Every finding on record at Medilodge of Richmond

This citation pertains to Intake 2709236.Based on observation, interview, and record review, the facility failed to ensure two-person assistance to prevent a fall from the bed during care for one resident (R901) of three residents reviewed for falls, resulting in pain and a left leg laceration that became infected, required surgical debridement, and requires continued wound treatment. Findings include: Review of Intake 2709236 revealed an allegation that R901 fell from their bed on 12/06/25 while being provided incontinence care. The allegation indicated that one staff member was providing the care rather than two staff that was required.Review of the facility record revealed R901 was admitted into the facility on [DATE] and their diagnoses included Congestive Heart Failure, Morbid Obesity, and Abnormal Posture. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14/15 indicating intact cognition.On 01/07/26 at 12:09 PM, R901 was interviewed in their room. The resident was observed in bed. Although the resident's bed was wider than standard, there appeared to be limited space on either side of the bed to accommodate rolling side to side in the bed. When queried regarding any recent falls R901 reported they had a fall out of the bed three or four weeks ago. The resident indicated they are supposed to have two staff members to complete incontinence care and there was a Certified Nursing Assistant (CNA) who thinks they can do it without help. R901 reported the staff is [CNA A]. R901 reported they questioned CNA A about not having a second person to assist and the CNA indicated they didn't need any help because they were strong enough to handle it alone. R901 reported the CNA rolled them onto their left side during the brief change and they fell off the bed on the opposite side. When asked if they were injured from the fall the resident stated I was in a lot of pain. I have a lot of arthritis, and it hurt all over. I hit my head, and I had a huge gash on my leg. I had to go to the hospital, and they had to put 16 stitches in my leg.Further review of R901's record revealed the following active Activities of Daily Living (ADL) care plan interventions: Toileting: Extensive two-person assist with check, changes, and bed pan (most recently revised 12/04/25) and Bed Mobility: Extensive two-person assist (Most recently revised 5/19/25). Review of R901's progress notes revealed a 12/06/25 note authored by Licensed Practical Nurse (LPN) B documenting they received a report R901 had fallen out of bed, Resident was laying slightly on the right side. Resident was bleeding from behind left ear and LLE (left lower extremity).On 01/07/26 at 2:30 PM, LPN B was interviewed via phone and reported they did recall R901 having a fall on 12/06/25. When asked to describe their understanding of what happened LPN B reported CNA A was changing the resident and the resident fell from the bed. They indicated they were not aware of anyone else being present during the incident. When asked what their understanding of R901's required assistance for a brief change was, LPN B reported they knew R901 require two-person assistance.Attempts to call CNA A were unanswered and the voice mailbox was full.Review of R901's current physician orders revealed the resident did receive intravenous (IV) antibiotic treatment for infection of the leg laceration as well as wound vac (mechanical wound evacuation device) and continued wound care treatment as well as oral medication treatment for pain control.On 01/07/26 at 3:00 PM, the facility Director of Nursing (DON) was interviewed and said their understanding was R901's care plan for two-person assistance pertained primarily to concerns of the resident's history of accusatory behaviors rather than physical safety concerns during bed mobility/brief changes. In reviewing the care plan the DON acknowledged the resident's care plan specified extensive two-person assist for check/change and bed mobility in addition to the issue of potential behaviors. The DON confirmed R901's left leg laceration became infected requiring debridement, IV antibiotics, wound vac, and continuing wound treatment.On 01/07/26 at 4:35 PM, the facility Administrator (NHA) was interviewed and reported their expectation is that staff would follow the plan of care regarding assistance level provided during care.Review of the facility policy Fall Prevention Program dated 10/26/23 revealed the policy statement Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.

This citation pertains to intake 1183138.Based on observation, interview and record review, the facility failed to ensure sufficient staff to provide timely care to seven (R5, R18, R33, R34, R40, R95, and R99) of 24 residents. Findings include: On 07/21/25 at 9:38 AM during the initial screening of the facility residents: R95 reported Sometimes there is a long wait, like a half hour or more, when you push the call light for staff to come help you. R95 reported, It takes a half hour or so for call lights to be answered. R95 further reported they required assistance to eat and some staff don't like to feed (the residents). On 07/21/2025 at 10:19 AM, R33 was sitting up in bed dress in a hospital style gown. R33 reported concerns about not enough briefs and not enough staff. R33 reported they have waited longer than 30 minutes to get out of bed when they ask because they are a two-person transfer and their CNA has to go to another hall to get help. On 07/21/2025 at 10:30 AM, R5 was observed to be in bed connected to a tube feeding pump. The pump had a screen which read inactive and made a beeping sound. The sound was audible from the hallway. At 11:08 AM, the pump continued to be idle and beeping. On 07/21/2025 at 10:38 AM, R34 was observed sitting up in bed with oxygen in use. The resident's call light was observed to be on the floor, out of the resident's reach. Staff were observed to enter and exit the room, and the call light remained on the floor. The resident was reported by staff to be dependent on staff for care. At 1:34 PM, R34's call light continued to be in the same place on the floor, out of reach. Staff were observed entering and exiting the room to assist the resident with lunch; however, the call light remained on the floor throughout the interactions and was not repositioned within the resident's reach. At 2:46 PM, R34 was observed to be repositioned and Certified Nursing Assistant (CNA) O was observed to struggle while they tried to get the call light out from under the wheel on the bed. CNA O reported they carried a pager for notification when the call lights are activated. CNA O further reported they were assigned 15 residents and would have to get help with the residents who require mechanical lifts. On 07/21/2025 at 11:03 AM, R118 reported they felt the facility was short staffed as lights not answered quickly and many residents on their hall require two people. On 07/21/2025 at 11:34 AM, the visitor of resident R18 and R18 were interviewed. They verbalized the facility was short staffed and one nurse may have two units to cover. They further noted at nights and on the weekends, it seems like no one is at the facility with one CNA and one nurse. They also noted no one picks up the phone and medications may not be given on time on weekends On 07/21/2025 at 12:01 PM, Licensed Practical Nurse (LPN) S reported they had a split assignment for the day as a nurse had called in. LPN S reported they had residents on the north and south side of the facility and was assigned 26 residents. It was observed the two units were separated by two common areas and the snack bar. On 07/21/2025 at 10:40 AM, R99 commented they received cold food every day and feel they are the last one served (this was observed for two meals.) R99 commented there was not enough staff to get to them timely. It was further reported CNAs are supposed to ask about preferences for the planned menu items, but they don't always come. The delivery of trays for the lunch meal was observed for R99's hall. It took 27 minutes for the CNAs to get to the unit of R99 and begin to pass trays and 11 more minutes to complete the tray pass. A noted on the cart indicated the trays should not remain on the cart for 15 minutes or more. On 07/21/25 at 12:49 PM, R118 reported the facility was consistently short staffed and that led to tray delivery delays. On 07/22/2025 at 1:21 PM, Registered Nurse (RN) T was asked about staffing and reported call ins were the primary concern. LPN U reported there is a call in from a nurse almost daily and the standard of practice was to move staff around rather than replacing the nurse. On 07/22/25 at 1:49 PM, during the group meeting, the attendees verbalized concerns with call light in reach and long wait times for assistance when call light are turned on. On 07/22/2025 at 12:35 PM, the Medical Director was asked about staffing and reported staffing does come up in the Quality Assurance meetings and refers to getting more new hires. The Medical Director commented it would be nice to be able to round with the nurse to discuss medical issues, admitting it may be hard to find one not busy. On 07/23/2025 at 8:44 AM, CNA O reported R40 had a shower on 07/21/205 but do to staffing they just didn't have time to shave and do R40's fingernails. R40 was observed to be unshaven and with long, soiled fingernails on 07/21/25, 07/22/25 and 07/23/25. On 07/23/2025 at 3:35 PM, the Staffing Coordinator (Staff V) reported the staff postings provided were incorrect and did not reflect the true staffing on for the day. When asked what the biggest challenge for staffing nurse and CNAs, Staff V reported call-ins. It was noted six or seven nurses is the goal, but they have also started to use med techs (assisting with medication pass duty). Staff V noted each nurse should have around 17 residents. It was noted five nurses were on for 07/21/25. Staff V noted two med techs were on though their ability to pass certain medications was limited. A review of the call off reports revealed: -January 2025; 14 nurses and 74 CNAs called off,-February 2025; 14 nurse and 34 CNAs called off,-March 2025; 13 nurse and 65 CNAs called off,-April 2025; 26 nurses and 62 CNAs called off,-May 2025; 23 nurse and 30 CNAs called off,-June 2025 22 nurses and 35 CNAs called off. A review of the policy titled, Care Planning Special Needs revised 12/28/23 documented, The facility will provide the necessary care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of residents .

This citation pertains to intake 1183138Based on observation, interview, and record review, the facility failed to ensure necessary grooming and hygiene (shaving and nail care) was provided for two (Residents #40 and #13) of four residents reviewed for activities of daily living (ADLs) assistance. Findings include:R40On 07/21/2025 at 10:49AM, R40 was observed lying supine in bed with the head of the bed slightly elevated. R40's fingernails were irregular in length, some approximately a quarter inch past the tip of the finger, and visibly dirty. R40 was unshaven with an approximate eighth inch black stubble, and the toenails were long (eighth to quarter inch beyond the tips of his toes) and crusted. On 07/22/2025 at 3:20 PM, R40 was asked about facial hair and nails and R40 reported they preferred to be clean shaven and have their fingernails and toenails trimmed and kept clean. On 07/22/2025 at 3:25 PM, R40 was observed being repositioned and provided incontinence care by Certified Nursing Assistant's (CNA) M and N. R40's fingernails and toenails were long, and R40 was unshaven as on 07/21/2025. When asked about the policy for shaving and trimming nails, both CNAs stated, It should be done on shower day. A review of the medical record for R40 revealed they were admitted to the facility on [DATE]. Diagnoses included Arthritis, Contracture of Muscle Upper Arm, Chronic Respiratory Failure, and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE] indicated they were dependent on staff for all ADLs. The care plan identified an ADL self-care performance deficit, with interventions for assistance with personal hygiene and bathing. A review of the CNA documentation, plan of care response history, and progress notes for the past 30 days revealed no documentation revealed eight showers were completed without documentation of refusals related to grooming care, including nail care or shaving. R13 On 07/21/2025 at 10:48 AM, R13 was observed lying supine in bed with head of the bed almost flat. R13 ‘s fingernails were long and curled around the tips of his fingers and visibly dirty. R13 was unshaven with a thick, unkempt goatee. Long nose hairs were observed extending into their mustache area. The remainder of their facial hair was unshaven with an approximate one fourth to one half inch black stubble and extended beyond the appearance of a five o'clock shadow. On 07/21/2025 at 1:10 PM, R13 was observed with the head of the bed up, having just finished lunch. Facial hair and fingernails were observed as previous noted. On 07/22/2025 at 8:19 AM, R13 was observed in bed with the head of the bed slightly elevated with a large pillow to the left side. R13's facial hair remained unshaven with the thick, unkempt goatee, long nose hair which extended into the mustache area, and dark facial hair covering the cheeks and chin, consistent with the prior day's observation. On 07/22/2025 at 12:44 PM, an interview was conducted with R13's son regarding grooming. The son expressed concern about the length of R13's facial and nose hair and fingernails. R13's son indicated R13 would want to be kept neatly shaved, nose hair trimmed, and fingernails cleaned. On 07/23/2025 at 8:44 AM, R13 was observed in bed with the head of the bed slightly elevated. R13's fingernails remained long, curled, and visibly dirty. The facial hair, including the unkempt goatee and extended nose hairs, appeared unchanged from the prior observations on 07/21/2025 and 07/22/2025. A review of the medical record for R13 revealed they were admitted to the facility on [DATE]. Diagnoses included Stroke, Kidney Disease, Heart failure, and Diabetes. The MDS assessment dated [DATE] documented increased need for assistance with ADLs and severely impaired cognition. The care plan identified an ADL self -care performance deficit, with interventions for one person assistance with personal hygiene and bathing. On 07/22/2025 at 4:45 PM, Licensed Practical Nurse (LPN) Q unit manager, and Registered Nurse (RN) R unit manager, were interviewed regarding the facility's grooming policy related to fingernail care, toenail care, and shaving. Both staff stated that grooming should be completed on shower days and as needed (PRN). If a resident refused their care, the CNA was expected to notify the nurse. The nurse will speak to the resident, and if the refusal continues, the family and physician are notified, and a progress note is documented in the medical record. On 07/23/2025 at 8:44 AM, an interview was conducted with CNAs O and P. Both CNAs stated R40 and R13 don't refuse care. CNA O stated, (R40) received a shower on 07/21/2025 but, due to staffing issues, they did not have time to shave (R40) or clean (R40) nails. On 07/23/2025 at 12:15 PM, the Director of Nursing (DON) reported their expectations for grooming care, including fingernail, toenail, and shaving hygiene were that grooming should be completed on shower days and as needed (PRN). If a resident refuses care, staff are expected to notify the nurse. The nurse is responsible for speaking with the resident, and if the refusal continues, the family is notified and the refusal documented in the medical record. A review of the facility policy, Activities of Daily Living (ADLs), dated 10/30/2025, revealed, The facility takes measures to minimize the loss of residents functional abilities, including activities of daily living (ADLs). Activities of daily living include the ability to bathe, dress, and groom. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview, and record review, the facility failed to ensure that ordered laboratory work was completed for one (R34) of three residents reviewed for laboratory services. Findings include:A review of the medical record for R34 revealed they were admitted to the facility on [DATE] with diagnoses of high blood pressure, atrial fibrillation, respiratory failure and diabetes. The care plan, dated 09/25/2023, identified the resident as having impaired cardiovascular status and diagnostic testing should be completed as ordered. An order for routine laboratory testing, including a complete blood count (CBC/Diff) with differential, and comprehensive metabolic panel (CMP) was entered for R34. Documentation date 02/28/2025 indicated the lab was unable to obtain a sufficient blood sample, noting, Couldn't get a vein quantity not sufficient. A review of the medical record revealed no evidence that a follow-up attempt was made to redraw the laboratory tests, and there was no documentation to indicate the physician was notified. On 07/22/2025 at 2:45 PM, an interview was conducted with R34's physician regarding their expectations when laboratory staff are unable to obtain sufficient blood from a resident. The Physician confirmed they would expect the lab would be redrawn if the initial attempt was unsuccessful saying, I want it done or to be notified if unable to complete. On 07/22/2025 at 2:53 PM, Unit managers Licensed Practical Nurse (LPN) Q and Registered Nurse (RN) R reported if a laboratory redraw is needed, a new requisition must be entered into (name of electronic medical record system) and (name of laboratory service provider) is expected to follow up. During the interview, both unit managers attempted to locate laboratory results for R34 and were unable to find them. On 07/23/2025 at 12:11 PM, interview with Director of Nursing (DON) reported their expectations for handling unsuccessful laboratory draws. The DON reported when laboratory staff are unable to obtain a sufficient sample of blood, a new requisition should be completed and entered into (name of electronic medical record system). The laboratory is then expected to follow up and complete the lab work. On 07/23/2025 and 07/24/2025 three attempts to call (name of laboratory service provider) were made with no return call. A review of the facility policy, Laboratory and Diagnostic Guidelines, dated 01/01/2022, revealed, the guideline is set up to track the timely completion, reporting and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels. The physician should be notified of all refused lab or diagnostic test orders and reason why.

