Every finding on record at Medilodge of Port Huron

Based on interview and record review, the facility failed to offer a Covid-19 vaccination to one resident (R113) out of five reviewed for Covid-19 immunizations. Findings include:A review of R113's immunization status in their Electronic Medical Record (EMR) revealed documentation as not eligible for Covid-19 vaccination, with the reason for ineligibility described as admitted after flu season.A further review of R113's EMR revealed they were admitted into the facility 7/7/2026 with diagnoses of Chronic Obstructive Pulmonary Disease (lung disease), generalized muscle weakness, and hypertension (high blood pressure). Review of R113's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating impaired cognition.On 07/30/2026 at 10:31 AM, an interview was conducted with the facility's Infection Preventionist (IP) who indicated the reason R113 was not offered a Covid-19 vaccine was because the facility's Medical Director (MD) has implemented a policy of not offering residents the current Covid-19 vaccine starting July 1st until September. The IP explained this was so there would not be a delay in when residents are able to receive the updated version of the Covid-19 vaccine in September. According to the MD, there is a necessary waiting period after a Covid-19 vaccination when someone can receive a booster shot.On 07/30/2026 at 12:18 PM, an interview was conducted by phone with the facility's MD who said Covid-19 vaccinations are held starting in July so that residents will not have to wait to get a booster shot when the updated formulation for new Covid-19 strains becomes available in the Fall (of that same year).A review of a facility policy titled Covid-19 Vaccination, last reviewed/revised 4/2/2026, revealed COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC (Centers for Disease Control) and/or FDA (Federal Drug Administration) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine.

Based on interview and record review, the facility failed to implement blood pressure parameters for notifying the prescriber when administering blood pressure medication for one resident (R3) out of five reviewed for accidents. Findings include:A review of the medical record revealed R3 admitted into the facility on 6/1/2026 with the following medical diagnoses, heart disease and Urinary Tract Infection. Further review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6/15 indicating an impaired cognition. R3 also required staff assistance with bed mobility and transfers. Further review of an incident and accident report dated 7/9/26, documented the following, Incident Description: Resident Description: Patient (R3) states [they] were trying to stand and straighten out bed (fix bed sheets). Immediate Action Taken: Vitals taken- low blood pressure, all other vitals with normal range.Further review of the progress notes noted the following, 7/9/2026 0004 (12:04am) .Resident Fall-Resident's BP (Blood Pressure) was low. Intervention: Orthostatic Vitals (series of blood pressure and heart rate taken in different positions). 7/9/2026 00:44 (12:44 AM) .Orthostatic Vitals done post-fall. Laying down 98/45, sitting 76/33, standing 103/58.A review of the physician's orders noted the following; Order: Metoprolol Tartrate Oral Tablet 25 MG (milligram) .Directions: Give 0.5 tablet by mouth every morning and at bedtime related to heart disease . The order contained no blood pressure reading parameters for when to notifying the physician or when to hold the medication.A review of the July (2026) Medication Administration Record (MAR) for Metoprolol documented a BP reading of 98/63 on 7/12/2026 and a checkmark indicating the medication was given. Further review of the July (2026) MAR for Metoprolol noted a BP reading of 93/55 and the number five (5-indicating the medication was held).A review of the progress notes did not indicate physician notification for administration and/or holding of the medication with a systolic (top number of BP reading) less than 100. On 7/30/2026 at 11:32 AM, an interview was conducted with the Director of Nursing (DON) who stated physicians will sometimes give BP medication a parameter, but sometimes they do not. The DON stated nursing judgement should be used when holding a medication, even if there aren't parameters clearly defined in the order.On 7/30/2026 at 12:31 PM, a phone interview was conducted with the Medical Director (MD). The MD stated each case is individualized when it comes to parameters for blood pressure medications. The MD stated they expect nurses to use their judgement and call especially if the patient is symptomatic. According to the State Operations [NAME], Appendix PP: Guidance to Surveyors for Long-Term Care Facilities, the following must be included in the administration of medications, Defining general guidelines for specific monitoring related to medications, when ordered or indicated, including specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber;. (Centers for Medicare and Medicaid Services [CMS], 2025,p.594).

Based on observation, interview, and record review, the facility failed to apply a graded hand roll (hand splint used to assist with finger extension) and perform a range of motion (ROM) program for one resident (R74) of one resident reviewed for limited ROM. Findings include: On 5/19/25 at 11:39 AM, R74 was observed in bed with their right middle and ring fingers flexed unable to easily straighten. When asked if they wore a brace R74 stated, I have a thing for my hand, but no one is putting it on. At 2:00 PM, R74 was observed in bed not wearing a hand splint. On 5/20/25 at 10:30 AM, R74 was observed in bed not wearing a hand splint and confirmed no one has been in to work with their hand. Record review of R74's Electronic Health Record (EHR) revealed the most recent admission to the facility on [DATE] with diagnoses that included contracture of unidentified muscle, generalized muscle weakness, and acquired absence of left hip joint. Review of the Minimum Data Set (MDS) assessment dated [DATE] for R74 revealed a Brief interview for Mental Status (BIMS) of 15/15 intact cognition and substantial to maximum assist for upper body dressing and personal hygiene. Review of the Occupational Therapy (OT) Discharge Summary dated 4/11/25 revealed, Splint and brace program established. Pt (patient) to wear graded hand roll for 4 to 5 hours. Staff to provide assist with donning and doffing (putting on and taking off) and hygiene to decrease skin breakdown. Restorative program established = restorative ROM program restorative splint and brace program. ROM PROM (passive range of motion) to right hand before after donning graded hand roll after removing orthotic. Review of the OT Functional maintenance program sheet dated 4/14/25 revealed, ROM extremity R UE/hand (right upper extremity) graded handroll 4-6 hours 3-5 x/wk with ROM to be before graded hand roll. Splints R UE. Review of the orders, Kardex (care guide for the Certified Nurse Assistant), tasks and care plans did not reveal documentation of a restorative program. On 5/21/25 at 9:11 AM the Director of Nursing (DON) and Restorative Nurse (RN) A were interviewed and RN A said there was a break in the process, the therapy to restorative recommendation sheet was not brought to their attention to initiate the restorative program. RN A confirmed R74 did not begin the recommended restorative program and agreed R74 should receive the restorative program. The DON said the process was not followed and therapy should deliver the restorative recommendation to RN A to initiate restorative services. Review of the facility policy titled Restorative Nursing Programs revised 1/1/2022 revealed in part: The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility. A Restorative Nursing Program, when appropriate is based on the comprehensive assessment and resident. The following types of residents could benefit from a Restorative Program(s) but limited to: Contracture prevention and/or management. Areas that may indicate a referral to rehabilitation are warranted: End of therapy to continue goal achievement or maintenance and prevent decline. Restorative documentation requirements include Incorporated into the plan of care which is part of the clinical record.

Based on observation, interview, and record review, the facility failed to ensure a clean environment affecting three residents (R51, R7, and R26) of six residents reviewed for environmental concerns. Findings include: R51 On 04/30/24 at 9:10 AM, R 51 was observed lying in bed in their room. R51's bed was observed adjacent to the wall, with a patch of peeling paint/cracks approximately the size of a basketball. On 05/01/24 at 9:09 AM, R51 was observed lying in bed and was asked about the peeling paint on the wall. R51 stated, Don't like it. A record review of R51's medical record revealed, R51 was admitted on [DATE] with diagnoses of Dementia, Schizophrenia, and Unspecified Intellectual Disabilities. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] noted, R51's Brief Interview for Mental Status (BIMS) score of 11, which indicates mild cognitive impairment. R7 On 04/30/24 at 9:25 AM, R7 was observed lying in bed in their room watching television. There was an area behind the head of the bed which had deep scrapes in the wall and the paint was peeling. On 05/01/24 at 10:00 AM, R7 was observed sitting up in their wheelchair. R7 was asked about the peeling paint in their room. R7 stated, I think my wall should be fixed and painted. A record review of R7's medical record revealed, R7 was admitted on [DATE] with diagnoses of Vascular Dementia, Mood Disorder and Hemiplegia. A review of the most recent MDS assessment dated [DATE], revealed R7 with a BIMS score of 12 which indicates mild cognitive impairment. R26 On 04/30/24 at 9:30 AM, R26 was observed lying in bed in their room watching television. There was a large area behind the head of the bed which had several deep scrapes in the wall and several smaller areas of peeling paint. On 05/01/24 at 10:05 AM, R26 was observed sitting up in wheelchair near the door. R26 was asked about the peeling paint on their wall. R26 stated, I think my wall should be fixed and painted. Not nice looking. A record review of R26's medical record revealed, R26 was admitted on [DATE] with diagnosis of Alzheimer's Disease. A review of the most recent MDS assessment dated [DATE], revealed R26 with a BIMS score of 11 which indicates mild cognitive impairment. On 05/02/24 at 8:55 AM, a tour of the rooms was conducted with the Maintenance Director. The Maintenance Director was asked about the observations of the peeling paint/damaged walls in the resident's room. The Maintenance Director stated, This wing is one of the oldest parts of the building. I have been trying to work with admissions to fix rooms when they are empty. I can't fix a wall if the resident is in the room. The Maintenance Director was asked the facility's expectations for the walls in the resident's room and explained the expectation is for all rooms to be in good repair. A review of the facility's policy titled Safe and Homelike Environment with a revised date of 1/01/2022 revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risks .

Based on observation, interview, and record review, the facility failed to label and date a (wound) dressing for one resident (R2) out of one reviewed for skin conditions. Finding include: On 4/30/2024 at 9:30 AM, R2 was observed sitting in their wheelchair. R2 was noted to have a dressing on their lower left leg. The dressing was not dated. R2 stated they have problems with their legs and the nurse's put dressings on them. R2 stated they have sores on their legs sometimes and they bleed. R2 was also noted to have cream on their feet and paper towels in their shoes. On 5/1/2024 at 10:05 AM and at 5/2/2024 at 9:07 AM, R2 was observed with an undated dressing to their lower left leg. The dressing appeared to be soiled. R2 stated the dressing has not been changed since I spoke to them on 4/30/2024. R2 stated they do not remember when it was last changed or when it was put on. A review of the medical record revealed that R2 admitted into the facility on [DATE] with the following diagnoses, Cerebral Infarction and [NAME] Insufficiency. Further review of the Minimum Data Assessment set revealed Brief Interview for Mental Status score of 7/17 indicating an impaired cognition. R2 also required assistance with bed mobility and transfers. Further review of the physician orders did not show an order for the dressing use. On 5/2/2024 at 11:21 AM, an interview was conducted with the Director of Nursing (DON). The DON stated their expectation related to dressings is they are completed safely and properly. The DON stated they expect all dressings to be dated and a progress note as to why they put a dressing on. A review of a facility policy titled, Wound Treatment Management noted the following, .2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.

Based on observation, interview, and record review, the facility failed to maintain infection control practices (handling medication, proper storage of nebulizer mask, and wearing personal protective equipment [PPE] for contact isolation rooms) for two residents (R315 and R60) from a total sample of 35. Findings include: On 5/1/2024 at 6:32 AM, medication administration was completed with Licensed Practical Nurse (LPN) F. LPN F was observed taking a pill out of the medication cup with their hands without first performing hand hygiene or wearing gloves. On 5/2/2024 at 9:25 AM, medication administration was completed with Licensed Practical Nurse (LPN) G. LPN G was observed breaking a pill in half with their hands without first performing hand hygiene or wearing gloves. On 5/1/2024 at 11:00 AM, an interview was conducted with the Infection Control Preventionist (ICP). ICP stated the nurses should absolutely complete hand hygiene and should not handle anything going in someone's mouth without gloves. R315 On 4/30/2024 at 9:29 AM, a nebulizer mask was observed laying on the dresser next to the bed. The tubing was not dated, and the mask was not in a bag. On 5/1/2024 at 7:36 AM, a nebulizer mask was observed in the drawer. The mask was undated and was not in a bag. R315 was queried as to whether they used the nebulizer. R315 stated they used the nebulizer since being in the facility. A review of the medical record revealed that R315 admitted into the facility with the following diagnoses, Lobar Pneumonia and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment of 9/15 indicating an impaired cognition. R315 also required assistance with bed mobility and transfers. R60 On 4/30/2024 at 1:45 PM, 9:37 AM, and 5/1/2024 at 6:56 AM, a nebulizer mask was observed laying on the dresser. The tubing was not dated, and the mask was not in a bag. A review of the medical record revealed R60 admitted into the facility on [DATE] with the following diagnoses, Dysphagia and Sepsis. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 99 indicating that R60 was unbale to complete a cognition assessment. R60 also required assistance with bed mobility and transfers. Further review of the physician orders revealed an order for nebulizer use, every six hours. On 5/1/2024 at 11:00 AM, an interview was conducted with the Infection Control Preventionist (ICP). The ICP stated all nebulizer masks should be stored in bags with a label and date. On 4/30/2024 at 9:37AM, room [ROOM NUMBER] was noted to be on contact precautions. The two staff members were observed entering the room without any PPE. The two staff members were then observed being called out of the room and told to put PPE on. On 4/30/2024 at 12:17PM, a nurse was observed entering room [ROOM NUMBER] and giving bed one medication. The nurse was not observed wearing any PPE. On 5/1/2024 at 11:00 AM, an interview was completed with the ICP. The ICP stated that they expect that when someone walks into a contact isolation room for any reason, they should gown and glove per the signage on the door.

Based on observation, interview, and record review, the facility failed to assess and obtain consent for bed rails for one resident (R315) out of one reviewed for bed rails. Findings Include: On 4/30/2024 at 1:43 PM, R315 was observed laying in bed. R315 was noted to have full bed rails installed. R315 stated they do not use the bed rails for turning and repositioning. A review of the medical record revealed that R315 admitted into the facility with the following diagnoses, Lobar Pneumonia and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment of 9/15 indicating an impaired cognition. R315 also required assistance with bed mobility and transfers. Further review of the medical records did not reveal a consent or assessment for the used of the bed rails. On 5/2/2024 at 9:04 AM, an interview was conducted with the Registered Nurse (RN) D. RN D stated that when someone gets bed rails, they complete three assessments, and they obtain a consent. RN D stated R315 was not supposed to have bed rails and they had not been assessed for them. RN D stated R315 was in a bed that a previous resident was in. On 5/2/2024 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident comes in the facility they will be evaluated by therapy and the nurses. The DON stated they then complete a risk versus benefits to see if the bed rails are beneficial and then obtain consent. A review of a facility policy titled, Side Rails noted the following, . c. Obtain informed consent from the resident, or the resident representative for the use of bed rails, prior to installation/use. d. Determine whether the side/bed rail is a restraint. Side/bed rails will be considered a physical restraint when they limit the resident's freedom of movement and cannot be removed easily by the resident. In such cases, the facility shall follow procedures related to physical restraints. Document the medical diagnosis, condition, symptom, or functional reason for the use of the side/bed rail. f. Obtain physician orders for the use of side/bed rails.

This citation has two deficient practice statements. Deficient practice statement one. Based on observation, interview, and record review the facility failed to secure an oxygen tank for one sampled resident (R46) of seven, reviewed for accidents. On 4/30/24 at 9:22 AM, R46's room was observed with an oxygen tank, that stood free on the floor, inside of a black bag (that clips to the wheelchair), and not in a secured carrier. On 5/01/24 at 9:25 AM, R46's room was observed with an oxygen tank, that was behind a positioning wedge. The tank was leaning against the wall inside of the black bag, and not in a secured carrier. On 5/02/24 at 9:22 AM, R46 was observed in their room and was not able to provide information regarding the oxygen tank due to cognitive impairment. R46's room was observed with the oxygen tank, that was behind a positioning wedge. The tank was leaning against the wall inside of the black bag, and not in a secured carrier. On 5/02/24 at 9:23 AM, Unit Manager A was asked and alerted about the oxygen tank free standing in R46's room. Unit Manager A explained that the tank was not to be in R46's room without a secure carrier and explained that the tank could fall and explode, fire hazard, or too much oxygen could fill the room if leaking. A review of R46's medical record revealed, R46 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of Myocardial Infarction, Obstructive Sleep Apnea. Further review of R46's medical record noted, Order: Oxygen: RUN @ [2]L/MIN VIA [X] N/C [X] PRN (as needed) to maintain SPO2 greater than 90%. every shift related to NON-ST ELEVATION. MYOCARDIAL INFARCTION, OBSTRUCTIVE SLEEP APNEA. A review of R46's care plan noted, Focus: Resident is at risk for impaired respiratory status related to SOB (shortness of breath) d/t (due to) anxiety, pain Date Initiated: 03/29/2024. Goal: Resident will have reduced complications related to their altered pulmonary/respiratory status through next review. Date Initiated: 03/29/2024. Interventions: Observe vital signs and pulse oximetry as needed Date Initiated: 03/29/2024. Oxygen as ordered Date Initiated: 03/29/2024. On 5/02/24 at 11:27 AM, the Director of Nursing (DON) was asked the facility's expectation for oxygen storage. The DON explained the expectation is for the oxygen to be on a cart. A review of the facility's policy titled, Oxygen Safety dated, 1/01/2022, reveal, It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment . 4. Oxygen Storage c. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdyportable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty . 49102 Deficient practice statement two. Based on observation, interview, and record review the facility failed to secure an electronic cigarette and to provide supervision for one resident (R99) of seven, reviewed for accidents. Findings include: On 5/01/24 at 11:47 AM, an observation was made of R99 exhaling smoke from an electronic cigarette while lying in their bed. R99 was observed to quickly place device under the blanket. On 5/01/24 at 3:05 PM, Nurse C was asked about the observation of R99 smoking in their room. Nurse C stated, Residents should not have any smoking paraphernalia in the room. A review of R99's medical record revealed, R99 was admitted on [DATE] with diagnoses of Bipolar Disorder, History of Traumatic Brain Injury, and Acquired Absence of Left Leg above the Knee. A review of the most recent Minimum Data Set assessment dated [DATE] noted, R99 with a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. On 5/01/24 at 3:05 PM, the Director of Nursing (DON) was asked about the facility's expectation regarding residents smoking in their rooms. The DON stated, It is my expectation that residents will follow the protocol of no smoking. A review of the facility's policy titled, Smoking Policy Non-Smoking Campus-Residents dated 1/01/22 revealed, It is the policy of this facility to establish and maintain safe resident smoking practices for a non-smoking campus . Policy Explanation and Compliance Guidelines: Smoking Area: 1. Prior to, or upon admission, residents shall be informed that smoking is not permitted inside of facility or outside the facility on any facility property. This includes Electronic cigarettes .

Based on observation, interview, and record review, the facility failed to provide showers per preference and schedule for one resident (R70) out of three reviewed for showers. Findings Include: On 5/2/2024 at 11:04 AM, R70 was observed sitting in their wheelchair. R70 was interviewed regarding receiving showers per schedule and when requested. R70 stated they do not always receive their showers as scheduled and when they do, the staff rush through them. A review of the medical record revealed that R70 admitted into the facility on [DATE] with the following diagnoses, Pruritus and Anxiety Disorder. Further review of the Minimum Data Set assessment revealed a Brief Interview of Mental status score of 7/15 indicating an impaired cognition. R70 also required assistance with bed mobility and transfers. Further review of R70's shower documentation for March 2024 and April 2024 revealed that R70 did not receive a shower on the following days; 3/2, 3/6, 3/9, 3/13, 3/16, 3/20, 3/23, 3/27, 3/30, 4/4, 4/9, 4/16, 4/19, 4/23, 4/26, and 4/30/24. Documentation on these days revealed, Response not required. R70 received a total of seven showers within the 60-day period. On 5/2/2024 at 11:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they did find one refusal in the progress notes related to R70's showers. The DON stated that they know R70 does have refusals, but the nurses should put in a progress note each time R70 refuses a shower.

