residents (R16 and R141) of seven residents reviewed for maintenance of nutrition status, resulting in the potential for compromise in nutritional status. Findings include: Resident #16 A review of the Admission Record for Resident #16 (R16) revealed an admitted [DATE] with diagnoses that included pervasive developmental disorder (delay in development of social and communication skills), morbid obesity, and ventral hernia (bulge of abdominal tissue or organ). A Minimum Data Set (MDS) assessment of 3/23/23 documented severe cognitive impairment and supervision with set-up help only for eating. A review of the recorded weights for R16 documented the following: 3/20/23 - 201.2 lbs. 3/31/23 - 216.4 lbs. 4/5/23 - 215.4 lbs. 4/12/23- 220.4 lbs. According to the recorded weights, R16 experienced a 9.5% increase in her body weight in three weeks. A review of a facility document titled, Nutrition Data Collection/Evaluation, dated 3/20/23, and completed by Registered Dietitian (RD) F, revealed in part the following recommendations: Monitor intake at meals and offer alternate items as appropriate. Monitor weight weekly times four weeks to establish weight trend. On 4/19/23 at 11:47 AM during an interview and review of R16's clinical record, Regional Registered Dietitian (RD) B agreed that R16's had experienced a significant weight gain. RD B said that R16's weight increase was a concern and that there was a fifteen pound increase in R16's weight between 3/20/23 and 3/31/23 and this should have flagged R16 to be reweighed. RD B acknowledged that there had not been any follow-up by a RD since the initial nutrition evaluation of 3/20/23. On 4/20/23 at 1:08 PM during an interview and review of R16's clinical record, Director of Nursing (DON) agreed that R16 experienced a significant weight gain, and it should be evaluated. The DON said that R16 experienced a significant weight change and there should have been some type of recommendation even if it was to reweigh the resident. The DON said that the registered dietitian does the weight monitoring and there had not been a nutrition note for R16 since 3/20/23. The DON agreed that waiting three weeks for follow-up by the dietitian regarding a significant weight change was not timely. Resident #141 During an interview and observation on 4/18/2023 at 12:51 PM, Resident #141 (R141) had not been served lunch. R141 stated, I'm vegetarian, but I eat chicken, fish, and eggs. R141 indicated she previously informed the Nursing Home Administrator (NHA) that she did not eat meat and that the NHA would get her a salad, fruit, and apple juice. When R141 was informed about what was served at lunch, she stated, I could have had that. During an interview on 4/18/2023 at 1:41 PM, R141 stated, I'm going to therapy after 2:00 PM so I may not even be here when lunch comes. During an observation on 4/18/2023 at 2:00 PM, R141 still had not been served lunch. During an interview and observation on 4/18/2023 at 3:30 PM, R141 was observed eating a salad which consisted of lettuce, chopped carrots, and chopped red bell peppers. R141 was not served fruit or apple juice. A review of the Admission Record for R141 documented an admitted [DATE] and diagnoses that included diabetes mellitus-type 2, atherosclerotic heart disease, congestive heart failure, hypertension, hyperlipidemia, gout, chronic kidney disease-stage 3, and dysphagia. A MDS assessment dated [DATE] documented intact cognition and supervision with setup help only for eating. During an interview and record review on 4/19/23 at 11:58 AM with Regional Registered Dietitian (RD) B, it was confirmed that R141 had not been prescribed a diet. RD B identified that R141 had the following diagnoses that have nutrition implications: diabetes mellitus-type 2, morbid obesity, heart disease, congestive heart failure, hypertension, hyperlipidemia, chronic kidney disease-stage 3, gout, and dysphagia. RD B said all new admissions should have a diet order, so they are receiving the correct consistency and therapeutic diet. RD B acknowledged R141 was admitted to the facility on [DATE] and should have had a nutrition assessment and been prescribed a diet by now. During an interview on 4/20/2023 at 1:08 PM, the DON said diet orders should be established for newly admitted residents upon admission because they want to make sure they are following the right diet order. A review of the following facility policies revealed in part the following: Weight Monitoring, dated 1/1/2022: - Weight can be a useful indicator of nutrition status. Significant unintended changes in weight (loss or gain) .may indicate a nutritional problem. - The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: (a.) Identifying and assessing each resident's nutritional status and risk factors .(d.) Monitoring the effectiveness of interventions and revising them as necessary. - A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutrition status. - Weight analysis: .A significant change in weight is defined as (a.) 5% change in weight in 1 month (30 days). - Documentation: (a.) The physician should be informed of a significant change in weight and may order nutritional interventions. Resident Meal Service dated 1/1/2021: - Each resident shall receive the correct diet

Based on observation, interview and record review the facility failed to ensure adequate catheter care was provided for one elevated risk for urinary infections resident (R27) of three residents reviewed for UTI (urinary tract infection)/catheter care, resulting in the potential for urinary complications, including urethral tears and increased urinary tract infections. Findings include: On 4/18/23 at 10:50 a.m. during the initial pool process, R27 was observed in the room, comfortably sitting in a geriatric chair. R27 was not able to participate in an interview due to impaired cognition. R27 was observed with an indwelling catheter that was observed underneath the geriatric chair on the floor. There were no MDS indicators noted R27 had a catheter. On 4/19/23 at 1:58 p.m. review of the electronic medical record documented R27 was initially admitted into the facility on [DATE] and readmitted from the hospital on 3/27/23 with diagnoses that include acute kidney failure, cerebral infarction, neuromuscular dysfunction of bladder, dementia, and disorder of the kidney and ureter. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R27 had short term and long-term memory impairment, moderately impaired cognition and required total dependence with one person assistance with activities of daily living. Review of the bowel and bladder section (H) of the MDS did not document R27 had a catheter. Review of the hospital records dated 3/18/23 documented R27 received a urinary catheter, .Plan: 03/18/2023 Added bicarb drip for 1-2 day. Noted abdominal distension, foley catheter placed in Urology consulted for further evaluation . Review of the readmission nurse's progress note dated 3/27/2023 at 23:20 (11:20 PM) documented the following: Resident readmitted to facility from the hospital. New foley intact and patent . The physician's readmission encounter note dated 3/30/2023 at 01:00 (1:00 AM) documented the following: .Urinary retention f/u . He was recently readmitted from the hospital due to COVID, dehydration as well as UTI . His hospital course was complicated by urinary retention. He was started on Flomax and a Foley catheter was placed . Physician's orders for the indwelling catheter were not implemented until 4/14/23 (14 days after readmission): Catheter - Anchor Secured in Place every evening shift. Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes every shift. Foley catheter-Indwelling Catheter 20 French with 30 cc balloon inflation change as needed. Catheter care was not documented in the care guide until 4/14/23 (14 days after readmission). The Nursing Readmission Evaluation dated 3/28/23 did not document R27 was readmitted with an indwelling catheter (was not checked). There was no evidence of a catheter care plan until 4/20/23 after the Director of Nursing (DON) was interviewed. The MDS assessment dated [DATE] (upon readmission from the hospital), did not document R27 was readmitted with an indwelling catheter. On 4/20/23 at 12:37 p.m. the DON was interviewed regarding R27's indwelling catheter and said the resident had a follow up appointment on 4/5/23 with the urologist because there were no appropriate diagnoses for the catheter. The physician ordered to take out the catheter and have bladder scans done from 4/5-4/12. The catheter was put back in on 4/13/23 because of abdominal distention. That is when the orders for catheter care were put in place. Although there was not a care plan and orders in place for catheter care, the resident's catheter care was still done. However, there was no care plan for an indwelling urinary catheter or physician orders for R27 or an order to remove the catheter during 4/5/23 - 4/12/23. Review of the facility's policy titled Catherization dated 1/1/22 documented the following: It is the policy of this facility to ensure that a resident who is incontinent of bladder on admission receives services and assistance to maintain continence . Urinary catheterization will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma . Residents who incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections . The use of an indwelling urinary catheter will be in accordance with physician orders . The plan of care will address the use of an indwelling urinary catheter .

Based on observation, interview, and record review, the facility failed to provide at least 80 square/feet per resident in eight of fifteen resident bedrooms (#109, 110, 111, 112, 113, 114,115 and 116) and at least 100 square feet in one of five single bedrooms (room#102), resulting in the potential for inadequate space. Findings Include: Observations of resident rooms made on 3/8/21 at 2:40 PM during the environmental tour and review of the facility bed count information sheet with the Maintenance Director identified the following: Room# Square feet Beds 102 81 1 109 143 2 110 143 2 111 143 2 112 143 2 113 143 2 114 143 2 115 143 2 116 143 2 The health and safety of the residents was not affected by the room size. Interviews with the residents noted no complaints concerning the room size.

Based on observation, interview, and record review, the facility failed to: 1. Ensure warm water was available in the two kitchen handwashing sinks; 2. Consistently obtain and document food temperatures of food prepared for the residents; 3. Ensure food products were properly date labeled; 4. Ensure pots and pans were allowed to air dry before stacking; 5. Maintain reach-in cooler and reach-in freezer in a clean and sanitary condition; 6. Properly store utensils to prevent contamination; 7. Ensure scheduled cleaning of soiled stove crumb/drip tray; and 8. Ensure the kitchen floor and molding were properly cleaned. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: During the initial tour of the kitchen on 2/15/2022 at 9:15 AM, breakfast meal service had ended, and the tour of the kitchen was begun with AM Cook C, and the following observations were made: The hot water faucet was turned on in the handwashing sink located near the kitchen steam tables and allowed to run for approximately three minutes. Cook C was asked about the temperature of the water and said, The water feels cold. The water was allowed to run for two minutes more, and the temperature was measured at 56.4 ºF (Fahrenheit) using a metal stemmed thermometer. Cook C was asked about the food temperatures of the breakfast items served to the residents that morning. Cook C stated, Food temperatures have not been updated in a while. I didn't document food temps from this morning. A binder containing food temperature logs was reviewed and the five most recent food temperature logs were dated: 1/15/2022 (dinner only), 12/22/2021 (breakfast and lunch only), log dated Friday, 12/ (all three meals), 12/10/2021 (all three meals), and 12/8/2021 (all three meals). The following items were opened and undated in the reach-in coolers: - 1 gallon container of mayonnaise - 1 gallon container of ranch dressing - 5 pound container of sour cream - 3 quart container of chocolate pudding - 32 ounce container of heavy cream - 15 ounce container of white chocolate sauce - a pizza box containing two uneaten slices of pizza The following items, located in the reach-in cooler, had been prepared and were undated: - five peanut butter and jelly sandwiches. Cook C said one sandwich felt hard to the touch. - one ham sandwich - one turkey sandwich - one uncovered container of parfait. Cook C said, the parfait should be covered. - two 8-ounce glasses of a health shake According to Cook C, the lower front grill of the reach-in cooler was dirty. Cook C stated, We never clean those. On 2/15/2022 at approximately 9:45 AM, the tour of the kitchen was continued with Regional Registered Dietitian (RD) E: The food contact surface of one large steam table pan was noted to have droplets of water and was stored nestled with other cleaned pans. The following items were opened, undated, and stored on the shelf underneath the cook's prep table: - 12.9 fluid ounce bottle of Balsamic Glaze which indicated to refrigerate after opening. - 5 pound container of honey soiled with drips of dried honey along the full length of the bottle Food spills and chipped paint were observed on the shelf underneath the cook's table. All four legs of the cook's table were stained and dirty. RD E stated the table legs need to be cleaned. The stove top drip tray was soiled with crumbs and dried fluid. Spice powder debris was observed on the shelves in the small cook's pantry. Food debris was observed on the bottom of the reach-in freezer. RD E stated it was dirty. A large bag of frozen diced chicken was opened and undated in the reach-in freezer. The following was observed in the dry storage room: - An undated plastic storage container, containing about nine quarts of rice. RD E stated, It should be dated. - Three containers each separately containing forks, spoons, knives, were opened and uncovered. RD E stated, I wish they were covered. - An opened and undated large bag of spaghetti which was not properly closed/sealed. - Unlabeled, undated, opened bag of dried cranberries. - A storage bin containing oats with a use by date of 5/10/21. When the kitchen baseboards were observed, RD E said, They are dirty. Food debris was observed on the floor underneath the shelving containing loaves of bread. After the hot water faucet was turned on in the handwashing sink located next to the dish tank and was allowed to run for two minutes, the water temperature measured 51.9 ºF. RD E stated the hot water temperature should be around 100 degrees in order to properly wash your hands. During an interview on 2/15/2022 at 4:04 PM, RD E said that a new water heater had recently been installed and the switch on the water heater had to be turned on. She stated, We flipped the switch (today) and now we have hot water in the kitchen (specifically in the handwashing sinks). RD E also stated her expectations for date labeling needed to include the arrival date, date that it is opened, and the date it expires (this is for) food safety purposes. There is a cleaning schedule for the kitchen, but it's something I'm going to revamp to make sure staff are more accountable. During an interview on 2/16/2022 at 12:36 PM, Environmental Services Supervisor (ESS) F stated, The hot water heater (in the kitchen) was leaking. (Plumbing company) was called and determined that the water heater needed to be replaced, and they had a new water heater installed in a couple of hours on that same day. ESS F said the water heater instillation occurred on January 19, 2022 and the switch to turned on the gas to heat the water occurred today. ESS F stated, It's probably so that there had not been hot water for the kitchen handwashing sinks since 1/19/2022. The following facility policies were reviewed and revealed in part the following: Food Receiving and Storage dated 1/1/2021 - - Foods shall be received and stored in a manner that complies with safe food handling practices, as outlined in the FDA Food Code. - Food Services, or other designated staff, will maintain clean food storage areas at all times. - Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. - Dry foods that are stored in bins will be, labeled and dated (opened on and use by date). Such foods will be rotated using a first in - first out system. - Foods stored in the refrigerator or freezer will be covered, labeled and dated (opened on and use by date). Kitchen Sanitation dated 1/1/2021 - - The food service area shall be maintained in a clean and sanitary manner. - Kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. - Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. - Food preparation equipment and utensils that are manually washed will be allowed to air dry. According to the 2013 FDA Food Code: - Section 2-301.15 Where to Wash. Effective handwashing is essential for minimizing the likelihood of the hands becoming a vehicle of cross contamination. It is important that handwashing be done only at a properly equipped handwashing facility in order to help ensure that food employees effectively clean their hands. Handwashing sinks are to be conveniently located, always accessible for handwashing, maintained so they provide proper water temperatures and pressure, and equipped with suitable hand cleansers, nail brushes, and disposable towels and waste containers, or hand dryers. - Section 2-301.12 Cleaning Procedure. (A) Except as specified in (D) of this section, food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. Sink that is equipped as specified under § 5-202.12 and Subpart 6-301. (B) Food employees shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: .(1) Rinse under clean, running warm water; (4) Thoroughly rinse under clean, running warm water. - Section 3-101.11, entitled, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. - Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. - Section 4-602.13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - Section 4-903.11. Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. - Section 5-202.12 Handwashing Facility, Installation. Warm water is more effective than cold water in removing the fatty soils encountered in kitchens. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from the hands. ASTM (American Society for Testing and Materials) Standards for testing the efficacy of handwashing formulations specify a water temperature of 40°C ± 2°C (100 to 108°F).