Based on observation, interview, and record review, the facility failed to ensure meals were palatable and served in a timely manner for six residents (R21, R27, R33, R38, R99, R118) reviewed for food concerns from a census of 119 residents. Findings include:On 07/21/25 at 10:06 AM, during the initial screening, R21 reported their breakfast was cold today. On 07/21/2025 at 10:19 AM, during the initial screening, R33 stated, The food sucks. On 07/21/25 at 10:45 AM, R27 reported, they take good care of me, but the food is terrible, dried-up meat and almost choked on a hot dog. On 07/21/25 at 10:08 AM, R38 reported the meat can be tough and chewy, the eggs are served cold, and the Caesar salad was made with iceberg lettuce and served with Italian or ranch dressing. On 07/21/2025 at 10:40 AM, R99 reported the food is cold at one meal or another almost every day. R99 went on to say the oatmeal was served without brown sugar when requested so they had to buy their own; Staff can't or don't read the food tickets so R99 does not receive what is requested; They do not always get cereal or what was requested; The tater tots and hamburger were served cold, and fries were still frozen. R99 reported they feel they are the last to be served since they are at the end of the hall. On 07/21/2025 at 12:22 PM, the food tray cart was observed on the 600 unit. Staff were observed to walk down the hall and past the food cart; At 12:25 PM, dietary staff dropped a food tray cart on the 700 unit. One staff member was passing trays; At 12:47 PM, the cart from the 600 unit was moved to the 800 unit. At 1:00 PM, R99 was served their food. 38 minutes after the cart was delivered onto the unit. At 1:01 PM R99 reported the food was warm but not hot. On 07/21/2025 at 12:49 AM, R118 reported they feel the resident council and food committee meetings do not make much difference with the same complaints about food every month and the kitchen blames the CNAs for cold food. R118 feels at times the food is cold to begin with. R118 commented they told the facility they honestly think the dietary staff don't read the menu when residents send them back. R118 reported the chicken on their plate could be warmer and part of the issue is that the facility was short staffed all the way around. On 07/22/2025 at 11:44 AM, the lunch food tray cart was observed at the entrance to the 700 unit. At 12:18 PM, a food tray cart had not made it to the 800 unit. On 07/22/2025 at 12:51 PM, R99 was observed to have the turkey rice casserole, snap peas, a roll, and chocolate cake on their lunch plate. R99 reported they did not want any of it except the cake and that no one had come and asked them what they wanted. A review of the meal ticket revealed no changes or substitutions had been made on the ticket. 07/22/2025 1:09 PM, Certified Nursing Assistants (CNA) X and Y reported the procedure was to have the next day's meal tickets reviewed with the resident to determine their food preferences and then the CNA would sign the meal ticket when reviewed and return it too dietary. On 07/22/25 at 1:49 PM, during the group meeting, R8 reported the food was a joke and were served frozen fries. R118 reported they do have food council meetings, and they brought up the food was cold, and it was blamed on the CNAs for leaving the door to the cart open. R118 further noted the cold stuff is not cold and the ice cream was like soup. A review of the food committee minutes received for February 2025, March 2025, May 2025 and June 2025 documented consecutive cold food or timely delivery complaints. A review of the monthly Resident Tray Assessment Report received, documented an audit of one lunch meal with the last one completed on 06/02/25. On 07/23/2025 at 8:02 AM, the food tray cart was observed on the 700 unit, one staff was observed to begin delivery of the food trays; At 8:06 AM, a second staff was observed to pass trays on 700 unit; At 8:10 AM, the tray cart to was delivered to the 600 unit, At 8:21 cart was observed at the entry to 600 hall as before. Staff had started distribution of trays, and the cart was moved to the end of the hall then moved to the 800 unit. At 8:34 the meal tray for R99 was delivered. 24 minutes after arrival on the floor. The meal ticket was observed with preferences and noted corn flakes. R99 was served frosted flakes. R99 reported they did not get the plain corn flakes they had requested. Oatmeal was delivered per the ticket, but the requested brown sugar was not seen in the oatmeal or on the tray. On 07/23/2025 at 1:55 PM, the identified concerns were reviewed with the Dietary Manager (DM). The dietary manager confirmed the procedure was for CNAs to bring out the meal tickets the night before, review the menu items with the resident and then sign and return it. The DM reported the resident should be offered a second or third alternate to the main menu item. The DM reported the time the food cart was delivered to the floor was also documented. Dietary brings out the paper and once the food cart is delivered, they then have a nurse or CNA sign off. The signing of any paper was not observed to occur during the tray pass observation. The DM also noted the time it takes to fill the cart while in the kitchen was up to 15 minutes. When asked about the food committee, the DM noted they actively attended the meetings. A review of the facility policy titled, Nutritional Management revised 01/22/22 revealed, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutrition in the context of his or her overall condition . The Resident's goals and preferences regarding nutrition will be reflected in the Resident's plan of care .

Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed and ensure residents on oxygen had full oxygen tanks available for three residents (R8, R59, R39) out of three residents reviewed for respiratory care. Findings include: R8 On 06/11/24 at 10:06 AM, R8 was observed sitting in their wheelchair at the sink in room. R8's oxygen tubing on the back of their wheelchair was in a bag and dated 5/28/24. Additional oxygen tubing was attached to a portable oxygen tank and dated 5/14/24. The oxygen tank on the back of the wheelchair was empty. R8 was not wearing oxygen at this time. On 06/11/24 at 12:17 PM, R8 was observed sitting in their wheelchair in the hallway. The oxygen tubing on the back of the wheelchair was still dated 5/14/24 and the oxygen tank was empty. R8 was not wearing oxygen at this time. On 06/12/24 at 08:18 AM, R8 was observed awake lying in bed using oxygen at two liters per nasal cannula (NC) by concentrator. Portable oxygen tank on back of wheelchair remained empty. On 06/12/24 at 11:37 AM and 12:44 PM, R8 was observed sitting up in their wheelchair. Oxygen tubing on back of wheelchair was still dated 5/14/24 and 5/28/24. Oxygen tank on wheelchair remained empty. R8 was not wearing oxygen at this time. On 06/12/24 at 01:31 PM, R8 was observed sitting in their wheelchair in the hallway and was asked if they ever wear oxygen during the day R8 stated not usually but if they feel they need it they ask for it. A review of the medical record revealed that R8 admitted into the facility on [DATE] with the following diagnosis, Chronic obstructive pulmonary disease. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 11/15, indicating an impaired cognition. R8 also required assistance with bed mobility and transfers. Further record review of R8's care plan stated the following: R8 will periodically remove their oxygen. Encourage them to wear. Administer Oxygen at 2L (liters) NC continuous as ordered. Provide oxygen as needed when resident exhibits signs/symptoms of difficulty breathing (short of breath, cyanosis, low 02 sats) R8's physician order documented the following: Oxygen: Run at 2L/MIN via N/C continous. Oxygen tubing/filter change every week. R59 On 06/11/24 at 01:01 PM, R59 was observed sitting in their wheelchair in the hallway talking to R8 with oxygen two liters via nasal canula with portable tank. Oxygen tubing dated 5/28/24. On 06/12/24 at 08:20 AM and 1:33 PM, R59 was observed sleeping in bed wearing oxygen two liters nasal canula via concentrator. Portable oxygen tank in wheelchair was empty. On 06/12/24 at 02:24 PM, R59 was observed being pushed in their wheelchair in the hall without wearing oxygen. On 06/13/24 at 09:38 AM, R59 was observed sleeping in bed with oxygen on per concentrator. Oxygen tank in wheelchair was empty. A review of the medical record revealed that R59 admitted into the facility on [DATE] with the following diagnosis, Chronic obstructive pulmonary disease. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 14/15 impaired cognition. R59 also required assistance with bed mobility and transfers. Further record review of R59's care plan stated the following: Resident has an impaired pulmonary/respiratory status related to chronic respiratory failure with COPD and requires supplemental oxygen. Administer Oxygen at 2L NC continuous as ordered. The Physician order documented Oxygen: Run at [2]L/MIN via N/C continous. R39 On 06/13/24 at 02:00 PM, R39 was observed sitting in their motorized wheelchair in a common area at a table with other residents. R39 had an oxygen nasal cannula in place and the oxygen tank on the back of the wheelchair was empty. A review of the medical record revealed that R39 admitted into the facility on [DATE] with the following diagnosis, Chronic obstructive pulmonary disease. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 14/15 impaired cognition. R39 also required assistance with bed mobility and transfers. Further record review of R39's care plan documented the following: Resident has an impaired pulmonary/respiratory status related to COPD (chronic obstructive pulmonary disease)/Emphysema, obesity, respiratory failure, shortness of breath, sleep apnea. Oxygen continuous 3L NC as ordered. The Physicians orders documented: Oxygen: Run at [3]L/MIN via N/C continous. On 06/13/24 at 09:43 AM, during an interview, Certified Nurse Assistant (CNA) D states the oxygen tanks are changed by the CNA's and that the oxygen tubing is located in the supply room and is changed by supply people. On 06/13/24 at 10:14 AM, during an interview the Unit Manager (UM) E stated a company comes every Tuesday to change oxygen tubing and confirmed that oxygen tubing should be dated. On 06/13/24 at 1035 AM, during an interview Infection Control Preventionist (ICP) C stated they believed oxygen tubing should be changed by a company and stated the unit manager usually rounds to ensure it was completed. ICP C was unsure of the time frame they needed to be changed. In an additional interview the Director of Nursing (DON), stated residents on oxygen should have full oxygen tanks and have oxygen available is something happens. The DON stated it is the expectation that oxygen tubing be changed weekly. 34851 R78 On 6/11/24 at 12:50 PM, R78 was observed in bed with a trach (tracheostomy - surgical hole in neck to assist with breathing) collar on their neck. The oxygen (O2) concentrator and trach tubing were observed without a date. On 6/12/24 at 9:53 AM, R78 was observed in bed with the O2 tubing and trach tubing undated. A review of R78's orders did not reveal orders regarding the frequency to change the tubing. On 6/13/24 at 10:19 AM, Unit Manager E was observed to look for dates on the tubing on R78's equipment and was unable to locate a date as to when the tubing was last changed. Unit Manager E was asked how often is the tubing changed. Unit Manager E explained, the tubing is to be changed weekly and labeled with a date. A review of R78's medical record revealed, R78 was admitted to the facility on [DATE] with diagnosis of Anoxic Brain Damage. R78's care plan noted, Focus: Resident has an impaired pulmonary/respiratory failure, tracheostomy, asthma. Date initiated: 05/26/2024. Goal: Resident will have reduced complications related to their altered pulmonary/respiratory status through next review. Date Initiated: 05/26/24. Intervention: Provide oxygen as needed when the resident exhibits signs/symptoms of difficulty breathing (short of breath, cyanosis, low O2 sats). Date Initiated: 05/30/2024. A review of the facility policy titled Oxygen Administration noted the following: change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change nebulizer tubing and delivery devices every 72 hours, or per manufacturer recommendation, and as needed if they become soiled or contaminated.