Based on observation, interview, and record review, the facility failed to provide follow-up to the PASARR (preadmission screening/annual resident review) form 3877 for two residents (R24 and R77) of three reviewed for PASARR concerns, resulting in the potential for unmet care needs. Findings Include: R77 A review of the medical record revealed that R77 admitted into the facility on [DATE] and readmitted on [DATE] with the following diagnoses, Bipolar Disorder, Psychotic Disorder with Delusions, and Schizophrenia. A review of the physician orders revealed that R77 was currently prescribed the following medications, Prozac (antidepressant), Seroquel (antipsychotic), Zyprexa (Antipsychotic), and Ativan(Antianxiety). A review of R77's documents revealed the following Annual Resident Review (ARR) revealed that questions 1-4 were checked yes for Mental Illness and Dementia. Further review of the ARR noted the following, Distribution: If any answer to items 1-6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested . Further review of the medical record did not reveal a follow up 3878 or Level II screening. On 2/15/2023 at 1:40 PM, an interview was conducted via phone with Social Worker (SW) F regarding R77's 3878 exemption or Level II. SW F stated that R77 would be a dementia exemption and that it was completed in October (2022), however it was in the queue for the physician to sign. 39918 R24 A review of R24's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and most recently readmitted on [DATE]. R24 was assessed to have a moderately impaired cognition with medical diagnoses of Stroke, Dementia, Anxiety, Depression, and Psychotic Disorder. Further review revealed that the resident requires extensive assistance from staff for most activities of daily living (ADLs). R24's record indicated that the resident has a legal guardian who is responsible for making their medical and financial decisions. Review of R24's record revealed a Pre-admission Screening (PAS)/Annual Resident Review(ARR) (3877) dated 10/15/2022. Section II included Yes answers to questions 1 through 4. A follow up Level II screening (3878) was not found. On 2/14/23 at 1:53 PM, after requesting Level II screenings from the facility for R24 and R77, the Nursing Home Administrator (NHA) replied with the following via email: The 3878s for [R77] and [R24] are in (name of computer tracking system) awaiting physician signature. The physician has been notified. On 2/15/23 at 8:04 AM, the NHA was interviewed as a follow-up to her email. When queried regarding if R24 and R77 should have a current Level II screening on file, the NHA indicated she would have to check with corporate staff, as they had been handling some social work duties for the facility. On 2/15/23 at 1:05 PM, the NHA forwarded correspondence from a corporate staff member which read, .They won't see [R24] but then we figured out the state (State Agency) marked him as no longer needed so I emailed the help desk - she requested I do this. The facility was unable to provide any formal documentation related to R24's missing Level II screening prior to survey exit. A review of the facility's policy/procedure titled, Resident Assessment - Coordination with PASARR Program (Michigan), Reviewed/ Revised 01/01/2022, revealed, 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening .ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs .3 A record of the pre-screening shall be maintained in the resident ' s medical record .

Based on observation, interview and record review the facility failed to ensure care plans were revised to reflect the current needs and condition of the resident for four sampled residents (R98, R102, R173, R375) of 24 residents whose care plans were reviewed, resulting in and the potential for unmet care needs. Findings include: R98 On 02/13/23 at 12:50 PM, R98 was observed to be in bed laying on their back with the head of the bed up around 30-45 degrees. R98 reported poor control of their urine when they had to go. R98 verbalized they were often incontinent and would have to call staff to come in and change their incontinence brief. R98 then reported they were currently wet and had told staff, and staff said they would change them before lunch. Staff was not observed to provide care prior to R98 having received their lunch. R98 further mentioned that when they were admitted into the facility they had a tube into their bladder (indwelling urinary catheter-tube into the bladder to collect urine) to help them urinate. R98 said it had been removed while at the facility and now they were incontinent and often wet. R98 was asked about options for urination and reported that they had a urinal (small plastic pitcher style device to urinate into) up until the past week. R98 verbalized some difficulty to use the urinal independently at times because of the need to open the brief quickly enough to catch the urine. A urinal was not observed in the area around the bed. On 02/14/23 at 8:39 AM and 10:36 AM, R98 was observed to be in bed, a urinal was not visible around the area of the bed and R98 reported they did not have one. On 02/14/23 at 1:02 PM, Certified Nurse Assistant C reported R98 had used a urinal and that it may be spilled by R98 during use. On 02/15/23 at 9:14 AM, was observed to be seated in bed and dressed. R98 reported they were wet and were waiting on staff to respond to the call light. Staff entered at that time. Certified Nurse Assistant (CNA) B was asked about a urinal for R98 and replied that R98 had one yesterday and would get one for R98. On 02/15/23 at 12:14 PM, R98 was observed to be in bed. A urinal was observed on the tray table on the right side of the bed with clear yellow urine in it. On 02/15/23 at 12:19 PM, Unit Manager and Registered Nurse (RN) A reported they were familiar with R98 and reported on query that at times the urinal may be kept in the bathroom rather than the bedside. RN A further reported a possible reason for this was that R98 had trouble using the urinal independently (would spill the urine) and was asked to call when they needed the urinal. RN A also note that R98 may not always call when they needed to use the urinal. RN A was asked about the care plan and whether the placement of the urinal and R98's ability to use it with assistance was in the care plan, and reported they would have to check. On 02/15/23 at 12:24 PM, CNA B reported that they had not assisted R98 with the urinal. CNA B verbalized R98 had one yesterday and it was possible to have been taken away on nights. CNA B further noted they try to leave the urinal at the bedside for residents who use them. A review of the record for R98 revealed R98 was admitted into the facility on [DATE]. Diagnoses included Weakness and Spinal Fusion. The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for extensive assistance of one or two persons for bed mobility, transfer, toilet needs and personal hygiene. The MDS also documented the presence of an indwelling catheter. A review of the care plan documented the indwelling catheter but did not document interventions for the use of the urinal or a toileting program. R173 A review of the facility record for R173 revealed R173 was admitted into the facility on [DATE] and discharged on [DATE]. Diagnoses included Dementia and Deep Tissue Damage of the Sacral (lower back/tailbone) Region. A review of the MDS assessment dated [DATE] indicated impaired cognition and documented the presence of an indwelling catheter. A review of the resident needs activities of daily living assistance care plan initiated 03/02/22, revised 03/07/22 revealed, Toilet needs: Resident requires assistance for catheter care . The resident has an indwelling catheter due to urinary retention care plan was initiated and last revised 03/23/22. On 02/15/23 at 12:55 PM, a review of the documentation for R173's indwelling catheter indicated removal at the doctor's office on 04/06/22 in a nurse progress note dated 04/07/22. A review of the 04/06/22 urology consult note did not indicate removal of the indwelling catheter at the appointment but did document a post void residual amount. This would likely indicate the indwelling catheter was not present. 34851 R102 On 2/13/23 at 9:21 AM, 2/14/23 at 9:27 AM and on 2/15/23 at 9:07 AM, R102 was observed asleep in bed. R102's Minimum Data Set (MDS) assessment indicated that the resident had an indwelling catheter (tube inserted into the bladder to collect urine). During observation of R102, a catheter was not observed. A review of R102's medical record revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Subarachnoid hemorrhage from intracranial artery and Muscle Weakness. A review of R102's quarterly MDS assessment dated [DATE] noted R102 with an indwelling catheter, moderately impaired cognition and required total assistance by staff for activities of daily living. Further review of R102's medical record revealed, current care plan Focus: resident has an IDC (indwelling catheter) in place for urinary retention with abdominal distention Date Initiated: 01/04/2023. Revision on: 01/18/2023. Goal: The resident will be/remain free from catheter-related trauma through review date. The resident will show no s/sx (signs and symptoms) of Urinary infection through review date. Date Initiated: 01/04/2023. On 2/14/23 at 2:46 PM, Registered Nurse (RN D) was asked if R102 had a catheter and stated, No they [discontinued] that. They went back and forth about it. RN D was explained that R102's care plan still noted R102 with a catheter. RN D stated that would need to be removed from the care plan. A review of R102's orders revealed, Discontinued: Maintain indwelling catheter- 16 F/30cc (cubic centimeters) balloon. Order Date 1/18/2023. Discontinued 1/30/23. 44750 R375 On 2/14/2023 at 2:38 PM, R375 was observed sitting at the table in the main dining area. R375 was observed with regular socks on and attempting to move from chair to chair. R375 appeared to be unsteady on their feet. A review of the medical record revealed that R375 admitted into the facility on [DATE] with the following diagnoses, Dementia, Repeated Falls, and Muscle Weakness. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental score of 3/15 indicating an impaired cognition. R375 also required extensive one person assist with bed mobility and transfers. A review of Incident and Accident reports since admission revealed that R375 had falls on the following dates, 1/25, 1/29,2/1,2/2,2/4,2/12, and 2/14/23. Further review of the fall care plan did not reveal immediate interventions related to the falls. On 2/15/2023 at 9:00 AM, an interview was conducted with Unit Manager (UM) D related to R375 falls and interventions. UM D stated that they have tried a lot of interventions for R375 and that they are a big fall risk. UM D was queried as to why interventions were not put in place immediately following a fall. UM D stated that they would have to look into it. On 2/15/2023 at 10:41 AM, an interview was conducted with the Director of Nursing (DON) regarding falls and immediate interventions. The DON stated that an immediate intervention should be put in when someone falls. The DON stated that the Interdisciplinary Team will then look into the interventions and see f it is appropriate and update it if needed. On 2/15/2023 at 1:00 PM, the QAPI task was completed with the Nursing Home Administrator (NHA). The NHA stated that fall prevention has a PIP (Performance Improvement Plan) and they are working on increasing engagement of residents in activities and increased monitoring as needed. A review of a facility policy titled, Fall Prevention Program noted the following, 6. When any resident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated.

Based on interview and record review, the facility failed to verify eligibility for and obtain consent (from legal guardian) prior to administering a COVID-19 vaccine for one resident (R24) of five reviewed for immunizations, resulting in the potential for residents and/or resident representatives to not be fully informed of the benefits and potential risks associated with the COVID-19 vaccine. Findings include: A review of R24's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and most recently readmitted on [DATE]. R24 was assessed to have a moderately impaired cognition with medical diagnoses of Stroke, Dementia, Anxiety, Depression, and Psychotic Disorder. Further review revealed that the resident requires extensive assistance from staff for most activities of daily living (ADLs). R24's record indicated that the resident has a legal guardian who is responsible for making their medical and financial decisions. On 2/14/23 at 12:51 PM, a review of R24's medical record revealed a documented administration of a SARS-COV-2 (COVID-19) Moderna Bivalent Booster on 12/2/2022 by Registered Nurse (RN) E. Further review of R24's immunizations revealed that the resident/representative had refused consent for the first dose of the COVID-19 vaccine (primary series). A signed consent/declination from the resident/legal guardian for the 12/2/22 administered booster was not found in the record nor provided by the facility upon request. On 2/14/23 at 12:54 PM, the Director of Nursing (DON) was queried if RN E was available for interview. The DON indicated that RN E was a former employee and used to be a Unit Manager. Further review of R24's record revealed the following progress notes, written by RN E: -12/2/2022 11:53 (AM) Nurses' Notes Note Text: Resident received Bivalent vaccine to Left arm. Tolerated well. -12/2/2022 15:10 (3:10 PM) Nurses' Notes Note Text: Resident was given Bivalent vaccine but initial COVID vaccine in the immunization record was refused. [Physician] office notified. Waiting on further orders. -12/2/2022 15:58 (3:58 PM) Nurses' Notes Note Text: Spoke via phone with [Physician] regarding Bivalance (sic) administration. No further orders at this time. On 2/14/23 at 12:56 PM, the Infection Preventionist (IP) RN was interviewed. The IP was queried regarding R24 receiving the COVID-19 Bivalent booster on 12/2/22 without having received the primary vaccine series. The IP was also asked about the lack of a signed consent/declination form that corresponded to the administered booster. The IP confirmed that the COVID-19 Bivalent booster was administered to R24 by RN E during a COVID vaccination clinic despite not receiving the primary series and without consent (or declination) from the legal guardian. The IP stated it was not his expectation for that to have occurred. The IP indicated that the situation was brought to the DON as well as the Physician's attention. The IP added that the local health department was contacted regarding next steps, the resident received three days of post-injection monitoring (confirmed through record review), and that the incident was entered into VAERS (Vaccine Adverse Event Reporting System). The IP indicated that per the direction of the local health department, the booster dose was treated as the first dose of a primary series and the resident/guardian was offered a second dose which was declined (declination documentation verified). On 2/14/23 at 1:25 PM, R24 was interviewed and queried if they recalled receiving a COVID vaccine. R24 indicated they remembered receiving one shot and indicated they felt no ill effects. R24 indicated that a second dose of the COVID vaccine was declined. On 2/14/23 at 2:01 PM, the DON was interviewed and presented documentation regarding an inservice held with RN E right after the incident as well as education provided to the other Nurse Unit Managers in the facility. The inservice information included validating residents' current vaccination status, vaccination need, and consents prior to administration of vaccination to ensure they are administered per CDC recommendations. The DON stated that R24's guardian was contacted post-incident to inform them of what happened. When queried, the DON indicated that contacting the guardian was not documented. A review of the facility's policy/procedure titled, COVID-19 Vaccination, Reviewed/Revised 06/04/2022, revealed, .16. COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine .20. Prior to offering the COVID-19 vaccine, staff, residents, or the resident ' s representative, will be educated regarding the risks, benefits and potential side effects associated with the vaccine in a form and manner that can be accessed and understood .22. Residents or their representatives and staff will sign the consent form prior to administration of the COVID-19 vaccine. This information will be retained in the resident ' s medical record or the staff ' s medical file .26. The resident ' s medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or; c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. d. Follow-up monitoring of the resident post vaccination .

This citation pertains to Intake MI00133768. Based on observation, interview and record review, the facility failed to ensure interventions to prevent the development of pressure ulcers were implemented for one resident (R102) of four reviewed for skin conditions, resulting in the potential for skin breakdown. Findings include: On 2/13/23 at 9:21 AM, R102 was observed asleep in bed. Two green protective heel boots were observed sitting in a chair near R102's bed and night stand. An observation of R102's feet revealed R102 was also wearing heel protector boots on their feet. On 2/14/23 at 9:27 AM, R102 was observed in bed. R102's was observed with a wedge under their knees but with their feet laying on the ma. The green heel boots were observed on the floor next to the bed. On 2/14/23 at 2:46 PM, R102 was observed in bed, and the boots remained on the floor and not on R102's feet. RN D walked by the room and was asked when R102 is to have the boots on and stated, We should have them (resident's feet) floated (off of the mattress). On 2/15/23 at 1:32 PM, the Director of Nursing (DON) was asked about R102's protective heel boots and when their heels are to be floated and stated, On at all times while in bed. The DON later came and reported that the boots were not care planned, but was it was noted in R102's care plan that the heels are to be floated. A review of R102's care plan revealed, Focus: The resident has potential impairment to skin integrity of the extremities related to hx (history) of convulsions, malnutrition, anemia, require total dependence for care due to Subarachnoid hemorrhage from intracranial artery, encephalopathy, convulsions Date Initiated: 05/19/22. Date Revision on: 6/6/2022. Goal: The resident's risk of significant skin injury will be reduced, minimized Date Initiated: 5/18/22. Revision on: 01/06/2023. Interventions: Float heels while in bed as resident allows. Date Imitated: 6/6/2022. Further review noted, R102 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Subarachnoid hemorrhage from intracranial artery and Muscle Weakness. A review of R102's Minimum Data Set (MDS) assessment noted R102 was at risk for pressure ulcer development and required total assistance by staff for activities of daily living. A review of the facility's policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol dated, 10/30/2022, noted, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .

Based on observation, interview and record review, the facility failed to maintain a call light within reach for four (R2, R34, R102, R106) of 24 sampled residents, resulting in impaired resident access to requesting and receiving assistance in a timely manner. Findings include: R2 Review of the facility record for R2 revealed an admitted [DATE] with diagnoses that included Alzheimer's disease, Schizophrenia and Traumatic brain injury. Minimum Data Set (MDS) assessment indicated R2 required primarily set-up to supervision assistance from staff for self care and mobility. Brief Interview of Mental Status (BIMS) score was 10 indicating moderate cognitive impairment. On [DATE] at 11:00 AM, R2 was initially interviewed in their room. There was no call light visible in the room and the call light wall jack was empty. No hand bell or other call light alternative was observed. On [DATE] at 10:30 AM, No call light was observed in R2's room. R2 was asked about the lack of a call light in the room and stated, They (facility) never got me one. On [DATE] at 12:24 PM, R2 was observed in their room. No call light or hand bell was observed and when asked about how they request assistance R2 stated, There is a pull string in the bathroom but not by my bed. A pull-string call unit was observed on the wall adjacent to the bed, next to the outlet where a call light would plug in, but there was no string attached. When asked about this, R2 stated, I think I could push that button but I can't reach it if I'm in bed. No hand bell was observed in the room. On [DATE] at 1:06 PM, the Director of Nursing (DON) and this surveyor visited R2 regarding the call light concern and the DON acknowledged that there was no call light in place in R2's room. R34 Review of the facility record for R34 revealed an admitted [DATE] with diagnoses that included Alzheimer's disease, Depression and Acute respiratory failure. MDS assessment indicated R34 required maximum self care assistance from staff for activities of daily living. R34's BIMS score was 5 indicating severe cognitive impairment. On [DATE] at 9:38 AM, R34 was initially interviewed in their room. R34's call light was observed hanging over the back of the chair adjacent to the bed. When asked if they were able to demonstrate call light use R34 was not able to reach the call light. R106 Review of the facility record for R106 revealed an admitted [DATE] with diagnoses that included Alzheimer's disease, Anxiety disorder and Peripheral vascular disease. MDS assessment indicated R106 required maximum self care assistance from staff for activities of daily living. R106's BIMS score was 10 indicating moderate cognitive impairment. On [DATE] at 9:49 AM, R106 was initially interviewed. No call light was visible and upon asking R106 about the call light they stated, I think it's on order, I think it was broken. A hand bell was observed on the window sill out of reach from the resident. On [DATE] at 10:35 AM, the DON reported that the expectation for resident call lights is that the call light be placed within the resident's reach. On [DATE] at 10:40 AM, the DON reported that the expectation if a resident's call light is not functional or in place is that a hand bell be provided within reach of the resident. 34851 R102 On [DATE] at 9:21 AM, during initial tour, R102 was observed asleep in bed. R102's call light was observed on the floor near the bed. On [DATE] at 9:27 AM, R102 was observed with their eyes open, but was unable to be interviewed due their cognitive impairment. R102's call light was observed on the floor near the bed. On [DATE] at 9:07 AM, R102 was observed in the bed and their call light was observed on the floor, under the bed. A review of R102's medical record revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Subarachnoid hemorrhage from intracranial artery and Muscle Weakness. A review of R102's Minimum Data Set (MDS) assessment noted a severely impaired cognition and required total assistance by staff for activities of daily living. On [DATE] at 9:35 AM, Registered Nurse (RN) D was explained the observation with R102's call light and asked the expectation for the position of the call light. RN D stated, Technically it should be pinned to the bed. On [DATE] at 1:31 PM, the DON was asked the facility's expectations for call lights in residents rooms and stated, Within the resident's reach. The DON further explained that R102's call light may need to be changed to a touch pad. Review of the facility policy entitled, Call Lights: Accessibility and Timely Response with the most recent review/revision date of [DATE], revealed the general policy statement, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. This policy further stated, Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied .

Based on interview and record review, the facility failed to ensure accurate advance directive information was in place for two residents (R5 and and R47) of two reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: R5 On 2/13/23 at 2:50 PM, a record review was completed for R5 and the advanced directive on file was observed to be incomplete. A review of the form titled Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt. noted, This is to acknowledge that I have been informed, in writing and in a language that I understand, of my rights and all rules and regulations regarding decision concerning medical care, including: the right to accept or refuse medical or surgical treatment. The right to formulate and to issues Advance Directives to be followed should I become incapacitated. (Box Checked) I have chosen to formulate and issue the following Advance Directives. I understand it is my responsibility to provide to the facility copies of all pertinent documentation which verify those advance directives specified below for placement in my medical record. -Medical Durable Power of Attorney, Living Will, Guardian, Do Not Resuscitate, Do Not Hospitalize, Organ Donation, Autopsy Request, Feeding Restrictions. Type: Medical Restrictions, Other Treatment Restriction, Other Advance Directives. (All of these above selections were blank without a choice made.) Acknowledgment Signatures: Blank, Legal Representative: Blank. Facility Representative/Titled: Signed (Facility's staff), LPN Date: 3/14/20. Name: [R5]. On 2/15/23 at 1:31 PM, the Director of Nursing (DON) was asked about the above form for R5 and stated, Yes something should be checked and family signed. The DON was asked if this advanced directive was incomplete and stated, Yes. R47 A record review was completed for R47 and the advanced directive was not located in the medical record. On 2/15/23 at 9:20 AM, a request was made via email to the Nursing Home Administrator (NHA) for R47's advanced directive. On 2/15/23 at 10:57 AM, the NHA replied and attached a document .You will note that the date is today. Thank you for bringing this to our attention. A review of the attachment noted, R47's advance directive was now completed and dated for 2/15/23. A policy regarding Advanced Directives was not obtained by the end of the survey.