Based on observation, interview, and record review the facility failed to ensure routine dental services were provided to one of one resident (R#28) reviewed for routine dental services, resulting in unmet oral health needs, pain and discomfort, and loss of dignity. Findings include: On 2/15/22 at 12:36 p.m. during the initial pool process, R28 was observed in the room and voiced concern not having received dental care after requesting to see a dentist. R28 was observed with missing teeth on both sides (one missing in the front, top left). R28 stated, I've been wanting and waiting to see the dentist. I thought the facility would have the dentist come to the facility especially since a lot of us can't go out to see one. I'm not in pain but I have difficulty chewing some of my food. When I lived with my parents before coming here, I was getting a lot of dental work done. The dentist I was seeing said eventually I would need to get dentures. R28 covered her mouth when she smiled. On 2/16/22 at 12:44 p.m. review of the electronic clinical records documented R28 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R28 was cognitively intact (BIMS= 15) and required extensive one-person assistance with activities of daily living. The MDS assessment did not document R28's current dental status (no broken or loose teeth). A dental care plan was absent from the medical record. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Readmission nursing assessment dated [DATE] documented: Last dental exam (blank) . Did resident indicate refusal to see dentist despite need- No . Teeth: Obvious or likely cavity or broken natural teeth. On 2/16/22 at 1:51 p.m. Social Services G was interviewed and stated, We haven't had routine dental services come in since January of 2021. If someone needs to see a dentist for a special reason, I will arrange for them to be sent out. The company that was coming in terminated services, so another company was to take over. Prior to that, they were not coming in due to Covid. A referral was not sent for the resident but will be seen on the visit at the end of this month. On 2/16/22 at 2:10 p.m. Social Service G submitted a letter from the contracted dental company dated 7/26/21 which documented the following: . (Name of dental service) will assume all (previous dental service) agreements and will begin scheduling clinical visits for your residents effective September 1, 2021 . On 2/16/22 at 4:31 p.m., review of the facility's policy titled Dental Services dated 1/1/2021 documented: Routine and 24-hour emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

Based on observation, interview and record review the facility failed to administer medications accurately for two sampled residents (Resident #'s 6 and 30) from a total sample of five residents observed during medication pass, resulting in a medication error rate of 7.14%. R#3 On 3/9/21 at 7:59 AM, an [MEDICATION NAME] Diskus Aerosol inhaler was prepared by Nurse A for administration to R#3. The nurse gave the inhaler to resident and instructed the resident to inhale two (2) times on the mouth piece of the inhaler. Review of the physician's orders [REDACTED]. At 8:07 AM, Nurse A was queried why she instructed the resident to inhale 2 times and not as ordered 1 time. Nurse A stated, (R#3) doesn't take a full dose, so I have (R#3) take another puff so (R#3) gets the whole dose. Nurse A was asked if they had notified the physician of the resident not taking the full dose and getting the order changed to which Nurse A responded, No. Record review revealed that R#3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 2/12/2021 Quarterly Minimum Data Set Assessment (MDS) indicted the resident was cognitively intact. Review of the facility's policy titled, Medication - Inhaler dated 1/1/21 documented, Medications are administered as prescribed, in accordance with current nursing principles and practices and only by persons legally authorized to do so. Resident #6 On 3/9/21 at 12:48 PM, a [MEDICATION NAME] (insulin pen containing rapid acting insulin) was prepared by Nurse A for administration to R#6 for a random blood sugar of 261. Review of the physician's orders [REDACTED]. Inject as per sliding scale: if 201 - 250 = 3 give insulin after meals; 251 - 300 = 5 give insulin after meals; 301 - 350 = 7 give insulin after meals; 351 - 400 = 9 give 8 units if insulin is 351->400. Notify MD if over 400; 401+ = 9. Subcutaneously before meals for check BS before meals and administer insulin after meals give half of sliding scale dose if (R#6) doesn't eat. Per the order the nurse was to administer 5 units of insulin to R#6. The nurse dialed the flex pen to the ordered amount of insulin (5 units) without first priming the pen with 2 units of insulin. Nurse A then injected the [MEDICATION NAME]into the residents right arm. At 1:18 PM, Nurse A was queried about the insulin administration and how could they ensure the resident received the entire dose of insulin with out first priming the pen and said, We only have to prime the insulin pen when we first open it, not for any doses after that. I don't want to waste any insulin. Record review revealed that R#6 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/4/21 Quarterly Minimum Data Set Assessment (MDS) indicated the residents cognition was intact. A 1/27/2020 care plan titled, DIABETIC STATUS: Dx Diabetes Mellitus, documented, experiences both hyper and hypoglycemic episodes and requires strict, vigilant management of disease process, medication and dietary regimens; barriers include: is non-compliant with balancing dietary intake with medication administrations, is cognitively & functionally impaired. Per 2019 manufactures guidelines, Attach a new needle. Prime your pen. Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Turn the dose selector to select the numbers of units you need to inject . Per the facility's policy tilted Medication Administration. Subcutaneous Insulin dated 1/2007 documented, Always perform a safety test before each injection .select a dose .press the injection button all the way in. Check if insulin come out of the needle tip .if no insulin comes out, check for air bubbles and repeat safety test two more times to remove them . At 1:38 PM, During an interview with the facility's Director of Nursing (DON), the DON said that the nurse should have made sure there was insulin coming through the needle to ensure complete dosing, before administering the insulin to the resident. The DON went on to say that the nurse should have followed the physician's orders [REDACTED].

This citation pertains to intake # MI 700. Based on observation, interview, and record review the facility failed to ensure safety measures were followed per the resident plan of care; resulting in a fall with injury (fractured left hip) in one (#301) of 4 sample residents reviewed for falls. Findings included: According to the admission face sheet for resident 301, resident 301 was an [AGE] year old female admitted to the facility on 3- 9-19 with [DIAGNOSES REDACTED]. The facility reported to the State Agency on 5/19/18 that resident #301 had a fall, and after x-ray results was admitted to the hospital. The facility completed a Facility Past Non-Compliance on 5/22/18. The minimum data set (MDS) dated (MONTH) 16, (YEAR) noted a BIMS (Brief Interview of Mental Status) of 13, indicating the resident was cognitively intact, in addition, she required extensive assistance and one-person support with transfers, and toilet use. According to the MDS, the balance of resident #301 during transitions and walking was unsteady and she was only able to stabilize with staff assistance. According to the Activities of Daily Living care plan initiated on 3/12/18 and a Falls care plan initiated on 3/12/18 interventions included: Toilet Use with Bedpan, with extensive assistance from 2 persons. Be sure the resident's call light is within reach and, anticipate and meet the resident's needs based on nursing assessment. The incident and accident report dated 5/19/18 noted that resident #301 was on the floor of the restroom on her left side. Her head was by the door way. The post incident investigation dated 5/19/18 revealed resident #301 was observed laying on the back hall bathroom floor after staff responded to hearing her yell out for help. An immediate physical assessment was completed by the nurses and revealed a small reddened area to her left hip on which she was laying. Neuro checks were also initiated. The staff assisted the resident back to bed where she began to complain about pain to her left hip. The doctor was notified of the events and an X-ray of the left thigh and hip were ordered. The x-ray results showed a [MEDICAL CONDITION] hip and the doctor ordered the resident sent to the hospital where she received hip surgery. The facility past non-compliance document dated 5/22/18 revealed the CNA (certified nursing assistant) whom was involved with resident #301 during the time of the incident, revealed the resident had on her call light and stated she needed to use the bathroom. The CNA transferred her to a wheelchair and took her across the hall to the bathroom and transferred her onto the toilet. The CNA stated she provided resident 301 with the call light and informed her to pull the call light when she was done. and The CNA stated she would return to help her. The CNA stated she left the bathroom to answer another call light. The CNA stated as she was walking down the hallway, she noticed the resident had put on her call light and she turned back around and went back to resident's #301 bathroom. The resident stated she was done and the CNA assisted her to a standing position. Resident #301 stated she was passing gas and she should try to have a BM (bowel movement). According to the document, the CNA assisted her back on the toilet. The CNA left the bathroom for a second time after providing the resident with a call light and went to answer another call light. After leaving she heard the resident yell out for help, returned to the bathroom, and discovered her laying on her left side on the floor. According to the Facility Pass Non- Compliance document dated 5/22/18, the root cause of the incident was the facility not following the Care Plan. The facility has experienced 3 resident falls ( dating 5/23, 5/31, and 6/1, (YEAR)) since the submission of the Facility Non-Compliance document dated 5/22/18). On 6/5/18 at PM resident #301 was observed sitting in her wheelchair in the hallway. When asked how she was doing the resident stated, not good. The resident stated, my leg hurts from my fall. I had surgery, but my leg still hurts. Resident #301 was observed grimacing in pain when shifting her weight in her wheelchair. The resident stated, can you give me the phone, (pointing to the facility phone) so I can call my husband. When informed the surveyor could not provide her the phone, the resident became angry and started screaming in the hall.