Based on observation and interview, the facility failed to maintain a clean, homelike environment for three residents R9, R31, and R60 out of three residents reviewed for environment. Findings include: R9 On 06/11/24 at 9:30 AM, R9 was observed lying in bed in their room watching television. An observation of the privacy cubical curtains revealed several round brown stains on it. When asked about the dirty curtains, R9 nodded his head and stated clean. A record review revealed that R9 was admitted on [DATE] with the medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side; Chronic Obstructive Pulmonary Disease, Apasia and Muscle Weakness. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 0 which indicates impaired cognition. R31 On 6/11/24 at 9:32 AM, R31 was observed lying in bed in their room watching television. An observation of the privacy cubical curtains revealed several round brown stains on it. When asked about the curtains, R31 stated I would prefer a clean curtain in his room. A record review revealed that R31 was admitted on [DATE] with the medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side; Hyperlipidemia, Anxiety and Major Depressive Disorder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 13 which indicates intact cognition. R60 On 06/11/24 at 11:50 AM, R60 observed siting up in bed watching television. An observation of the privacy cubical curtains revealed several dark black splatter and stains on it. When asked about the curtains, R60 stated It is not good and should be cleaned. A record review revealed that R31 was admitted on [DATE] with the medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side; Diabetes Type II, and Mood Disorder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 14 which indicates intact cognition. On 6/13/24 at 10:30 AM during an observation and interview with the Housekeeping Supervisor, (Staff A) they confirmed, These curtains are dirty. It is my expectation the curtains are clean in the resident rooms. Residents should have a clean home like environment. A review of the facility policy titled Safe and Homelike Environment which was implemented on 7/28/20 and revised on 1/01/22, revealed the following, The facility will provide a safe, clean, comfortable and home-like environment.

This citation pertains to Intake MI00143507. Based on observation, interview, and record review, the facility failed to provide twice weekly showers for one (R33) of five residents reviewed for showers. Review of the facility record for R33 revealed an admitted [DATE] with diagnoses that included Multiple Sclerosis, Neuromuscular Dysfunction of the Bladder and Urinary Tract Infection. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] was scored 15/15 indicating intact cognitive function. On 06/11/24 at 11:15 AM, R33 reported they had not consistently been assisted with a shower twice weekly as they had in the past. R33's spouse was on speaker phone at the time of the interview and reported they visit regularly and stated I know [R33] doesn't always get a shower twice a week. On 06/12/24 at 1:26 PM, R33 was observed to appear generally well groomed and clean. When asked about the frequency of being showered R33 stated I just had one on Sunday. I got them (showers) on the regular schedule last week but before that I think I only had one for a couple weeks. R33 was asked how they felt about the missed showers and stated I know they're busy sometimes but I don't think twice a week is too much to ask. I feel dirty going that long without a shower. Review of the facility Task item that documents shower completion indicated that R33 received one shower the week of 05/19/24 and no showers the week of 05/26/24. No resident refusal of showers were documented for those weeks. Documentation of R33's shower completion was requested from the facility to rule out additional sources of documentation such as hand written shower sheets. A shower report document was provided that matched the shower completion dates from the Task record and no additional information. On 06/13/24 at 12:09 PM, the facility Director of Nursing (DON) reviewed R33's record and agreed that no shower or shower refusal was documented between 5/23/24 and 06/02/24. The DON reported their expectation is resident's are offered a shower or bath twice weekly and any completion or refusal should be documented. Review of the facility policy Activities of Daily Living dated 12/28/23 revealed the entry 3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. A facility policy specifically addressing the frequency of bathing services being offered/provided was requested but not provided.

Based on interview and record review, the facility failed to administration an intravenous (IV) antibiotic as ordered for one resident (R105) out of two reviewed for IV antibiotic use, resulting in missing eight doses of IV antibiotics. Findings Include: On 06/11/24 at 11:35 AM, R105 reported when they were admitted into the facility, they were on IV antibiotics and the medication ran out and they were without the treatment for at least a day. A review of the medical record revealed that R105 admitted into the facility on [DATE] with the following diagnoses, Acute Osteomyelitis, Right Ankle and Foot and Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Fat Layer Exposed. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental status score of 15/15 indicating an intact cognition. R105 also required assistance with bed mobility and transfers. Further review of the physician orders revealed the following orders; -Ampicillin-Sulbactam Sodium Injection Solution Reconstituted 3 (2-1) GM (Ampicillin & Sulbactam Sodium) Directions: Use 3 gram intravenously every 6 hours related to OTHER ACUTE OSTEOMYELITIS, RIGHT ANKLE AND FOOT until 06/10/2024 23:59 . -Lab (name of lab tests) weekly. Directions: every day shift every Fri (Friday) for Infection. A review of the Medication Administration Record (MAR) revealed a number 9 documented on May 28th and May 29th indicating that R105 missed eight doses of their IV antibiotic. Further MAR notes stated the IV antibiotic was On order on these days. No note was observed stating the physician was notified. A review of R105's laboratory did not show any results for 6/7. On 6/13/2024 at 10:57 AM, an interview was conducted with Infection Control Preventionist (ICP) C. ICP C stated if R105 medication was on order then the physician should have been notified. ICP C stated they have been having problems with the lab and they are unsure why it was not drawn on 6/7 as it was ordered. On 6/13/2024 at 11:16 AM, an interview was completed with the Director of Nursing (DON). The DON stated if a medication is not available, the nurses should look in the back up system first, call the pharmacy and see where the medication is and then notify the physician. The DON stated there should have been some follow up with R105's IV Antibiotics. A review of a facility policy titled, Antibiotic Stewardship program noted the following, b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out) .v. Random audits of antibiotic prescriptions may be performed to verify completeness and appropriateness (Process measure).

Based on observation, interview, and record review, the facility failed to develop and implement interventions for reducing and/or eventually discontinuing the use of a restraint, and document and provide ongoing monitoring and evaluation for the continued use of a physical restraint for one sampled resident (R69), of one resident reviewed for restraints resulting in the potential for physical and psychosocial harm using the reasonable person concept. Findings include: On 6/5/23 at 12:47 PM, R69 was observed asleep in a Posey bed (a tent-like enclosure entirely covering a hospital bed. Someone on the outside of the bed must unzip one of the tent flaps before the individual can get out of the bed). A review of R69's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Schizophrenia, Developmental Disorder of Speech and Language, Seizures, and Anxiety. A review of R64's Quarterly Minimum Data Set (MDS) assessment dated for 3/25/23 revealed that the resident was severely cognitively impaired, and required extensive assistance of one person for dressing, toilet use and eating. Further review of the medical record revealed that the resident has had the posey bed in placed since 7/8/21. Further review of R69's medical record revealed that the following care plan, Focus: Resident may resist care r/t (related to) dx (diagnosis). Per family, resident may become combative if [R69] does not want to do something. [R69] constantly trying to get out of [their] bed, wheelchair and has a history of constant falls. [R69] now has a posey bed in place. [R69] may take off brief and tends to spread [their] BM [bowel movement] all over. [R69] will often scream loudly, even after staff have just been in [their] room. [R69] does not tolerated being up for long periods of time. [R69] is followed by psych and OBRA (Omnibus Budget Reconciliation Act of 1987, which was implemented to enhance the quality of care of residents in nursing facilities) and is on psychotropic meds. dx of developmental d/o (disorder), major depression, anxiety d/o and Schizophrenia. Date Initiated: 08/29/2020. Revision on: 03/30/2023 .Interventions: Resident uses a posey bed to assist in keeping [their] psychosocial well being stable. Date Initiated: 03/31/2022. Revision on: 04/18/2023 . Further review of R69's medical record revealed four quarterly Safety Device Data Collection Evaluations dated as follows: 12/15/2021-Incomplete, 4/25/2022-Complete, 7/4/2022-Complete, and 3/24/2023-Incomplete. Further review of R69's medical record revealed four Physical Restraint Elimination Reviews dated as follows: 1/25/2022-Complete, 8/10/2022-Complete, 12/28/2022-Complete, and 4/18/2023-Complete. Further review of R69's medical record revealed a Level II OBRA assessment dated for 4/10/23 revealed the following recommendations: OBRA Specialized Mental Health Services (SMHS) is recommended to assist in the coordination of services among the providers, establish a behavior plan with the assistance of the rehabilitation department, social work and nursing department for a graded out of Posey bed program while maintaining [their] safety in [their] lounge chair and wheelchair. [Legal Guardian] is in agreement with anything that may assist [their family member] in spending time out of the Posey Bed . On 6/7/23 at 10:31 AM, an interview was completed with Social Worker J regarding the implementation of R69's OBRA recommendations specific to the restraint of the Posey Bed, and obtaining a communication board for the resident. Social Worker J explained that previously, R69 had not been successful with spending time outside of their Posey Bed, and gets angry after being up for about an hour. Regarding the communication board, Social Worker J explained that it had not been successful in the past. Regarding the process of implementing interventions from the OBRA assessments, Social Worker J explained that she usually reads the assessments and informs the IDT (Interdisciplinary Team) of those recommendations, but was unable to explain why R69's recommendations had not yet been implemented. On 6/7/23 at 11:36 AM, Unit Manager (UM) K was asked about R69 being trialed out of their Posey Bed, and recommendations being implemented from the OBRA assessment. UM K explained that she was unaware of those recommendations, but did indicate that R69 had some time ago been trialed out of the Posey bed, but they always yell to go back in. On 6/7/23 at 11:14 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were asked about specific documentation and/or periodic assessment of trials of attempting to reduce R69's time in the Posey bed, and they reported that they did not have anything formally in place. On 6/7/23 at 11:53 AM, the Director of Nursing (DON) was asked about implementing recommendations from the OBRA assessment regarding an out of bed Posey program. The DON explained that she could not speak on the subject as she recently returned from a medical leave. The DON was asked who is supposed to complete, and how often the Restraint Elimination Assessments and Safety Device Data Collection and Evaluations are supposed to be completed. She explained that she believes that the Safety Device Data Collection Evaluations should be done quarterly, and that it is triggered by MDS however, she explained that she would investigate and get back with the surveyor however, this information was not provided by the end of the survey. A review of the facility's Restraint policy did not address the need for ongoing monitoring, evaluation, and documentation regarding use, nor did it address interventions to reduce the use of a restraint.