This citation pertains to intake MI00128730. Based on interview and record review, the facility failed to protect a resident's (R89) right to be free from physical abuse by another resident (R373), resulting in the resident getting hit on the shoulder and subsequent feelings of anxiety and psychosocial distress. Findings Include: A review of a Facility Reported Incident (FRI) dated 5/12/2022 revealed the following: Investigation: The incident was not witnessed by staff. Staff answered [R89] call light and [R89] reported that [R373] had hit [them] in the shoulder. A review of the R89's medical record revealed that the resident admitted into the facility on [DATE] with diagnoses of, Chronic Obstructive Pulmonary Disease, Pain, and Major Depressive Disorder. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderately impaired cognition. R89 also required extensive two-person assist with transfers. On 2/14/2023 at 9:25 AM, an interview was conducted with R89 regarding the incident. R89 stated that they remember the incident well and will never forget it. R89 stated they were sitting up in the chair and R373 came over and started, Punching and laying into me. R89 stated that R373 turned over their bedside tray and threw all their things on the floor. R89 stated that they activated the call light and screamed for the nurse. R89 stated that the nurse came in and took R373 out of the room. R89 stated that they never saw R373 again after that. A review of R373's medical record revealed that the resident was admitted into the facility on [DATE] with the following diagnoses, Psychotic Disorder with Delusions and Anxiety. A review of the most recent MDS assessment dated [DATE] revealed a BIMS score of 0/15 indicating severely impaired cognition. R373 also required two-person extensive assist with transfers. A review of R373's record revealed the following behavior progress notes: Date: 1/26/2022. Resident exhibiting confusion, agitation, and aggression. [They] are attempting to exit through the fire exit at the end of the hall near room [ROOM NUMBER]. Another nurse and I were able to redirect [them] back to [their] room however [they] were intermittently threatening, verbally and physically aggressive with closed fist drawn back as if ready to hit someone. Will continue to monitor. Date: 1/26/2022. Resident observed making weapons from [their] silverware, breaking the handles into sharp points. When I asked what [they] were doing [they] made statements that [they] were trapped, and people were lying to [them] and [they] were going to fight [their] way out . Date: 5/1/2022. Was confused, combative after returning to bed from having a spell; trying to hit staff with bed control, swearing at staff .hospice notified of no medications in place and erratic behavior. One on one resident in room at this time to protect others. Date: 5/4/2022. Res. Was yelling out at staff, trying to hit staff, and trying to stand up out of [their] wheelchair and walk around on [their] own .resident started swearing and hitting at staff. Resident was administered PRN (as needed) (IM) (intramuscularly) Ativan injection .Resident spit in the other nurse's face . Date: 5/5/2022. Res. Very agitated just before lunch, had been up in front of the building yelling and cursing at staff . Date: 5/13/2022. SS (Social Services) followed up with resident regarding incident that happened on 5/12/2022 in which the resident had a physical altercation with another resident . On 2/15/2023 at 10:27 AM, an interview was conducted with the Director of Nursing (DON) regarding the FRI involving R89 and R373. The DON was queried regarding why R373 was moved into a room with someone, and they had a history of behaviors. The DON stated that R373 was moved into a room with R89 because they were no longer skilled and had to be moved to a long-term care bed. The DON stated that the facility did acknowledge that R373 hit R89 but did not substantiate abuse because R373 had dementia. The DON stated that after the incident R373 was moved to their own room. A review of a facility policy titled, Abuse, Neglect, and Exploitation, Date Reviewed/ Revised: 10/24/2022, noted the following, Policy: 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 .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .

Based on observation, interview, and record review, the facility failed to answer a call light in a timely manner affecting one sampled Resident (R22) of one resident reviewed for call lights resulting in, the potential for unmet care needs. Findings include: On 11/15/21 at 2:39 PM, R22 was observed lying in bed with their call light on. A review of R22's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/15/21 at 3:07 PM, an unidentified Certified Nursing Assistant (CNA) walked past the room and failed to answer the call light. On 11/15/21 at 3:08 PM, R22 was asked about their call light being on, and stated, I just want some coffee. R22 was asked about call light wait times and stated, It takes a while for call lights to be answered on all shifts. R22 further explained that prior to their current independent roommate, they would have to yell for assistance for their previous roommate, because no one would answer the call light. On 11/15/21 at 3:15 PM, R22's call light was observed to be answered by this surveyor, 39 minutes after activation. On 11/17/21 at 1:25 PM, the Nursing Home Administrator was asked for their expectations for answering call lights and stated, I do want them answered .we go by the 20-minute thing .we want call lights answered timely . A review of the facility's Call Lights: Accessibility and Timely Response dated, 1/2/21 outlined the following, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .7. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on interview and record review the facility failed to ensure bathing was provided and or documented as provided for two non sampled residents (R71 and R82) of three reviewed for bathing resulting in the potential for unmet care needs. Findings include: On 11/16/21 at 2:00 PM, during the group meeting the residents were asked if they were consistently provided at least two showers per week. R71 reported that it depended on which aide they had. One aide would always get it done and others did not. R82 reported it can take a long time (up to 30 minutes) for the call light to be answered and sometimes it was not answered until the next shift. A review of the facility record for R71 revealed, R71 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The documented showers in the last thirty days were on Thursday 10/21/21, Monday 10/25/21, Thursday 10/28/21, Monday 11/1/21, Thursday 11/4/21 and Thursday 11/11/21. Thursday 10/21/21 and Monday 11/1/21 were listed as not applicable for the type of bath provided and no shower was documented between the showers on 11/4/21 and 11/11/21. The nursing care plan titled, The resident needs activities of daily living assistance related to: [CONDITION(S)], Intellectual Disabilities . revealed, .Bathing/showering: Provide sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 10/29/2019. Bathing/showering: The resident requires the following amount of assistance, to bathe [extensive] with [1] number of staff. Date Initiated: 10/03/2019 Revision on: 10/03/2019 . The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for the total assistance of one for bathing and extensive assist of one for personal hygiene. A review of the facility record for R82 revealed, R82 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the showers documented in the last thirty days were documented on Saturday 10/23/21, Saturday 10/30/21. Saturday 11/6/21 and Wednesday 11/10/21. A review of the the nursing care plan titled, The resident needs activities of daily living assistance . revealed, Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 04/14/2021. Bathing/Showering: The resident requires the following amount of assistance to bathe [extensive] with [1] number of staff. Date Initiated: 04/14/2021. Revision on: 04/14/2021 . A review of the MDS dated [DATE] indicated intact cognition and the need for one person assist with bathing and personal hygiene. On 11/17/21 at 12:43 PM, documentation of bathing for R71 and R82 was reviewed with the Director of Nursing (DON), along with bathing assignment sheets. R82 had documentation for 10/23/21, 11/3/21, 11/6/21 and 11/10/21. Documentation for 10/13/21, 10/20/21 and 10/27/21 were not provided. R71 had documentation for 10/7/21, 10/11/21, 10/14/21, 10/25/21 and 11/11/21. No documentation that R71 had been provided their second shower between 11/4/21 and 11/11/21 was received. The DON reported a sheet for that day was not found. The DON further noted that not applicable was never an appropriate answer for the bathing task when documented on a scheduled shower day. The DON was asked to provide any documented refusals or additional documentation of showers for R71 and R82 and none were received prior to survey exit. On 11/17/21 at 1:00 PM, the Nursing Home Administrator (NHA) was interviewed in regard to shower documentation and stated, Shower documentation-that is a struggle getting them (staff) to document, they do them (showers), they don't always document that they did it. On 11/17/21 at 1:46 PM, Nurse B was asked about R82 and reported that the the resident's shower was not normally completed on their shift, but was not aware of any refusals of showers or baths. On 11/17/21 at 1:48 PM, Nurse C was asked about R71 and reported that R 71 was not one to refuse a bath and liked their bath on the midnight shift. A policy for (Certified Nurse Assistant) CNA task/shower documentation was requested on 11/17/21 at 12:19 PM but not received prior to survey exit.

Based on observation, interview and record review, the facility failed to follow up on recommendations following an outside physician visit for one Resident (Resident #38) of one resident reviewed for appointments, resulting in missed medication changes, and the likelihood of unresolved medical complications. Findings include: On 11/15/2021 at 09:48 AM, Resident #38 was observed to be sitting up in their wheelchair, dressed and groomed. Resident #38 was calm and pleasant, but unable to answer questions appropriately. On 11/15/2021 at 02:33 PM, Confidential Witness A was interviewed via telephone. According to Confidential Witness A, they took Resident #38 to a Cardiologist appointment for follow up care. Confidential Witness A stated, I could not physically handle (Resident #38), I won't be able to do that again. Confidential Witness A further explained that Resident #38 was supposed to follow up with the Cardiologist again at a later date. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #38 was most recently admitted to the facility following a hospitalization on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38 needed extensive assistance with transfers, dressing and bed mobility, and had a Brief Interview for Mental Status (BIMS) score of 07, indicating an impaired cognition. A record review of the consult for Cardiology on 09/28/2021 revealed the following information regarding Resident #38: On the consult form, in handwriting, the following recommendations were ordered: .Stop [MEDICATION(S)] (heart medication); Increase [MEDICATION(S)] (heart medication) to 75 mg (milligrams) .4 mn (month) f/u (follow up). The dictated report stated the following: .presents for Cardiovascular Review and AFib .comes to me for post hospital follow-up .has a history of [CONDITION(S)] ([CONDITION(S)]/stroke) .during one of these hospitalization s has had [CONDITION(S)] with both fast ventricular rate and slow ventricular rate .On my evaluation today (Resident #38) is in [CONDITION(S)] with poorly controlled ventricular rate .I will stop the [MEDICATION(S)] and increase the dose of [MEDICATION(S)] ([MEDICATION(S)]) to 75 mg daily. If (Resident #38) again becomes bradycardic (low heart rate) (Resident #38) may need permanent pacemaker to more effectively deal with the fast ventricular rate . A record review of the Physician Orders for Resident #38 revealed the following orders: [MEDICATION(S)] 5 mg at bedtime and [MEDICATION(S)] 50 mg daily. Both orders were the original orders from Resident #38's most recent admission into the facility on [DATE]. A record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/17/2021 at 08:09 AM, the Director of Nursing (DON) was interviewed in regard to the recommendations the Cardiologist had ordered for Resident #38. The DON stated,Yes, we can't find that (the order was followed through with). We faxed it over to the Doctor (primary care Doctor at facility) yesterday and are waiting for a response. On 11/17/2021 at 01:00 PM, the Nursing Home Administrator (NHA) was interviewed in regard to the process of follow up appointments. The NHA explained that when a resident goes on an outside appointment, that the recommendations then get passed on to the primary care physician for approval and the changes are addressed. The NHA did not provide an explanation of the missed recommendations of the Cardiologist for Resident #38. A review of the facility policy titled Physician/Practitioner Orders-Consultation dated 01/01/2021 revealed the following: .2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order. b. Document the verification order by entering the order and the time, date, and signature on the physician order sheet .c. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident was treated with dignity and respect, affecting one sampled Resident (R62) of two reviewed for dignity, resulting the potential for feelings of diminished self-worth using the reasonable person concept. Findings include: On 11/15/21 at 9:48 PM, R62 was observed in bed watching television. R62 was asked about their care at the facility and stated, They don't have enough help here. R62 was asked about specifics on their care, however, R62 started talking about Certified Nursing Aides (CNAs) pay compared to fast food restaurants and was not easily redirected. R62 stated that they had no plans to leave the facility because they (R62) were needed to protect the residents. On 11/15/21 at 12:54 PM, R62 was observed sitting in their wheelchair in the dining area. R62's catheter collection bag was observed with ambered colored urine, and without a dignity bag while other residents were eating lunch. 11/16/21 11:31 AM, R62 was observed in the dining area with their eyes closed while sitting in their wheelchair. Their urinary catheter collection bag observed with urine, and and without a dignity bag. A review of R62's medical record noted their admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R62's Brief Interview for Mental Status (BIMS) noted a score of 99 (resident was unable to complete the interview). The medical record also reflected R62 was totally dependent and required two staff for assistance with all activities of daily living. A review of R62's care plan dated 9/24/21 noted the following: Focus: The resident is verbally aggressive r/t (related to) Ineffective coping skills, Poor impulse control. Intervention: Monitor behaviors per kardex and as needed. Document observed behavior and attempted interventions. Date Initiated: 09/24/2021 On 11/16/21 at 12:56 PM, the Director of Nursing (DON) was interviewed about R62's Foley Catheter Collection Bag being without a dignity bag while in the dining area and the DON stated, (R62) is very difficult .We always send two staff into the room because he is verbally abusive. After questioning the DON, review of R62's progress notes dated 11/16/21 at 2:01 PM reflected the following: Resident declined dignity bag over catheter bag. A review of the facility's Resident Rights policy dated 1/1/21 reflected the following: Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