This citation pertains to Intake #MI 789. Based on interview and record review the facility failed to accurately administer prescribed medication ([MEDICATION NAME]-sedative and antihypertensive drug) to the correct resident for one of one sampled resident's (#501) reviewed for medication services from a total sample of three, resulting in a [MEDICATION NAME] overdose. Findings include: On 12/19/16 at 1:30 p.m., record review revealed that Resident #501 was originally admitted into the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident's cognition was intact and required supervision with all activities of daily living. Review of a document titled, Medication Discrepancy Report dated 11/20/16 documented, Resident (#501) was given another resident's medication in error ([MEDICATION NAME]). The resident was sent out to the hospital for [MEDICAL CONDITION] (Low blood pressure). Review of the physician's orders [REDACTED].#501 was not prescribed [MEDICATION NAME]. A nurses note dated 11/19/16 documented, At 9:00 blood pressure (B/P) 126/72 .B/P dropping and call placed to (Attending Physician's name) who stated take B/P every hour and if systolic ([MEDICAL CONDITION] pressure in the circulatory system) pressure falls below 100, call him back. B/P 64/36 .at 9:35. (Attending Physician's name) ordered (Resident #501) to be sent to (Name of local hospital) emergency room via ambulance . Review of the emergency room hospital records dated 11/19/16 revealed that Resident #501 was seen at the hospital for, An accidental dose of [MEDICATION NAME] 0.2 milligram (mg) tables times two doses. The patient currently is not taking any blood pressure medications, but was given these two doses of [MEDICATION NAME] with a significant drop in her blood pressures down to the 60's systolic. The patient complaining of significant lightheadedness as well as dizziness .She was started on a [MEDICATION NAME] (a chemical use to increase low blood pressure) and then transferred to Step-down unit for further evaluation. After a two day hospital stay, Resident #501 was readmitted back into the facility on [DATE]. Review of a Physician's Assistant note dated 11/28/16 documented, Reason for Appointment: [MEDICAL CONDITION], [MEDICATION NAME] overdose (od). Treatment: [MEDICAL CONDITION] resolved, due to [MEDICATION NAME] od. She got (vaso-vascular) pressors in hospital. On 12/19/16 art 2:30 p.m., review of a document titled Performance Improvement Form for Staff Nurse A (the nurse who wrongly administered the two doses of [MEDICATION NAME] to Resident #501) documented, The employee violated (Facility name) policy (policy number). The nurse gave another resident's medication to another resident. Nurse (Nurse A) educated previously on the process. Nurse reeducated on medication pass. At 2:45 p.m., The facility's Director of Nursing (DON) was asked about the medication error for Resident #501. The DON said that Nurse A accidently gave Resident #501 another resident's medication, causing the resident's blood pressure to drop and subsequently sent out to the hospital for treatment. Along with the DON the personnel file for Nurse A was reviewed and revealed that Nurse A had previously been disciplined for medication pass errors. The DON revealed documentation where Nurse A was provided Administering Medications inservices on 1/7/16 through 1/8/16 and again on 4/27/16 (two times prior to the medication administration error that incurred on 11/19/16). On 12/19/16 at 3:00 p.m., review of the facility's policy titled, Administering Medications dated 12/21/10 documented, 5. The individual administering medications must verify the resident's identify before giving the resident his/her medication. Methods of identifying the resident include: A. Checking identification band; B. Checking photograph attached to medical record; C. Calling resident by name; and D; If necessary, verifying resident identification with other facility personnel. 6. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method of administration before giving medication. ( )

This citation pertains to MI 135. Based on observation, interview and record review, the facility failed to ensure proper transfer technique according to the resident's assessment was utilized for one Resident (#701) of three residents reviewed for accidents and falls from a total of three sampled residents, resulting in a fall with injury. Findings include: On 9/25/2014 at 8:45 a.m., an unannounced abbreviated survey was conducted at the facility related to an allegation that Resident #701 "fell and sustained an injury after a staff member attempted to transfer Resident #701 without assistance." On 9/25/2014 at 9:30 a.m., Resident #701 was observed being propelled in a high back reclining wheelchair with a modified seat support by a family to the courtyard. Resident #701 was not observed to participate in the mobility process. On 9/25/2014 at 9:40 a.m., review of the Facility Incident and Accident (I and A) dated 8/28/2014 at 7:30 a.m. revealed Resident #701 had sustained a right hip fracture. Further review of the I and A revealed: -Registered Nurse (RN) "B" was "called to room...by (staff "C") and observed (Resident #701) sitting on the floor at the left side of the bed with (Certified Nursing Assistant/CNA "A") kneeling on the floor behind the resident. (CNA "A's") right knee was supporting the resident. (CNA "A") had her arms around (Resident #701)." -Resident #701 was assessed to use a two person mechanical lift with transfers. -Upon further interview RN "B" further stated "I was called to the room by" CNA C "who stated (Resident #701) is on the floor. Upon entering the room I observed (Resident #701) sitting on the floor on the buttock to the right side of the bed but facing the foot of the bed. (Resident #701's) legs were extended out in front of the resident but bent at the knees...(CNA "A") was kneeling on the floor behind (Resident #701) with her knee extended forward supporting (Resident #701's) rt (right) leg..We assessed the resident and did a three person lift into the wheelchair." -Resident #701 denied pain until 8/29/2014 at 1:43 p.m. The doctor ordered a Xray of the right hip. -8/29/2014 at 8:41 p.m. the Xray results revealed "right intertrochanteric fracture." On 9/25/2014 at 10:00 a.m. CNA "C" stated during an interview regarding Resident #701's fall, "I didn't see nothing. The door was closed. I opened it and saw (Resident #701) on the floor and (CNA "A") in front. (CNA "A") asked me to help get the resident up. I said what's going on and ran and got the nurse...We always review the residents' care guides before rendering care." CNA "C" denied ever caring for Resident #701 and was unaware of the resident's care status. On 9/25/2014 at 11:30 a.m. The Director of Nursing/Administrator (DON/Admin) stated during an interview CNA "A" was no longer employed at the facility. During a record review of CNA "A's" employee record, the following was revealed: -hired 4/11/12 into the facility -orientation completed 4/12/12 -two annual evaluations and competencies were completed with no concerns -5/9/14 was in-serviced for not having safety equipment in place for a resident in which no injury occurred to the resident -6/12/14 was inserviced for not transferring resident according to the care plan in which no injury occurred. Upon the completion of the record review the DON/Admin stated "We first suspended pending investigation. We termed after review of the findings because we felt she was purposeful. There was no excuse." On 9/25/2014 at 12:00 p.m., Review of Resident #701's medical record revealed the following: -Per Minimum Data Assessment ((MDS) dated [DATE], Resident #701 was admitted into the facility with [DIAGNOSES REDACTED]. Also, Resident #701 required extensive two person physical assistance with bed mobility and total two person physical assistance with transfers. -Per a physician not dated 8/27/14 Resident #701 also suffered form "significant Kyphoscoliosis" (an abnormal front to back curvature of the spine). -Per the face sheet Resident #701 also suffered from [DIAGNOSES REDACTED] (painful facial nerve pain). -Per review of the fall care plan updated 8/15/14 "extensive assistance times two with mechanical lift for transfers...extensive assistance times two with bed mobility and toileting needs." RN "B" was not available for interview by the end of the survey. On 9/25/2014 at 1:00 p.m. during and interview with the DON/Admin regarding the fall and Injury Resident #701 sustained of 8/28/2014 the DON/Admin stated, "We did all we could do to prevent it. There should have been two people to transfer. I don't know what else to say." ( )

This citation pertains to MI 539. Based on observation, interview, and record review, the facility failed to recognize, evaluate and analyze falls and fall risks, and implement adequate supervision and assistive devices to decrease fall risk for 3 of 4 sampled residents at risk for falls (Resident #101, Resident #102, and Resident #103), from a total of 4 sampled residents, resulting in a fall with serious injury for Resident #101, and repeated falls for Resident #102 and Resident #103. Findings include: "Fall" refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred." (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals /downloads/som107ap_pp_guidelines_ltcf.pdf) Review of the facility SAFETYPROGRAM/pol(,[DATE]), revealed, "We at (facility) commit our united efforts to identify risks and intervene to promote safety based upon the following comprehensive program...It is the goal of the Safety Program to identify and reduce risk factors whenever possible...To meet this goal, the Safety Program utilized the following components...Incident/Accident Reporting - Policy and form to report incidents and accidents. Investigations - In-depth analysis of events surrounding the incident/accident. If unable to identify the causative factor, determine that abuse has been ruled out and report the incident to the appropriate government agency...Quality Assurance - Guidance for data analysis to uphold corporate compliance...Definitions...Fall - a sudden, unplanned movement to the ground from a higher elevation; or an episode where a resident lost his/her balance and would have