This citation pertains to Intake M100137029. Based upon observation, interview and record review, the facility failed to implement/document the care plan for repositioning frequency for one (R26) of two residents reviewed for repositioning, resulting in increased potential for skin breakdown. Findings include: Review of the facility record for R26 revealed an initial admitted [DATE] and a most recent admission of 05/25/23 following hospitalization with diagnoses that included Multiple Sclerosis, Paraplegia and Epilepsy. The Minimum Data Set (MDS) assessment dated [DATE] indicated R26 requires total assistance for bed mobility and all self care. The Brief Interview for Mental Status score was not recorded. R26 did not communicate verbally with the surveyor and did lightly nod their head at times in response to questions. Review of R26's Care Plan dated 03/22/23 revealed the Focus area description The resident has potential for impairment to skin integrity related to fragile skin, immobility secondary to contractures with diagnosis of MS [Multiple Sclerosis]. The Intervention area within this focus description included the interventions Reposition with two people with mechanical lift and Yellow Dot program (every two hours) for turning and repositioning. On 06/05/23 at 9:15 AM, R26 was observed laying on their back in bed. ON 06/05/23 at 11:40 AM, R26 was observed laying on their back in bed. On 06/06/23 at 9:49 AM, R26 was observed laying on their back in bed. On 06/06/23 at 11:59 AM, R26 was observed sitting up the reclining chair in their room. The call light was not within reach of R26 and they did not have socks on or have their feet covered. On 06/06/23 at 3:11 PM, R26 was observed sitting up in the reclining chair with no observable position change from the 11:59 AM observation. On 06/07/23 at 8:01 AM, R26 was observed during medication administration in bed turned toward their right side. On 06/07/23 at 10:34 AM, R26 was observed toward their right side-lying position as observed at 8:01 AM. Review of R26's Kardex task completion chart for repositioning for dates 05/09/23 - 06/06/23 revealed a maximum of three task completion entries per date. On 06/07/23 at 1:27 PM the facility Director of Nursing (DON) reported that the facility interprets each entry as indication that care plan directions (repositioning every 2 hours) were completed for the entire shift rather than having an entry for every episode of repositioning. Additional review of the Kardex revealed only two entries (two shifts during a 24 hour period) on the dates 06/01/23, 06/02/23 and 06/03/23 and no resident refusals are documented. On 06/07/23 at 1:27 PM the facility DON reported that the expectation for residents on the yellow dot program is that they are turned/repositioned every two hours. Review of the facility policy titled Comprehensive Care Plans dated 06/30/22 included the entry The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practible physical, mental and psychosocial well-being. Review of the facility policy titled Turning and Repositioning dated 01/01/22 revealed the Policy statement It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management.

Based on observation, interview, and record review, the facility failed to ensure residents were positioned appropriately during meals affecting two (R35 and R61) reviewed for the dining task, resulting in resident difficulty with self-feeding. Findings include: R61 On 6/5/23 at 12:49 PM, R61 was observed in their bed. R61's lunch tray was in front of them on the overbed table, however, the resident was slumped all the way over to their left side. R61 was holding an empty cup. A piece of cake was observed to have dropped out of the cup and onto the resident's bed. R61 expressed that they felt terrible. R61 was asked if they were comfortable. R61 asked why and stated, Because I'm sitting crooked? R61 then straightened themselves upright somewhat, but was unable to position themselves completely upright. On 6/5/23 at 1:20 PM, R61 remained completely slumped over to their left side in bed. R61's call light was noted to be on their right side, but the resident was unable to locate it. R61's cup of coffee had been spilled onto their lunch tray and onto themselves and their bedding. R61 indicated that the coffee had no longer been hot when they spilled it. R61's empty cake cup and cake were now noted to be on the floor to the left of the resident's bed. R61 indicated they have weakness on both sides of their body. On 6/5/23 at 1:28 PM, R61 remained completely slumped over to their left side in bed. R61 stated they were, About to open my mouth (to call for help). At 1:33 PM, R61 could be heard in the hallway, calling out, Hello? from their room. On 6/5/23 at 1:41 PM, Certified Nursing Assistant (CNA) A entered R61's room. CNA A did not knock on the door or announce herself before entering the room. CNA A expressed shock at seeing R61 and indicated she would help the resident get cleaned up. A review of R61's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and is currently receiving hospice services. R35's medical diagnoses include Heart Failure, Diabetes, Bipolar Disorder, and Chronic Lung Disease. Further review revealed that the resident requires set-up/supervision assistance from one staff for meals and extensive assistance for bed mobility. A review of R61's care plan revealed: -Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Date Initiated: 06/23/2022. -Anticipate and meet the resident's needs based on nursing assessments Date Initiated: 05/26/2022. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 05/20/2022. -[R61] will receive interventions to maintain optimal level of comfort through review date Date Initiated: 06/08/2022. R35 On 6/6/23 at 12:34 PM, R35 was observed in their bed. R35's lunch tray was in front of them on the overbed table, however, the resident was slumped over to their right side. R35 expressed that they were leaning too far over. R35 attempted to reach a cup of juice on their tray but was unsuccessful. R35 appeared frustrated and indicated that they lost their appetite. A review of R35's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on [DATE] and most recently readmitted on [DATE]. R35's medical diagnoses include Dementia, Heart Disease, Diabetes, Seizures, Malnutrition, Muscle Weakness, and Abnormal Posture. Further review revealed that the resident is severely cognitively impaired and requires set-up assistance/supervision from one staff for meals and extensive assistance for bed mobility. A review of R35's care plan revealed: Resident requires long term care with daily supervision due to dementia and extensive care needs .Date Initiated: 04/06/2022. On 6/7/23 at 8:37 AM, CNA C, who works on the unit where R35 and R61's rooms are located, was asked how residents should be positioned in bed during meals. CNA C indicated that residents should be sitting as upright as possible if eating their meal while in bed. On 6/7/23 at 11:40 AM, the Director of Nursing (DON) was interviewed and indicated that residents who choose to eat their meals while in bed should be positioned upright. The DON added that she would expect staff to be making rounds to correct any positioning concerns. A review of the facility's policy/procedure titled, Activities of Daily Living (ADLs), reviewed/revised 1/1/2022, revealed, The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to: 1. Bathe, dress, and groom; 2. Transfer and ambulate; 3. Toilet; 4. Eat; and 5. Use speech, language or other functional communication systems .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .The facility will maintain individual objectives of the care plan and periodic review and evaluation.

This citation pertains to Intake: MI00135394. Based on observation, interview, and record review, the facility failed to provide timely incontinence care to one resident (R35), and provide and document showers for one resident (R38) of 10 reviewed for activities of daily living (ADLs) resulting in soiled bedding, unmet care needs, resident discomfort, and the potential for skin breakdown. Findings include: A review of R35's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on [DATE] and most recently readmitted on [DATE]. R35's medical diagnoses include Dementia, Heart Disease, Diabetes, Seizures, Malnutrition, Muscle Weakness, and Abnormal Posture. Further review revealed that the resident is severely cognitively impaired and requires extensive assistance for toilet use and is always incontinent of bowel and bladder. On 6/6/23 at 11:41 AM, R35 was observed lying in bed, surrounded by positioning pillows and covered with a blanket. R35 expressed extreme discomfort and indicated that their back was itching terribly. At this time, Licensed Practical Nurse (LPN) G was right outside of R35's room and queried regarding the resident's discomfort. LPN G and the Director of Nursing (DON) helped turn R35 on their side to assess the resident's back. R35's disposable incontinence brief was noted to be completely saturated with urine and had soaked through to the resident's bedding. This observation was confirmed by LPN G and the DON. R35 continued to express that their left lower back was itching. The skin on R35's buttocks appeared to be moisture-laden but was intact. R35's skin on their left lower back was reddened with white indentations/wrinkles (from a green cloth chux pad) - indicative of the resident being positioned on that side for an extended period. The DON was then queried if R35 is able to use their call light or knows when they need to be changed. The DON indicated that the resident is not aware of when they need to be changed and no longer has the cognitive capability to understand use of the call light. The DON also indicated she would have to check R35's care plan in regards to the resident's specific care requirements. On 6/6/23 at 11:51 AM, as lunch trays were being passed out to residents, Certified Nursing Assistant (CNA) A was queried regarding the expectation for checking and changing incontinent residents, as well as the last time she checked/changed R35. CNA A indicated that check/changes are completed every two hours. CNA A was unsure of the exact time she had checked/changed R35 last, but believed it had been around 8:30 AM. CNA A stated she had been planning on checking R35's brief after lunch. On 6/7/23 at 11:40 AM, DON was interviewed and indicated that what was observed on 6/6/23 at 11:41 AM involving R35 did not meet her expectation of care. A review of R35's care plan revealed: -Resident requires long term care with daily supervision due to dementia and extensive care needs .Date Initiated: 04/06/2022. -BRIEF USE: The resident uses disposable briefs. Check q (every) 2 hours and change prn (as needed) Date Initiated: 01/28/2021. -The resident has risk for pressure ulcer development to the following areas (bony prominences) secondary to immobility, DM (Diabetes Mellitus, dementia, weakness, incontinence, malnutrition and hx (history) of pressure injury. Date Initiated: 01/19/2021, Revision on: 03/22/2023. 40384 R38 A review of Intake (complaint called into the State Agency) revealed the following, On 3/1/23 consumer reported to writer that [they] had not received a shower since early February. On 6/6/23 at 12:03 PM, R38 was interviewed and asked if they were receiving their showers. R38 explained that they are surprisingly receiving showers although the facility seems short staffed at times. R38 further explained that the one of the issues that they are having, is getting their brief changed regularly. A review of R38's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Respiratory Failure, Diabetes, and Depression. Further review of R38's medical record revealed an initial Minimum Data Set assessment dated for 1/18/23 indicating that the resident was cognitively intact and required extensive assistance for bed mobility, bathing, and toilet use. Further review of R38's medical record revealed the following care plan, Focus: The resident needs activities of daily living assistance related to: respiratory failure, HTN (hypertension), seizure disorder. Date Initiated: 01/15/2023. Revision on: 01/19/2023 .Interventions: BATHING/SHOWERING: [R38] requires extensive assistance x 1 staff member. [R38] prefers to get in the shower. Date Initiated: 02/05/2023. Revision on: 02/05/2023 . A review of shower documentation provided by the facility revealed that R38 had not received any showers between 2/1/23 and 2/23/23. On 6/7/23 at 12:02 PM, the Director of Nursing (DON) was asked about R38 not receiving their showers, and explained that showers and the documentation of them, is something that is being worked on in QAPI (Quality Assurance Performance Improvement), and ensuring that CNAs (Certified Nursing Assistants) are completing their documentation when showers are given. A review of the facility's policy/procedure titled, Activities of Daily Living (ADLs), reviewed/revised 1/1/2022, revealed, The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to: 1. Bathe, dress, and groom; 2. Transfer and ambulate; 3. Toilet; 4. Eat; and 5. Use speech, language or other functional communication systems .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .The facility will maintain individual objectives of the care plan and periodic review and evaluation.

Based on observation, interview and record review, the facility failed to provide and document repositioning of one sampled resident (R54) of two residents reviewed for positioning and skin management resulting in, the resident developing a facility acquired Deep Tissue Injury (DTI), pain, and the potential for the worsening/development of pressure ulcers. Findings Include: On 6/5/23 at 9:28 AM, R54 was observed in bed lying flat on their back, and asked how they were feeling on this date. R54 explained that they were uncomfortable due to be constipated, and had recently developed skin breakdown on their tailbone which causes them discomfort. R54 was asked if they had the skin impairment prior to being admitted into the facility, and they stated, No. R54 was asked about interventions being put into place to assist with healing the skin, and explained that they were recently provided a low air loss mattress, and is supposed to be seen by the wound care nurse. R54 was asked if they can reposition themselves, and stated, No. R54 was asked if staff reposition them regularly, and stated, No. A review of R54's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Heart Disease, Diabetes, Hypertension and Depression. Further review of the medical record revealed a Minimum Data Set (MDS) assessment dated for 5/21/23 revealing a Brief Interview for Mental Status score of 12/15 indicating a moderately impaired cognition. Further review of R54's MDS revealed that they required extensive assistance of 1 person for bed mobility, transfers, and dressing. Further review of R54's medical record revealed a SOC Wound (Standard of Care) assessment noting the following, Wound care notified by nursing of new skin condition. Upon assessment, there is discoloration to the coccyx. The coccyx has a deep tissue pressure injury. The resident reports mild tenderness to the touch. The wound is epithelialized and not open at this time. Treatment orders for barrier cream placed for protection of wound. Powered low air loss mattress ordered. Yellow dot program was previously initiated, resident need(s) assistance repositioning with pillows . Further review of the medical record revealed a pressure ulcer care plan initiated on 11/14/22 indicating the following, The resident is at risk for pressure ulcer development to [their] bony prominences. Date Initiated: 11/14/2022. Revision on: 11/16/2022 .Interventions: The resident needs reminding to turn/reposition at least every 2 hours, more often as needed or requested. Date Initiated: 11/16/2022. Revision on: 11/16/2022. The resident requires low air loss mattress. Date Initiated: 11/16/2022. Revision on: 11/16/2022 . Further review of R54's medical record revealed POC (point of care) documentation for bed mobility revealed that in the last 30 days, the number of times the resident was turned and repositioned: 5/8/23: 05:55 (5:55am), 14:59 (2:59) and 15:40 (3:40) 5/9/23: 04:31 (4:31am) and 10:49 (10:49pm) 510/23: 00:47 (12:47am), 08:11 (8:11am), 16:27 (4:27pm), 23:20 (11:20pm) 5/11/23: 14:59 (2:59pm) and 22:59 (10:59pm) 5/12/23: 02:22 (2:22am), 14:34 (2:34pm) and 20:55 (8:55pm) 5/13/23: 05:49 (5:49am), 08:49 (8:49am), 15:52 (3:52pm) 5/14/23: 01:52 (1:52am), 07:45 (7:45am), 16:07 (4:07pm), 23:18 (11:18pm) 5/15/23: 12:20 (12:20pm) and 15:50 (3:50pm) 5/16/23: 05:32 (5:32am), 14:42 (2:42pm), 18:43 (6:43pm) 5/17/23: 04:04 (4:04am), 09:17 (9:17am), 22:59 (11:59pm) 5/18/23: 00:55 (12:55am), 07:58 (7:58am), 16:19 (4:19pm), 23:32 (11:32pm) 5/19/23: 09:47 (9:47am), 22:59 (10:59pm) 5/20/23: 02:22 (2:22am), 14:00 (2:00pm), 20:47 (8:47pm), 23:47 (11:47pm) 5/21/23: 14:00 (2:00pm) and 19:09 (7:09pm) 5/22/23: 00:01 (12:01am), 12:00 (12:00pm), 21:24 (9:24pm) 5/23/23: 02:33 (2:33am) and 22:59 (11:59pm) 5/24/23: 03:11 (3:11am), 08:00 (8:00am), 17:31 (5:31pm), 23:33 (12:33pm) 5/25/23: 09:00 (9:00am), 22:59 (11:59pm) 5/26/23: 01:56 (1:56am), 09:34 (9:34am), 18:38 (6:38pm) 5/27/23: 05:35 (5:35am), 08:03 (8:03am),15:20 (3:20pm) 5/28/23: 01:14 (1:14am), 18:08 (6:08pm) 5/29/23: 03:54 (3:54am), 11:57 (11:57am), 16:39 (4:39pm) 5/30/23: 02:24 (2:24am), 08:49 (8:49am), 15:24 (3:24pm) 5/31/23: 04:28 (4:28am), 08:08 (8:08am), 19:52 (7:52pm), 23:27 (11:27pm) 6/1/12: 10:23 (10:23am), 20:57 (8:57pm) 6/2/23: 05:18 (5:18am), 07:39 (7:39am), 16:53 (4:53pm) 6/3/23: 07:46 (7:46am), 20:31 (8:31pm) 6/4/23: 04:41 (4:41am), 09:41 (9:41am), 22:59 (10:59pm) 6/5/23: 05:19 (5:19am), 07:26 (7:26am), 15:32 (3:32pm). On 6/7/23 at 12:01 PM, the Director of Nursing (DON) was asked about R54's wound and lack of turning and repositioning. She explained that her expectation is that staff complete and document that they are turning and repositioning residents. A review of the facility's Turning and Repositioning policy was reviewed and revealed the following, .1. All resident at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed. 2. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. 3. The facility has established routine turning and repositioning schedules consisting of 2-4 hours .