This Citation Pertains to Intake Number MI 388. Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure thorough assessment and timely interventions following a fall with injury for one (#701) of two Residents reviewed for falls, resulting in lack of comprehensive neurological and physical assessment following an unwitnessed fall, delay in treatment, Resident #701 experiencing a displaced digit (finger) fracture requiring surgical intervention, and unnecessary pain. Findings include: On 9/22/20 at 9:05 AM, an interview was completed with Family Member A. When queried regarding Resident #701's care in the facility, Family Member A revealed Resident #701 was their parent and they had multiple concerns. With further inquiry regarding their concerns, Family Member A revealed Resident #701 had fell in the facility and suffered injuries to their face and hand. Family Member A stated, (Resident #701) fell on ,[DATE] and they (facility) didn't do an X-Ray until 8/30! When asked, Family Member A stated, When they (facility) called to say (the Resident) had fell , they said (Resident #701) was fine. Then my (sibling) called (Resident #701) Wednesday (8/26/20) and (Resident #701) told them their thumb really hurt. Family Member A continued, (Resident #701) hit their head when they fell and is on blood thinners (medication which increases the risk of bleeding). Family Member A was asked about the Resident's pain and stated, We (family) called the facility because (Resident #701) said they weren't doing anything about it. My (sibling) even talked to the DON (Director of Nursing) about it. When queried regarding the DON's response to their concerns, Family Member A replied, The DON said the X-ray (order) was in the system but not done yet because of the way it was ordered. Family Member A then stated, The X-ray wasn't even done until the 30th (8/30/20) and it showed a fracture with displacement, the bone was completely broke off and (the Resident's) thumb was bent. You could see something was wrong with it! When queried what occurred after the X-ray, Family Member A revealed Resident #701 went to see an Orthopedic Physician on 8/31/20 and the Resident had surgery scheduled on 9/23/20 to repair the fracture. When queried regarding Resident #701 hitting their head when they fell , Family Member A stated, (Resident #701) had a big, green bruise six days later (on face) and their glasses were broke. (Another family member) had to bend them back so (the Resident) could even wear them. Family Member A revealed they were exceptionally concerned about the Resident hitting their head when they fell because Resident #701 had been more confused since the fall. When asked about the Resident's baseline cognition, Family Member A replied, (Resident #701) was forgetful at times but not bad and reiterated the Resident was displaying increased confusion. Family Member A was asked when they saw the Resident after the fall and identified the bruising and broken glasses and revealed members of the Resident's family had accompanied them to Health Care appointments outside of the facility. When queried regarding interventions implemented by the facility after the fall, Family Member A replied, They (Facility) said they moved everything around in the room so (Resident #701) couldn't hit their head which is odd because they never said (Resident #701) did (hit head) in the first place. With further inquiry, Family Member A stated, We (family) even called the Doctor and they told us they were not notified when (Resident #701) fell . At this time, Family Member stated, (Resident #701) fell again last night. They (facility) said (the Resident) was okay but how can we believe them? With further inquiry regarding the fall which had occurred the previous evening, Family Member A indicated they were only told that the Resident had fell from their wheelchair and were fine. Family Member A proceeded to state, I tried to call (Resident #701) and they (staff) said (the Resident) was tucked into bed at like 8:30 (PM) and did not want to take them the phone. I was worried and just wanted to talk to them. On 9/22/20 at 11:20 AM, Resident #701 was observed sitting in a wheelchair in their room. The Resident was wearing regular socks without shoes. One wheel of the wheelchair was noted to be unlocked. An additional cushion was in place on the seat on the wheelchair. The cushion was visibly worn with the front aspect of the cushion more compressed than the back which caused Resident #701 to be in a forward leaning position and to slide forward while seated. A walker was noted in the room, within reach of the Resident. The Resident's call light was noted to be laying off the side of another chair in the room and not within the Resident's reach. Fading yellow/green colored bruising was noted surrounding the Resident's left eye and extending to the lateral side of their cheek and their left hand was wrapped with purple colored co-band (self-adhesive wound dressing) in a splint with their thumb positioned upward. When asked what had happened to their hand, Resident #701 replied, I fell . With further inquiry regarding the fall, Resident #701 revealed they had to use the bathroom and fell when they were going back to bed and stated, I fell sideways. When asked about the discoloration on the left side of their face, Resident #701 stated, That's from when I fell and hurt my hand. When asked if they hit their head when they fell , Resident #701 replied, I must of, there was a puddle of blood (from head). When queried if they experienced pain after the fall, Resident #701 replied, Yes. With further inquiry, Resident #701 revealed their head and finger hurt. Resident #701 was asked if they were still having pain and replied, Only in my finger when I try to do something. Resident #701 then revealed they needed to have surgery on their hand because of the injury. When asked if they had any other falls at the facility, Resident #701 replied, Yes and stated they had fell out of their wheelchair two times. When queried if the facility had implemented any additional interventions and/or changed anything in regards to their care following the falls, Resident #701 stated, No. At 11:30 AM on 9/22/20, while speaking with Resident #701 in their room, Physical Therapist B entered the Resident's room and indicated they were going to change the Resident's wheelchair today. Record review revealed Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADLs). Review of Resident #701's care plans revealed two care plans related to falls. The first care plan was titled, The resident is actual for fall related to: Deconditioning (Initiated: 8/25/20; Revised: 9/15/20). The care plan included the interventions: -Anticipate and meet the resident's needs based on nursing assessments (Initiated: 8/25/20) -Bed wheels locked at all times, unless transporting or moving (Initiated: 8/25/20) -Educate resident to use call light whenever times when needs assistance (Initiated: 8/25/20) -Physical Therapy/Occupational Therapy to evaluate and treat as ordered or as needed (Initiated: 9/21/20) -Home [MEDICAL CONDITION] to be worn at night and when napping with home settings (Initiated and Revised: 9/2/20) The second care plan related to falls was titled, The resident has/is at risk for acute pain related to a fall (Initiated: 8/25/20) and included the intervention, Anticipate the resident's need for pain relief and respond immediately to any complaint of pain (Initiated: 8/25/20). There was no care plan in place related to the Resident's fracture including but not limited to the immobilization splint in place on their hand and/or assessment of the injury, immobilization device, and/or peripheral perfusion. Additional review of Resident #701's medical record revealed the following progress note documentation: -8/25/20 at 9:30 PM: Pertinent Charting-Falls . Date of Fall: 8/25/20. Situation Details: observed on floor outside of bathroom on belly. Assessment: Neuro checks Small laceration to RT (right) temple Abrasion to LT (left) knee. Mitigating Factors: Resident did not use walker, left it in the bathroom . Interventions: Staff Education Resident education. MD Notification: comm. (communication) sent. Responsible Party Notification: (Family Member C) . -8/30/20 at 2:47 AM: Nurses' Notes . (Family) notified of x-ray results . On call provider notified of results -9/15/20 at 12:11 PM: SOC-Falls . F/u (follow up) fall on 8/25/20. Situation: Resident was observed on floor on stomach outside of the bathroom. Injury . laceration to head, bruise to head and abrasion to R knee . X-ray reveals fracture of distal phalange of 1st digit (thumb) left hand. Factors involved: Resident is a short-term patient who is used to being more independent at home. Resident did not use call light to ask for assistance when getting up to use restroom. Notifications: completed. Analysis of interventions to implement: Resident educated to use call light to ask for assistance when needing to get up. Referrals: none . -9/21/20 at 9:10 PM: Pertinent Charting-Falls . Date of Fall: 9/21/20. Situation Details: resident found on floor in front of wheelchair. Assessment: un-witnessed . Review of Resident #701's Orthopedic Consultation Documentation in the medical record revealed a splint for the Resident's fractured thumb was ordered by the Orthopedic Specialist on 8/31/20. Detailed review of the Resident's medical record included the following: -8/31/20: Orthopedic Provider Documentation: Chief Complaint: Left Thumb Pain . History of Present Illness . presents for evaluation of left thumb injury. Patient states that they fell on [DATE] and developed pain in the left thumb. Patient states that there may have been bleeding under the fingernail . rates pain a 7/10 (10 being the greatest amount of pain imaginable) . Mental Status . orientated to time, place and person . Left Fingers Examination . tenderness to palpation over the left thumb . mild swelling . There appears to have been an injury to the nail . X-Ray Findings . show a displaced distal phalanx fracture of left thumb . Treatment plan . Recommend use of a stack splint along with rest and elevation for pain and swelling. Patient is prescribed a short course of Keflex . Based on patient's response to current treatment, the patient may need further treatment in the form of MRI (Magnetic Resonance Imaging) or CT (Computerized Tomography), Physical Therapy, injections, bracing/casting, possibility of surgery or referral to a specialist . Patient will return to the office in one week for reevaluation . Office Procedures: Finger splint was applied . -8/31/20: Orthopedic Provider Report of Consultation Form: Fracture of Left Thumb . Distal phalanx . Recommendations/New Orders: Keflex (antibiotic) X 5 days . Maintain splint to left hand, may remove for hygiene. Elevate for swelling. Follow up 1 week . Included with the consultation form was a written prescription for 15 tablets of Keflex 500 milligrams (mg) orally every eight hours. -9/14/20: Orthopedic Provider Report of Consultation Form: Recommendations/New Orders: Continue splint, Daily skin checks. Rest, ice and elevate . Follow up with (Orthopedic Specialist) . -9/17/20: Orthopedic Provider Report of Consultation Form: Recommendations/New Orders: Leave splint in place. May be removed if absolutely necessary to perform hand hygiene . Also included with the Consultation documentation was information related to a scheduled surgical repair for the Resident's injury on 9/23/20. There was no documentation of interventions, assessment, and/or follow up care pertaining to the Resident's finger, immobilization, orthopedic appointment, and/or [MEDICAL CONDITION] in the progress note documentation. The task, Per ortho: Left thumb splint to remain in place, may remove for hygiene and every shift for Fx (fracture) distal phalanx left thumb related to displaced fracture of distal phalanx of left thumb . (Start Date 9/15/20) was listed on the Resident's Medication Administration Record [REDACTED]. Review of Resident #701's diagnostic imaging results revealed the Resident had a X-ray of their left hand on 8/30/20. The results of the x-ray included, [MEDICAL CONDITION] phalanx of the first digit with displacement. Review of Resident #701's facility Health Care provider orders divulged the following: -Stat x-ray left hand and thumb related to pain, swelling and bruising of the left thumb 2 views STAT for Pain (Verbal Order: 8/29/20; Completed: 8/29/20) -X-ray of the left hand and thumb related to pain, swelling and bruising of the left thumb every shift related to acute pain due to trauma left hand and thumb (Verbal Order: 8/28/20; Discontinued 8/28/20) -Per ortho: Left thumb splint to remain in place, may remove for hygiene and skin checks every shift for Fx (fracture) distal phalanx left thumb related to displaced fracture . (Verbal Order: 9/15/20) Review of facility provided Incident and Accident reports for Resident #701 revealed reports for two falls on 8/25/20 and 9/21/20. Detailed review included the following: -8/25/20 at 9:25 PM: Location: Resident Room . Unobserved . Brief Description: Resident found on floor on stomach outside bathroom . Injury Type: Laceration (Head), Hematoma (Head), Abrasion (to right knee, rug burn) . Treatment: Assessment Neurochecks . First Aid . Action Taken: Staff Reeducation . Resident Education . Fall Investigation Report . Conclusion Resident to be educated to use call light when wanting to get up. Additional Care Plan/Nurse Aide Assignment Updates: Resident has a BIMS (Brief Interview Mental Status Score) of 14 (out of 15) and still try's to be independent as possible, however, require assist of one for ambulation and toilet use . -9/21/20 at 8:20 PM: Location: Resident Room . Unobserved . Brief Description: Resident slipped from wheelchair to floor . Treatment: Assessment Neurochecks . Type of injury: No apparent injury . Fall Investigation Report . 8. Describe Resident's mental status prior to fall: confused . Additional Care Plan/Nurse Aide Assignment Updates: Skilled Therapy eval for w/c (wheelchair) positioning . Review of scanned documents in Resident #701's medical record revealed a Neurological Evaluation Flow Sheet initiated 8/25/20 at 9:25 PM. The flow sheet indicated neurological assessments were to be completed, Every 15 minutes X 1 hour; Every 30 minutes X 2 hours; Every 1-hour X 2 hours; Every shift X 72 hours. Documentation revealed the last completed neurological assessment for Resident #701 was documented on 8/27 Nights (No time specified). Neurological assessments were not completed as indicated on 8/27/20 (day and afternoon shift), 8/28/20 (night, day, and afternoon shift and on 8/29/20 (night shift). An interview was conducted with the DON on 9/22/20 at 2:26 PM. When queried regarding the frequency of neurological assessments following an unwitnessed fall in the facility, the DON replied, Per policy. Resident #701's neurological assessment flow sheet was reviewed with the DON at this time. When queried regarding the missing neurological assessments, the DON stated, Maybe someone started another one (flow sheet). I will check. The DON was then asked about the length of time following the fall and X-ray completion. The DON indicated they were not aware the Resident was having pain following the fall until the X-ray was initially ordered on [DATE]. When asked why the X-ray was not completed until 8/30/20 when it was ordered on [DATE], the DON did not provide an explanation. On 9/22/20 at 2:45 PM, an interview was completed with Registered Nurse (RN) D. When asked if they were Resident #701's assigned nurse on 8/25/20 when they fell , RN D replied, Yes. With further inquiry, RN D stated, (Resident #701) had left their walker in the bathroom and they were on their belly (on floor). RN D was then asked if Resident #701 was bleeding from their injuries and stated, Yeah, from their head. When queried regarding the Resident's head injury, RN D stated, (Resident #701) did not require sutures. Resident #701's medical record and the Incident and Accident form they had completed related to the fall was reviewed with RN D at this time. When asked where they had documented the Resident had bleeding from their head, RN D indicated they checked First Aid on the Incident and Accident form. When asked if they documented the treatment/first aid and/or injury anywhere else in greater detail, RN D revealed they did not. RN D was then asked what Communication sent meant in regards to Physician Notification on the Incident and Accident form and stated, It's a one page thing that gets filled out to tell (Physician) injuries. When queried how the Physician receives the form, RN D replied, We fax it. When asked if they received a fax confirmation, RN D indicated they did and stated, It gets scanned in (to medical record). Resident #701's medical record was reviewed with RN D at this time. A fax confirmation and/or communication form pertaining to injuries and the fall on 8/25/20 was not present in the medical record. RN D was then asked why they did not call the Physician after the Resident fell and hit their head while taking blood thinners. RN D replied, Our goal is to treat here. When asked if the Resident experienced any neurological changes following the fall, RN D indicated the Resident's neurological assessments were normal following the fall and stated, That was my first time meeting (Resident #701) too. On 9/22/20 at 4:12 PM, an interview was conducted with Physician E. When queried how they are normally made aware of a Resident fall by facility staff, Physician E stated, They (nursing staff) usually call. Physician E was then queried regarding typical policy/procedure when a Resident who is on anticoagulants (blood thinners) has an unwitnessed fall with a head injury. Physician E indicated Residents are not always sent to the hospital following a fall and care and treatment is determined by assessment of the Resident as well as what medications the Resident is taking. When asked about a Resident taking [MEDICATION NAME] and Aspirin who had a fall with a head injury, Physician E replied, If there is no significant bruising, we may do hourly checks. When queried how they should be notified by nursing staff of a Resident fall when the Resident is taking [MEDICATION NAME] and Aspirin with a [MEDICAL CONDITION] and bruising, Physician E replied, They (staff) should definitely call for any head injury. Physician E was then asked if they recalled Resident #701's fall on 8/25/20 with resulting fracture and indicated they were. When queried regarding documentation indicating they were notified of the fall by a faxed communication form and if/when they received the fax, Physician E reviewed documentation in their office and revealed they did not receive a fax from the facility regarding Resident #701's fall on 8/25/20. Physician E stated, I only have documentation (communication form from facility) dated 9/1 for (Resident #701). With further inquiry regarding why they were not notified of Resident #701's fall when it occurred, Physician E stated, They (staff) should have called. Should have called immediately. That is the protocol and I would like to get to the bottom of that. A second interview was completed with RN D on 9/22/20 at 4:45 PM. When asked if Resident #701 complained of pain following their fall on 9/21/20, RN D revealed they could not recall and stated, (Resident #701) was holding their head where it was bleeding. I think that was what hurt the most at the time, that and the blood. When asked if they assessed the Resident's hand for injury and Range of Motion (ROM), RN D revealed they did not and usually only check to make sure there are no major issues related to ROM with a Resident's arms and/or legs. An interview was conducted with the DON and facility Administrator. When queried regarding completion of Resident #701's neurological assessments, the DON revealed they were unable to locate any additional documentation that neurological assessments were completed for Resident #701 following their fall. When asked if neurological assessments should have been completed, the DON revealed they should have been. When queried regarding facility policy/procedure related to Physician notification following an unwitnessed fall with head injury, including Physician E not being notified in a timely manner of Resident #701's fall, the DON and Administrator indicated they would need to review the situation. No further explanation was provided. When queried regarding the delay in treatment and lack of documentation of implementation of interventions as recommended/ordered by the Orthopedic Physician, further explanation was not provided. Review of facility policy/procedure entitled, Falls - Clinical Protocol (Revised 6/2018) revealed, 1. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall . c. Once a fall occurs it is important to gather as much information as possible; i. Observe for evident trauma .d. Provide emergency care and assessment/s as indicated e. Residents who have fallen and have been witnessed to hit their head or suspected to have hit their head should have neurochecks per MD orders or resident's conditions warrants. All un-witnessed falls should have neurochecks completed, regardless of resident's cognitive status, per MD orders or residents' condition. f. The Physician and Responsible party should be notified as soon as the resident is stabilized. g. Document findings in the resident's medical record per standard protocol. 1. Post fall analysis will review (not all inclusive) . b. The nurses' notes . e. Review for other acute clinical changes . Upon request for a facility policy/procedure related to a change in Resident condition, the policy, Physician and Representative Notification - Change in a Resident's Condition or Status (Revised 10/7/10) was received. Review of the policy detailed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a. An accident or incident involving the resident . 6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

This Citation Pertains to Intake Number MI 388. Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure accurate assessment of oral health status and implement appropriate interventions for one (Resident #701) of two Residents reviewed for oral care, resulting in facility staff not being aware of the Resident's dentures, lack of interventions, and Resident #701 not having their dentures removed and/or cleaned, developing oral [MEDICAL CONDITION]/infection, and experiencing unnecessary discomfort and pain. Findings include: On 9/22/20 at 9:05 AM, an interview was completed with Family Member A. When queried regarding Resident #701's care in the facility, Family Member A revealed they had multiple concerns regarding the care their parent (Resident #701) and was receiving in the facility. With further inquiry, Family Member A revealed Resident #701 only had top dentures when they entered the facility because their lower denture had been lost at a different facility. Family Member A further revealed they had taken Resident #701 to an appointment outside of the facility to get their lower dentures replaced. When asked, Family Member A indicated the appointment was in early September 2020. Family Member A stated, At the appointment, they took the upper denture out and it looked like a Petri dish! Family Member A continued, (Resident #701) said they had been wearing the denture constantly and hadn't taken it out when they (dental staff) asked them. With further inquiry, Family Member A stated, I will send you pictures of it (Denture removed at the external dental provider). It was awful. The (external dental staff) said it one of the worst they ever saw. Family Member A continued, (Resident #701) had sores in their mouth from it and their gums are all red and inflamed. Family Member A was then asked if Resident #701 had required assistance with their dentures at home and replied, They need to have the equipment, they (facility) didn't even give (Resident #701) a denture cup or cleaner! With additional inquiry, Family Member A stated, The dentist ordered a rinse because of the sores and they (facility) didn't do it. I took (the Resident) back to the dentist yesterday and they (dentist) ended up just changing it to salt water so it would be easier for the facility. Family Member A continued, I talked to (Resident #701) on the phone last night. They were in bed and they told me no one helped them to take out their dentures. Family Member A further stated, (Resident #701) can't even eat the food they bring them. They don't even help (Resident #701). When asked about specific instances and/or details, Family Member A replied, (Resident #701) has sores in their mouth now, only one set of dentures, and a broken thumb (from a fall at the facility) and they (facility) brought a ham steak to them to eat. (Resident #701) can't cut that with their thumb and they can't chew it even if they could cut it! Family Member A further indicated they were concerned that Resident #701 would become dehydrated from not receiving fresh fluids and Resident being admitted with a Urinary Tract Infection [MEDICAL CONDITION] and having a history of dehydration. Review of the images provided by Family Member A included an image of Resident #701's denture. The top of the denture plate (aspect of denture that is directly against the roof of the mouth) was noted to be very soiled and coated with a significant amount of gray/brown and white colored build up with visible chunks. On 9/22/20 at 11:20 AM, Resident #701 was observed sitting in a wheelchair in their room. The Resident was observed to have top teeth in their mouth and no bottom teeth. Two beverage cups were noted on the overbed table sitting next to the Resident. One of the cups was dated 9/22/20 and contained a clear fluid. The paper straw cover remained on the top aspect of the straw, outside of the cup. The other beverage cup on the table was had dark brown spots on the lid and was half full of a dark colored fluid. There was no ice present in the cup. An interview was conducted at this time. When asked, Resident #701 revealed they only had one of their dentures (uppers) because their lower dentures had been lost at a different health care facility. Resident #701 was then asked if they are able to remove, clean, and care for their dentures themselves and revealed they need assistance and are not supposed to walk without help. When queried if they are assisted by staff to remove their dentures nightly, Resident #701 stated, Since I have been going to (External Dental Provider) but not before. With further inquiry about assistance prior to going to the Dental Provider, Resident #701 replied, Never took it (denture) out. I didn't have anything to put it in or any cleaner and revealed denture cleaner was provided by the facility within the past few days. Resident #701 was then asked if they were assisted to remove and clean their dentures last night (9/21/20) and stated, No. I was completely neglected. My dentures stayed in and they didn't even give me salt (water). When asked about the salt water, Resident #701 stated, (External Dental Provider) said I have sores (in mouth) and told me I need to rinse my mouth with salt water. Resident #701 was asked if their mouth hurt and replied, Yes. When queried if they asked staff for assistance with their dentures and oral care, Resident #701 revealed they did and stated, It takes them forever to get here and continued, When they get here, they don't always do it. Resident #701 revealed they did not like to complain and were scared if they did or asked for too much that they would get kicked out and not get (physical) therapy. Record review revealed Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident required set up/clean up assistance with oral hygiene. Resident #701's Nursing Admission Evaluation (Dated: 8/24/20 and Locked: 8/25/20) revealed, 4. a. Does the Resident have any artificial teeth that are broken, chipped, uncleanable or have any other damage? No . b. Does the Resident use dentures or partials? No . Comments: (Blank) . Review of Resident #701's care plans revealed a care plan titled, The resident needs activities of daily living assistance related to: UTI, dehydration .[MEDICAL CONDITION](stoke) with L (left) sided weakness (Initiated and Revised: 8/25/20). The care plan included the active interventions: -Oral Care Routine . (AM, PC-after meals, HS-bedtime) brush teeth, rinse mouth with wash (Initiated and Revised: 8/25/20) -Oral Care: The resident has own teeth (Initiated and Revised: 8/25/20) -Personal Hygiene: The resident requires (Extensive assistance) by (1) staff with personal hygiene and oral care (Initiated and Revised: 8/25/20) A second care plan titled, The resident has potential oral/dental health problems r/t (related to) edentulous (missing teeth) (Initiated and Revised: 9/4/20) included the following interventions: -Coordinate arrangements for dental care, transportation as needed/as ordered (Initiated: 9/4/20) -Provide dentures/partials/device required for eating (Initiated: 9/4/20) -Remove dentures at HS (bedtime), cleanse mouth with toothette and encourage resident to rinse and cleanse mouth (Initiated: 9/4/20) -Use soft toothbrush for dental care (Initiated: 9/4/20) Review of Resident #701's Oral care per Care Plan and PRN (as needed) documentation from 8/24/20 to 9/22/20 revealed the following documentation of Was oral care provided per the plan of care: -No documentation of oral care completion on: 8/25/20, 9/4/20, 9/5/20, 9/8/20, 9/9/20 -Documentation of oral care was completed once on: 8/24/20 (9:42 PM), 8/26/20 (6:00 PM), 8/27/20 (8:20 PM), 8/28/20 (11:29 AM), 8/31/20 (7:42 PM), 9/1/20 (12:55 PM), 9/2/20 (9:02 AM), 9/3/20 (9:05 AM), 9/6/20 (6:57 AM) 9/7/20 (8:52 PM), 9/10/20 (5:19 PM), 9/12/20 (6:39 AM), 9/15/20 (7:16 PM), 9/17/20 (7:58 AM), 9/22/20 (7:02 AM) -Documentation of oral care was completed twice per day on: 8/29/20, 8/30/20, 9/11/20, 9/13/20, 9/14/20, 9/16/20, 9/18/20, 9/19/20, 9/20/20, and 9/21/20. Only five of these dates indicated oral care was completed after 7:00 PM. Review of Resident #701's Health Care Provider orders, Medication Administration Record [REDACTED] -Salt water rinse 3 times a day after meals for oral infection. Salt water rinse after meals (Start Date: 9/21/20) -[MEDICATION NAME] Powder (anti-fungal agent) 0 UNIT/GM (gram) Apply to Clean denture topically every day shift for oral infection for 14 Days. Apply thin layer to inside of clean denture once daily for 2 weeks (Start Date: 9/23/20). There was no documentation that the treatment was completed. -[MEDICATION NAME] Powder 0 UNIT/GM (gram) Apply to Clean denture topically every day evening shift for oral infection for 14 Days. Apply thin layer to inside of clean denture once daily for 2 weeks (Start Date: 9/22/20; Discontinued: 9/22/20). There was no documentation that the treatment was completed. Additional documentation revealed the following External Dental Care Provider Orders: -A prescription dated 9/10/20 detailing, Rinse mouth for 30 seconds with warm salt water TID (Three times a day) . -A prescription for the [MEDICATION NAME] treatment, dated 9/21/20 No documentation or assessment of the Resident's oral cavity and/or oral [MEDICAL CONDITION] were present in the facility medical record. An interview was conducted with the DON (Director of Nursing) on 9/22/20 at 2:26 PM. When queried regarding Resident #701's admission assessment indicating they did not have dentures upon admission to the facility, the DON stated, They may have not been in their mouth. When queried regarding facility policy/procedure and if staff should have documented if the Resident did not have any teeth, the DON replied, I would have. With further inquiry regarding where the dentures may have been if they were not present in the Resident's mouth when they were admitted , the DON indicated they would be documented on the Resident's admission inventory documentation form. Review of Resident #701's medical record with the DON revealed no inventory form. When asked, the DON indicated the form may not have been scanned into the medical record yet and indicated they would check with medical records. The DON was then asked about Resident #701 not having a care plan with interventions related to dentures upon admission to the facility and how staff knew to assist the Resident to remove their dentures and perform appropriate oral care. The DON revealed the staff would not be aware unless they asked the Resident. The DON was shown the picture of Resident #701's denture at this time. When queried if dentures that are cleaned regularly have that significant of a build up, the DON indicated they should not. When queried regarding lack of documentation of oral care three times a day, the DON did not provide an explanation. The DON was then asked about the lack of implementation of a salt water rinse on 9/10/20 with Dental care provider recommendation and the subsequent [MEDICAL CONDITION] and infection that developed in the Resident's mouth, the DON revealed they would need to review the Resident's documentation. Review of Resident #701's progress note documentation in the medical record revealed the following notes related to oral health and/or dental care: -9/10/20: Social Services Progress Notes .spoke with the res (resident) (child) at length regarding the res concerns/(family) concerns. follow up . with ST (Speech Therapy) to complete another eval, communication with floor nurses and cenas to update and reaffirm care interventions - ie: oral care, nails, hands, chin hair if any, cutting up food, assistance with utensils, message left (External Dental Provider) to request mouthwash that was given, communication to team to make aware of (family) concerns, communication to dietary to review care plans r/t the res assistance with trays, communication to psych services to follow up for added support, communication to activities to for res preferences . -9/11/20: Therapy Note . Patient was evaluated by ST (Speech Therapy) today. Patient was observed eating regular, mechanical soft, and puree textures during lunch. Patient with severely prolonged and effortful mastication. Mild oral stasis and coughing frequently after swallowing regular/soft textures were observed. Spoke with (family), notifying of ST eval and diet recommendations at this time. Per (family), patient is waiting for bottom dentures to be made. No documentation related to Resident #701's external Dental appointments were noted in the progress notes. On 9/22/20 at 2:45 PM, an interview was completed with Registered Nurse (RN) D. When queried if Resident #701 had teeth and/or dentures in place on 8/25/20 when they were assigned to care for the Resident, RN D replied, Yes, most definitely. An interview was conducted with the DON and facility Administrator on 9/22/20 at 5:00 PM. When queried if they located any additional documentation pertaining to Resident #701's dentures and/or oral care, the DON revealed they had not. No further explanation was provided. Review of facility policy/procedure entitled, Mouth Care (Dated 1/6/2011) revealed, Purpose: The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth . Review the resident's care plan to assess for any special needs of the resident . The following information should be recorded in the resident's medical record: 1. The date and time the mouth care was provided. The name and title of the individual(s) who provided the mouth care. All assessment data obtained concerning the resident's mouth. The certified nursing assistant should report to the licensed nurse to record in the medical record. 2. Complaints of pain or discomfort of mouth or any bleeding of gums or open areas if noted. The certified nursing assistant should report to the licensed nurse to record in the medical record .