fallen if not for staff intervention..." In an interview, on [DATE] at 10:14 AM, NHA/Nursing Home Administrator (who concurrently served as the facility DON/Director of Nursing) #1, reported she did not require staff to document on the Incident/Accident form when a resident "slides to the floor". NHA #1 presented the facility definition of a fall (see above) and reported she knew the facility definition was different than the Federal Nursing Home Regulation's definition. When asked why residents at risk for falls did not have Fall care plans, NHA #1 stated, "We include it in Mobility care plans". On [DATE] at 1:35 PM, surveyor observed Activities Director #18 and Admissions Director #19, both with their arms around resident #10, ambulating off sample resident #10 without a gait belt in the hall. Activities Director #18 and Admissions Director #19 reported off sample resident #18 was walked down to an activity by NHA #1 without a gait belt, and needed their assistance to return from the activity because she was unsteady by herself. Resident #101 "Spinal injuries include fractures, contusions, and compressions of the vertebral column, usually the result of trauma to the head or neck. The real danger lies in possible spinal cord damage...The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage." Stabilization of the head and neck is done prior to moving the victim to prevent secondary injuries such as paralysis from destabilization of a cervical vertebrae fracture..." (Diseases: Causes and [DIAGNOSES REDACTED].). Pennsylvania: Springhouse.). In a telephone interview, on [DATE] at 11:38 AM, Resident #101's daughter stated, "(Resident #101) was a fall risk; one night, they found her legs dangling over the side of the bed. I told (RN/Registered Nurse #8) I wanted (Resident #101) in a low bed, the kind that goes all the way to the floor, but they never did it. They did not notify me right away when (Resident #101) fell . When I went to see her the next day, (Resident #101) was complaining of severe neck and head pain. I insisted she be sent to the hospital". According to Resident #101's Minimum Data Set, dated dated [DATE], Resident #101 entered the facility on [DATE], scored 14 on the Brief Interview for Mental Status (indicating she was cognitively intact), needed extensive (2 +) person assist with bed mobility, was totally dependent on staff for transfers, was not steady, only able to stabilize with staff assistance for moving from seated to standing position, and surface-to-surface transfers, had [DIAGNOSES REDACTED]. According to Resident #101's CAA/Care Area Assessment Summary, dated [DATE], Falls were triggered in Column A and Column B for Falls was checked. The CAA instructed facility staff: "For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days...Check column B if the triggered care area is addressed in the care plan..." Review of Resident #101's Fall(s) - Review of Indicators of Fall Risk, dated [DATE], revealed Falls were triggered for Resident #101 due to Impaired balance during transitions, Medications, Circulatory/Heart factors, Neuromuscular/functional factors, and Perceptual factors. Review of Resident #101's Medical Record revealed Resident #101 had no Plan of Care for (Problems/Conclusions) Falls or Mobility. According to nursing Progress Notes, dated [DATE] at 11:38 PM, "(Resident #101) remains alert but confused..." The only documentation of a fall Resident #101 sustained appeared in the nursing Progress Notes. According to nursing Progress Notes, dated [DATE] at 8:00 AM, LPN/Licensed Practical Nurse #6 documented, "Alert and responsive with confusion. (Resident #101) observed restless and agitated at beginning of shift. Ativan (antianxiety medication) rec'd (received) via peg tube (feeding tube) along with pain medication...Observed on floor by CNA (nurse aide #13) at approx (approximately) (2:45 AM). When nrs (nurse) entered room (Resident #101) was noted lying on stomach on mat by bed...Medium sized bump to right side of forehead with approx ,[DATE]" (inch) cut noted. ROM (range of motion) performed without difficulty. Assisted back to bed. Ice pack applied to bump. (Physician #14) notified. Order rec'd to cont with ice to forehead, begin Neuro checks, and apply dry drsg (dressing) to cut. Spoke with daughter and notified her of incident..." The time that the doctor and daughter were notified, when Resident #101 was last observed/toileted prior the fall, whether the call light was within reach and assistive devices were in place, and whether Resident #101 complained of pain resulting from to the fall were not documented in the Progress Notes. The facility had no Incident/Accident report for a fall Resident #101 sustained on [DATE]. LPN #6 and nurse aide #13 no longer worked at the facility at the time of the investigation. Surveyor attempted to reach LPN #6 via phone on [DATE] at 10:18 AM and [DATE] at 2:37 PM without success, and nurse aide #13's phone was disconnected. Per a hospital Discharge Summary regarding Resident #101, dated [DATE], "Date of Admission: [DATE]. Date of Discharge: [DATE]. History of Present Illness: This was an [AGE] year-old white female admitted to the hospital through the emergency room where she was sent from the nursing home where she was residing after a fall. Apparently the patient fell out of bed in the middle of the night and was found on the floor. The patient did not remember the details of the fall and she was complaining of neck and head pain. An abrasion was observed over the forehead...The day of admission to the hospital, the patient was supposed to have renal dialysis. However, it was canceled because of her injury. A CT scan (imaging report)of the head and cervical spine done in the Emergency Department showed an acute (new) or subacute (recent) type 2 odontoid fracture (neck fracture)...The patient was given a cervical collar..." According to the Certificate of Death, Resident #101 died a Natural death on [DATE]; cause of death: "a. Pending Right Cerebellar Infarction (stroke); b. Arteriosclerotic Cardiovascular Disease; Other significant conditions contributing to death...Cervical (neck) Spine Fracture, Dialysis Dependent, Diabetes Mellitus". ( ) Resident #102 On [DATE] at 12:14 PM, Resident #102 was observed sitting alone in a Broda chair (reclining, high-backed wheelchair) in her room. There was no personal alarm on Resident #102 and her call light was not within reach. When asked if she could reach her call light, Resident #102 looked at her call light that was laying on her bed, smiled and made an attempt to reach it, but was unable to do so. According to Resident #102's Minimum Data Set, dated dated [DATE], Resident #102 was admitted to the facility on [DATE], scored 10 on the Brief Interview for Mental Status (indicating moderate cognitive impairment), needed extensive (2 +) person assist with bed mobility and transfers, was not steady, only able to stabilize with staff assistance for moving from seated to standing position, and surface-to-surface transfers, had upper and lower extremity impairment on one side of her body, had [DIAGNOSES REDACTED]. According to the Review of Indicators of Fall Risk, Resident #102 has a history of anxiety and becomes agitated; Requires extensive assist of two for transfers, was on Antianxiety, Antidepressants, and Diuretics (water pill), had Neuromuscular/functional factors, Orthopedic (bone) factors, Perceptual factors and Psychiatric or cognitive factors; the document indicated that a Care Plan "will be developed". According to physician progress notes [REDACTED]. Review of Resident #102's Medical Record revealed Resident #101 had no Plan of Care for (Problems/Conclusions) Falls. According to Resident #102's Mobility Plan of Care, dated [DATE], Resident #102 was to have, "Personal alarm at all times". Review of nursing Progress Notes, revealed Resident #102 had falls on [DATE], [DATE], [DATE], and [DATE], but the facility had no Incident/Accident reports for the falls on [DATE] and [DATE]. According to nursing Progress Notes, dated [DATE] at 7:25 PM, "At approx (7:00 PM), (Resident #102) observed sliding out of bed onto floor mat at bedside. Resident safely transferred back to bed. Daughter had just left from visiting 20 min (minutes) prior. Resident was checked, and in clean, dry brief. Wanted bedside fan turned off. Did not utilize call light. No injury apparent. Resident care plan accounts for this behavior of self-transfer attempts, and safety is maintained". Vital signs, neuro checks, physician and family notification, whether the call light was within reach and assistive devices were in place, and whether new interventions were put in place were not documented in the Progress Notes. According to nursing Progress Notes, dated [DATE], "At (3:30 PM) (Resident #102) observed lying prone on floor...Resident calm and not demonstrating increased anxiety or discomfort after transfer to bed". The time the responsible party was notified was not documented in the Progress Notes. According to the Accident/Incident Report, dated [DATE] at 3:30 PM, Resident #102 was, "observed lying prone on floor adjacent to bed", and "Steps taken to avoid immediate repetition: meds (medications) given as scheduled plus prn (as needed) Roxanol (narcotic pain medication) for comfort given post incident (see below)"; notification of responsible party was not documented on the Accident/Incident Report. According to nursing Progress Notes, dated [DATE] at 11:42 PM, "At (9:45 PM) writer was walking past room and resident was at the end of the bed and slid on buttocks onto floor mat. Bed in low position. Safety measures in place. Resident kept yelling I can walk, I can walk. Tried to explain to (Resident #102) that she could not walk. Helped resident back to bed". Vital signs, neuro checks, physician and family notification, whether the call light was within reach and what assistive devices were in place, and when resident was last observed/toileted, and and whether new interventions were put in place were not documented in the Progress Notes. In a telephone interview, on [DATE] at 9:57 AM, Resident #102's responsible party, daughter #102, reported, ",[DATE] times, (Resident #102) has fallen since she's been at the facility. I have them all