This citation pertains to Intake MI00134479. Based on interview and record review the facility failed to ensure that fall interventions were implemented for one resident (R701) of three residents reviewed for falls, resulting in R701 falling out of bed and experiencing scratches to the left hand. Findings include: On 3/8/23 at 12:49 PM, an interview was conducted with Social Services Director (SSD) C regarding any information they knew about an incident involving R701 falling out of bed on/around 1/16/23. SSD C indicated that the only thing they recalled was that R701 might have fallen out of bed around the middle of January 2023. SSD C further indicated that R701 was on hospice and stated, They (facility nursing staff) said he had an end stage event. On 1/16/23 at 12:55 PM, a review of a website titled Crossroadhospice.com defined the following, End-of-life Timeline Stages: Days or hours before end of life: May experience a sudden and brief surge of energy. On 3/8/23 at 1:30 PM, a progress noted located in R701's electronic medical record (EMR) dated 1/16/23 6:40 PM, was reviewed and stated the following, Resident was observed on the floor next to the bed in their room. A scratch on the L (left) outer backside of the hand was noted. Neurochecks were put in place per on call NP (Nurse Practitioner). [Hospice nurse] at [Hospice agency] was notified along with POA [Power of attorney/Family member]. POC (Plan of care) interventions were not in effect at time of fall the CNA (Certified nursing assistant) was given immediate education and Interventions are currently in place. On 3/8/23 at 1:35 PM, further review of R701's EMR revealed that R701 was most recently admitted to the facility on [DATE] with diagnoses that included Congestive heart failure and Chronic obstructive pulmonary disease (COPD). R701's most recent quarterly Minimum data set assessment (MDS) dated [DATE] revealed that R701 had a Moderately impaired cognition and required extensive assistance and/or was totally dependent for all Activities of daily living (ADLs) other than eating. On 3/8/23 at 1:42 PM, R701's fall care plan was reviewed and revealed the following, Focus: res (Resident) at risk for falls r/t (related to) impaired mobility .Date initiated: 08/07/2016 Revision on: 01/17/2023 Cancelled date: 01/07/2023. Goal: res (Resident) safety and manage risks for falling .Date initiated: 08/07/2016 Revision on: 01/17/2023 Target date: 03/07/2023 Canceled date: 01/17/2023. Interventions: Bed in low position when not providing care .Date initiated: 12/30/2019 Revision on: 01/17/2023 Canceled date: 01/17/2023 .Bi-Lat (Lateral) body pillows in place while in bed for body positioning .Date initiated: 10/22/2019 Revision on: 01/17/2023 Canceled date: 01/17/2023 .floor mats to bil (Bilateral) side of bed .Date initiated: 07/16/2019 Revision on: 01/17/2023 Canceled date: 01/17/2023 . On 3/8/23 at 1:55 PM Nurse/LPN E was interviewed regarding R701's fall on 1/16/23. Nurse/LPN E stated, The CNA [CNA F] was not following the resident's fall care plan interventions Nurse/LPN E was asked which interventions the CNA F was not following and stated Low bed position, no safety mats by bedside, and something else that I cannot remember. On 3/8/23 at 2:06 PM, CNA F was contacted by phone and interviewed about R701's fall which occurred on 1/16/23. CNA F stated, I had just changed [R701] and started to lower his bed, I heard screaming coming from another resident's room on the unit and went to assist the other resident. I did not put [R701's] body pillow on their bed. CNA F was asked if they had put R701's bed in the lowest position. CNA F stated, No, it had a few inches to go. On 3/8/23 at 2:38 PM, the Administrator (NHA) was interviewed regarding their expectations for staff following interventions on a resident's care plan and stated, Staff should follow interventions as they are stated on the resident's care plan. On 3/8/23 at 2:45 PM, a facility policy titled, Baseline Care Plan Date Reviewed/Revised: 01/01/2022 was reviewed and stated the following, Policy: The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care.

This citation pertains to intakes: MI00130200, MI00131441, and MI00133577. Based on observation, interview, and record review the facility failed to ensure adequate staff were available to answer resident requests in a timely manner for one resident (R700) of three residents reviewed for staffing and call light response, resulting in resident complaints of care needs not being met, resident feelings of anger, and the potential for accidents. Findings include: On 2/7/23 at 12:57 PM, R700 was met in their room and interviewed about staffing and call light response by staff at the facility. R700 indicated that they frequently had to wait a long time for staff assistance. R700 further indicated that yesterday (2/6/23) evening they waited two hours for staff to assist them with using the bathroom and finally got out of bed and used the toilet on their own because, I had to go and no one was answering my call light. My legs get weak at night, I need assistance to use the bathroom. R700 was asked how it made them feel when staff did not respond to their call light and said angry. On 2/7/23 at 1:01 PM, R700's call light was activated with the surveyor present in R700's room. On 2/7/23 at 1:41 PM, Certified Nursing Assistant (CNA) A entered R700's room, placed R700's lunch tray on their bedside table and exited R700's room without acknowledging the acitvated call light. On 2/7/23 at 1:48 PM, the Director of Nursing (DON) who was present on R700's unit, was interviewed about how facility staff was notified when a resident's call light was on (activated). The DON stated, It's on their phone. The DON was further interviewed and asked their expectations for staff responding to a resident call light. The DON stated, within fifteen minutes. The DON indicated that the facility knew that they had some staffing issues and said we are working on them. On 2/7/23 at 1:50 PM, CNA A was interviewed and asked if they had received notification of R700's call light being on since 1:01 PM. CNA A stated, probably, I've been so busy. I'm sorry. On 2/7/23 at 2:11 PM, resident council meeting minute notes were reviewed for the months of November 2022 through January 2023. The meeting minute notes indicated that call light response was an ongoing concern for all resident council meeting attendees. On 2/8/22 at 9:40 AM, CNA G was interviewed about staffing at the facility and stated, Some days it's okay and some days it isn't. We have a lot of residents that require use of a (name of a 2 person mechanical lift) and you have to find another CNA to help you with that. On 2/8/22 at 10:23 AM, R700's electronic medical record was reviewed and revealed that R700 was admitted to the facility on [DATE] with diagnoses that included Hypertension and Dementia. R700's most recent minimum data set assessment (MDS) dated [DATE] revealed that R700 had an intact cognition and required one person physical assistance for transfers and toilet use. On 2/8/22 at 10:32 AM, a facility policy titled Call Lights .Timely Response Date Reviewed/Revised: 1/1/2022 was reviewed and stated the following, Policy: .Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 7. All staff members who see or hear an activated call light are responsible for responding .