This Citation Pertains to Intake MI 732 Based on observation, interview and record review, the facility failed to ensure appropriate and safe use of a Hoyer lift (mechanical lift) during a transfer for one (#701) of three Residents reviewed for accidents, resulting in a Resident suffering unnecessary pain and a preventable laceration requiring emergency medical attention and sutures. Findings include: Record review on 9/4/19 revealed Resident #701 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADLs). Record review further revealed the Resident was transferred from the facility to the hospital on [DATE] and had not returned at this date. Review of Resident #701's care plans on 9/4/19 revealed a care plan entitled, The resident needs activities of daily living assistance related to: [MEDICAL CONDITION] (Initiated and Revised: 6/27/19). The care plan included the intervention, Staff to be re-educated on Hoyer lift use and precautions (Initiated: 7/18/19; Revised: 6/27/19). Record review of facility provided Incident and Accident Report, dated 7/19/19 at 1:30 PM, for Resident #701 revealed, Resident observed bumping leg on Hoyer during transfer from wheelchair to bed. Laceration to right lower leg observed .Place of fall/accident: Resident Room . Environmental factors: Hoyer lift . Interventions prior to fall/accident: 2 person Hoyer lift transfer . Last care provided by (Nursing Assistant A) and (Nursing Assistant B) . Fall Investigation Report . initial root cause . Inaccurate use of Hoyer lift . Describe interventions to prevent future skin trauma: Staff education completed . Hoyer lift not accurately used causing laceration . An interview was conducted with Witness C on 9/4/19 at 10:35 AM. When queried regarding Resident #701's care within the facility, Witness C indicated there were multiple concerns related to care and stated, One of the CNA's (Nursing Assistants) dropped the Hoyer on (Resident #701's) leg on (MONTH) 17th. (Resident #701) had to go to the hospital and get six stitches. With further inquiry regarding what had occurred, Witness C indicated they were unsure what had happened but that was what they had been told. Record review of Resident #701's medical record on 9/4/19 revealed the following documentation: -7/17/19 at 3:24 PM:Skin Note . Event Date: 7/17/19 . Location of skin area being documented: right lower extremity, laceration. Description: laceration approximately 5 cm (centimeter) long . Sent to (Hospital) for treatment do it being a laceration. Fluid drainage due to increased fluid of the lower extremities . -7/17/19 at 8:59 PM: The resident returned from (Hospital) by EMS @ 1900 (7:00 PM) with sutures in RLE (Right Lower Extremity), no new orders given . -7/17/19 at 11:24 PM:Right lower extremity, laceration . resident has sutures in the RLE due to trauma that occurred, the wound is weeping fluid, c/o (complaints of) pain and discomfort noted . -7/18/19 at 2:23 PM: Patient suffered trauma to rt (right) lower leg while being transferred with Hoyer lift, 4 cm x 0.2 cm x unknown depth, wound was sutured, draining moderate serous drainage, dry dressing in place to change daily and prn (as needed) for excess drainage . -7/22/19 at 3:48 AM: Resident has sutures in the RLE due to trauma that occurred, the wound is weeping fluid . Review of Resident #701's emergency room discharge documentation revealed the Resident was seen for a laceration with suture placement. The discharge instructions also revealed the sutures should be removed in seven days, around 7/24/19. An interview was conducted with Nursing Assistant B on 9/4/19 at 1:00 PM. When queried regarding Resident #701's leg laceration, Nursing Assistant B stated, We were hoyering (Resident #701) back to the bed from their wheelchair. They were up in the air already. I was not controlling the Hoyer, I was guiding (the Resident's) legs and body. (Resident #701) was over the bed when it happened. I was on the side of the bed by their feet. I was holding the Hoyer sling by where it hooks in between the legs, I pushed up to position the Resident higher in bed as the Hoyer was going down and the whole thing shifted. (Resident #701) moved, the whole lift moved, and they hit their leg on the battery/electrical box part of the Hoyer lift. When asked how the whole lift moved, Nursing Assistant B stated, I don't think the (Hoyer) wheels were locked. A demonstration in an empty Resident room with a Hoyer lift was then provided, upon request by Nursing Assistant B. Observation of demonstration revealed Nursing Assistant B was positioned on the right side of the bed where the Hoyer lift had been placed when Resident #701 was in the lift. Nursing Assistant B demonstrated appropriate placement of their hands to assist in guiding and positioning the Resident in bed as the lift was being lowered. Nursing Assistant B then showed how the Resident and the entire lift moved outward from under the bed which caused the Resident to swing in the lift and their leg to hit the electrical box on the main support beam of the Hoyer. At this time, the Hoyer lift was attempted to be moved with the wheel locks engaged by applying pressure to the sling, the Hoyer did not move. When pressure was applied with the wheel locks not engaged, the Hoyer lift moved. On 9/4/19 at 1:25 PM, an interview was completed with Nurse D. When asked if they had completed the Incident and Accident Report for Resident #701 on 7/17/19, Nurse D revealed they had. When asked what had occurred, Nurse D indicated they were not in the room at the time the incident occurred and stated, The CNAs were transferring (Resident #701) in the Hoyer to bed and they accidentally bumped (the Resident's) leg and cut it. When queried regarding the characteristics of the laceration, Nurse D stated, There was a lot of blood and fluid. (Resident #701) had a lot of [MEDICAL CONDITION]. It was really long, not sure how deep. I got the wound care nurse and they decided to send (the Resident) out (to the hospital). An interview was conducted with the Director of Nursing (DON) on 9/4/19 at 2:30 PM. When asked if the provided Incident and Accident Report was all the information and investigation completed for the incident involving Resident #701 on 7/17/19, the DON stated, We did (staff) competencies but I can't find them for the life of me. The Incident and Accident Report was reviewed with the DON at this time. When asked what occurred and what inaccurate use of the Hoyer meant, the DON replied, My concern was that they (staff) were not spotting (Resident #701) initially. That is why we did education. When asked if the Hoyer was locked at the time of the transfer, the DON replied, I don't know. The DON then revealed the Hoyer lift was examined by maintenance following the incidence to ensure it was functioning properly. When asked if staff interviews were completed and/or statements were obtained pertaining to the incident, the DON stated, No. On 9/4/19 at 2:13 PM and 2:35 PM, Nursing Assistant A was attempted to be contacted by phone without success. A message with return phone number was left. An interview was completed with Staff Development Nurse [NAME] on 9/4/19 at 2:36 PM. When queried regarding education provided to staff following the incident involving Resident #701, Nurse [NAME] stated, I educated all the Nursing Assistants on two (hall). When asked where staff are taught to hold the Hoyer when positioning Residents, Nurse [NAME] stated, The handles on the sling where it hooks on the middle thing. When asked if they meant the part of the Hoyer sling that goes in-between the Resident's legs, Nurse [NAME] indicated they did. When asked if the Hoyer is supposed to be locked when Resident's are being lowered into bed by the lift, Nurse [NAME] indicated the lift should be locked. On 9/4/19 at 2:50 PM, an interview was conducted with the facility Administrator. When queried regarding the incident involving Resident #701 and the investigation indicating inaccurate use of Hoyer and the investigation not containing witness statements, the Administrator said, We always get witness statements. The Administrator then reviewed the provided Incident and Accident Report and stated, They aren't there. It is what it is. When queried regarding the education following the incident not being with the investigation and not able to be located by the DON, the Administrator stated, If we don't have it, we don't have it. When queried regarding service on the Hoyer lift following the incident, the Administrator revealed the facility maintenance director was not in the building. The Administrator stated, The Hoyer was removed from service immediately after it happened and checked. The Hoyer lift maintenance records were reviewed with the Administrator at this time. Review of the maintenance records revealed the Hoyer was checked by maintenance prior to the incident with Resident #701, as scheduled with no concerns. Records also showed the Hoyer lift was checked after the incident and the Hoyer lift was found to have no mechanical concerns. Review of facility policy entitled, Mechanical Lift (Revised: 8/2016) on 9/4/19 revealed, The purpose of this procedure is to help lift residents using a manual lifting device . Two (2) nursing assistants will be required to perform and any mechanical lift procedure . Transfer resident following manufacturer's recommendations . Review of facility policy entitled, Accidents and Incidents- Investigation and Reporting (Revised 12/1/17) revealed, All accidents or incidents involving Resident . occurring on our premises must be investigated and reported to the Administrator . The Statements of Witnesses: Incidents often call for witness interviews .