written down...One person, (nurse aide #12) is able to transfer h(Resident #102) by herself; she grabs the back of (Resident #102's) pants and grabs her under her arms; doesn't not use a gait belt. I've seen (nurse aide #12) do that many, many times. I've never seen any staff use a gait belt or an assistive device to transfer (Resident #102)." Resident #103 According to Resident #103's Minimum Data Set, dated dated [DATE], Resident #103 scored 8 on the Brief Interview for Mental Status (indicating moderate cognitive impairment), had 1 fall with no injury and 1 fall with injury since prior assessment. According to Resident #103's CAA, dated [DATE], she triggered and was care planned for falls. According to a History and Physical, dated [DATE], Resident #103 had a history gait imbalance and falls and "needs 24 hour care and safety". Review of Resident #103's Medical Record revealed Resident #103 had a Plan of Care for (Problems/Conclusions) Falls, but it was not initiated until [DATE]. In it's entirety, Resident #103's Fall Plan of Care stated, "Problems/Conclusions - FALLS: (Resident #103) is at risk for falls r/t (related to) recent falls, increased anxiety and increased confusion. Measurable Goals - (Resident #103) will be free from injury with any falls. Approaches/Interventions - (Resident #103) will request assistance when needed; skid free foot ware while awake; Clear room and floor of clutter". Resident #103's Progress Notes revealed Resident #103 fell on twice on [DATE], once on [DATE], and once on [DATE]. The facility had no Incident/Accident report for the second fall on [DATE] and the possible fall on [DATE]. (According to progress notes documented by physician #14, Resident #103 sustained the second fall on [DATE] at 8:15 PM, and according to progress notes documented by RN #15, Resident #103 sustained a fall on [DATE] at 12:36 AM.) According to an Accident/Incident Report, RN/Registered Nurse #8 documented, "Date of Accident/Incident: [DATE]; Time: 3:15 PM; Location: Room 120...(Resident #103) laying on her back on right side of bed towards the foot of the bed. Wheelchair was next to her at foot of bed. Call light within reach on bed. She had her shoes on. Pillow was on the floor and her lap quilt was on the floor. Bruise and swelling right side of her right eye. Alert and orient to self. Stated my back is hurting a little. Stated my right shoulder hurts. Had full ROM (range of motion)...Steps taken to avoid immediate repetition...will move bed against wall..." According to Progress Notes, dated [DATE] at 8:30 PM, physician #14 documented, "(Resident #103) just a fall and hit her left side of the forehead and sustained a large bruise. (Resident #103) alert and responsive and was able to express pain in the shoulder. (Resident #103) is not able to detail the fall and can't remember why and how of the event. Pain is acute on chronic in nature. (Resident #103) also c/o (complains of) nausea and retching... no FND (findings) at the moment but it has been (only) 15 minutes into the fall...Wet thick moist cough and increased urinary frequency as reported by daughter..." According to nurses' Progress Notes, dated [DATE] at 12:36 AM, RN #15 documented, "Fall with injury. Resident observed on floor at bed. She has a hematoma next to her rt (right) eye and c/o (complaint of) rt shoulder pain. Noted to have a loose cough. (Physician #14) in bldg (facility) and ordered a stat (immediately) CXR (chest x-ray) and Rt. (right) shoulder x-rays. X-rays obtained and neg." In an interview, on [DATE] at 3:00 PM, RN #15 denied that Resident #103 fell on [DATE] at 12:36 AM. RN #15 stated, "(RN #8) told me she would write the Incident Report if you chart on it. I did the assessment; (Resident #103) was sitting on her bed. They had just put her back to bed, and I did the head-to-toe assessment and started neuro checks. I notified the family later. I don't remember how much later". On [DATE] at 1:50 PM, Resident #103 was observed sitting up in her bed; she was alert and smiling. Resident #103's call light cord was curled up on the floor, approximately 3 feet away from Resident #103. Resident #103 reported she remembered she had fallen, but could not remember how often or when. When asked if she could reach her call light, Resident #103 looked at the call light on the floor and stated, "No. That's where they (staff) always keep it. I get up and crawl on the floor to get it." There were no assistive devices observed such as personal alarms or fall mats in place, and Resident #103's room was at the end of the hall - the room farthest from the nurse's station. It was observed that Resident #103's roommate, off sample resident #16's, call light was also not within resident #16's reach. ( )

THIS CITATION PERTAINS TO INTAKE MI 080. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ELOPEMENT FOR 1 (#201) OF 6 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT IN A TOTAL SAMPLE OF 6, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #201, WHO HAD BEEN PREVIOUSLY IDENTIFIED AS AN ELOPEMENT RISK AND WHO ELOPED FROM THE FACILITY ON 10/9/12 AT APPROXIMATELY 3:00 PM, UNBEKNOWNST TO THE FACILITY STAFF. THIS DEFICIENT PRACTICE PLACED RESIDENT #101 AT HIGH RISK FOR PHYSICAL HARM OR DEATH. AS A RESULT OF THE FACILITY'S FAILURE TO SUPERVISE AND IMPLEMENT SAFETY DEVICES (LOCKED AND ALARMED EXIT DOORS), 2 OTHER RESIDENTS IDENTIFIED AS ELOPEMENT RISKS WERE PLACED AT HIGH RISK FOR ELOPEMENT WHICH COULD HAVE RESULTED IN PHYSICAL HARM, INJURY OR DEATH. FINDINGS INCLUDE: ON ENTRANCE, 11-29-2012 AT 9:30 A.M., THE DIRECTOR OF NURSING (DON) #1 WAS INTERVIEWED. THE FACILITY INCIDENT REPORT, NURSES' NOTES AND INVESTIGATION WERE REVIEWED. THE INCIDENT REPORT, DATED 10-09-12 AT 3:00 P.M., DOCUMENTED THAT A STAFF MEMBER, IDENTIFIED AS THE MAINTENANCE DIRECTOR (MD) #3, WHO WAS ALREADY "OFF-DUTY" FOR THE DAY, REPORTED THAT RESIDENT #201 WAS OBSERVED WALKING EASTBOUND ON THE SIDEWALK IN FRONT OF THE FACILITY. ACCORDING TO DON #1, MD #3 PULLED HIS CAR OVER AND IMMEDIATELY ALERTED HER OF RESIDENT #501'S WHEREABOUTS. THE FACILITY STAFF RESPONDED AND ESCORTED RESIDENT #201 BACK INTO THE FACILITY. THE RESIDENT HAD CROSSED THE STREET AND WALKED LESS THAN ONE BLOCK. THE ACCIDENT/INCIDENT REPORT DATED 10-09-12, READ, "THE STAFF REPORTED TO DON (#1) THAT (#201) WAS WALKING DOWN THE STREET. (#201) APPEARS TIRED. VITAL SIGNS: BLOOD PRESSURE 162/96, TEMPERATURE 96.8, RESPIRATION 24, PULSE 65. COMPLETE BODY ASSESSMENT COMPLETED WITH NO BRUISES, CUTS OR SCRAPES. ASSURED WANDERGUARD (A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY) ALARM WORKING; EVERY 10 MINUTES PRESENCE CHECKS INITIATED. SIGNS POSTED AT EXITS." THE REPORT FURTHER DOCUMENTED THAT RESIDENT #501'S RESPONSIBLE PARTY AND PHYSICIAN WERE NOTIFIED OF THE ELOPEMENT. THE FACILITY ELOPEMENT POLICY AND PROCEDURE WAS REVIEWED. ACCORDING TO THIS POLICY, ELOPEMENT WAS DEFINED AS "ANY RESIDENT WHO WANDERS BEYOND THE END OF THE RAMPS ON THE WEST SIDE OF THE BUILDING, THE RAMPS ON THE SOUTH SIDE OR TO THE SIDEWALKS ON THE NORTH SIDE OF THE BUILDING." AN AT-RISK RESIDENT WAS DEFINED BY THE POLICY AS "A RESIDENT WHO HAS A HISTORY OF WANDERING AND/OR EXPRESSES A DESIRE TO LEAVE AND/OR IS CAPABLE OF OPERATING THE SECURITY ALARM SYSTEM." RESIDENT #201'S CLINICAL RECORD WAS REVIEWED. THE RESIDENT WAS admitted on [DATE] FROM ANOTHER FACILITY AND HAD AN INDIVIDUAL NAMED AS HAVING POWER OF ATTORNEY. RESIDENT #201 HAD [DIAGNOSES REDACTED]. THE ELOPEMENT RISK ASSESSMENT, DATED 9/24/2012, NOTED THAT RESIDENT #201 WAS AT RISK FOR ELOPEMENT AND A WANDERGUARD BRACELET WAS APPLIED. THE NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING, DATED 10-1-2012, IDENTIFIED RESIDENT #201 AS HAVING COGNITIVE PATTERNS THAT WERE MINIMALLY IMPAIRED. THE RESIDENT WAS ALERT WITH PERIODS OF CONFUSION, DISORIENTATION AND PARANOID BEHAVIORS. RESIDENT #201 REQUIRED SUPERVISION OR LIMITED ASSISTANCE WITH ACTIVITY OF DAILY LIVING SKILLS. RESIDENT #201 HAD A PLAN OF CARE IN PLACE THAT ADDRESSED HIS POTENTIAL FOR ELOPEMENT DUE TO HIS EXIT-SEEKING BEHAVIOR; HIS ABILITY TO AMBULATE INDEPENDENTLY; AND HIS EXPRESSED DESIRE TO LEAVE THE FACILITY. THE CARE PLAN NOTED THAT RESIDENT #201 WAS INTELLIGENT, OBSERVANT AND HAD A WORK HISTORY THAT INDICATED HE HAD BEEN ABLE TO FORMULATE AND CARRY OUT COMPLEX PROJECTS. THE INTERVENTIONS INCLUDED MONITORING THE RESIDENT WITH USE OF THE WANDERGUARD (SYSTEM), ENCOURAGING PARTICIPATION IN ACTIVITIES AND REMINDING RESIDENT #201 OF THE IMPORTANCE OF REMAINING IN THE FACILITY. ON 10/25/2012, RESIDENT #201 WAS TRANSFERRED TO ANOTHER FACILITY. ON 11-29-2012 AT 10:50 A.M., MD #3 (WHO OBSERVED RESIDENT #201 OUTSIDE OF THE FACILITY) WAS INTERVIEWED. HE STATED, "I WAS LEAVING FOR THE DAY AT APPROXIMATELY 3:00 P.M. I PULLED OUT THE PARKING LOT AFTER WARMING UP MY VEHICLE AT 3:06 OR 3:07 P.M. I WAS GOING EAST ON (THE STREET IN FRONT OF THE FACILITY), WHEN I NOTICED THE RESIDENT (#201) WALKING ON THE RIGHT SIDE OF THE STREET. I WAS GOING TO STOP BUT I DID NOT REALIZE IT WAS (RESIDENT #201) UNTIL I PASSED HIM. I PULLED OVER AND HE CROSSED THE STREET. I TURNED AROUND AND IMMEDIATELY GOT THE DIRECTOR OF NURSING. I RUSHED, NOT WANTING HIM (#201) TO GET AWAY. THE DIRECTOR OF NURSING PULLED HER CAR AROUND AND THE RESIDENT WAS RETURNED BACK INTO THE FACILITY WITHOUT A PROBLEM." THE STATEMENT FOR THE FACILITY INVESTIGATION WAS REVIEWED AND WAS CONSISTENT WITH THIS INTERVIEW. ON 11/29/12 AT 3:00 P.M. EMPLOYEE #6, THE ACTIVITY SUPERVISOR AND EMPLOYEE #7, THE THERAPIST ASSISTANT, WERE INTERVIEWED. THEY STATED, "THE RESIDENT (#201) WAS IN THE DAY ROOM FOR THE ACTIVITY AT 3:00 P.M. (ON 10/9/12), BUT HE WOULD GET UP AND GO IN AND OUT (OF THE AREA)." ACCORDING TO BOTH EMPLOYEES, #6 AND #7, THEY DID NOT RECALL SEEING THE RESIDENT LEAVE THE ACTIVITY ON 10/9/12. THEY STATED, "WE NORMALLY TRY TO REDIRECT (RESIDENT #201) BACK INTO THE ACTIVITY OR A SUPERVISED AREA (WHEN HE LEAVES)." ON 11/29/2012 DURING THE ENTRANCE CONFERENCE, DON #1 STATED, "I WAS AT THE NURSING STATION (ON 10-9-12 AT 3:00 P.M.) AND THE WANDERGUARD (ALARM) HAD NOT SOUNDED. UPON RETURNING THE RESIDENT INTO THE FACILITY, THE WANDERGUARD (BRACELET WORN BY RESIDENT #201) WAS IN PLACE AND WORKING." REVIEW OF THE ACCIDENT/INCIDENT REPORT INVESTIGATION (ELOPEMENT), DATED 10/12/12, REVEALED