This citation pertains to Intake: MI 645 and MI 601. Based on observation, interview and record review, the facility failed to document and provide routine showers/baths for two sampled Residents (R901 and 907) of six residents reviewed for activities of daily living (ADLs), resulting in unmet care needs. Findings include: Resident #901 (R901) A review of Intake MI 65 revealed the following, Complainant states the resident is supposed to be showered 2x (two times) per week, but it will be more than a week before [the resident] receives a shower . On 8/4/2022 at 8:55 AM, R901 was observed in bed asleep. Attempts to awaken R901 were made to no avail. A review of R901's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS) assessment revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9/15 indicating a moderately impaired cognition and required limited assistance for bathing. Further review of R901's medical record revealed that within the last 30 days, the resident received a shower on 7/23/2022 and a bed bath on 7/31/2022. There was no other documented showers/baths or documented refusals noted in the resident's medical record. Resident #907 (R907) On 8/4/2022 at 3:50 PM, R907 was observed asleep sitting in the common area. A review of R907's medical record revealed that they were admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R907's most recent MDS assessment revealed that the resident had a BIMS score of 6/15 indicating a severe cognitive impairment and was totally dependent on staff for bathing. Further review of R907's medical record revealed that within the last 30 days, R907 had no documented showers or bed baths provided. On 8/4/2022 at 4:17 PM, the Director of Nursing was interviewed and asked about the shower documentation for R901 and R907 and upon review acknowledged that the showers were not documented, which was not her expectation for showers provided to residents. A review of the facility's Activities of Daily Living (ADLs) policy revealed the following, .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on observation, interview, and record review, the facility failed to prevent neglect for three Residents (#14, #47, and #335) when staff transferred residents in an unsafe manner, neglecting to follow their Minimum Data Set (MDS) RAI (Resident Assessment Instrument) assessments and individualized Care Plans, of 22 residents reviewed for neglect. This deficient practice resulted in actual harm and unsafe transfers, with psychosocial distress and feelings of fear for Resident #14, rough treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #14 Review of Resident #14's Minimum Data Set (MDS) assessment, dated 2/09/22, revealed admission on 1/25/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment revealed Resident #14 required one-person assistance with bed mobility, dressing, and toileting, and two-person total assistance with transfers. The BIMS (Brief Interview for Mental Status) revealed a score of 15/15, which indicated Resident #14 was cognitively intact. The PHQ-9 depression assessment revealed a score of 0/27, with showed Resident #14 had no signs or symptoms of depression. Review of Resident #14's MDS showed she was 65 inches tall and 181 pounds. During an interview on 4/25/22 at 4:13 p.m., Resident #14 described an incident last Thursday (4/21/22) when she almost fell out of the sling of a total body mechanical lift onto the floor in her room. Resident #14 reported Certified Nurse Aide (CNA) A, was transferring her from her wheelchair in a half sling back to her bed. Resident #14 explained the sling did not fit her size as her bottom was hanging out through a hole (where sling legs crossed); Resident #14 reported she had never used this sling prior with any other aide for her transfers. Resident #14 further described the sling skimmed the floor so her brief touched the floor, and her feet and ankles bounced against the dressers as she was so low to the ground. She reported the transfer caused discomfort and bruising to the back of her hands, which she showed Surveyor, and on her ankles, which were covered by socks. Resident #14 showed Surveyor a red mark on the left side of her face and a scratch on her left arm, which she reported were caused by the occurrence during the transfer back into the bed, which was rough as the lift barely elevated her to the level of the bed . Resident #14 reported they had told multiple staff of the occurrence, and felt fearful of CNA A transferring her again in the lift. Resident #14 reported she was upset and struggled to disengage with the Surveyor. Resident #14's roommate, Resident #47, was in the room during the interview, and confirmed she witnessed the incident. Resident #47 reported CNA A nearly dropped Resident #14 out of the sling on 4/21/22, and reported she was rough with them during cares. Both Resident #14 and Resident #47 reported the incident happened in the afternoon. During an interview on 4/26/22 at approximately 12:00 p.m., CNA A was noted to be Resident #14's scheduled aide. Resident #14 reported she wanted to get up out of bed in the afternoon for any activity but did not feel comfortable having CNA A transfer her. Resident #14 stated, I don't do transfers with [CNA A] as she almost made me fall and scared me. [CNA A] has a bad hand and can't do everything. Surveyor reported this to Resident #14's nurse and nursing staff. During an interview on 4/26/22 at 1:45 p.m., Both CNA F and CNA T confirmed Resident #14 was currently designated as using a two-person mechanical lift for transfers. Resident #14 refused CNA A's assistance for the full lift transfer. However, then Resident #14 reported to CNA F and CNA T with Surveyor present she was not performing the mechanical lift transfer as she was afraid and would only do a stand pivot transfer. The CNA's explained this was not in her Care Plan, but she insisted due to fear of the sling and lift. The CNA's left the room to get Physical Therapist (PT) U to determine what to do as Resident #14 did want to get up to go to activities. The other two aides were next unavailable, and Resident #14 agreed to a pivot transfer with CNA A and PT U. PT U explained stand pivot transfers were unsafe as Resident #14 had half of their heel missing on one foot, and her knees were partly bent while standing. PT U applied a gait belt to Resident #14, and after removing the wheelchair armrest, with two-staff assistance slid Resident #14 into their wheelchair for a sit pivot transfer. Before the transfer, CNA A required a safety cue by Surveyor to apply gripper socks, with PT U present. PT U soon after reported they could not clear staff two-person transfers with either sit or stand pivot transfers due to safety concerns with staff, and Resident #14 would need to continue with mechanical lift transfers with full body sling due to Resident #14's inability to demonstrate safe pivot transfers and due to lower extremity wounds. On 4/26/22, Resident #14's nurse, Licensed Practical Nurse (LPN) V, reported she was unaware of the incident involving CNA A's unsafe transfer of Resident #14. There was no time for a full skin assessment to be performed as Resident #14 was headed to an activity at 2:00 p.m. An observation of the full mechanical lift on 4/26/22 [obtained by nursing aides for the planned transfer] at approximately 2:00 p.m. revealed the lift showed signs of wear and tear, including paint rubbed off at the top, and 3 metal prongs sticking out of the lift uncovered, which would place the user at risk for a skin tear or injury. Review of Resident #14's fall assessment reports showed no falls in the last 90 days. Review of Resident #14's skin assessment dated [DATE] showed bilateral lower and upper extremity discolorations, as did the skin assessment dated [DATE]. It was noted during review of the Electronic Medical Record (EMR) which showed Resident #14 was transferred to Emergency Department (ED) on 4/14/22 (for hypertension, chest pain). During an interview on 4/26/22 at 5:26 p.m., CNA A was asked about the incident reported by Resident #14. CNA A responded, It might have been that I didn't have the whole sling; it was the half sling; usually I try to grab the whole sling. I don't like the half sling either. CNA A explained, It's [the half sling] fits up higher [near the tailbone], and has long straps. We do use them. I would rather use a whole sling when I put a resident to bed. CNA A acknowledged she was alone (unassisted) during this transfer. CNA A explained when staff do not use a full body sling the resident's bottom hangs out of the sling. CNA A could not give a reason for using the half sling. CNA A denied Resident #14 hit the ground, and said it was a good transfer, then added, No one likes the half sling. Surveyor observed CNA A's hand had two fingers with black Velcro strapping them together at the base [known as a buddy splint]. When surveyor asked about this small finger splint, CNA A reported this hand had a fracture but she was now cleared to go back to work by her physician. When asked why CNA A completed a two-person transfer she said she could not find anyone to assist. She explained staffing limitations were why she transferred residents without a second staff, as often only one staff was available. CNA A and LPN V were earlier asked if CNA A's total mechanical lift transfers could be observed by them with two-person assistance, and no opportunities were provided. During an interview on 4/26/22 at approximately 6:00 p.m., LPN G (Resident #14's afternoon nurse) was asked if they were aware of the incident Resident #14 described regarding CNA A's unsafe transfers with the lift, and denied any awareness. On 4/27/22 at 9:38 a.m., the Director of Nursing (DON), the Assistant DON (ADON), and the Nursing Home Administrator (NHA) were asked if they were aware of any incidents involving Resident #14 and CNA A related to falls, accidents, and the mechanical lift, and all denied any awareness. During an interview on 4/27/22 at 9:15 a.m., Resident #14 reported she was afraid of staff using the lift to transfer her. She showed her left heel injury from an old wound on her left foot, and she did not want any more injuries. Resident #14 said this was sad for her as she did want to get up and go to afternoon activities. Resident #47 During a follow-up interview with Resident #47 on 4/27/22 at 9:47 a.m., Resident #47 corroborated the incident occurred last Thursday afternoon, on 4/21/22. Resident #47 reported, You're supposed to be sitting there [in the sling] and these strap things were behind; [Resident #14] was falling down in the air and I saw her go way down [to the ground] and she was so low .she kept hitting the cabinet and dresser drawers. [Resident #14] was swinging and touched the dresser drawer [with her feet], and [Resident #14] was slipping. Then [CNA A] put her on the bed real hard on part of her face and her shoulder. [CNA A] is always in a hurry. Two people [staff] are supposed to be there [with the mechanical lift transfers]. Resident #47 next described how CNA A was changing her recently and after CNA A was done, she set her down hard on the bed, and flung the hard plastic call button at her. Resident #47 added, I just think [CNA A] could be more careful. [CNA A] is too rough. You talk to her and [CNA A] doesn't respond to what you're saying. [CNA A] got real nasty with [Resident #14] and said, I know you know how to do it [the transfer]. [Resident #14] had anxiety and was panicking and scared she was going to fall. [Resident #14] wasn't positioned on their [sling] right. Resident #47 reported LPN X, their afternoon/night nurse, was aware of the incident, and reported the incident concerned them. During an interview on 4/27/22 at approximately 10:05 a.m., LPN D (Resident #14's LPN) was asked about the incident with the lift. LPN D confirmed the staff in the facility knew about the concern, and they were aware the transfer with Resident #14 and CNA A (from the wheelchair to the bed with the mechanical lift) didn't go well. LPN D confirmed there was no change in staff or any intervention to address when Resident #14's confirmed fearfulness was mentioned. LPN D reported regarding the lifts, Normally you would have to have two people to do the transfer. During an observation on 4/27/22 at approximatey 11:45 a.m., Resident #14 was heard telling staff she was not getting up out of bed with the mechanical lift. A nursing staff schedule was requested and received from nursing management staff for 4/21/22. The afternoon/night shift nurse, LPN X, who worked on the 400 hall on 4/21/22, was unable to be reached on 4/27/22 at 10:13 a.m A confidential voicemail was left; the call was not returned by the end of the survey. During an observation on 4/27/22 at 12:43 p.m., Resident #14 agreed to a skin assessment (skin sweep), with LPN D completing the sweep, with private areas covered. Surveyor and LPN D observed no bruising to Resident #14 other than some discoloration to the dorsum of both hands. LPN D determined the left hand bruising was likely from a blood draw, and the right hand bruises (two bruises a 1 and a 2 on the dorsum of the hand) were concerning, as well as Resident #14's report of the incident involving CNA A to LPN D during the skin sweep. LPN D stated, I will call my DON right away. During an interview on 4/27/22 at 1:43 p.m., the Central Supply manager, Staff W reported they were responsible for ordering slings. Surveyor had asked for management to interview a facility staff knowledgeable of facility slings and fitting. When Surveyor asked if Staff W was qualified and knowledgeable about the slings and fitting, Staff W reported the facility management had asked them to come speak with the surveyor about the slings, and did not give any qualifications. Staff W reported most full body lift slings in the building are whole but a few are half. They reported a full body sling was better for a bigger, taller resident per their understanding. Review of Resident #14's Care Plan, accessed 4/27/22, revealed the type or size of sling was not designated, only the level of assist. This Care Plan showed Resident #14 required a mechanical lift x 2 person assistance. During an interview on 4/27/22 at 2:16 p.m., PT U confirmed the Care Plan did not designate the sling type, only the level of assistance. During a phone interview on 4/27/22 at 2:35 p.m., CNA C confirmed they were Resident #14's aide on 4/21/22. When asked about any incident with Resident #14, CNA C reported they (CNA C and CNA A)went in to talk with Resident #14, who stated, [CNA A] was putting me back to bed and I almost fell out of the sling; she dragged me out of the chair. CNA C reported she had seen CNA A lift residents on many occasions not high enough, so their (residents] bottom drags across the chair wheelchair. CNA C confirmed the CNAs were always supposed to have two person assistance with a mechanical lift, but CNA A would do everything by herself including transfers. CNA C stated, I would never put [Resident #14] in a half sling because she can't she move her legs very well .and no way would use a half sling . CNA C reported this was due to Resident #14's taller height and size. When asked about any other incidents involving CNA A harming a resident, CNA C reported CNA A transferred a resident incorrectly, resulting in a shoulder fracture for Resident #335. Review of the [brand name] patient sling owner's manual, provided via email by the DON, revealed a two-person attendant was required for all types of slings, including full body and wrap-around [divided leg/half slings]. The [brand name] sling sizing chart showed the size/weight designations are merely estimates and basic guidelines, and a proper fit would depend on factors other than weight measurements, including the height and weight of a patient. A proper fit will involve the judgment of the caregiver, per this manual. Review of the policy, Investigating and Reporting of Accidents & Incidents, dated 10/30/20, revealed, All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises must be investigated and reported to the Administrator. Policy Explanation and Compliance Guidelines: Regardless of how minor an accident or incident might be, including injuries of unknown source, it must be reported to the department supervisor as soon as such an accident/incident is discovered, or when information of such as incident is learned .A report must be completed. An employee witnessing an accident or incident involving a resident .must report each occurrence to his immediate supervisor .The nurse supervisor/charge nurse must be immediately informed so medical attention can be provided. The nurse supervisor/charge nurse will immediately report to the DON and Administrator . During a survey team interview with the DON at approximately 4:00 p.m. the DON reported they were working on their own investigation after learning of the incident involving Resident #14 and CNA A from the Surveyor today. The DON acknowledged the incident Resident #14 reported involving CNA A and incorrect transfers occurred with one-person assistance, but denied any injury. A follow up phone call was made to CNA A at 4:07 p.m.; a confidential voicemail was left, with no call returned by the end of the survey. Resident #335 Review of Resident #335's MDS assessment dated [DATE] revealed admission on 11/13/20, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Neither pain nor falls was noted on these assessments. The assessment showed Resident #335 was able to feed herself with set up, and required two-person assistance for transfers and toileting, and one-person assistance for bed mobility and dressing. The BIMS revealed a score of 8/15, which showed Resident #335 had moderate cognitive impairment. Resident #335 has been discharged from the facility. During a phone interview on 4/27/22 at 2:45 p.m., Certified Nurse Aide (CNA) C confirmed CNA A had injured Resident #335 during a transfer (moving a resident from one surface to another), resulting in a shoulder fracture for Resident #335. CNA C described she and another aide were working across the hall, and offered to assist CNA A with Resident #335's transfer. Soon after, CNA C reported she was walking up from the opposite hall and heard [Resident #335] screaming. CNA C reported she observed CNA A come out of Resident #335's room and said, She always screams. CNA C discovered CNA A had transferred Resident #335 alone, which was not Care Planned. CNA C reported CNA A was off work the following three days for an investigation, and then returned to work. CNA C reported she and other staff had reported concerns about CNA A's work performance to management, including regarding this incident. Review of Resident #335's progress note, dated 6/29/21 at 7:12 p.m., revealed, Writer [unnamed] was informed by midnight nurse staff [unnamed] that resident's [#355's] lt [left] shoulder is swollen and sore. This was noted at resident's first check and change of shift. Resident is guarding her shoulder, and c/o [complains of] pain when touched. Resident refusing to allow arm to be moved . with an urgent x-ray ordered. Review of Resident #335's Accident and Incident report, dated 6/29/21 at 2:00 a.m., received per request from the DON on 4/27/22, revealed, Noted swelling to left shoulder and left upper arm. Res [Resident #335] unable to verbalize how arm/shoulder injury occurred. X-ray for left shoulder and left humerus is obtained STAT [urgently] . Review of Resident #335's Radiology Report [by an area Imaging Company], dated 6/29/21 at 2:41:59 p.m., [about 12 hours later] revealed, There is a fracture [break] of the proximal [upper arm] left humerus [at the shoulder]. There is mild displacement of the distal (lower humerus at the elbow] fragment .Conclusion: There is a fracture as described above. The lack of callus formulation [cartilage or bone formation] suggests that the fracture is recent . Review of Resident #335's Activities of Daily Living (ADL) Care Plan, cancelled 8/31/21 (resident discharged to hospital Emergency Department), revealed since upon admission 6/16/2020 due to her stoke, Resident #335 required, TRANSFER: The resident requires x 2 [person] assist. This level of assistance did not change during the course of Resident #335's stay per review of their Care Plan. Review of Certified Nurse Aides (CNA) A Witness Statement Form, dated 6/29/21, revealed, Date of Incident: 6/29/21 .About 3 - 3:30 p.m. I got [Resident #335] out of bed with a gait belt so [Maintenance Director B] could fix the bed remote on her bed. Got [Resident #335] out of bed by a gait belt and pivoted her to the chair by her pants and gait belt and she [Resident #335] did fine. [Resident #335] was not complaining of any pain while transferring her from the bed to the chair. And while I was changing her throughout the night she did not complain of any pain . Then to the side of form was added, [Resident #335] put her arms around my neck [during the transfer]. Signed by CNA A. A second witness statement by CNA A dated 6/29/21 (no time) revealed, I [CNA A] was changing [incontinence brief] [Resident #335] during my shift, rolling her on her left side, she [Resident #335] did her normal yelling at first changing her. The last time I changed her she was screaming a bit more than usual [word stuck out] and said she was o.k. Signed by CNA A. Review of a witness statement dated 6/29/21 by a former Assistant Director of Nursing (ADON), dated 6/29/21, revealed: Interview with [Resident #335] @ 1644 [4:44 p.m.] 6/29/21: [former social worker] present. [Resident #335] is A [alert] + O[oriented] x 2 [in two spheres, such as name and time]. No complaints of pain or problems. When directly asked if her left arm hurt, she [Resident #335] stated, My arm hurts when I try to move it. [Resident #335] has no recollection of when the pain started . Review of Resident #335's physician note, dated 7/06/21 at 7:37 [a.m.] revealed, Patient with swelling left upper extremity, recent left humeral [shoulder] fracture. Nursing did provide the patient with her pain medication. She also has swelling which is due to dependent [CONDITION(S)] [swelling] and the fracture. Patient's arm is elevated on the pillow. Encourage elevation and compliance with her sling. Patient will require continued monitoring for pain control and swelling and improvement in her bruising. Patient requires 24 hour assistance with all ADLs (activities of daily living) . During an interview with the DON and surveyor team on 4/27/22 at 5:51 p.m., the DON followed up on earlier team inquiry pertaining to CNA C's reporting of CNA A improperly transferring Resident #335. The DON brought documentation to confirm the reported incident was internally investigated. The DON reported CNA A did get written up for using the improper method of transfers by having a resident's arms around their neck, which could cause a dislocation. Surveyor brought up concern with Resident #335 requiring two-person assistance and CNA A using one-person assistance, which was acknowledged by the DON. The DON explained CNA A would not be returning to work. Review of other employee witness statements, provided by the DON per request on 4/27/22 (from 6/29/22), revealed there was no witness statement by CNA C. Review of the disciplinary actions for CNA A by the Director of Nursing (DON) on 4/27/22 included: - 7/23/20: Called the scheduler an inappropriate name. professionalism. - 2/21/21: Refused mandating (to work over) when required. - 7/02/21: Failing to use the Kardex, and follow the resident's care plan. - 3/09/22: Using obscene, inappropriate, abusive, or threatening language. - 4/05/22: Improve communication. - 4/30/22: Refused mandating. Violation insubordination. Review of CNA A's competencies showed competency checked for mechanical lifts on 6/08/22, however there was nothing marked on the competency sheet marked for transfers and mobility (manual/pivot functional sit or stand transfers). A functional transfer policy was requested from the DON on 4/27/22, and was not received by the end of survey.