Based on observation, interview and record review, the facility failed to ensure that 1 (#502) of 3 sampled residents reviewed for pressure ulcers (wounds caused by pressure) from a total sample of 23, did not develop an avoidable, stage III pressure ulcer (full thickness tissue loss) and received consistent assessment, monitoring, and documentation of the pressure ulcer as well as ensure implementation of planned and functioning interventions, resulting in unnecessary and untreated pain and the potential for delayed healing and increased risk of infection. Findings include: Record review on 10/24/17 at 10:00 AM revealed that resident #502 was most recently admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, was incontinent of bowel and bladder, and required extensive to total assistance to perform Activities of Daily Living (ADL's). Additional review revealed the Resident was admitted to Hospice on 1/2/17. On 10/24/17 at 11:25 AM, interview and observation occurred of hygiene care for Resident #502 by Nursing Assistant Q and Nursing Assistant P. Upon entering the room, Resident 502's right wrist was observed to be wrapped in a gauze dressing. A small amount of red colored shadowing was observed on the dressing, on the inside of Resident #502's wrist. When queried regarding the dressing, Nursing Assistant Q stated, I noticed the skin tear on Monday. Nursing Assistant Q then stated, I don't know what happened, (Resident #502) doesn't move on their own. The only thing I could think of was it must have happened when they were being transferred. At this time, Nursing Assistant Q was observed performing peri-care and restoring hygiene for Resident #502. A wound was observed on Resident #502's sacral/coccyx area. The area did not have a dressing in place. When queried, Nursing Assistant Q stated, I had to remove it. There was poop under it. It (bowel movement) was in the pressure ulcer. When queried how often the pressure ulcer is uncovered, Nursing Assistant Q replied, Often. Nursing Assistant P indicated their agreement with Nursing Assistant Qs statement. Observation of the pressure ulcer at this time revealed an irregularly shaped, open pressure ulcer located on the Resident's sacral coccyx area. The wound appeared to have a bridge with the left side of the pressure ulcer being larger and deeper. The right side of the pressure ulcer had a dark, black colored base and the left (deeper) side of the pressure ulcer was observed to have a red colored base with a moderate amount of white colored, slough. The edges of the pressure ulcer were unattached and it was unable to be determined if tunneling was present with observation. As Nursing Assistant Q and Nursing Assistant P were dressing Resident #702, a scattered, red area, approximately six inches long was observed along Resident #702's spine, located directly over [MEDICATION NAME] area of the spine. When queried regarding the red area, Nursing Assistant P stated, It is right where (the Resident's) bones stick out. I noticed it before. Nursing Assistant Q then stated, We are putting cream on it. With further inquiry, Nursing Assistant P touched the red area, no blanching was observed when the Nursing Assistant touched the area. Nursing Assistant Q then applied Hydrogel cream, present at Resident #502's bedside, on the red area. Throughout the care provided by Nursing Assistant Q and Nursing Assistant P, Resident #502 was making moaning noises and facial grimacing was observed. An air mattress was observed on Resident #502's bed. The settings on the air mattress controller indicated the mattress was set at Normal pressure and at 180 lbs (pounds). On 10/24/17 at 11:45 AM, observation occurred of wound care treatment for [REDACTED]. When Nurse H cleansed the wound, Resident #502 began moaning. Nurse H then measured the wound using a disposable, paper measuring tape and stated, It's 1.8 (centimeters- cm) X 2.8 cm. When queried regarding the stage of the pressure ulcer, Nurse H replied, It has slough so it's unstageable. When queried regarding the depth of the wound, Nurse H folding the paper measuring tape in half and inserted the tape into the wound bed. The measuring tape was unable to be placed in the deepest part of the wound due to the size and shape of the tape. When queried if they always fold the measuring tape to obtain wound depth measurements, Nurse H replied, No, sometimes I use a stick. With further inquiry regarding how they maintain accurate wound measurements if they do not utilize consistent methods for measurement, Nurse H stated, Well I don't want to open the wound all the way up. Nurse H then applied pressure on Resident #502's buttocks and spread open the wound and stated, The depth is less. With further inquiry related to wound measurements being larger overall when Resident's buttocks was pulled apart, Nurse H did not provide further explanation. Resident #502 was observed stating, Ow, ow, ow repeatedly and displaying facial grimacing throughout care. After placing a dressing on Resident #502's sacral coccyx pressure ulcer, Nurse H and Nurse I applied skin prep to both of Resident #502's heels. When queried, Nurse I indicated Resident #502 had pressure ulcers on both their heels in the past. When queried regarding Resident #502's air mattress settings, Nurse I reviewed the settings on the air mattress controller and stated, I know (Resident #502) is not 180 lbs. Some body must have messed it up. Nurse I proceeded to adjust the air mattress control setting to 120 lbs. When queried regarding staff monitoring of air mattress settings, Nurse I replied, You would have to talk to (Unit Manager Nurse A). On 10/24/17 at 12:05 PM, an interview was completed with Unit Manager A. When queried regarding monitoring and documentation of settings for Resident air mattresses, Manager A stated, The nurses should check it but they don't document it anywhere. With further inquiry regarding Resident #502's air mattress settings, Manager A stated, No that isn't right. When queried regarding physician orders [REDACTED]. No further explanation was provided. At this time, Nurse I entered the room and stated, (Resident #502) is 104.6 lbs. I fixed the settings on the air mattress. On 10/24/17 at 2:10 PM, Resident #502 was observed in a common area of the facility, sitting in a Geri-Chair (reclining wheelchair). The Resident was reclined in the chair at approximately a 120 degree with a pillow observed on each side of the Resident's body. A pressure reduction pad was not observed on the Resident's Geri-Chair. On 10/24/17 at 4:35 PM, Resident #502 was observed in a common area of the facility, sitting in a Geri-Chair (reclining wheelchair). The Resident was reclined in the chair at approximately a 120 degree with a pillow observed on each side of the Resident's body. A pressure reduction pad was not observed on the Resident's Geri-Chair. An interview was conducted with Nursing Assistant R at this time. When queried regarding how long Resident #502 had been sitting up in the Geri-Chair and how often the Resident is repositioned when sitting in their Geri-Chair, Nursing Assistant R stated, I'm not really sure but (the Resident) did get change about an hour ago so they laid down for a second to be changed then. When queried regarding a pressure reduction pad on Resident #502's Geri-Chair, Nursing Assistant R looked at the Geri-Chair and stated, No, I've never seen one on there (Resident #502's Geri-Chair) On 10/24/17 at 4:45 PM, an interview was conducted with Nursing Assistant J. When queried how long Resident #502 had been sitting up in their Geri-Chair, Nursing Assistant J stated, (Resident #502) was up (in the Geri-Chair) when I got here. With further inquiry, Nursing Assistant J stated, I got here around 2:00 PM. When queried the frequency that Resident #502 is repositioned while sitting in their Geri-Chair and when in bed, Nursing Assistant J did not provide a response. On 10/24/17 at 5:00 PM, an interview was completed with Wound Nurse H. When queried regarding Resident #502, Nurse H stated, It is facility acquired. The onset date was 9/1/17. When asked, Nurse H stated, (Resident #502) has had pressure ulcers before. They had one on their coccyx in February (2017) that healed and the ones on their heels. Nurse H then stated, I have only been here a few months, I am not sure about any other ones but (the Resident) does have a history (of pressure ulcers). Record review of Resident #502's medical record on 10/24/17 at 5:15 PM of Resident #502's medical record Medication Administration Record [REDACTED]. Additional record review revealed Resident #502 did have active physician orders [REDACTED]. Review of Pain Level Summary within the Weights & Vitals section of the medical record indicated the last documented pain level for Resident #502 occurred on 4/16/7 at 10:02 AM. Review of Resident #502's care plans at this time revealed the following active care plans and interventions: At risk for pain related to: Decreased mobility with weakness. H/o (History of) Fx (fracture) L hip/ hemiarthroplasty L leg/knee turn inward, decreased ROM (Range of Motion), Arthritis. Needs assist with repositioning. Dx (Diagnosis) Alzheimer's Dementia, with decreased cognition/communication, Potential for Unidentified Pain. h/o pressure ulcers healed, 08-24-2016. Now under Hospice care 01-2017, r/t (related to) Dx End Stage Alzheimer's Dementia (Initiated: 10/21/16, Revised: 1/9/17). Target: Resident will have pain managed, no non verbal s/sx (signs/symptoms) of pain AEB (As Evidenced By): no noted increased restlessness s/moaning or calling out, no noted sad/pained or worried facial expressions, no noted rubbing or guarding of body parts (Initiated: 10/21/16; Revised: 10/13/17) Interventions: -May have generalized pain, h/o L hemiarthroplasty and hematoma. May not always be able to verbalize if in pain. Potential for Unidentified Pain. Assist with repositioning PRN, observe daily and PRN with care/adls/skin txs and PRN for any verbal and non verbal s/sx of pain AEB: any increased restlessness/moaning or calling out, any sad/pained or worried facial expressions, any rubbing or guarding of body parts. (Initiated and Revised: 10/21/16) -Monitor response on PAINAD pain scale related to: medications, treatments, procedures (Initiated: 10/21/16; Revised: 2/2/17) -Observe the need for routinely scheduled medication rather than PRN (as needed) pain medication (Initiated: 10/21/16) -Observe for efficacy and side effects of pain management PRN (Initiated and Revised: 10/21/16) The resident has potential for impairment to skin integrity and h/o an acquired stage II PI to coccyx (healed as of 2/8/17) r/t Fragile skin, incontinence, decline in medical condition, H/o pressure ulcer to L heel, now has hard callous type formation on L heel. 9/1/17 unstageable pressure ulcer to sacrum. Dx Alzheimer's Dementia, severely impaired cognition, resident does not understand risks of skin breakdown. (Initiated: 1/9/17; Revised: 9/14/17) -Air mattress to the bed for pressure redistribution (Initiated: 2/2/17) -The resident has a cushion to geri chair for comfort, has a pressure redistribution mattress (Initiated: 1/9/17; Revised: 2/23/17) -Increased risks of skin breakdown. Assist with repositioning PRN, observe skin daily and PRN with care/adls/skin tx's (treatments) and PRN for any s/sx of skin breakdown (Initiated and Revised: 1/9/17) Review of Physician documentation pertaining to Resident #502's pressure ulcer revealed the last documented Physician documentation occurred on 9/14/17 at 5:52 PM. The note indicated, Full thickness ulcer with Large yellow [MEDICATION NAME] slough and small red granulation tissue present measuring 2.0 x 3.0 x 0.2 cm. Stage III pressure ulcer. Review of facility provided wound documentation indicated the pressure ulcer was Unstageable with a facility acquired onset date of 9/1/17 and measured 2.0 centimeters (cm) X 3.0 cm X UTD (Unable To Determine) at the time of onset. On 10/25/17 at 7:45 AM, an interview was completed with Wound Nurse H. When queried regarding pain management for Resident #502, the Resident's repeated verbalizations of ow, ow, ow and observation of facial grimacing during wound care, and the Resident not receiving any pain medications during the month of October, 2017, Nurse H stated, I didn't know that. I will have to look into it. Nurse H then stated, I will make sure it is taken care of. When asked about Resident #502's air mattress settings, Nurse H indicated they were aware of the incorrect settings. With further inquiry regarding effectiveness of air mattress for pressure reduction when settings were incorrect, Nurse H stated, It isn't effective. When queried regarding a pressure reduction device for Resident #502's wheelchair, Nurse H replied, They should have one. With further inquiry regarding the length of time the Resident was sitting in the chair on 10/24/17 and not having a pressure reduction device on their Geri-Chair, Nurse H stated, I am going to check their room. I wonder if it just got taken off and set somewhere. Observation of Resident #502's room occurred with Nurse H at this time. A pressure reduction pad for Resident #502's Geri-Chair was not present within the Resident's room. When queried, Nurse H stated, No, it is not here. I don't know. We will have to get one for (Resident #502). On 10/25/17 at 8:15 AM, Resident #502 was observed in their room in bed. The Resident was positioned on their back with the head of the bed elevated. Nursing Assistant G was observed in the room assisting Resident #502 to eat their breakfast. An interview was conducted with Nursing Assistant G at this time. Nursing Assistant G indicated they do not normally provide care to Resident #502. When queried regarding a pressure reduction pad for Resident #502's Geri-Chair, Nursing Assistant G stated, No, (the Resident) doesn't have one but they should. When asked how often Resident #502 is repositioned when in bed, Nursing Assistant G stated, I turn my Resident's every two hours but not everyone does that. When queried regarding how often Residents are repositioned when sitting in chairs, Nursing Assistant G replied, Not everyone repositions (Residents). On 10/25/17 at 12:50 PM, an interview was conducted with the facility Administrator. When queried regarding Resident #702's pressure ulcer and interventions including no pressure reduction pad on the Resident's Geri-Chair and the air mattress settings, the Administrator stated, I really can't say anything about that. When queried regarding turning and repositioning, the Administrator stated, We (facility) have been doing audits on that. (The Director of Nursing -DON) can tell you more about that. On 10/25/17 at 1:20 PM, an interview was completed with the DON. When queried regarding Resident #502's pressure ulcer interventions, the DON stated, Even if (Resident #502's) air mattress was not set up right, they were being turned and that is the most important thing. When queried regarding documentation of turning and repositioning, the DON stated, We have been doing turning audits. With further inquiry, the DON stated, The audits are probably done two to three times a week, they are random audits. The DON then stated, We have been doing them for a long time. The DON referred to an audit completed in February 2017. When queried if the audits were being completed when Resident #502 developed their current facility pressure ulcer and the facility acquired pressure ulcer in February, the DON replied, Yes. When queried regarding Resident #502's pain management and pain assessment, the DON stated, We (facility staff) have not noted (Resident #502) having pain. When asked about Resident #502 repeating, Ow, ow, ow and displaying facial grimacing, the DON stated, (Resident #502) doesn't say words. With further inquiry regarding Resident #502's last documented Pain Level Summary within the Weights & Vitals section of the medical record documentation, the DON replied, We do pain assessments. Pain levels documented on the pain assessment won't show there (Pain Level Summary). Review of Resident #502's pain assessment revealed the assessment was completed once a month. When queried regarding frequency of pain assessment, the DON replied, That is when we complete them unless there is a need. On 10/25/17 at 4:30 PM, an interview was completed with Nurse H. When queried regarding the discrepancy between Physician documentation of Pressure ulcer as a Stage III and facility documentation of pressure ulcer being unstageable, Nurse H stated, I noticed that when I went to print the doctor notes you asked for. I didn't notice it before. With further inquiry, Nurse H stated, It (Resident #502's) pressure ulcer has slough so I have left it as unstageable. I faxed something to the doctor about it and asked them when they were going to come back and see (the Resident). When queried regarding the non-blanchable area observed along Resident #502's spine and the cream applied by nursing assistant staff, Nurse H replied, I didn't know anything about that. Nurse H then stated, Hospice leaves the creams in the Resident's room. I am going to go and take them out of there now. They (staff) shouldn't just put it (Hydrogel) on. Record review of facility provided policy entitled, Pain- Clinical Protocol (Revised 3/22/11) on 10/25/17 at 5:15 PM revealed, The physician and staff will identify individuals who have pain or who are at risk for having pain . The staff and physician will identify the nature and severity of pain including characteristics (location, intensity, frequency, duration, etc.) .The staff will reassess the individual's pain and consequences of pain at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Record review of facility policy entitled, Support Surface Guidelines (Dated 3/23/11) revealed, Support surfaces may be modifiable. Individual Resident needs differ. The policy further revealed, The following information should be recorded in the Resident's medical record: 1. The specialty bed settings are appropriate and correspond with care plan or physician's orders [REDACTED]. The date and time device placement occurred or when the specialty bed settings were checked . A pressure ulcer prevention/skin care policy was requested by not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to ensure that one (#704) of five residents reviewed for pressure ulcers (wounds caused by pressure) from a total sample of 23 residents did not develop unavoidable, re-occurring pressure ulcers, receive timely and appropriate treatment of [REDACTED]. Findings include: Record review of Resident # 704 electronic medical record (EMR) on 1/9/17 at 11:30 AM revealed that Resident #704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ( MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status(BIMS) score of 00, related to the resident's [DIAGNOSES REDACTED]. Resident #704 was able to communicate verbally with minimal spoken words and by means shaking head yes or no in response to questions. An observation of incontinence care occurred on 1/10/17 at 10:30 AM. Incontinence care was performed by Certified Nurse Assistant (CNA) H and CNA I. Upon removal of Resident #704's incontinence brief, a moderate amount of bright red colored blood was observed on the soiled incontinence brief as well as a small amount on the draw pad lying on the bed underneath the resident. A pressure ulcer was observed on the right side of Resident #704's buttocks. Pressure ulcer on right buttocks was observed to be actively weeping bright red colored fluid. A second pressure ulcer was observed on resident #704's coccyx without discharge or drainage observed. CNA H exited the resident's room to find the nurse. Resident #704 was groaning loudly and said ah[***] several times during incontinence care. Resident #704 was asked whether they were experiencing pain in buttocks and coccyx area, and stated uh-huh and shook head indicating yes. On 1/10/17 at 11:00 AM, Nurse J entered resident #704's room. Nurse J performed wound care on resident #704's pressure ulcers. Nurse J cleansed both pressure ulcer sites with normal saline solution, applied a sting -free barrier, and covered right buttocks site with a split drain foam gauze pad. Resident #704 was observed making loud moaning sounds and saying ah[***] several times during wound care procedure. Resident #704 was queried whether they were experiencing pain in buttocks and coccyx area, and stated uh-huh and shook head indicating yes. During an interview on 1/10/17 at 11:15 AM, when queried regarding Resident # 704's pressure ulcers, Nurse J stated that the pressure ulcers were acquired at the facility. When queried regarding the dates that pressure ulcers were first observed, Nurse J stated I don't know, they come and go. When queried regarding pain management for Resident #704, Nurse J stated Resident #704 gets scheduled pain med's. Record review of Resident #704's Medication Administration Record [REDACTED]. Resident #704 had an active order to receive [MEDICATION NAME] 7.5/325 mg orally every 6 hours as needed and [MEDICATION NAME] 50 mg (non-narcotic pain medication) orally every 6 hours as needed. Resident #705 had not received [MEDICATION NAME] 7.5/325 or [MEDICATION NAME] 50 mg orally before or after expressing complaints of pain during incontinence and wound care. Additional Record review of Resident #704's EMR revealed no active Treatment Administration Record for Resident #704. Record review of Resident #704's care plan titled Actual Skin Breakdown revealed that the care plan was initiated on 7/19/16 was not updated until 12/30/16. Updated interventions included New stage II pressure ulcer to coccyx. Nurse to do weekly skin assessment and PRN. Measure area weekly and PRN., Resident has a h/o previous PI to coccyx/sacrum with scar tissue formation. This area is at increase risk of breakdown, and Resident is on the Yellow Dot Program for turning and repositioning. Unit Manager M was interviewed at 3:30 PM on 1/10/17 regarding the development of resident #704's pressure ulcers. When queried if Resident #704's physician had been notified of the status of the pressure ulcers, Unit Manager M stated I'm sure they are aware but I don't think that they have seen it. Unit Manager M was unable to produce documentation of physician notification, physician assessment, and/or physician recommendations pertaining to care of Resident #704's pressure ulcers. Unit Manager M was unable to provide weekly wound assessment measurements as indicated were to be completed in Resident #704's care plan. When queried regarding the date that the coccyx pressure ulcer and the right buttock pressure ulcer were first observed, Unit Manager M stated well I'm not sure, those areas come and go on Resident #704. When queried if both recurring pressure ulcers were facility acquired, Unit Manager M stated yeah. When queried regarding updated interventions following pressure ulcer development for Resident #704, Unit Manager M stated we do the normal. During an interview with Nurse Manager N on 1/10/17 at 4:00 PM, Unit Manager N stated I get wound measurements weekly. Wound measurements were requested. Record review of facility provided documentation of Resident #704's pressure ulcers on 1/11/17 at 7:30 AM revealed that Resident #704 had been receiving treatment for [REDACTED].# 704's coccyx since 10/13/16. Additional review revealed that a second pressure ulcer located on Resident #704's right buttocks was first observed by the facility on 12/16/16. No wound care orders for the pressure ulcer located on Resident #704's right buttocks were noted within the electronic medical record. The order for wound care present within the EMR and present on the EMR dated 12/22/16 indicated skin prep wipes. Apply to coccyx topically every shift for Pressure injury. Apply barrier cream. During an interview with Nurse A on 1/11/17 at 8:15 AM, Nurse A provided documentation regarding Resident #704's pressure ulcer from Gentel Fastcare Computer documentation system. Nurse A indicated that facility documentation of wounds is completed in both the EMR and the Gentel documentation systems. When queried, Nurse A stated that Resident #704's physician was not notified of new pressure ulcer because Resident #704 was already being treated for [REDACTED].#704's pressure ulcers, Nurse A was unable to provide an explanation. Nurse A further stated there was a delay between the Gentel system and entering treatment orders (in the EMR). Nurse A further stated I fixed the orders yesterday, they were not worded right. With additional inquiry, Nurse A stated there weren't really any orders for the right buttocks pressure ulcer until yesterday. When queried regarding Resident #704's care plan with initiation date of 7/19/16 not being updated until 12/30/16 when the coccyx pressure ulcer was first observed by the facility on 10/13/16 and the right buttock pressure ulcer was first observed by the facility on 12/16/16, Nurse A stated there is definitely a delay there. During an interview with the Director of Nursing (DON) on 1/11/17 at 11:15 AM, the DON was unable to provide an explanation for the lack of timely and appropriate treatment, specific interventions, orders, care plan updates, physician notification and pain management for Resident #704. When queried regarding the location of wound treatments in the EMR, the DON stated all wound treatments should be in the TAR (Treatment Administration Record) in the computer. When queried if Physicians are notified when a Resident develops a pressure ulcer or has a pressure ulcer that is not improving or getting worse, the DON stated yes, they should be. During an interview with Nurse Manager N on 1/11/17 at 1:35 PM, facility provided printed wound measurements from the Gentel system were reviewed. On 12/16/17, the date that the pressure ulcer was discovered, the documented right buttocks wound measurements were 4 X 3 X 0.1. On 12/22/16, the documented right buttocks wound measurements were 2.5 X 4 X 0.1. On 1/6/17, the documented right buttocks wound measurements were 3 X 2 X 0.1. No unit of measure was included on provided facility documentation. When queried why documentation within the Gentel system was not entered by Nurse Manager N if they obtain wound measurements, Nurse Manager N stated well who ever enters it is who's name shows up. An interview was conducted with facility Wound Care Consultant Nurse O on 1/11/17 at 1:45 PM. Wound Care Consultant Nurse O stated that the wound measurements entered (into Gentel system) do not seem accurate. I think that they (facility staff) are not consistent in what they measure for the wound border. Wound Care Consultant Nurse O stated should not just be using barrier on the right buttocks wound and they need help with wounds here. I only come in once a month. Wound Care Consultant Nurse O also indicated that the recommendations for care of Resident #704's right buttock pressure ulcer were provided on 1/5/17 but were not implemented until 1/10/17. An interview was conducted with Unit Manager N on 1/11/17 at 1:50 PM. Unit Manager N stated I have something to tell you. I entered the wound info into the Gentel system on 1/5/17 but it didn't get transferred over (to the EMR) to get ordered, I messed up.' Record review on 1/11/17 at 1300 of facility policy entitled Wound Care with a revision date of 3/23/2011 indicated verify there is a physician's orders [REDACTED]. ( )