THAT THE FACILITY DETERMINED THAT RESIDENT #201 WAS ABLE TO LEAVE THE FACILITY BY WALKING FROM THE THERAPY ROOM, INTO THE KITCHEN AND OUT OF THE FACILITY BY EXITING THROUGH THE KITCHEN DOOR, WHICH WAS NOT LOCKED OR ALARMED. THE ACCIDENT/INCIDENT REPORT INVESTIGATION (ELOPEMENT) CONCLUDED THAT THE DOOR BETWEEN THE FACILITY THERAPY ROOM AND THE KITCHEN "WHICH IS A CODE/LOCKED DOOR WAS FOUND TO NOT COMPLETELY LOCK/CLOSE WHEN VENT (VENTILATION) HOOD IN KITCHEN IS ON. THE DOOR TO OUTSIDE FROM THE KITCHEN IS NEITHER CODE LOCKED/OR ALARMED. RES (RESIDENT #201) WAS ABLE TO EGRESS TO OUTSIDE." OBSERVATION OF THE KITCHEN EXIT DOOR ON 11-29-2012 AT 10:00 A.M. AND 12/3/2012 AT 2:00 P.M. REVEALED THAT THE DOOR HAD BEEN EQUIPPED WITH AN ALERT CHIME ALARM. WHEN THE ALERT CHIME ALARM SOUNDED, THE VOLUME OF THE AUDIBLE ALARM WAS VERY LOW AND WOULD BE DIFFICULT TO HEAR AND EASY TO IGNORE WHEN THE KITCHEN STAFF WAS BUSY PREPARING MEALS OR CLEANING. OBSERVATION OF THE THERAPY ROOM ADJACENT TO THE FACILITY KITCHEN ON 11/29/2012 AT 10:00 A.M. AND ON 12/3/2012 AT 2:00 P.M. REVEALED THAT THE DOOR THAT LED INTO THE KITCHEN FROM THE THERAPY ROOM HAD A KEYPAD LOCK. UPON OPENING THIS DOOR, IT WAS NOTED THAT THE PRESSURE FROM THE KITCHEN'S VENTILATION PREVENTED THE MAGNETIC DOOR FROM CLOSING COMPLETELY. ON 11/29/2012 AT 5:38 P.M., THE DIRECTOR OF NURSING (#1) WAS INFORMED OF THE IMMEDIATE THE IMMEDIATE JEOPARDY THAT BEGAN ON 10-09-12, AS A RESULT OF THE FACILITY'S FAILURE TO SUPERVISE AND IMPLEMENT SAFETY DEVICES (LOCKED OR ALARMED EXIT DOORS) TO PREVENT THE ELOPEMENT OF RESIDENT #201, AND PLACING 2 ADDITIONAL RESIDENTS AT HIGH RISK FOR ELOPEMENT AND THE RISK OF SERIOUS HARM, INJURY, OR DEATH. ON 11/29/2012 AND 12/3/2012 THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: ON 10/10/2012 THE DIETARY MANAGER MET WITH THE ADMINISTRATOR AND THE DECISION WAS MADE TO KEEP THE DOOR TO THE DIETARY DEPARTMENT (KITCHEN) LOCKED IN BETWEEN MEAL SERVICE. THE POLICY WAS PRESENTED TO THE DIETARY MANAGER ON 10/10/2012 AND DIETARY STAFF WERE IN-SERVICED ON 10/10/2012. ON 11/1/2012 AN ALARM WAS INSTALLED TO THE EXTERIOR DOOR. THIS ALARM WAS NOT CONNECTED TO THE WANDERGUARD ALARM SYSTEM, BUT IS A STAND-ALONE, BATTERY OPERATED ALARM. ON 11/01/2012, THE DIETARY MANAGER WAS IN-SERVICED ON THE OPERATION OF THIS ALARM. ON 10/29/2012 THE DIETARY STAFF WAS IN-SERVICED ON THE PURPOSE OF THIS ALARM. ON 11/1/2012 THE PLANT OPERATIONS MANAGER AND THE ASSISTANT MAINTENANCE SUPERVISOR WERE IN-SERVICED ON ADDING THE NEW ALARM TO THEIR WEEKLY ALARM AUDIT. TWO OTHER RESIDENTS ARE DESIGNATED AS ELOPEMENT RISKS. ON 10/10/2012, CARE PLANS FOR THESE TWO RESIDENTS WERE REVIEWED AND NO REVISIONS WERE NEEDED. POLICIES AND PROCEDURES WERE REVIEWED AND THE FOLLOWING WERE DEVELOPED: 1. STAND UP MEETINGS ARE HELD DAILY AND IN-SERVICE TRAINING WAS HELD WITH ALL DEPARTMENT HEADS ON 9/26/12. 2. EXTERIOR DOOR ALARM IN-SERVICE WAS HELD WITH ALL DIETARY STAFF ON 10/29/12. 3. EXTERIOR DOOR ALARM SOUNDER IN-SERVICE WAS HELD WITH DIETARY STAFF ON 10/29/12 4. NOTIFICATION OF ALL DEPARTMENTS OF AN ELOPEMENT RISK IN-SERVICE WAS HELD FOR ALL DEPARTMENT HEADS ON 9/26/12. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 10/09/2012 WAS REMOVED ON 11/01/2012. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS PAIN AND ADMINISTER PAIN MEDICATION AS ORDERED FOR WOUND CARE FOR ONE (#208) OF EIGHT RESIDENTS REVIEWED FOR PAIN, OUT OF A TOTAL SAMPLE SIZE OF 12, RESULTING IN THE RESIDENT EXPERIENCING EXCRUCIATING PAIN DURING WOUND CARE. FINDINGS INCLUDE: ON 3/29/12, AT 2:00 P.M., RESIDENT #208'S RECORD WAS REVIEWED AND IT REVEALED RESIDENT #208 WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE], INDICATED RESIDENT #208 WAS COGNITIVELY INTACT AND REQUIRED EXTENSIVE PHYSICAL ASSISTANCE FROM STAFF FOR ALL CARE NEEDS. ON 3/30/12 AT 9:10 A.M., STAFF NURSE "I" STATED, "I NEED TO PREMEDICATE RESIDENT #208 PRIOR TO PERFORMING THE WOUND CARE TREATMENT. ON 3/30/12 AT 9:20 A.M., NURSE "I" WAS OBSERVED PROVIDING WOUND CARE AND DRESSING CHANGE FOR RESIDENT #208. NURSE "I" REMOVED THE DRESSING FROM RESIDENT #208'S RIGHT HEEL. RESIDENT #208 GROANED FROM PAIN, RAISED SELF FROM THE BED IN A SUDDEN JERKING MOVEMENT IN PAIN AND PULLED HER RIGHT HEEL BACK EACH TIME NURSE "I" TOUCHED THE WOUND. RESIDENT #208 YELLED OUT LOUDLY IN PAIN MULTIPLE TIMES, "OUCH, THAT HURTS, AND THAT HURTS SO BAD". NURSE "I" DIDN'T STOP THE WOUND CARE TREATMENT, BUT CONTINUED AND DID NOT ACKNOWLEDGE RESIDENT #208'S SIGNS AND SYMPTOMS OF PAIN OR ALTER THE MANNER IN WHICH THE TREATMENT WAS PROVIDED. NURSE "I" WAS QUERIED AT THE TIME AND WAS ASKED WHY SHE DIDN'T STOP THE WOUND CARE TREATMENT AND ASSESS RESIDENT #208 FOR PAIN OR OFFER ANY PAIN MEDICATION TO MANAGE THE PAIN. NURSE "I" STATED, "I DON'T KNOW." SHE ACKNOWLEDGED THAT SHE SHOULD HAVE STOPPED THE TREATMENT. REVIEW OF RESIDENT #208'S "MEDICATION ADMINISTRATION physician's orders [REDACTED]. REVIEW OF THE "MEDICATION ADMINISTRATION RECORD" (MAR) REVEALED NURSE "I" DID NOT ADMINISTER RESIDENT #208 ANY MEDICATION FOR PAIN PRIOR TO THE DRESSING CHANGE. NURSE "I" REPORTED THAT SHE DIDN'T PREMEDICATE RESIDENT #208 PRIOR TO THE WOUND CARE TREATMENT AND THAT SHE DIDN'T ASSESS RESIDENT #208 FOR PAIN PRIOR TO WOUND CARE. ON 3/30/12 AT 9:58 A.M., A RECORD REVIEW AND AN INTERVIEW WAS CONDUCTED WITH THE FACILITY'S DIRECTOR OF NURSING (DON), REGARDING RESIDENT #208'S PAIN DURING A DRESSING CHANGE. RECORD REVIEW REVEALED DOCUMENTATION FROM "THE NURSING ADMISSION ASSESSMENT," THAT RESIDENT #208 WAS NOT admitted INTO THE FACILITY WITH ANY WOUNDS. ON 1/28/12, RESIDENT #208'S "NURSING PROGRESS NOTES" DOCUMENTED THAT RESIDENT #208 DEVELOPED A RIGHT HEEL PRESSURE SORE. THE PRESSURE SORE WAS DESCRIBED AS "RIGHT INNER FOOT, MEASURES 6 CENTIMETER (CM) X 4 CM, DARK AREA UNDER SKIN IS 6 CM X 1.5 CM." THE DON WAS QUERIED AS TO WHY THE NURSE DID NOT STOP THE WOUND CARE WHEN RESIDENT #208 WAS YELLING OUT IN PAIN. THE DON WAS UNABLE TO EXPLAIN OR PROVIDE A VERBAL EXPLANATION. A PAIN EVALUATION AND PAIN SCORE WERE REQUESTED FOR RESIDENT #208 FROM THE DON. THE DOCUMENTATION WAS NOT PROVIDED BY THE END OF THE SURVEY. THE FACILITY'S POLICY FOR PAIN, UNDATED, DOCUMENTED, "MEDICATIONS-...PRN'S (AS NEEDED) MAY BE VALUABLE WHEN GIVEN BEFORE ACTIVITIES THAT EXACERBATE A RESIDENT'S PAIN. PAIN MEDICATION MUST BE MONITORED FOR EFFECTIVENESS." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND IMPLEMENT SAFETY DEVICES/INTERVENTIONS FOR THREE (#'S 205, 208, AND 212) OF FIVE SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 12, RESULTING IN FALLS AND A FRACTURE. FINDINGS INCLUDE: ON 3/30/12 AT 8:55 AM, THE CLINICAL RECORD AND INCIDENT/ACCIDENT (I/A) REPORTS FOR RESIDENT #212 WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE FACE SHEET REVEALED THAT RESIDENT #212 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE] AND 10/19/11, NOTED THAT RESIDENT #212 WAS NON-AMBULATORY, SEVERELY COGNITIVELY IMPAIRED, AND REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS AND BED MOBILITY. A "MOBILITY" CARE PLAN DATED 11/8/10 THRU 10/14/11 FOR RESIDENT #212 NOTED: "(THE RESIDENT) IS UNABLE TO AMBULATE OR STAND WITHOUT ASSIST. SHE IS UNABLE TO STRAIGHTEN HER KNEES WHEN STANDING DUE TO ARTHRITIS. SHE USES A WHEELCHAIR FOR LOCOMOTION. SHE HAS A FEAR OF FALLING." INTERVENTIONS INCLUDED A FALL SAFETY ALARM AND A FALL SAFETY FLOOR MAT. RESIDENT #212'S I/A REPORTS NOTED THE FOLLOWING: 1. ON 10/4/11 AT 5:50 AM, RESIDENT #212 STATED, "I fell OUT THE BED WHILE I WAS SLEEPING. I WOKE UP AND WAS ON THE FLOOR. DON'T ASK ME HOW I DID. I JUST DID." THE RESIDENT WAS NOTED TO HAVE A SAFETY ALARM BUT, "ALARM WAS NOT SOUNDING" AND "RESIDENT IS CAPABLE OF REMOVING (ALARM)." THE I/A REPORT DID NOT CLARIFY WHETHER THIS WAS THE CASE, NOR DID THE CHART DOCUMENT THAT THE resident had a history of [REDACTED]. THERE WAS NO NOTED INJURY. THE STEPS TAKEN TO AVOID IMMEDIATE REPETITION: "WEDGE (CUSHION) WAS ADDED TO BED IN ADDITION TO (ALARM) AND LOW BED." RESIDENT #212'S "HISTORY OF FALLING" CARE AREA ASSESSMENT (CAA) IN THE 10/19/11 MDS NOTED: "(RESIDENT) HAD DEMENTIA AND OSTEOARTHRITIS. SHE HAS A FEAR OF FALLING. SHE STATES SHE ROLLED OUT OF BED WHILE SLEEPING....WILL PROCEED TO MOBILITY PLAN OF CARE. (RESIDENT) HAS HISTORY OF FALLS." INTERVENTIONS FOR THE RESIDENT'S NEW "MOBILITY" CARE PLAN DATED 10/14/11 NOTED INTERVENTIONS THAT INCLUDED: FLOOR MAT, SAFETY ALARM, AND WEDGE CUSHION. THERE WAS NO MENTION OF SAFETY DEVICES TO PREVENT ROLLING OUT OF BED OR TO PREVENT THE RESIDENT FROM REMOVING THE ALARM. 2. ON 12/3/11 AT 2:30 AM: "(STAFF) HEARD (ALARM) SOUNDING OFF AND A VOICE YELLING HELP ME. (STAFF NOTED (RESIDENT #212) LYING ON FLOOR BY BED ON RIGHT SIDE. STATED SHE DIDN'T KNOW WHAT SHE WAS DOING AND BEGAN CRYING....BED IN LOW POSITION. WEDGE IN PLACE." IMMEDIATE ACTIONS TAKEN: SAFETY ALARM AND "WEDGE IN PLACE." A STAT (IMMEDIATE) X-RAY TO THE RIGHT HIP REVEALED: "fell , PAIN, RULE OUT FRACTURE....ACUTE NONDISPLACED RIGHT INTERTROCHANTERIC FEMORAL FRACTURE (FRACTURED RIGHT HIP)." RESIDENT #212 WAS hospitalized from [DATE] THRU 1/5/12 FOR SURGICAL REPAIR OF THE RIGHT HIP AND RETURNED TO THE FACILITY WITH 16 STAPLES TO THE HIP. THE I/A INVESTIGATION OF RESIDENT #212'S FALL AND FRACTURE CONTAINED AN "ASSISTIVE DEVICES" CHECKLIST. THE CHECKLIST NOTED THAT THE RESIDENT HAD "BODY PILLOWS BEHIND BACK AND UNDER FEET" WHEN THE FALL OCCURRED BUT, DID NOT HAVE A FALL SAFETY FLOOR MAT IN PLACE. WHEN QUERIED ABOUT INTERVENTIONS TO PREVENT ROLLING OUT OF BED AFTER THE FIRST FALL ON 10/4/11, THE DON SAID, "SHE HAD A PILLOW BEHIND HER BACK" AND THAT THE PILLOW WAS "USED TO PREVENT FALLS." THE DON EXPLAINED THAT ONE SIDE OF THE RESIDENT'S BED WAS AGAINST THE WALL TO PREVENT FALLING OUT ON THAT SIDE OF THE BED. THE PILLOW WAS BEHIND THE BACK TO PREVENT ROLLING OUT OF THE OTHER SIDE OF THE BED. HOWEVER, THE DON WAS UNABLE TO EXPLAIN HOW A BACK PILLOW WOULD PREVENT ROLLING OUT OF BED. SHE WAS UNABLE TO EXPLAIN WHY THE FALL SAFETY MAT WAS NOT IN PLACE DURING THE INCIDENT. PER THE FACILITY'S UNDATED "IN-DEPTH INVESTIGATION OF I/A REPORTS-SAFETY" POLICY: -THE FACILITY IS "EXPECTED TO EVALUATE THE RESIDENTS INVOLVED TO IDENTIFY POTENTIAL CAUSATIVE FACTORS OF THE EVENT. -"THE THERAPY DEPARTMENT IS RESPONSIBLE TO EVALUATE ALL ASSISTIVE DEVICES USED BY THE RESIDENT FOR APPROPRIATENESS