Based on observation, interview, and record review, the facility failed to properly cool potentially hazardous food items, failed to maintain the dry storage room and a wall mounted fan in the dish machine room in a sanitary manner, and failed to store wiping cloths in a chemical sanitizer solution, resulting in the increased potential for foodborne illness and cross contamination. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 4/25/22 between 12:20-1:10 PM, during an initial tour of the kitchen with District Manager P, the following items were observed: In the walk-in cooler, there was a container of marinara sauce dated 4/18-4/24. In addition, there was a container of puree eggs dated 4/25 and a container of sausage gravy dated 4/25. Both containers were tightly covered with a plastic lid, and the outside of the containers were warm to the touch. The internal temperature of the puree eggs was measured (at 12:30 PM) to be 72 degrees Fahrenheit, and the internal temperature of the sausage gravy was 104 degrees Fahrenheit. When queried, District Manager P stated, I'll have to check if they are on the cooling log. Review of the cooling log revealed the following: Puree Eggs- 9:00 AM 155 degrees Fahrenheit, 11:00 AM 69 degrees Fahrenheit. Sausage Gravy- 9:00 AM 155 degrees Fahrenheit, 11:00 AM 69 degrees Fahrenheit. It was noted on the cooling log, that the 2 hour temperature must be below 70. According to the 2013 FDA Food Code section 3-501.14 Cooling, (A) Cooked POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less. In the dish machine room, there was a large, wall mounted fan blowing air towards the clean side of the dish machine. Once the fan was turned off, it was noted that the fan blades and the outer caging were coated with dust. District Manager P confirmed the dusty fan, but provided no explanation. According to the 2013 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The stainless steel cart holding the microwave and toaster, was observed with clean bowls and food strainers stored on the shelving underneath. There was a buildup of crumbs and food debris on the shelving around the clean dishware. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. There were wet wiping cloths observed stored on the counter at the food preparation area, and on the soiled drainboard of the 3 compartment sink. According to the 2013 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; In the dry storage room, the flooring was observed with onion skins scattered about, dead bugs, a buildup of grime in the corners and along the baseboards, and brown colored stains on the floor. There were cobwebs underneath the racks, and in the window well. According to the 2013 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.

Based on observation, interview and record review, the facility failed to provide a dignified care environment by ensuring call lights were available and answered timely for six Residents (#11, #15, #28, #46, #286 and #78) of six Residents reviewed for dignity. This deficient practice resulted in the potential for feelings of helplessness and humiliation. Findings include: Resident #11 A review of Resident #11's most recent Minimum Data Set (MDS) Assessment, dated [DATE], revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #11's MDS Assessment revealed Resident #11 required extensive, two-person assistance with bed mobility, transfers and toilet use. Resident #11 scored 14 out of 15 (,d+[DATE]) on the Brief Interview for Mental Status (BIMS), indicating Resident #11 had intact cognition. An observation on [DATE] at 1:57 p.m., revealed Resident #11 sleeping in bed. Resident #11's call light cord was observed to be wrapped around the right upper grab bar of the bed with the call light cord hanging down with the red bulb out of Resident #11's sight and reach. Further observation revealed the call light cord was not attached to the activation mechanism on the wall behind Resident #11's bed. There was no manual call bell in Resident #11's room at the time of the observation. An observation on [DATE] at 9:43 a.m., revealed Resident #11 sleeping in bed. Resident #11 was shifted to the right side of the bed with his right upper extremity and right lower extremity resting on the right edge of his bed with approximately 20 inches of space between the Resident and the left edge of the bed. Resident #11's call light cord was wrapped around the right upper grab bar of the bed with the red bulb hanging down the side of the bed, out of the Resident's sight and reach. Further observation revealed the call light cord was detached from the activation mechanism located on the wall behind Resident #11's bed. During an interview on [DATE] at 2:10 p.m., Resident #11 reported he was unable to shift positions in bed without staff assistance. Resident #11 stated he often shifted to the right side of the bed and felt as though he was sitting in a hole and was uncomfortable. When asked how he called for staff assistance to reposition, Resident #11 pointed to the call light cord now observed to be wrapped around the right upper grab bar of the bed with the red bulb resting on the Resident's bed, within the Residents sight and reach. Resident #11 reported being provided the call light earlier that afternoon. Further observation revealed the call light cord was attached to the activation mechanism located on the wall behind Resident #11's bed. Resident #11 reported being provided the call light earlier that afternoon but had not had the call light available for days. Resident #11 stated prior to being provided the call light earlier that morning, the only means he had to call for assistance was to yell out for help or wait for staff to check on him. A review of Resident #11's care plan revealed the following, in part: The resident is at risk for falls (related to) balance deficits post [CONDITION(S)] (stroke). Date Initiated: [DATE] . Interventions: Be sure resident's call light is within reach and encourage the resident to use if for assistance when needed. Date Initiated: [DATE]. During an interview on [DATE] at 3:32 p.m., the Director of Nursing (DON) stated staff should be ensuring call lights or manual call bells were working and withing resident's sight and reach prior to exiting resident's rooms after care. The DON confirmed residents should not be expected to have to wait to ask for assistance or yell out for help. Resident #15 A review of Resident #15's most recent MDS Assessment, dated [DATE], revealed an admitted [DATE]. Further review of Resident #15's MDS Assessment revealed Resident #15 required supervision with bed mobility, transfers and toileting. Resident #15 scored 15 out of 15 (,d+[DATE]) on the BIMS, indicating Resident #15 had fully intact cognition. An observation on [DATE] at 1:12 p.m., revealed Resident #15 sitting on the right-side edge of her bed. Resident #15's call light was observed hanging from the wall behind the left side of the Resident's bed and nightstand. When asked how she called for assistance, Resident #15 reported when needing assistance, she had to walk to the hallway to seek staff to help. When asked why she did not use the call light, Resident #15 stated she could not reach the call light cord. Resident #15 reported the call light, didn't work anyway. Resident #15 stated she had been told by staff on the evening shift, the call light did not work. Resident #15 reported she did not have a manual call bell to ask for assistance, I used to have a bell, but they took it. On [DATE] at 2:26 p.m., Resident #15 was heard yelling out, hey, from her room. Three staff members were observed to be standing at the end of the hallway near the nurse server but did not respond to the Resident's call for assistance. Upon entering Resident #15's room, the resident was observed to be sitting on the right-side edge of her bed. Further observation revealed the Resident's call light hanging from the wall behind the left side of the Resident's bed and nightstand, out of Resident #15's reach. On [DATE] at 2:36 p.m., Certified Nurse Aide (CNA) F was alerted to Resident #15's call for assistance by this Surveyor. Upon entering Resident #15's room, CNA F was asked to check the functioning of Resident #15's call light. CNA F was observed attempting to reach between the Resident's bed and nightstand to reach Resident #15's call light cord. CNA F moved the nightstand toward the wall, away from Resident #15's bed and stepped behind the nightstand and the bed to retrieve the call light. After activating the call light, CNA F checked the pager in her pocket and informed the Resident #15 the call light was functioning. In an interview immediately following the observation, CNA F stated call lights should always be within Resident's reach. CNA F reported if the Resident's light had not been functioning, Resident #15 should have been provided with a manual call bell. CNA F confirmed Resident #15 did not have a manual call bell. A review of Resident #15's care plan revealed the following, in part: The resident is at risk for falls (related to) confusion, gait/balance problems, pain and psych medications. Date Initiated: [DATE]. Interventions: Be sure resident's call light is within reach and encourage resident to use it for assistance as needed. Date Initiated: [DATE]. A review of the facility policy titled, Call Lights: Accessibility and Timely Response, dated [DATE], revealed the following, in part: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside . to allow residents to call for assistance . 5. 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 . (Examples include replace call light, provide a bell or whistle . Resident #28 Review of Resident #28's MDS assessment dated [DATE] revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment showed Resident #28 required two-person assistance with transfers and toileting, and was incontinent of bladder and bowel. The BIMS assessment revealed a score of ,d+[DATE], which indicated Resident #28 had moderate cognitive impairment. During an interview on [DATE] at 10:54 a.m., Resident #28 reported she was left on the commode frequently for extended periods of time, over one hour recently to use the commode, and eight hours one weekend when she was sitting in diarrhea. She reported this caused her to feel upset and uncomfortable, and her bottom had become sore as this had occurred on several occasions. Resident #46 Review of Resident #46's MDS assessment dated [DATE] revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment showed Resident #46 required two-person assistance with transfers and toileting, and was incontinent of bladder and bowel. The BIMS assessment revealed a score of ,d+[DATE], which indicated Resident #46 was cognitively intact. During an interview on [DATE] at 8:46 a.m., Resident #46 reported she waited up to an hour and a half in the afternoons for assistance with toileting needs. She explained on one occasion she waited so long for an aide she became short with them in her response, and the aide stated, You better stop or I'm not taking care of you. When asked when this occurred, Resident #46 stated the extended call wait times continued to occur on the afternoon shift. Resident #286 Review of Resident #286's MDS assessment revealed an admission of [DATE]. The assessment was not completed. Resident #286 was interviewable and oriented to herself, time, and her situation and surroundings. Resident #286 reported she was blind in her right eye, and had very limited vision in her left eye. During an interview on [DATE] at 3:22 p.m., Resident #286 reported she had waited for the call light or was left on the commode for extended periods of time, up to 45 minutes, which she reported bothered her and scared her due to her poor vision. Resident #286 also reported staff seemed hurried and were not gentle with her, and had told her facility physician about her concerns. During an interview on [DATE] at approximately 11:02 a.m., Resident #286 was asked how she can tell time, and reported her cell phone can tell her the time. Resident #286 demonstrated pushing the large home button on her cell phone by feeling the button, which was programmed via voice commands to tell her the time. Surveyor heard the phone speaker give the correct time to Resident #286, which she was able to repeat. Resident #286 reported she had her phone available on her person at all times. Resident #286 mentioned on another occasion after she had waited for the toilet about 45 minutes, and then waited on the commode an extended period. Resident #286 reported afterwards she was placed in the hallway instead of her room per her preference. Resident #286 stated this made her feel anxious, as the facility surroundings were not familiar yet, and she was most comfortable in her room due to her low vision/[CONDITION(S)] Resident #78 On [DATE] at 8:53 a.m., Resident #78 indicated he had a recent fall which required going to an acute care hospital for further evaluation. During this interview, an hand call bell was observed sitting on a dresser. The call light cord was also observed out of reach and dangling on the opposite side of the bed. A floor mat was observed in place obstructing the ability of Resident #78's ability to get to the call light cord. Resident #78 was sitting up in his wheelchair at the time of this interview. Resident #78 was not eating a meal at the time of the interview. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief interview for Mental Status (BIMS) score of 14 indicating cognition was intact. On [DATE] at 1:00 p.m., during an interview, CNA N stated Resident #78 does use the call light at times and calls out at other times. When asked about the location of the hand bell and if it would be a problem, CNA N agreed the hand call bell should not have been out of reach of the resident. CNA N also stated there was a new intervention in the care plan to have Resident #78 out in the common areas during the day when he is not eating meals in his room. This Surveyor indicated to CNA N Resident #78 was in his room at the time of the observation and he was not eating a meal. CNA N agreed Resident #78 should have been out in the common area then as part of the care plan change for his safety regarding falls. On [DATE] at 3:34 p.m., during an interview, the Director of Nursing (DON) stated the expectation was call lights and call bells should be in reach before leaving the resident. [DATE] 10:29 IDT-Interdisciplinary Progress Note Late Entry: . Resident (#78) attempyted (sic) to self transfer at approx (approximately) 0110 (1:10 a.m.), resident (#78) was on edge of bed and fell on to floor while nurse was at sink. Resdient (sic [#78]) did hit head,left side with lump noted. Resident (#78) c/o (complained of) pain tol (sic 'to') eft (side 'left') [NAME] (sic 'side'), neuro(neurological) asessment (sic) complted (sic). BP (Blood Pressure) elevated ,d+[DATE], team health notified, new order to send to ER (emergency room )for eval (evaluation) r/t (related to) fall . Fall score 22, care plan intervntions (sic) in place to prevent major injury, new care plan intervention to contact guard asssit (sic) while at edge of bed before transfer. Resdient (sic [#78]) has a BIMS score of 14 and able to be educate on safe transfers. resident (#78) impulivse (sic) with transfers, will continue to provide safety education and remind resident (#78) to wait for assistance.