This citation pertains to MI 503 and MI 576 Based on observation, interview and record review, the facility failed to prevent an intentional act of physical abuse when one (#801) of three residents reviewed for abuse, out of a total of a total sample of three, was dragged across the floor with the use of his right arm and and then again (second time) by the use of both legs, resulted in a rug burn and bruising, skin alteration (s), further abuse, mental anguish and increased behaviors. Findings include: On 7/20/16 at 7:00 a.m., record review of the intake revealed the following documentation: It was alleged Registered Nurse (Nurse B) grabbed resident's arm dragged the resident (Resident #801) on the floor to the mat. The resident sustained [REDACTED]. This was reported by the Certified Nursing Assistant( CNA) within two hours of the incident . On 7/20/16 at 10:45 a.m., Certified Nursing Assistant (CNA A) was interviewed by telephone. CNA A stated, I reported it to CNA B. CNA B told her nurse (Nurse D). It happened on 7/2/16 around 3:00 a.m. The resident was care planned to be on the floor mat as desired because he often puts himself there. Resident #801 was on the floor near the bathroom. Instead of Nurse B letting me help him, Nurse B dragged him by the arm and placed him on the mat. That was the first time. The second time Resident #801 was on the floor and off the mat, I went to get help. Resident #801 had made it to the hall. Nurse B was there. I went to get CNA C to help, who would have been the third person. By the time we had gotten back to help, Nurse B had dragged Resident #801 from the hall, a further distance than before, and he (#801) sustained rug burns, [MEDICAL CONDITION] his bottom. CNA C told her nurse (Nurse D). Nurse D asked me what happened. I told him. He then called the on-call nurse (Nurse E). She talked to me twice. I told her what happened. Nurse E called the Director of Nursing (DON). The DON talked to me over the phone. They saw the injuries ([MEDICAL CONDITION] Resident #801). I was still present in the facility. They called me to Resident #801's room. The carpet burn was just above his butt crack. Nurse B was sent home. I found out that he was fired on Tuesday. On 7/20/16 at 11:15 a.m., record review of Resident #801's clinical record revealed the following: Resident #801's skin assessment, dated 7/2/2016 at 3:13 a.m., written by Nurse B revealed the following: This patient is constantly crawling out of bed and is now schoching (scooting) on his bottom to move around. There is a reddened area noted on coccyx (coccyx). Skin prep was applied. On 7/3/2016 at 22:37 (10:37 p.m.) a skin note was written by a staff nurse (Nurse H) that revealed the following documentation: Area to above coccyx=red and stage I according to skin guidelines in drug blood, oozing--skin prepped and protective cream applied, bruising noted to bilat (bilateral) buttocks color of blue, safety measures intact, supervised while in w/c (wheelchair) for safety. Review of a skin assessment, dated 6/30/2016 at 13:46 (1:46 p.m.), indicated no skin alterations to Resident #801's coccyx. Resident #801's face sheet indicated an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #801's admission Minimum Data Set (MDS) assessment dated [DATE] indicated a severely impaired cognition. The MDS assessment indicated that Resident #801 required two plus persons physical assistance for transfers and bed mobility, and extensive assistance for other activities of daily living (ADL's). On 7/20/2016 at 11:55 a.m., Resident #801 was observed sitting in his wheelchair in the hallway just outside of his room. He was alert and was only able to answer simple questions. On 7/20/16 at 12:05 p.m., a skin assessment was conducted on Resident #801 in the presence of CNA F and CNA G. Resident #801's lower coccyx area was reddened with a superficial skin tear, approximately one half inch long. The edges were irregular and the surrounding area was red. There was no drainage noted. On 7/20/16 at 12:17 p.m., the facility's Administrator and the DON were both interviewed regarding the incident. The Administrator stated, The incident happened on 7/2/16. The DON was called around 3:30 a.m. The DON stated, When I came in that night the CNA did not say anything about Resident #801 was dragged across the floor. The nurse told me he dragged him by his arm pits. The Administrator reported that she wrote the summary of the incident. The summary was titled Allegation of Physical Abuse, dated 7/7/16. The summary revealed the following documentation of the incident: On 7/2/2016, CNA A reported to CNA C that Nurse B told her that he had dragged Resident #801 across the floor to the mat near his bed. CNA C reported this to Nurse D. Nurse B was interviewed on 7/2/2016 and stated that the resident was on the floor, on his buttocks, with his feet toward the doorway. Nurse B stated that he was concerned that the patient was in danger of hitting his head on the tile floor or his legs on the doorway and puled him to the mat to prevent him from injuring himself. CNA A was interviewed on 7/2/2016 and stated that she saw Nurse B taking the patient (#801) back to the mat from the bathroom . On 7/5/2016 CNA C was interviewed and stated that on 7/2/2016 around 2:15 a.m., she was outside taking a break when CNA A approached her asking for help transferring a patient from the floor, back to his bed. CNA A re-entered the building, shortly followed by CNA C. CNA C walked up on CNA A who was talking to Nurse B. CNA C heard CNA A say to Nurse B, 'You can't do that.' CNA C questioned CNA A as to what was happening with the resident (#801) and CNA A replied that Nurse B had dragged the patient back to the mat without assistance. On 7/5/2016, CNA A was interviewed and stated that on the morning of 7/2/2016 at approximately 1 a.m., she had observed Resident #801 on the floor of his room in the doorway of the bathroom. She asked Nurse B for help to assist Resident #801 back to the mat near the bed. Nurse B came into the room, and pulled Resident #801 across the floor by his right arm, lying on his left side. At around 3 a.m., CNA A observed the patient scooting on his bottom in the hallway of the unit in from of his room. She asked Nurse B for help and then she went to get CNA C to help them assist the resident back to the mat near his bed. On the way to the unit, Nurse B met CNA A in the hallway in front of the copy room and told her that he no longer needed help, as he was able to pull him (#801) back to the mat again by himself. CNA A then told him 'you can't do that and then told CNA C that he dragged the patient back to the mat. On 7/5/2016, Nurse B was interviewed and stated that the patient (#801) had been restless and crawling on the floor a lot on the morning of 7/2/2016. He stated that around 3 a.m., he had observed the patient on the floor in the doorway of his room in the hallway on his side .so he pulled the patient (#801) from the doorway on his back toward the mat near his bed while placing his hands under his calves. Nurse B stated that the patient was wearing a housecoat and gown, so he slid him across the floor to the mat and turned him around to place his head over the mat . Review of the actual Statement of Witness interviews on the day of 7/5/2016, conducted by the facility's Administrator, revealed the following: The Statement of Witness interview, dated 7/5/2016, from Nurse B revealed the following documentation: Patient (#801) is crawling on the floor a lot/restless at approximately 3-4 a.m. The patient (#801) was on the floor in the doorway of his room in the hallway on his side, yelled for help from the CNAs, did not get a response. He then pulled the patient from the doorway on his back toward the mat near his bed by his legs while placing his hands under his calfs (calves). The patient was wearing a house coat and gown, so he slid him across the floor to the mat and spun him around in order to place his head on the mat to prevent injury. The Statement of Witness interview, dated 7/5/2016, from the Unit Manager (Nurse E) revealed the following documentation: Received call from Nurse D at 3:05 a.m. to report that CNA C told him that Nurse B had dragged a patient across the floor. Nurse E asked to speak to CNA C. CNA C said she had not witnessed it, but CNA A had told her that she saw Nurse B drag the patient across the floor .CNA A stated she had watched Nurse B dragging the resident across the floor by his arm .Nurse E called back to the facility, talked to Nurse B, asked him what happened. He said he had pulled the resident (#801) by his feet across the floor. Nurse B said Resident #801 had been crawling around and restless all night .The DON and Nurse E took the resident from common area to his room, assessed the resident for injuries .Nurse E witnessed interviews conducted by the DON with CNA A where CNA A said she witnessed Nurse B pulling Resident #801 from under his arms. She also indicated he (Nurse B) had told her that he had pulled the patient by the feet .The DON then interviewed Nurse B in the office on station three with Nurse E. Nurse B told the DON that he dragged him (#801) on the floor by his feet. The DON got on the floor and asked Nurse B to demonstrate what he did to the patient. He took her feet and spun her around on her buttocks. On 7/21/2016 at 5:10 p.m., review of the facility's policy titled Reporting Abuse to Facility Management, revised October 2012, revealed the following documentation: Mental abuse is defined as, but not limited to humiliation, harassment, threats of punishment, or withholding of treatment or services. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Past noncompliance documentation revealed the following: 1. On 7/5/2016, education for all employees began for proper reporting of abuse type incidents. On 7/7/16, education for all employees began for proper transfer of resident/patients from the floor. 2. What corrective actions will be done for residents found to have been affected by the deficient practice? The resident remains in the facility and has no s/s if a negative outcome. The nurse involved in the incident has been suspended and subsequently terminated. 3. How facility will identify other residents having potential to be affected by practice and what corrective action will be taken place? Residents that were in this nurse's care have the potential to be affected. On Wednesday 7/8/16 the current residents that were under this nurses care in the past two months have been interviewed, skin assessments were completed and residents are free from harm. No negative outcome has occurred. 4. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Facility staff is being re-educated of reporting of perceived resident abuse, and proper transfer techniques by the Director of Staff Development/designee and will be completed by 7/13/16 and again re-approached by 7/15/16 to verify understanding of perceived abuse reporting. Any employee that was not available ( due to vacation, absence, etc) and has not received the education will be educated prior to starting their shift. The Administrator/Staff Development Director will complete the Residents Rights, Resident Abuse and reporting, and the Elder Justice Act during new employee orientation. As part of nursing orientation, nursing employees will receive instruction on proper resident transfer techniques. Facility employee will receive training on Resident Rights, Resident Abuse and reporting and the Elder Justice Act quarterly by the Director of Staff Development/designee. 5. How the corrective action(s) will be monitored to ensure the deficient practices will not recur? The DON/designee will complete random rounds/observations of resident care with special attention to resident transfer techniques 5 x' s' /week for 2 weeks, then 3 x' s'/week for 2 weeks, weekly x's 4 weeks, followed by monthly until substantial compliance is sustained and maintained, and with the approval of the facility QAPI Committee. The Administrator will be responsible for sustained compliance. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 056. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT The services provided or arranged by the facility must meet professional standards of quality IN 4 OF 8 SAMPLED RESIDENTS (# 101, # 102, # 103 AND # 104 ), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO SUSTAINED A LARGE IRREGULARLY SHAPED FIRST DEGREE BURN IN ROUGH AREA COVERING 10 CENTIMETER (CM) X 12 CM OF HIS RIGHT THIGH AND 3 SECOND [MEDICAL CONDITION] L CM X 2 CM, L CM X L CM, AND 1/2 CM X 1/2 CM ON HIS RIGHT THIGH AND ASSOCIATED PAIN AFTER RECEIVING SUPERFICIAL THERMOTHERAPY (MOIST HEAT PACK THERAPY) AND THE POTENTIAL FOR INJURY TO RESIDENTS # 102, # 103 AND # 104 WHO ALSO RECEIVE SUPERFICIAL THERMOTHERAPY. FINDINGS: RESIDENT #101: ACCORDING TO THE FACE SHEET DATED 10/21/2010 RESIDENT # 101 WAS A [AGE] year OLD MALE THAT WAS admitted to the facility on [DATE]. THE MINIMUM DATA SET ((MDS) dated [DATE], IDENTIFIED RESIDENT # 101 AS AN ALERT RESIDENT THAT EASILY MADE HIMSELF UNDERSTOOD VERBALLY. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 11/24/2010 AT 9:35 AM RESIDENT #101 SAID HE WAS HAVING HEAT THERAPY PROVIDED BY NURSING STAFF WHEN HE SUSTAINED A BURN ON THE RIGHT THIGH. INSPECTION OF THE RIGHT THIGH REVEALED A BANDAGE OF 4 X 4'S AND TAPE. ONCE REMOVED A LARGE IRREGULARLY SHAPED REDDENED IN ROUGH AREA COVERING 10 CENTIMETER (CM) X 12 CM AND 3 OPEN BLISTERS MEASURING APPROXIMATELY L CM X 2 CM, L CM X L CM, AND 1/2 CM X 1/2 CM WERE OBSERVED ON THE LATERAL ASPECT OF THE RIGHT THIGH, SLIGHTLY DISTAL TO THE KIP. OTHERWISE THE LOWER EXTREMITY ASSESSMENT WAS UNREMARKABLE. RESIDENT # 101 SAID " ...THE HOT PACK WAS HOT WHEN THEY PUT IN ON, REALLY HOT ... " RESIDENT # 101 SAID THE HOT PACK WAS ON FOR A LONG TIME "...IT WAS QUITE A WHILE, DON'T KNOW HOW LONG REALLY..." RESIDENT # 101 SAID FACILITY STAFF CAME IN TO TALK, BUT NO ONE ASSESSED THE LEG AFTER THE HOT PACK WAS PUT ON, UNTIL IT WAS TAKEN OFF MUCH LATER. RESIDENT #101 SAID " ...THE PAIN FROM [MEDICAL CONDITION] BAD AT FIRST ... " BUT HAD DECREASED WITH TREATMENTS SINCE. ACCORDING TO THE FACILITY INCIDENT REPORT DATED 11/22/2010, RESIDENT # 101 REQUESTED THE USE OF A HEAT PACK FOR RIGHT LEG DISCOMFORT ON 11/21/2010. SUPERFICIAL THERMOTHERAPY WAS INITIATED BY WAY OF MOIST HEAT PACK THERAPY AND WHEN REMOVED REDDENED AREAS WERE NOTED ON THE TOP OF RESIDENT # 101'S THIGH AND THREE QUARTER SIZED FLUID FILLED BLISTERS WERE OBSERVED ON RESIDENT # 101'S RIGHT THIGH. THE ENTIRETY OF THE CLINICAL RECORD WAS REVIEWED. THERE WAS NO PHYSICIan order for [REDACTED]. ON 11/24/2010 AT 10:10 AM THE DIRECTOR OF THERAPY SAID RESIDENT #101 WAS RECEIVING A MOIST HOT PACK TREATMENT. THE DIRECTOR OF THERAPY SAID THIS IS A MOIST HEATING PAD USED FOR RELIEF OF PAIN OR CONTRACTURES. THE DIRECTOR OF THERAPY EXPLAINED THAT A HEATING PAD IS HEATED BY BEING SOAKED IN A TEMPERATURE CONTROLLED [MEDICATION NAME] (A LIQUID FILLED HEATING DEVICE) UNIT. THE DIRECTOR OF THERAPY SAID THE HEATED PAD IS THEN WRAPPED IN A TERRYCLOTH COVER, SIX TO EIGHT TOWEL BARRIERS ARE PLACED BETWEEN THE RESIDENT AND THE HOT PACK, AND THE PACK IS APPLIED DIRECTLY OVER THE AREA REQUIRED FOR THERAPY. THE DIRECTOR OF THERAPY SAID TREATMENTS ARE APPLIED USUALLY FOR 20 TO 30 MINUTES. THE DIRECTOR OF THERAPY SAID THAT DURING OFF HOURS ANY REGISTERED NURSE (RN) OR LICENSED PRACTICAL NURSE (LPN) CAN USE THE EQUIPMENT INCLUDING THE MOIST HOT PACK, BUT WAS NOT AWARE OF ANY OFF HOURS HOT PACK TREATMENTS BEING DONE. THE FACILITY POLICY RELATED TO HOT PACK TREATMENTS PROVIDED BY THE DIRECTOR OF THERAPY, SAID " ...obtain a physician ' s order...towels or a commercial cover and a timer are needed for treatment ...SENSATION TESTING OF HOT/COLD AND SHARP/DULL SHOULD BE PERFORMED PRIOR TO USE OF THIS MODALITY TO ENSURE SAFE USE ...PREPARE PACKS WITH 6-8 LAYERS OF TOWELING OR COMMERCIAL COVER. ADDITIONAL PADDING MAY BE NECESSARY IF THE UNIT IS VERY HOT...CHECK THE SKIN OCCASIONALLY ...REMOVE THE PACKS AFTER THE DESIRED TIME, 20-30 MINUTES ...DOCUMENT IN THE MEDICAL RECORD ..." ON 11/29/2010 AT 1:00 P.M., THE OCCUPATIONAL THERAPIST SAID THAT DURING HOT PACK TREATMENTS THE AREA OF TREATMENT IS INSPECTED OCCASIONALLY FOR SIGNS OF REDNESS. " ...THIS WOULD BE AN EARLY SIGN OF A BURN..." ACCORDING TO " THERAPEUTIC MODALITIES FOR MUSCULOSKELETAL INJURIES " BY CRAIG R. DENEGAR, ETHAN SALIBA, SUSAN FOREMAN SALIBA, 2005, SUPERFICIAL THERMOTHERAPY SHOULD BE USED WITH CAUTION IN PATIENTS WITH IMPAIRED CIRCULATION OR SENSATION. MOIST HOT PACKS MUST BE APPROPRIATELY WRAPPED IN LAYERS OF TOWELING OR A COMMERCIAL COVER FOR PROTECTION FROM SKIN INJURY. ON 11/24/2010 AT 10:50 AM THE DIRECTOR OF NURSING (DON) SAID THAT CNA #1 WAS INSTRUCTED BY THE LPN #1 TO OBTAIN A MOIST HEAT PACK FOR RESIDENT # 101. THE DON SAID RESIDENT # 101 ' S THIGH WAS ASSESSED PRIOR TO THE TREATMENT AND THERE WERE NO SKIN PROBLEMS PRESENT. The DON said MOIST HEAT PACK THERAPY WAS INITIATED DESPITE THE FACT THAT resident # 101 HAD NO VALID PHYSICIan order for [REDACTED]. THE DON SAID THAT ACCORDING TO HER INVESTIGATION RESIDENT # 101 RECEIVED NO SENSATION TESTING AS REQUIRED PRIOR TO INITIATION OF THE THERAPY. ON 11/24/2010 AT 11:35 AM CNA #1 SAID THAT ON 11/21/2010 HE PERFORMED THE SUPERFICIAL THERMOTHERAPY treatment for [REDACTED].# 101'S LEG WAS FREE FROM ANY TYPE OF INJURY. CNA #1 SAID HE TOOK THE HOT PACK OUT OF HYDROCULATOR, PLACED IT IN ONE TOWEL AND PUT THE HOT PACK ON RESIDENT # 101. CNA #1 SAID HE NEVER KNEW HOT PACKS REQUIRED A PHYSICIAN'S ORDER AND 6-8 LAYERS OF TOWELING OR A COMMERCIAL COVER BECAUSE HE HAD NEVER RECEIVED ANY EDUCATION ABOUT THE USE OF HOT PACKS. ON 11/24/2010 AT 1:10 PM LPN #1 SAID THAT ON 11/21/2010 SHE INSTRUCTED CNA #1 TO PUT A MOIST HOT PACK ON RESIDENT # 101'S LEG. LPN #1 SAID THAT the DON " ...told me it's kind of a grey area whether there is an order required to do hot pack treatments ...neither " RESIDENT # 101 NOR RESIDENT # 102 " have orders for treatments ... " LPN #1 SAID THAT PRIOR TO HOT PACK THERAPY SHE CHECKED FOR PROBLEMS WITH THE SKIN, AND ASSESSED RESIDENT # 101'S PAIN LEVEL, BUT NO OTHER ASSESSMENTS WERE COMPLETED AS REQUIRED BY POLICY. LPN CLARIFIED 2 TIMES THAT NO OTHER ASSESSMENTS WERE COMPLETED INCLUDING SENSATION TESTING OF HOT/COLD AND SHARP/DULL. LPN #1 SAID SHE RECEIVED HAS NO TRAINING ON HYDROCULATOR'S OR MOIST HOT PACK TREATMENTS. ON 11/29/2010 AT 11:24 AM THE DIRECTOR OF NURSING WAS ASKED TO PROVIDE ANY ADDITIONAL EVIDENCE THAT MOIST HEAT WAS APPLIED IN ACCORDANCE WITH professional standards of quality AND FACILITY POLICY FOR RESIDENT #101. BY THE DATE OF THE CONCLUSION OF THE COMPLAINT INVESTIGATION THE FACILITY FAILED TO PROVIDE ANY EVIDENCE THAT EVIDENCE. RESIDENT #102: ACCORDING TO THE FACESHEET DATED 11/1/2010, RESIDENT #102 LIVED IN THE FACILITY SINCE 12/11/2008. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #102 WAS A [AGE] year OLD ALERT MALE. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 11/24/2010 AT 1:10 PM LPN #1 SAID RESIDENT #102 HAS RECEIVED SUPERFICIAL THERMOTHERAPY BY WAY OF MOIST HOT PACK TREATMENTS " ...ON AND OFF FOR THE LAST COUPLE OF WEEKS... " LPN #1 SAID THAT the DON " ...told me it's kind of a grey area whether there is an order required to do hot pack treatments ...neither " RESIDENT # 101 NOR RESIDENT # 102 " have orders for treatments ... " THE ENTIRETY OF THE CLINICAL RECORD WAS REVIEWED. THERE WAS NO PHYSICIan order for [REDACTED].#102. THERE WAS NO DOCUMENTATION RELATED TO THE PROVISION OF SKIN ASSESSMENTS DURING TREATMENTS FOR RESIDENT #102. THE FACILITY FAILED TO PROVIDE EVIDENCE THAT MOIST HEAT WAS APPLIED IN ACCORDANCE WITH professional standards of quality AND FACILITY POLICY FOR RESIDENT #102 RESULTING IN THE POTENTIAL FOR BURNS. RESIDENT #103: ACCORDING TO THE FACESHEET DATED 11/19/2010, RESIDENT #103 LIVED IN THE FACILITY SINCE 8/14/2007. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #103 WAS A [AGE] year OLD ALERT MALE. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 11/29/2010 AT 1:24 PM LPN #2 SAID RESIDENT #103 HAS RECEIVED SUPERFICIAL THERMOTHERAPY BY WAY OF MOIST HOT PACK TREATMENTS TWICE. THE ENTIRETY OF THE CLINICAL RECORD WAS REVIEWED. THERE WAS NO DOCUMENTATION RELATED TO SENSATION TESTING OF HOT/COLD AND SHARP/DULL PRIOR TO HOT PACK APPLICATION FOR RESIDENT #103. THERE WAS NO DOCUMENTATION RELATED TO THE PROVISION OF SKIN ASSESSMENTS DURING TREATMENTS FOR RESIDENT #103. ON 11/29/2010 AT 1:24 PM LPN #2 WAS GIVEN THE OPPORTUNITY TO REVIEW RESIDENT # 103'S CLINICAL RECORD. LPN #2 SAID THE PROCEDURE WAS NOT PERFORMED IN ACCORDANCE WITH FACILITY POLICY AND SAID " ...WE HAVE NEVER BEEN TRAINED ... " THE FACILITY FAILED TO PROVIDE EVIDENCE THAT MOIST HEAT WAS APPLIED IN ACCORDANCE WITH professional standards of quality AND FACILITY POLICY FOR RESIDENT #103 RESULTING IN THE POTENTIAL FOR BURNS. RESIDENT #104: ACCORDING TO THE FACESHEET DATED 9/10/2010, RESIDENT #104 LIVED IN THE FACILITY SINCE 6/30/2009. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #104 WAS AN [AGE] year OLD ALERT MALE. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 11/24/2010 AT 10:10 AM THE DIRECTOR OF THERAPY SAID RESIDENT #104 HAS RECEIVED SUPERFICIAL THERMOTHERAPY DUE TO CHRONIC PAIN ISSUES. THE ENTIRETY OF THE CLINICAL RECORD WAS REVIEWED. THERE WAS NO DOCUMENTATION RELATED TO SENSATION TESTING OF HOT/COLD AND SHARP/DULL PRIOR TO HOT PACK APPLICATION FOR RESIDENT #104. THERE WAS NO DOCUMENTATION RELATED TO HOW THE HOT PACK WAS PREPARED FOR RESIDENT #104. THERE WAS NO DOCUMENTATION RELATED TO THE PROVISION OF SKIN ASSESSMENTS DURING TREATMENTS FOR RESIDENT #104. THERE WAS NO DOCUMENTATION RELATED TO THE LENGTH OF HOT PACK THERAPY FOR RESIDENT #104. THE FACILITY FAILED TO PROVIDE EVIDENCE THAT MOIST HEAT WAS APPLIED IN ACCORDANCE WITH professional standards of quality AND FACILITY POLICY FOR RESIDENT #104 RESULTING IN THE POTENTIAL FOR BURNS. THE ADMINISTRATOR WAS INFORMED ON 11/29/2010, AT 1:42 P.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 11/21/10 AT 6:00 P.M. WHEN THE CNA APPLIED MOIST HEAT THERAPY TO RESIDENT #101 AND FAILED TO MONITOR THE RESIDENT'S SKIN RESULTING IN A FIRST DEGREE BURN AND THREE SECOND DEGREE BURNS. ON 11/30/2010, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #101'S FIRST DEGREE BURN AND THREE SECOND [MEDICAL CONDITION] ASSESSED ON 11/29/10 AND WERE BEING TREATED WITH SIGNS OF HEALING ASSESSED. 2. ON 11/29/2010, THE SURVEYOR CONFIRMED THE FACILITY'S ACTION TO REMOVE THE KEY TO THE LOCKED [MEDICATION NAME] FROM STAFF ACCESSIBILITY. 3. ON 11/29/2010, THE SURVEYOR CONFIRMED THE REVISIONS OF THE FACILITY ' S POLICY REGARDING APPLICATION OF MOIST HEAT PACKS. 4. ON 12/1/2010, THE SURVEYOR CONFIRMED THAT 24 OUT OF 32 LICENSED NURSING STAFF, 37 OUT OF 46 CNAS AND 100% OF THERAPY STAFF WERE INSERVICED ON THE NEW POLICY. ALL STAFF WERE INFORMED THAT HOT MOIST HEAT TREATMENTS WILL NOT LONGER BE USED BY ANYONE OTHER THAN TRAINED THERAPY STAFF AND THAT ALL RESIDENTS REQUIRE A PHYSICIAN ' S ORDER TO RECEIVE MOIST HOT PACK THERAPY. 5. ON 12/1/2010, THE SURVEYOR CONFIRMED THAT THERAPY AND NURSING ADMINISTRATION DEVELOPED AN ASSESSMENT TOOL TO BE UTILIZED FOR ANY RESIDENT RECEIVING MOIST HEAT PACK THERAPY. DATE, TIME, VERIFICATION OF PHYSICIAN ORDERS, SIGNATURE OF ADMINISTERING TRAINED THERAPY STAFF MEMBER AND DOCUMENTATION WILL BE REQUIRED ON THE ASSESSMENT TOOL. 6. ON 12/1/10, 100% OF THERAPY STAFF WERE INSERVICED ON THE NEW TOOL AND DOCUMENTATION RELATED TO USING THE TOOL. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/29/10, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY BECAUSE SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 056. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION TO PREVENT ACCIDENTS IN 4 OF 8 SAMPLED RESIDENTS (# 101, # 102, # 103 AND # 104 ), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHO SUSTAINED A LARGE IRREGULARLY SHAPED FIRST DEGREE BURN IN ROUGH AREA COVERING 10 CENTIMETER (CM) X 12 CM OF HIS RIGHT THIGH AND 3 SECOND DEGREE BURNS MEASURING L CM X 2 CM, L CM X L CM, AND 1/2 CM X 1/2 CM ON HIS RIGHT THIGH AND ASSOCIATED PAIN AFTER RECEIVING SUPERFICIAL THERMOTHERAPY (MOIST HEAT PACK THERAPY) AND THE POTENTIAL FOR INJURY TO RESIDENTS # 102, # 103 AND # 104 WHO ALSO RECEIVE SUPERFICIAL THERMOTHERAPY. FINDINGS: RESIDENT #101: ACCORDING TO THE FACE SHEET DATED 10/21/2010 RESIDENT # 101 WAS A[AGE] year OLD MALE THAT WAS admitted to the facility on [DATE]. THE MINIMUM DATA SET ((MDS) dated [DATE], IDENTIFIED RESIDENT # 101 AS AN ALERT RESIDENT THAT EASILY MADE HIMSELF UNDERSTOOD VERBALLY. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 11/24/2010 AT 9:35 AM RESIDENT #101 SAID HE WAS HAVING HEAT THERAPY PROVIDED BY NURSING STAFF WHEN HE SUSTAINED A BURN ON THE RIGHT THIGH. INSPECTION OF THE RIGHT THIGH REVEALED A BANDAGE OF 4 X 4 ' S AND TAPE. ONCE REMOVED A LARGE IRREGULARLY SHAPED REDDENED IN ROUGH AREA COVERING 10 CENTIMETER (CM) X 12 CM AND 3 OPEN BLISTERS MEASURING APPROXIMATELY L CM X 2 CM, L CM X L CM, AND 1/2 CM X 1/2 CM WERE OBSERVED ON THE LATERAL ASPECT OF THE RIGHT THIGH, SLIGHTLY DISTAL TO THE KIP. OTHERWISE THE LOWER EXTREMITY ASSESSMENT WAS UNREMARKABLE. RESIDENT # 101 SAID " ...THE HOT PACK WAS HOT WHEN THEY PUT IN ON, REALLY HOT ... " RESIDENT # 101 SAID THE HOT PACK WAS ON FOR A LONG TIME "...IT WAS QUITE A WHILE, DON'T KNOW HOW LONG REALLY..." RESIDENT # 101 SAID FACILITY STAFF CAME IN TO TALK, BUT NO ONE ASSESSED THE LEG AFTER THE HOT PACK WAS PUT ON, UNTIL IT WAS TAKEN OFF MUCH LATER. RESIDENT #101 SAID " ...THE PAIN FROM THE BURNS WAS BAD AT FIRST ... " BUT HAD DECREASED WITH TREATMENTS SINCE. ACCORDING TO THE FACILITY INCIDENT REPORT DATED 11/22/2010, RESIDENT # 101 REQUESTED THE USE OF A HEAT PACK FOR RIGHT LEG DISCOMFORT ON 11/21/2010. SUPERFICIAL THERMOTHERAPY WAS INITIATED BY WAY OF MOIST HEAT PACK THERAPY AND WHEN REMOVED REDDENED AREAS WERE NOTED ON THE TOP OF RESIDENT # 101 ' S THIGH AND THREE QUARTER SIZED FLUID FILLED BLISTERS WERE OBSERVED ON RESIDENT # 101 ' S RIGHT THIGH. ACCORDING TO THE FACILITY INVESTIGATION REPORT DATED 11/22/2010, MOIST HEAT PACK THERAPY WAS INITIATED BY THE CERTIFIED NURSE ASSISTANT (CNA #1) AT APPROXIMATELY 6:30 PM ON 11/21/2010. ACCORDING TO THE SIGNED STATEMENT FROM CNA #1 DATED 11/22/2010 MOIST HEAT PACK THERAPY WAS INITIATED AT APPROXIMATELY 6:30 PM ON 11/21/2010. CNA #1 RETURNED TO THE ROOM APPROXIMATELY 20 MINUTES LATER AND AGAIN 45 MINUTES LATER. ACCORDING TO THE FACILITY ' S " SKIN ALERT " FORM DATED 11/21/2010 THREE QUARTER SIZED FLUID FILLED BLISTERS WERE OBSERVED ON RESIDENT # 101 ' S RIGHT THIGH AFTER HEAT PACK THERAPY. ON 11/24/2010 AT 10:10 AM THE DIRECTOR OF THERAPY SAID RESIDENT #101 WAS RECEIVING A MOIST HOT PACK TREATMENT. THE DIRECTOR OF THERAPY SAID THIS IS A MOIST HEATING PAD USED FOR RELIEF OF PAIN OR CONTRACTURES. THE DIRECTOR OF THERAPY EXPLAINED THAT A HEATING PAD IS HEATED BY BEING SOAKED IN A TEMPERATURE CONTROLLED HYDROCOLLATOR (A LIQUID FILLED HEATING DEVICE) UNIT. THE DIRECTOR OF THERAPY SAID THE HEATED PAD IS THEN WRAPPED IN A TERRYCLOTH COVER, SIX TO EIGHT TOWEL BARRIERS ARE PLACED BETWEEN THE RESIDENT AND THE HOT PACK, AND THE PACK IS APPLIED DIRECTLY OVER THE AREA REQUIRED FOR THERAPY. THE DIRECTOR OF THERAPY SAID TREATMENTS ARE APPLIED USUALLY FOR 20 TO 30 MINUTES. THE DIRECTOR OF THERAPY SAID THAT DURING OFF HOURS ANY REGISTERED NURSE (RN) OR LICENSED PRACTICAL NURSE (LPN) CAN USE THE EQUIPMENT INCLUDING THE MOIST HOT PACK, BUT WAS NOT AWARE OF ANY OFF HOURS HOT PACK TREATMENTS BEING DONE. ON 11/24/2010 AT 10:10 AM THE DIRECTOR OF THERAPY SAID THE HYDROCOLLATOR TEMPERATURE ON 11/21/2010 WAS NOT MEASURED, BUT THE TEMPERATURE OF THE WATER AND THE HOT PACKS WAS KEPT AT APPROXIMATELY 160 DEGREES FAHRENHEIT. ACCORDING TO THE HYDROCULATOR TEMPERATURE LOG DATED NOVEMBER 2010 THE TEMPERATURE OF THE WATER ON 11/19/2010 WAS 160 DEGREES FAHRENHEIT, THE TEMPERATURE OF THE WATER ON 11/20/2010 AND 11/21/2010 WAS NOT MEASURED, AND THE TEMPERATURE OF THE WATER ON 11/21/2010 WAS 160 DEGREES FAHRENHEIT. THE FACILITY POLICY RELATED TO HOT PACK TREATMENTS PROVIDED BY THE DIRECTOR OF THERAPY, SAID " ...SENSATION TESTING OF HOT/COLD AND SHARP/DULL SHOULD BE PERFORMED PRIOR TO USE OF THIS MODALITY TO ENSURE SAFE USE ...PREPARE PACKS WITH 6-8 LAYERS OF TOWELING OR COMMERCIAL COVER. ADDITIONAL PADDING MAY BE NECESSARY IF THE UNIT IS VERY HOT...CHECK THE SKIN OCCASIONALLY ...REMOVE THE PACKS AFTER THE DESIRED TIME, 20-30 MINUTES ...DOCUMENT IN THE MEDICAL RECORD ..." ON 11/29/2010 AT 1:00 P.M., THE OCCUPATIONAL THERAPIST SAID THAT DURING HOT PACK TREATMENTS THE AREA OF TREATMENT IS INSPECTED OCCASIONALLY FOR SIGNS OF REDNESS. " ...THIS WOULD BE AN EARLY SIGN OF A BURN..." ACCORDING TO " THERAPEUTIC MODALITIES FOR MUSCULOSKELETAL INJURIES " BY CRAIG R. DENEGAR, ETHAN SALIBA, SUSAN FOREMAN SALIBA, 2005, SUPERFICIAL THERMOTHERAPY SHOULD BE USED WITH CAUTION IN PATIENTS WITH IMPAIRED CIRCULATION OR SENSATION. MOIST HOT PACKS MUST BE APPROPRIATELY WRAPPED IN LAYERS OF TOWELING OR A COMMERCIAL COVER FOR PROTECTION FROM SKIN INJURY. ON 11/24/2010 AT 10:50 AM THE DIRECTOR OF NURSING (DON) SAID THAT CNA #1 WAS INSTRUCTED BY THE LPN #1 TO OBTAIN A MOIST HEAT PACK FOR RESIDENT # 101. THE DON SAID RESIDENT # 101 ' S THIGH WAS ASSESSED PRIOR TO THE TREATMENT AND THERE WERE NO SKIN PROBLEMS PRESENT. THE DON SAID THAT THE MOIST HOT PACK WAS REMOVED FROM THE HYDROCULATOR, PLACED IN 1 TOWEL, WITH NO PROTECTIVE SLEEVE AND WAS PLACED ON RESIDENT # 101'S LEG. THE DON SAID THE MOIST HEAT PACK THERAPY BEGAN AT APPROXIMATELY 6:30 PM AND STOPPED AT APPROXIMATELY 8:00 PM, 90 MINUTES LATER. THE DON SAID THAT STAFF DID NOT STAY WITH PATIENT THROUGHOUT THE SESSION AS THEY SHOULD HAVE SINCE THE CNA DID NOT KNOW THE RESIDENT ' S RESPONSE TO THE THERAPY. THE DON SAID THAT AFTER 20 MINUTES A VERBAL CHECK WAS DONE BY CNA #1, BUT NO SKIN ASSESSMENT WAS COMPLETED. THE DON SAID THAT AFTER 45 MINUTES A VERBAL CHECK WAS DONE BY CNA #1, BUT NO SKIN ASSESSMENT WAS COMPLETED. THE DON SAID THAT ACCORDING TO HER INVESTIGATION RESIDENT # 101 RECEIVED NO SENSATION TESTING AS REQUIRED PRIOR TO INITIATION OF THE THERAPY. ON 11/24/2010 AT 11:35 AM CNA #1 SAID THAT ON 11/21/2010 HE PERFORMED THE SUPERFICIAL THERMOTHERAPY treatment for [REDACTED].# 101'S LEG WAS FREE FROM ANY TYPE OF INJURY. CNA #1 SAID HE TOOK THE HOT PACK OUT OF HYDROCULATOR, PLACED IT IN ONE TOWEL AND PUT THE HOT PACK ON RESIDENT # 101. CNA #1 SAID HE NEVER KNEW HOT PACKS REQUIRED 6-8 LAYERS OF TOWELING OR A COMMERCIAL COVER BECAUSE HE HAD NEVER RECEIVED ANY EDUCATION ABOUT THE USE OF HOT PACKS. CNA #1 SAID HE DID NO SKIN CHECKS FOR RESIDENT # 101 AT ANY TIME AFTER THE TREATMENT WAS INITIATED BECAUSE HE HAD NEVER RECEIVED ANY EDUCATION ABOUT THE USE OF HOT PACKS. ON 11/24/2010 AT 1:10 PM LPN #1 SAID THAT ON 11/21/2010 SHE INSTRUCTED CNA #1 TO PUT A MOIST HOT PACK ON RESIDENT # 101 ' S LEG. LPN #1 SAID " ...I DON'T KNOW EXACTLY HOW LONG THE HOT PACK WAS ON FOR ...SOMEWHERE BETWEEN 45 MINUTES AND AN HOUR ... " LPN #1 SAID ONCE THE MOIST HOT PACK WAS REMOVED FROM RESIDENT # 101 ' S LEG, REDDENED AREAS AND 3 FLUID FILLED BLISTERS WERE FOUND ON HIS RIGHT THIGH. LPN #1 SAID " ...WE HAVE DONE HOT PACK THERAPIES ON AND OFF SINCE 11/16/2010, NEVER HAD PREVIOUS PROBLEMS ... " LPN #1 THAT PRIOR TO HOT PACK THERAPY SHE CHECKED FOR PROBLEMS WITH THE SKIN, AND RESIDENT # 101'S PAIN LEVEL, BUT NO OTHER ASSESSMENTS WERE COMPLETED. LPN CLARIFIED 2 TIMES THAT NO OTHER ASSESSMENTS WERE COMPLETED INCLUDING SENSATION TESTING OF HOT/COLD AND SHARP/DULL. LPN #1 SAID SHE RECEIVED HAS NO TRAINING ON HYDROCULATOR'S OR MOIST HOT PACK TREATMENTS. LPN #1 SAID SHE DID NO SKIN CHECKS FOR RESIDENT # 101 AT ANY TIME AFTER THE TREATMENT WAS INITIATED BECAUSE SHE HAD NEVER RECEIVED ANY EDUCATION ABOUT THE USE OF HOT PACKS. ON 11/29/2010 AT 11:24 AM THE DIRECTOR OF NURSING WAS ASKED TO PROVIDE ANY ADDITIONAL EVIDENCE THAT MOIST HEAT WAS APPLIED SAFELY FOR RESIDENT #101. BY THE DATE OF THE CONCLUSION OF THE COMPLAINT INVESTIGATION THE FACILITY FAILED TO PROVIDE ANY EVIDENCE THAT THE MOIST HEAT WAS APPLIED SAFELY FOR RESIDENT #101. RESIDENT #102: ACCORDING TO THE FACESHEET DATED 11/1/2010, RESIDENT #102 LIVED IN THE FACILITY SINCE 12/11/2008. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #102 WAS A [AGE] year OLD ALERT MALE. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 11/24/2010 AT 1:10 PM LPN #1 SAID RESIDENT #102 HAS RECEIVED SUPERFICIAL THERMOTHERAPY BY WAY OF MOIST HOT PACK TREATMENTS " ...ON AND OFF FOR THE LAST COUPLE OF WEEKS... " THE ENTIRETY OF THE CLINICAL RECORD WAS REVIEWED. THERE WAS NO DOCUMENTATION RELATED TO SENSATION TESTING OF HOT/COLD AND SHARP/DULL PRIOR TO HOT PACK APPLICATION FOR RESIDENT #102. THERE WAS NO DOCUMENTATION RELATED TO HOW THE HOT PACK WAS PREPARED FOR RESIDENT #102. THERE WAS NO DOCUMENTATION RELATED TO THE PROVISION OF SKIN ASSESSMENTS DURING TREATMENTS FOR RESIDENT #102. THERE WAS NO DOCUMENTATION RELATED TO THE LENGTH OF HOT PACK THERAPY FOR RESIDENT #102. THE FACILITY FAILED TO PROVIDE EVIDENCE THAT MOIST HEAT WAS APPLIED SAFELY FOR RESIDENT #102 RESULTING IN THE POTENTIAL FOR BURNS. RESIDENT #103: ACCORDING TO THE FACESHEET DATED 11/19/2010, RESIDENT #103 LIVED IN THE FACILITY SINCE 8/14/2007. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #103 WAS A [AGE] year OLD ALERT MALE. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 11/29/2010 AT 1:24 PM LPN #2 SAID RESIDENT #103 HAS RECEIVED SUPERFICIAL THERMOTHERAPY BY WAY OF MOIST HOT PACK TREATMENTS TWICE. THE ENTIRETY OF THE CLINICAL RECORD WAS REVIEWED. THERE WAS NO DOCUMENTATION RELATED TO SENSATION TESTING OF HOT/COLD AND SHARP/DULL PRIOR TO HOT PACK APPLICATION FOR RESIDENT #103. THERE WAS NO DOCUMENTATION RELATED TO HOW THE HOT PACK WAS PREPARED FOR RESIDENT #103. THERE WAS NO DOCUMENTATION RELATED TO THE PROVISION OF SKIN ASSESSMENTS DURING TREATMENTS FOR RESIDENT #103. THERE WAS NO DOCUMENTATION RELATED TO THE LENGTH OF HOT PACK THERAPY FOR RESIDENT #103. ON 11/29/2010 AT 1:24 PM LPN #2 WAS GIVEN THE OPPORTUNITY TO REVIEW RESIDENT # 103 ' S CLINICAL RECORD FOR EVIDENCE THAT MOIST HEAT WAS APPLIED SAFELY. LPN #2 SAID THE PROCEDURE WAS NOT PERFORMED IN ACCORDANCE WITH FACILITY POLICY AND SAID " ...WE HAVE NEVER BEEN TRAINED ... " THE FACILITY FAILED TO PROVIDE EVIDENCE THAT MOIST HEAT WAS APPLIED SAFELY FOR RESIDENT #103 RESULTING IN THE POTENTIAL FOR BURNS. RESIDENT #104: ACCORDING TO THE FACESHEET DATED 9/10/2010, RESIDENT #104 LIVED IN THE FACILITY SINCE 6/30/2009. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #104 WAS AN [AGE] year OLD ALERT MALE. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 11/24/2010 AT 10:10 AM THE DIRECTOR OF THERAPY SAID RESIDENT #104 HAS RECEIVED SUPERFICIAL THERMOTHERAPY DUE TO CHRONIC PAIN ISSUES. THE ENTIRETY OF THE CLINICAL RECORD WAS REVIEWED. THERE WAS NO DOCUMENTATION RELATED TO SENSATION TESTING OF HOT/COLD AND SHARP/DULL PRIOR TO HOT PACK APPLICATION FOR RESIDENT #104. THERE WAS NO DOCUMENTATION RELATED TO HOW THE HOT PACK WAS PREPARED FOR RESIDENT #104. THERE WAS NO DOCUMENTATION RELATED TO THE PROVISION OF SKIN ASSESSMENTS DURING TREATMENTS FOR RESIDENT #104. THERE WAS NO DOCUMENTATION RELATED TO THE LENGTH OF HOT PACK THERAPY FOR RESIDENT #104. THE FACILITY FAILED TO PROVIDE EVIDENCE THAT MOIST HEAT WAS APPLIED SAFELY FOR RESIDENT #104 RESULTING IN THE POTENTIAL FOR BURNS. THE ADMINISTRATOR WAS INFORMED ON 11/29/2010, AT 1:42 P.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 11/21/10 AT 6:00 P.M. WHEN THE CNA APPLIED MOIST HEAT THERAPY TO RESIDENT #101 AND FAILED TO MONITOR THE RESIDENT'S SKIN RESULTING IN A FIRST DEGREE BURN AND THREE SECOND DEGREE BURNS. ON 11/30/2010, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #101'S FIRST DEGREE BURN AND THREE SECOND DEGREE BURNS WERE ASSESSED ON 11/29/10 AND WERE BEING TREATED WITH SIGNS OF HEALING ASSESSED. 2. ON 11/29/2010, THE SURVEYOR CONFIRMED THE FACILITY'S ACTION TO REMOVE THE KEY TO THE LOCKED HYDROCOLLATOR FROM STAFF ACCESSIBILITY. 3. ON 11/29/2010, THE SURVEYOR CONFIRMED THE REVISIONS OF THE FACILITY'S POLICY REGARDING APPLICATION OF MOIST HEAT PACKS. 4. ON 12/1/2010, THE SURVEYOR CONFIRMED THAT 24 OUT OF 32 LICENSED NURSING STAFF, 37 OUT OF 46 CNAS AND 100% OF THERAPY STAFF WERE INSERVICED ON THE NEW POLICY. ALL STAFF WERE INFORMED THAT HOT MOIST HEAT TREATMENTS WILL NOT LONGER BE USED BY ANYONE OTHER THAN TRAINED THERAPY STAFF. 5. ON 12/1/2010, THE SURVEYOR CONFIRMED THAT THERAPY AND NURSING ADMINISTRATION DEVELOPED AN ASSESSMENT TOOL TO BE UTILIZED FOR ANY RESIDENT RECEIVING MOIST HEAT PACK THERAPY. DATE, TIME, VERIFICATION OF PHYSICIAN ORDERS, SIGNATURE OF ADMINISTERING TRAINED THERAPY STAFF MEMBER AND DOCUMENTATION WILL BE REQUIRED ON THE ASSESSMENT TOOL. 6. ON 12/1/10, 100% OF THERAPY STAFF WERE INSERVICED ON THE NEW TOOL AND DOCUMENTATION RELATED TO USING THE TOOL. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/29/10, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY BECAUSE SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY. ( )