AND FUNCTION." -"AS SOON AS THE CAUSE OF THE EVENT IS IDENTIFIED, A CONCLUSION AND AN INTERDISCIPLINARY PLAN OF ACTION TO PREVENT REOCCURRENCE WILL BE DEVELOPED BY THE SAFETY COMMITTEE....ALL STAFF INVOLVED WITH THE RESIDENT MUST BE AWARE OF THE STEPS IDENTIFIED TO ELIMINATE THE POTENTIAL FOR REPETITION OF A SIMILAR EVENT." ( ) REVIEW OF RESIDENT #205'S FACE SHEET REVEALED AN ADMISSION INTO FACILITY ON 4/4/10 WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM DATA SET (MDS) INDICATED THAT RESIDENT#205 REQUIRED STAFF ASSISTANCE IN TILTING AND AMBULATION AND HER GAIT WAS UNSTEADY. NURSING PROGRESS NOTES INDICATED THAT THE RESIDENT fell IN THE BATHROOM NEAR THE DINING ROOM ON 9/11/11. PER THE PROGRESS NOTES: "THE RESIDENT TAKEN TO THE BATHROOM NEAR THE DINING ROOM, INSTRUCTED HER TO USE CALL LIGHT, WOULD BE RIGHT OUTSIDE. BATHROOM DOOR WAS CRACKED TO HEAR RESIDENT, HEARD A LOUD NOISE, OPENED BATHROOM DOOR OBSERVED RESIDENT SLIDE TO FLOOR LANDING ON HER BUTTOCKS LEANING TO RIGHT SIDE." A REVIEW OF CLINICAL PROGRESS NOTES AND INCIDENT AND ACCIDENT REPORT INDICATED THAT RESIDENT fell on [DATE] , 8/31/11 AND 9/11/11. THE RESIDENT CARE PLAN (INITIATED ON 3 /23/11) REVIEW INDICATED THAT THE CARE PLAN WAS NOT REVIEWED OR UPDATED FOR FALLS THAT OCCURRED ON 9/11/11. ON 3/28/12 RESIDENT CARE PLAN REVIEW INDICATE THAT " RESIDENT# 205 HAS HISTORY OF FALLS. SHE HAS [DIAGNOSES REDACTED]. SHE IS ABLE TO AMBULATE USING THE ROLLING WALKER AND STAND BY ASSISTANCE (SBA)." ON 3/29/12 AT 3:30 P.M., RESIDENT #205'S DAUGHTER REPORTED THAT RESIDENT #250 HAD SEVERE DIZZINESS AND LIGHT HEADEDNESS. THE DAUGHTER FURTHER STATED, "MY MOM HAD FALLEN A FEW TIMES." ON 3/30/12 AT 9 A.M., THE CLINICAL RECORD WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE DON STATED, "WE TREAT EVERYONE AT HIGH RISK FOR FALLS HERE." THERE WAS NO FALL RISK ASSESSMENT WAS DONE FOR RESIDENT #205. THE DON WAS QUERIED ABOUT RESIDENT #205'S FALL ON 9/11/11 IN THE BATHROOM, WHY CNA LEFT THE RESIDENT ALONE IN THE BATHROOM, AND HOW WOULD THE CNA'S KNOW THE RESIDENTS' TOILETING NEEDS. THE DON STATED, "IT WILL BE ON THE ADL CARE SHEETS." HOWEVER, REVIEW OF ACTIVITIES OF DAILY LIVING (ADL) ADL SHEETS HAD NO MENTION OF RESIDENT #205'S HISTORY OF FALLS OR REQUIRED ASSISTANCE WITH TOILETING. THE ADL CARE RECORDS REVEALED DOCUMENTATION THAT READ, "REMIND RESIDENT TO USE CALL LIGHTS." THE FACILITY'S UNDATED MOBILITY POLICY DID NOT ADDRESS ANY SPECIFIC INTERVENTIONS REGARDING RESIDENT #205'S FREQUENT FALLS. ( ) ON 3/29/12 AT 9:30 A.M., RESIDENT #208 WAS OBSERVED LYING IN BED SLEEPING WITH A BED ALARM ATTACHED TO THE HEAD BOARD AND THE STRING WAS NOT ATTACHED TO THE RESIDENT, BUT IT WAS TUCKED UNDER THE PILLOW. THE DIRECTOR OF NURSING WAS QUERIED AND SHE WAS UNABLE TO PROVIDE A VERBAL EXPLANATION. ON 3/30/12 AT 9:58 A.M., THE CLINICAL RECORD AND INCIDENT/ACCIDENT (I/A) REPORTS FOR RESIDENT #208 WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE RESIDENT WAS admitted on [DATE], WITH [DIAGNOSES REDACTED]. RESIDENT #208'S, MINIMUM DATA SET ((MDS) dated [DATE], INDICATED THAT THE RESIDENT WAS NON-AMBULATORY, WAS COGNITIVELY INTACT AND REQUIRED EXTENSIVE PHYSICAL ASSISTANCE FROM THE STAFF FOR TRANSFERS AND BED MOBILITY. A "MOBILITY" CARE PLAN, DATED 10/31/11 THRU 4/26/12, FOR RESIDENT #208 NOTED: "(THE RESIDENT) HAD A "HISTORY OF FALLS RESULTED IN A FRACTURE OF THE RIGHT LEG; " INTERVENTIONS INCLUDED A FALL SAFETY ALARM, LOW BED WITH FALL SAFETY FLOOR MAT, WHEELCHAIR FOR LOCOMOTION, ALARM SEAT BELT AND WEDGE. RESIDENT #208'S I/A REPORTS NOTED THE FOLLOWING: 1. A FALL OCCURRED ON 11/18/11 AT 4:30 P.M. RESIDENT #208 STATED, "I DON'T KNOW WHAT I DID." THE I/A REPORT DID NOT CLARIFY WHETHER THE RESIDENT HAD AN ALARM IN PLACE AT THE TIME OF THE FALL OR IF THE ALARM SOUNDED. THE REPORT DID NOT NOTE WHY THE ALARM WAS NOT PLACED. THERE WAS NO NOTED INJURY. THE STEPS TAKEN TO AVOID IMMEDIATE REPETITION: "FLOOR MATS, KEEP PERSONAL BODY ALARM IN PLACE AND CALL LIGHT WITHIN REACH. "THE DON WAS QUERIED AND STATED, "I DON'T KNOW IF THE PERSONAL BODY ALARM WAS IN PLACE AT THE TIME OF THE FALL. THE DOCUMENTATION DOESN'T REELECT IT (PERSONAL BODY ALARM) SOUNDING." 2. ON 12/18/11 AT 6:55 A.M., RESIDENT #208 STATED, "I SLID OUT OF MY BED." THE I/A REPORT DOCUMENTED THE PERSONAL BODY ALARM WAS HANGING ON THE GRAB BAR AND NOT CLIPPED TO RESIDENT AT THE TIME OF THE FALL." THE DON WAS QUERIED AND STATED, "I DON'T KNOW WHY THE NURSE DIDN'T REAPPLY THE PERSONAL BODY ALARM." 3. A FALL OCCURRED ON 1/7/12 AT 7:00 A.M. RESIDENT #208 STATED, "I WAS TRYING TO ANSWER THE PHONE." THE I/A REPORT DOCUMENTED THAT NO FLOOR MATTS WERE IN PLACE AT THE TIME OF THE FALL AND THAT THE BED WAS NOT IN THE LOWEST POSITION. THERE WAS NO NOTED INJURY. THE STEPS TAKEN TO AVOID IMMEDIATE REPETITION: "ASSISTED RESIDENT BACK INTO BED, PERSONAL BODY ALARM IN PLACE, REASSURED RESIDENT REGARDING THE PHONE RINGING." THE DON WAS QUERIED AND STATED, "THE CERTIFIED NURSE ASSISTANT DIDN'T PUT THE FLOOR MATS BACK IN PLACE." ( )

THIS CITATION PERTAINS TO INTAKE: MI 608. BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF PRESSURE SORES IN 1 (#101) OF 4 RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL SAMPLE OF 4, RESULTING IN RESIDENT #101 DEVELOPING TWO STAGE 3 (OPEN, DEEP CRATER WITH LOSS OF TISSUE) PRESSURE SORES ON THE LEFT ISCHIUM AND BUTTOCKS AREA. FINDINGS INCLUDE: RESIDENT #101: ACCORDING TO THE MEDICAL RECORD, RESIDENT #101 WAS A [AGE] year OLD MALE WHO WAS RE-admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #101'S NURSING ADMISSION ASSESSMENT, DATED 10/18/11, REVEALED THE RESIDENT HAD A REDDENED AREA TO HIS COCCYX AND A BLISTER TO HIS RIGHT HEEL . THE PHYSICIAN PRESCRIBED A DAILY CLEANSE WITH DRESSINGS TO THE AREA AND WEEKLY SKIN ASSESSMENTS. ON 11/22/11, THE WEEKLY SKIN ASSESSMENTS NOTED THAT BOTH OF THESE SKIN ISSUES WERE RESOLVED. A CARE PLAN FOR SKIN CONCERNS WAS NOT LOCATED IN RESIDENT #101'S MEDICAL RECORD. HOWEVER, A NOTATION IN THE WOUND CARE NURSE'S LOG, DATED 10/19/11, READ AS FOLLOWS: "REGAIN SKIN INTEGRITY TO RIGHT HEEL." A SECOND NOTATION IN THE WOUND CARE LOG, DATED 11/15/11, READ AS FOLLOWS: "KEEP SKIN FREE FROM BREAKDOWN, KEEP RIGHT HEEL WOUND FROM RE-OPENING, KEEP HEELS FLOATED AND REFER TO MDS (MINIMUM DATA SET) CARE PLAN FOR OTHER PLANS IN PLACE." REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED THAT THERE WERE NO INTERVENTIONS, ASSESSMENTS, OR DOCUMENTATION REGARDING THE COCCYX AREA AND THERE WAS NO DOCUMENTATION TO SUPPORT THAT ANY ADDITIONAL ASSESSMENTS, OR INTERVENTIONS TO PREVENT ADDITIONAL SKIN BREAKDOWN WERE ADDED TO THE RESIDENT'S CARE. A REVIEW OF THE PRESCRIBED WEEKLY SKIN ASSESSMENTS, WOUND CARE NURSE'S NOTES, AND NURSING NOTES FROM 10/18/11 THROUGH 2/24/12 REVEALED THAT UPON ADMISSION (10/18/11), RESIDENT #101 HAD A REDDENED AREA TO THE COCCYX AREA. THERE WAS NO FURTHER DOCUMENTATION REGARDING THE RESIDENT'S SKIN CONDITION PERTAINING TO HIS COCCYX AREA UNTIL 12/7/11, WHEN THE PHYSICIAN PRESCRIBED [MEDICATION NAME] TO THE OPEN AREAS ON RESIDENT #101'S BUTTOCKS AS A physician's orders [REDACTED]. A WOUND CARE NOTE ON 1/16/11, (31 DAYS LATER) IDENTIFIED THAT RESIDENT #101 DEVELOPED AN OPEN AREA TO THE BUTTOCKS (STAGE 2 PRESSURE SORE, AN AREA WITH LOSS OF SKIN, PRESENTS LIKE A SHALLOW CRATER OR BLISTER). ON 1/20/12, THE PHYSICIAN HAD PRESCRIBED CLEANSING AND DRESSING CHANGES TWICE A DAY WITH SANTYL APPLIED TO AREAS OF SLOUGH. THEN, ON 1/22/12, THE WOUND CARE NURSE DOCUMENTED THAT RESIDENT #101'S STAGE 2 PRESSURE SORE HAD WORSENED TO A STAGE 3 AND HAD SLOUGH (NECROSIS OF TISSUE) AND MACERATION (SOFTENING OF DEAD TISSUE WITH THE DETACHMENT OF EPIDERMIS) TO THE AREA. RESIDENT #101 ALSO DEVELOPED A NEW PRESSURE SORE ON THE LEFT ISCHIUM AREA, WHICH WAS DESCRIBED AS STAGE 3. ACCORDING TO THE FACILITY'S WOUND CARE POLICY DATED 2/06, "THE FACILITY STAFF WILL ASSESS AND DOCUMENT RESIDENT'S WOUND CHARACTERISTICS; INITIALLY AND AT EVERY DRESSING CHANGE. THE WOUNDS WILL BE MEASURED WEEKLY AND AS NEEDS INDICATE. A CARE PLAN WILL BE INITIATED. THE CARE PLAN WILL INCLUDE POSITIONING NEEDS, PRESSURE RELIEF, ETC." A REVIEW OF THE CARE PLANS LOCATED IN RESIDENT #101'S MEDICAL RECORD REVEALED THAT THE CARE PLANS DID NOT ADDRESS OR IDENTIFY ANY SPECIFIC INTERVENTIONS OR PREVENTION MEASURES FOR PREVENTING SKIN BREAKDOWN OR THE DEVELOPMENT OF PRESSURE SORES OF THE COCCYX/BUTTOCKS AREA, EVEN AFTER THE RESIDENT WAS IDENTIFIED TO HAVE OPEN AREAS (STAGE 2). REVIEW OF THE CARE PLANS LOCATED IN RESIDENT #101'S MEDICAL RECORD DID NOT ADDRESS OR IDENTIFY ANY SPECIFIC INTERVENTIONS OR PREVENTATIVE MEASURES FOR PREVENTING SKIN BREAKDOWN OR THE DEVELOPMENT OF PRESSURE SORES AT THE COCCYX/BUTTOCKS AREA, EVEN AFTER THE RESIDENT WAS IDENTIFIED TO HAVE SKIN BREAKDOWN (STAGE 2). THERE WERE NO RISK ASSESSMENTS IN REGARDS TO THE DEVELOPMENT OF PRESSURE SORES, NOR WERE THERE ANY PREVENTIVE MEASURES OR INTERVENTIONS DOCUMENTED IN RESIDENT #101'S MEDICAL RECORD OR CARE CARD. A REVIEW OF THE WOUND CARE NOTES FROM 1/22/12 THROUGH 2/24/12, REVEALED THAT RESIDENT #101 HAD 3 WOUND ASSESSMENTS: 1) ON 1/22/12; 2) 10 DAYS LATER, 2/1/12; AND, 3) 14 DAYS LATER ON 2/14/12. RESIDENT #101 WAS TRANSFERRED TO THE hospital on [DATE] (10 DAYS AFTER HIS LAST ASSESSMENT OF PRESSURE SORES). DURING AN INTERVIEW ON 3/26/12 AT 3:10 P.M., THE WOUND CARE NURSE SAID THAT RESIDENT #101 WAS NONCOMPLIANT WITH POSITION CHANGES AND PREFERRED TO REMAIN IN THE WHEELCHAIR MOST OF THE DAY. SHE COULD NOT EXPLAIN WHY AREAS OF PRESSURE FOR RESIDENT #101 WERE NOT IDENTIFIED OR PREVENTION MEASURES PUT IN PLACE PRIOR TO THE DEVELOPMENT OF A PRESSURE SORE. THE WOUND CARE NURSE STATED THAT RESIDENT #101'S SON BROUGHT IN A SEAT CUSHION THAT FIT THE WHEELCHAIR FOR THE RESIDENT, AFTER THE PRESSURE SORE WAS DISCOVERED. THE WOUND CARE NURSE COULD NOT LOCATE ANY SKIN ASSESSMENTS AFTER 2/14/12 AND COULD NOT EXPLAIN WHY RESIDENT #101'S PRESSURE SORES WERE NOT ASSESSED OR MEASURED ON A WEEKLY BASIS. THE WOUND CARE NURSE SAID HER SKIN CARE PREVENTION MEASURES WERE LOCATED IN HER WOUND CARE LOG AND NOT IN THE MEDICAL RECORD BECAUSE SHE DID NOT WANT TO CONTRADICT ANY OTHER CARE PLAN THAT MAY BE IN THE MEDICAL RECORD. DURING AN INTERVIEW ON 3/27/12 AT 10:30 A.M., THE DIRECTOR OF NURSING (DON) SAID THAT ALL RESIDENTS ARE CONSIDERED AT RISK FOR SKIN BREAKDOWN, BUT COULD NOT EXPLAIN WHY SPECIFIC INTERVENTIONS FOR RESIDENT #101 WERE NOT IDENTIFIED OR DOCUMENTED IN THE MEDICAL RECORD, OR IMPLEMENTED AFTER OPEN AREAS TO THE RESIDENT'S BUTTOCKS WERE IDENTIFIED. THE DON SAID RESIDENT 101'S SKIN ASSESSMENTS SHOULD HAVE BEEN COMPLETED WEEKLY, IN ACCORDANCE WITH THE FACILITY'S POLICY. ( )

THIS CITATION REFERS TO INTAKE # MI 425. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT A SIGNIFICANT MEDICATION ERROR (CORRECTLY ADMINISTER [MEDICATION NAME] SULFATE AS PRESCRIBED) TO ONE RESIDENT (#501) OF 7 SAMPLED RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #501 WHO WAS admitted TO THE HOSPITAL FOR FURTHER OBSERVATION DUE TO ACUTE OPIATE TOXICITY AND MILD RESPIRATORY DISTRESS. FINDINGS INCLUDE: RESIDENT #501 WAS [AGE] years OLD AND WAS admitted to the facility on [DATE]. THE HISTORY AND PHYSICAL DATED 5/19/10 REVEALED RESIDENT #501 HAD A LEFT-[MEDICAL CONDITION]( [MEDICAL CONDITION] OR STROKE). RESIDENT #501 HAD SLURRED SPEECH AND A HISTORY OF [MEDICAL CONDITION]. ACCORDING TO THE MDS (MINIMUM DATA SET) DATED 8/19/10, RESIDENT #501'S COGNITIVE SKILLS WERE SEVERELY IMPAIRED WITH MEMORY PROBLEMS. SHE REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ADL'S (ACTIVITIES OF DAILY LIVING) SUCH AS TRANSFERS, TOILET USE, HYGIENE, AND EATING. THE physician's orders [REDACTED]. THE FACILITY INCIDENT REPORT DATED 9/13/10 REVEALED THAT ON 9/13/10 AT APPROXIMATELY 6:00 PM, LPN (LICENSED PRACTICAL NURSE) #3 ADMINISTERED 1.25 CC OF [MEDICATION NAME] TO RESIDENT #501. NURSE #3 IMMEDIATELY REALIZED HER MISTAKE AND CALLED THE PHYSICIAN ASSISTANT WHO ORDERED RESIDENT #501 TO BE TRANSFERRED TO THE HOSPITAL FOR FURTHER OBSERVATION. ACCORDING TO THE MEDICATION DISCREPANCY REPORT DATED 9/13/10 AT 6:30 PM, LPN #3 ADMINISTERED THE WRONG DOSAGE OF [MEDICATION NAME] SULFATE TO RESIDENT #501. THE ORDER WAS NOT CORRECTLY WRITTEN. LPN #3 DID NOT LOOK AT THE MEDICINE LABEL ON THE BOTTLE/VIAL AND DID NOT COMPARE THE MEDICINE LABEL WITH THE CURRENT physician's orders [REDACTED]. THE HOSPITAL EMERGENCY RECORDS DATED 9/13/10 REVEALED RESIDENT #501 RECEIVED THE WRONG CONCENTRATION OF [MEDICATION NAME] SULFATE. RESIDENT #501 WAS SUPPOSED TO RECEIVE 5 MG. OF [MEDICATION NAME] SULFATE BUT INSTEAD RECEIVED 25 MG. (20 ADDITIONAL MG.). RESIDENT #501 WAS treated for [REDACTED]. REVIEW OF THE AMBULANCE RUN SHEET DATED 9/13/10 REVEALED: "PER ECF (EXTENDED CARE FACILITY) STAFF, PATIENT RECEIVED AN ACCIDENTAL OVERDOSE OF ORAL [MEDICATION NAME] SULFATE . PATIENT WAS RECEIVING A PRESCRIBED DOSE OF 5 MG BUT RECEIVED 25 MG INSTEAD." IN AN INTERVIEW ON 9/24/10 AT 3:10 PM, PHYSICIAN #6 SAID THE ERROR WAS SIGNIFICANT. LPN #3 GAVE 5 TIMES THE PRESCRIBED DOSE. LPN #3 WAS INTERVIEWED BY TELEPHONE ON 9/24/10 AT 3:26 PM. SHE admitted GIVING RESIDENT #501 THE WRONG DOSAGE OF [MEDICATION NAME] SULFATE ([MEDICATION NAME]). SHE RECALLED GIVING 1.25 CC INSTEAD OF 0.25 CC. SHE WAS CONFUSED WITH THE DIRECTIONS WRITTEN IN THE MAR. SHE DENIED VERIFYING THE DOSE TO BE GIVEN WITH THE WRITTEN PHYSICIAN ORDER. SHE CONSULTED ANOTHER NURSE (#7), AND NURSE #7 AGREED THAT 1.25 CC SHOULD BE GIVEN AS DIRECTED IN THE MAR. LPN #3 ADMINISTERED 1.25 CC OF [MEDICATION NAME] SULFATE TO RESIDENT #501. NURSE #3 REALIZED IT WAS THE WRONG DOSAGE WHEN SHE DOCUMENTED AND COMPARED THE DOSAGE SHE GAVE TO THE DOSAGE ADMINISTERED PREVIOUSLY. NURSE #3 IMMEDIATELY NOTIFIED THE PHYSICIAN AND THE DIRECTOR OF NURSING (DON) OF THE INCIDENT. RESIDENT #501 WAS ALERT AND RESPONDING APPROPRIATELY TO QUESTIONS WHEN THE AMBULANCE TOOK HER TO THE HOSPITAL. RESIDENT #501 DID NOT SHOW SIGNS OF RESPIRATORY DISTRESS AT THAT TIME. ACCORDING TO THE DON ON 9/24/10 AT 11:30 AM, SHE SAID LPN #3 ADMINISTERED THE WRONG DOSAGE OF [MEDICATION NAME] SULFATE TO RESIDENT #501 ON 9/13/10. THE DON VERIFIED THAT RESIDENT #501 RECEIVED 1.25 CC OF [MEDICATION NAME] SULFATE INSTEAD OF 0.25 WHICH IS 5 TIMES THE PRESCRIBED DOSAGE. THE DON SAID RESIDENT #501 WAS NOT IN RESPIRATORY DISTRESS AND WAS OBSERVED AWAKE AND RESPONSIVE BEFORE SHE WAS TAKEN TO THE HOSPITAL VIA AMBULANCE ON 9/13/10. THE DON DID AN INVESTIGATION AND SUSPENDED THE STAFF INVOLVED IN THE MEDICATION ERROR. ON 9/28/10 AT 9:35 AM, THE DON WAS INFORMED OF THE IMMEDIATE JEOPARDY AS A RESULT OF LPN #3'S FAILURE TO ADMINISTER THE CORRECT MEDICATION TO RESIDENT #501 ON 9/13/10, RESULTING IN ADMISSION TO THE HOSPITAL FOR FURTHER OBSERVATION DUE TO ACUTE OPIATE TOXICITY AND MILD RESPIRATORY DISTRESS. ON 9/30/10, THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 9/13/10, RESIDENT #501 WAS TRANSFERRED TO THE HOSPITAL FOR FURTHER OBSERVATION. 2. ON 9/18/10, LPN #3 WAS IN-SERVICED ON THE 5 RESIDENT RIGHTS FOR MED PASS (RIGHT RESIDENT, RIGHT MEDICATION, RIGHT DOSAGE, RIGHT ROUTE, AND RIGHT FREQUENCY), AND SHE WAS DISCIPLINED. LPN #3 WILL COMPLETE A MEDICATION PASS AUDIT WEEKLY TO ASSURE 100 % ACCURACY FOR 6 WEEKS. 3. ON 9/14/10, ADON #4 (ASSISTANT DIRECTOR OF NURSING) RESPONSIBLE FOR THE MONTHLY TRANSCRIPTION RENEWALS AND MIDNIGHT NURSE #5 WHO RECEIVED THE DELIVERY OF THE [MEDICATION NAME] SULFATE VIAL FROM THE PHARMACY RECEIVED IN-SERVICE ON THE 5 RESIDENT RIGHTS FOR MED PASS, AND BOTH WERE DISCIPLINED ON 9/14/10. 4. ON 9/14/10, THE EMERGENCY BACK UP BOX WAS INSPECTED FOR ADDITIONAL BOXES OF [MEDICATION NAME]. NONE WERE FOUND. PHARMACY WAS NOTIFIED OF THE MEDICATION ERROR ON 9/14/10. PHARMACY WILL NOT SEND [MEDICATION NAME] FOR RESIDENTS AND THE BACK UP BOX WITHOUT NOTIFYING THE DIRECTOR OF NURSING. 5. ON 9/14/10, ALL RESIDENTS RECEIVING [MEDICATION NAME] AND [MEDICATION NAME] SULFATE WERE CHECKED FOR DUAL [MEDICATION NAME] AND [MEDICATION NAME] ORDERS AND MEDICATION. 6. ON 9/27/10, A FORM "MEDICATION ORDERS AUDIT TOOL" WAS DEVELOPED FOR NURSES TO TRACK ALL NEW MEDICATIONS AND DISCONTINUED MEDICATIONS. THE MIDNIGHT NURSE WILL NOTIFY THE PHARMACY OF ANY MEDICATION NOT RECEIVED AND WILL ASSURE ALL DISCONTINUED MEDICATIONS ARE REMOVED FROM THE MEDICATION CART. THE DON IS RESPONSIBLE TO REVIEW THE AUDIT TOOL FORM TWICE A WEEK AND REPORT INCONSISTENCIES TO THE PHARMACY. 7. THE DON OR DESIGNEE WILL CHECK LOCK BOXES AND EMERGENCY BACK UP BOXES WEEKLY TO ASSURE PHARMACY DID NOT SEND THE INCORRECT MEDICATION STRENGTH AND DOSAGE. 8. 2 OF 14 NURSES WERE IN-SERVICED (5 RESIDENT RIGHTS AND DOCUMENTATION) ON 9/14/10 AND ON 9/18/10. 3 OF THE REMAINING 12 NURSES WERE IN-SERVICED ON 9/27/10. ALL 14 STAFF NURSES WILL BE IN-SERVICED ON THE 5 RESIDENT RIGHTS FOR MEDICATION PASS AND CORRECT DOCUMENTATION ON THE MAR BY 9/30/10. WHILE THE IMMEDIATE JEOPARDY (IJ) WAS REMOVED ON 9/27/10, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN" AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

REFER TO INTAKE # MI 425 BASED ON INTERVIEWS AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE THE NECESSARY TREATMENT AND SERVICES TO PREVENT NEW PRESSURE SORES FROM DEVELOPING AND PROMOTE HEALING FOR 1 RESIDENT (#501) OF 7 SAMPLED RESIDENTS RESULTING IN THE DEVELOPMENT OF COCCYGEAL UNSTAGEABLE WOUND REQUIRING CHEMICAL DEBRIDEMENT AT THE HOSPITAL. FINDINGS INCLUDE: RESIDENT #501 WAS [AGE] years OLD admitted to the facility on [DATE]. HISTORY AND PHYSICAL DATED 5/19/10, REVEALED RESIDENT #501 HAD LEFT [MEDICAL CONDITION]( [MEDICAL CONDITION]) PRESENTED WITH SLURRED SPEECH AND HISTORY OF [MEDICAL CONDITION]. MDS (MINIMUM DATA SET) DATED 8/19/10, SHOWED COGNITIVE SKILLS WERE SEVERELY IMPAIRED WITH MEMORY PROBLEM. SHE REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ADL (ACTIVITIES OF DAILY LIVING) SUCH AS TRANSFERS, TOILET USE, HYGIENE AND EATING. SHE WAS INCONTINENT FOR BOTH BOWEL AND BLADDER ELIMINATION PATTERN. DURING CLINICAL RECORD REVIEW, NURSING ADMISSION assessment dated [DATE], REVEALED THAT RESIDENT #501 HAD LEFT SIDED [MEDICAL CONDITION] DUE TO RIGHT [MEDICAL CONDITION]. ALTHOUGH A SLIGHT REDNESS WAS NOTED ON THE COCCYX AREA, THERE WERE NO BREAKS OR OPEN AREAS ON SKIN OBSERVED. NO PRESSURE SORE WAS NOTED. ON 9/3/10, TREATMENT NURSE NOTED WOUND SITE #1 MEASURED 3.0 CM X 1.5 CM WITH 30% SLOUGH AROUND THE WOUND. SITE #2 MEASURED 1.0 CM X 1.5 CM WIDTH WITH 80 % SLOUGH AND 20 % GRANULATION. SKIN CHECK DATED 9/7/10, WOUND SITE MEASURED 3.2 CM (LENGTH) X 3.5 CM WIDTH WITH 90% SLOUGH. RESIDENT #501'S TAR (TREATMENT ADMINISTRATION RECORD) FROM 5/17/10 THROUGH 9/13/10. THERE WAS NO CAREPLAN FOR ALTERATION IN SKIN INTEGRITY FOUND IN RESIDENT #501 ' S CLINICAL RECORD FROM 5/17/10 THROUGH 9/13/10. PHYSICIAN WEEKLY PROGRESS NOTES DID NOT SHOW EVIDENCE THAT THE RESIDENT 501' S PRESSURE SORE WAS ASSESSED AND MONITORED BY THE ATTENDING PHYSICIAN. ALTHOUGH WOUND TREATMENTS WERE ORDERED (MOST OF THEM BY TELEPHONE ORDER) WOUND ASSESSMENTS AND PROGRESS OF WOUND TREATMENT WAS NOT NOTED BY THE ATTENDING PHYSICIAN FROM 5/17/10 THROUGH 9/13/10. ACCORDING TO THE HOSPITAL RECORD DATED 9/13/10, emergency room SKIN ASSESSMENT REVEALED: UNSTAGEABLE SACROCOCCYGEAL DECUBITUS ULCER. COCCYX MEASURED 3.5 X 3.0 X 0.75 UNSTAGEABLE PRESSURE ULCER; WOUND BED 75% YELLOW, 25 % DARK RED PURPLE; MODERATE YELLOW EXUDATE; SURROUNDING SKIN: CLEAR, INTACT. CHEMICAL DEBRIDEMENT WAS RECOMMENDED. ACCORDING TO THE TREATMENT NURSE #8 ON 9/30/10 AT 1:30 PM, SHE TOOK OVER THE TREATMENT NURSE RESPONSIBILITY 3 WEEKS AGO. SHE RECALLED THE TREATMENTS GIVEN TO RESIDENT #501. ON 9/7/10, HER WOUND MEASURED 3.2 CM (LENGTH) X 3.5 CM (WIDTH), 90 % SLOUGH. TREATMENTS WERE DONE PER DOCTOR'S ORDER. ACCORDING TO THE DON (DIRECTOR OF NURSING) ON 9/29/10 AT 11:15 AM, SHE WAS UNABLE TO FIND THE CARE PLAN FOR PRESSURE SORE IN RESIDENT #501 ' S CLINICAL RECORD. SHE WAS NOT AWARE OF RESIDENT #501 ' S SKIN STATUS AND EXTENT OF PRESSURE SORE WHILE SHE WAS AT THE FACILITY. THE DON EXPLAINED THAT THE FACILITY HAD A DIFFERENT TREATMENT NURSE 3 WEEKS AGO. THE PREVIOUS TREATMENT NURSE DID NOT KEEP A TREATMENT LOG. THERE WAS NO EVIDENCE OF A WEEKLY/MONTHLY LOG WAS MAINTAINED PRIOR TO September 2010. ACCORDING TO THE FAMILY MEMBER #9 BY TELEPHONE ON 9/24/10 AT 3:15 PM, RESIDENT # 501 DID NOT HAVE AN OPEN AREA OR BREAK IN SKIN WHEN SHE WAS admitted AT THE FACILITY IN MAY 2010. HE WAS SHOCKED OF HOW LARGE THE WOUND WAS ON HER BUTTOCKS WHEN RESIDENT #501 WAS EXAMINED AT THE emergency roiagnom on [DATE]. HOSPITAL STAFF DESCRIBED HOW BIG IT WAS. THE FLESH WAS EXPOSED AND WAS OOZING. RESIDENT #501 HAD CHEMICAL WOUND DEBRIDEMENT WHILE AT THE HOSPITAL. ( )