This citation is based on intake # MI 589. Based on observation, interview and record review, the facility failed to prevent an elopement, respond to an alarming door timely, secure a window, perform a thorough missing resident search, provide adequate supervision, and notify authorities timely for one sampled Resident (Resident #704) of three residents reviewed for elopement risks, resulting in an Immediate Jeopardy when Resident #704 exited the facility through an unsecured window, was found outdoors in inclement weather several hours later, deceased in a field approximately ,d+[DATE] mile away from the facility pulseless without breath sounds. Findings include: A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #704 was admitted to the facility on [DATE] with the diagnoses of Cerebral Infarction and Dementia. Resident #704 had a Brief Interview for Mental Status (BIMS) score of 10, indicating an impaired cognition. The MDS also indicated Resident #704, had the behavior of wandering being present ,d+[DATE] days per week that impacts significant risk of getting to a potentially dangerous place, and needed limited assistance with walking. A record review of the Progress Notes for Resident #704 revealed the following: [DATE] 2:24 (AM) Nurses' Notes .Resident is Alert to self. Writer spoke with daughter she states '[Resident #704] is very confused .needs someone to sit at .bedside 24 hours around the clock.'. Daughter also raised concern that she don't (sic) know how we could handle (Resident #704's) safety here with no sitters, and if .falls and breaks a bone we can expect a lawsuit. Writer has observer (sic) .walking up hallway several times, resident has poor safety judgement. Safety maintained at this time. Aide is sitting in hallway with resident at this time. [DATE] 18:40 (06:40 PM) Nurses' Note .Writer observed resident exiting 200 hall door. Alerted staff to help with retrieving resident back in facility. V/S (vital signs) stable with no visible injuries noted. Resident pleasant and easily redirected. MD (Medical Doctor) notified. [DATE] 14:05 (02:05 PM) Nurses' Notes .Spoke with daughter in regards to room move to, family agrees in room move to a unti (unit) that would be a better fit due to location facility [DATE] 12:17 (PM) .IDT (Interdisciplinary Team) Progress Note .Reviewed incident with the IDT concluded residnt (sic) was in line of vision during exit seeking behavior, no injuires noted, easily redirected. Process was followed upon admission with intervention in place applying wandergurd for risk of elopement. Door sounded, staff approached resident and redirected into building. Care plan updated, acvtiivites (sic) to assess for further need to distract resident from exit seeking bahavior (sic) Staff educated on particular verbiage resident uses that may possibly lead to increased wandering. 15 minute checks initated (sic) and room move occurred to increase monitoring of resident. [DATE] 08:24 (AM) .Physician Progress Note .I discussed .care with the administrator today. The administrator stated she would call a sister facility with a dementia unit today and inquire about a transfer. I told her I would be willing to make phone calls as well and to let me know if she needs my assistance . [DATE] 02:31 (AM) Nurses' Notes .Resident was in room at approximately 2230, attempted to give medication, resident refused. Writer informed resident that I would be back in a few minutes. Heard door alarm sound and responded to alarm. Area was searched inside and outside immediate area. Census was complete. Resident not found in room, unit, and facility grounds search. Administrator, DON, physician, and police notified. RP (Responsible Party) was called x3 a message was left to call facility as soon as message is heard. No response from RP at this time. Resident missing and search continues. Authored by Licensed Practical Nurse (LPN) C. [DATE] 05:04 (AM) Nursing Home Administrator (NHA) Note .Late entry residents daughter .called back to the facility from message left by earlier by the nurse. The daughter stated, '(Resident #704) pulled one of (their) Houdini acts and got out.' I explained to the daughter that the resident set off an alarm at approximately 10:58 p.m. The police were notified to assist in the search in and outside the facility. The police notified us that at approximately 3:27 a.m. (Resident #704) was found north of the facility. I informed her that I know EMS (Emergency Medical Services) was responding to the call but I do not know the disposition of the resident. The daughter stated, '(Resident #704) is deceased .' I told her 'I was so sorry for her loss.' I asked her if she had any questions. The daughter stated, 'No, I have no questions.' I also gave her the name and the number of the officer who took the initial report . On [DATE] at 11:53 AM, a walk-through of the 600 hallway, where Resident #704 had exited, revealed a fire door at the end of the hall that was alarmed with a 15 second door release bar. There was no wander guard alarm observed on that door. Room 610 was observed to be occupied with a new resident, and there was a large window in the room that lead to an unfenced area outside to the public. On [DATE] at 12:27 PM, the NH was interviewed in regard to what happened on the night of [DATE] with Resident #704. The NHA stated, I got the call from staff that [Resident #704] had gotten out, I immediately told the staff to call 911 and continue looking. (Resident #704) ended up going in a room after setting of the door alarm and got out through the window. It was the only room with plexiglass in it (instead of a screen). We had to take it out because the prior family was sneaking in alcohol to the resident that was in there. The NHA explained that the Resident was found several hours later in the field across the street from the building. I tried seeking other sister facilities help with a locked unit, (Resident #704) just needed a secure unit. Our unit (Dementia Unit) has a fire door in it, so that wouldn't have worked. The aide that was on the unit had to go to the front door to let the ambulance in for a different resident (at the time that Resident #704 was wandering down the 600 hall). On [DATE] at 12:42 PM, a review of the camera footage from [DATE] with the NHA revealed the following: 10:26 PM-Resident #704 observed walking down the hallway with no staff in sight, wearing a long-sleeved shirt, pants and socks. The Resident walked to the end of the 600 hallway to the fire door and presses the 15 second release handle. At that time, the NHA stated, See the light blinking (noted on the camera footage), that means the door is sounding. As the door lever was pushed, the Resident was seen looking towards the opposite end of the hallway, then moved away from the door, and then came back and pushed the door handle again (light seen blinking). 10:28 PM-Resident #704 entered room 610 and was not seen to come back out of that room after entering. 10:42 PM-Staff respond to alarming door. On [DATE] at 1:02 PM, Sergeant A (who responded to the 911 call) was interviewed via telephone. Sergeant A explained that there was an ongoing investigation and they responded to the 911 call from the facility and searched for the resident with a K9 unit. Hours later, the Resident was found in a field. Sergeant A was asked of the condition or Resident #704 when found, but was unable to state the medical condition. Sergeant A was asked about the clothing the Resident #704 was wearing when found and stated, I know that (Resident #704) was dressed but not for the weather, it was about 32 degrees (Fahrenheit) out. On [DATE] at 1:16 PM, Fire Chief B was attempted to be interviewed via telephone but was unable to disclose any information at the time. A request for the EMS (Emergency Medical Service) run reports was made. Record review of the care plan for Resident #704 revealed the following: Problem-The resident is an elopement risk/a wanderer/wants to go home r/t (related to) Disease process dementia, disoriented to place. Date Initiated: [DATE]. Focus-Discourage excessive napping during daytime hours Date Initiated: [DATE] Interventions-Encourage decreased intake of caffeine products during evening hours Date Initiated: [DATE] Identify pattern of wandering. (e.g., Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise?) Intervene as appropriate. Date Initiated: [DATE] Maintain consistent daily routine and consistent bedtime routine Date Initiated: [DATE] Monitor location every 15 min when displaying behaviors of wandering or ambulating up in hall, Document wandering behavior and attempted diversional interventions. Date Initiated: [DATE] Observe for acute process which may increase wandering Date Initiated: [DATE] WANDER ALERT: to right ankle Device # Model Date Initiated: [DATE] A review of the EMS run report dated [DATE] for Resident #704 revealed the following: Primary Complication: Cardiac .Secondary Complication: Hypothermia. Initial patient acuity-critical. Final patient acuity-critical. CPR (Cardio pulmonary resuscitation) Patient Response: Unchanged 03:31 ALS (Advanced Life Support) Assessment Patient Response: Unchanged 03:36 3-Lead ECG (Electrocardiogram) Patient Response: Unchanged 03:36 Warming Comments: blankets also applied; Patient Response: Unchanged 03:37 Oxygen Device: Bag Valve Mask (BVM); Flow Rate: 25 lpm (liters per minutes); Patient Response: Unchanged 03:41 IV (intravenous) Therapy 18 ga (gauge); Antecubital-Left; Normal Saline (.9% NaCl); Total Fluid: 50 ml (milliliter); Patient Response: Unchanged 03:43 Orotracheal Intubation 7.0; Placed At 23cm; Placement Verification: Auscultation, Chest Rise .Condensation in Tube, Airway Complications: None Patient Response: Unchanged 03:46 [MEDICATION(S)] 1:10 1 Milligrams (mg); Intravenous (IV); Patient Response: Unchanged; Complication: None 03:51 [MEDICATION(S)] 1:10 1 Milligrams (mg); Intravenous (IV); Patient Response: Unchanged; Complication: None 03:56 [MEDICATION(S)] 1:10 1 Milligrams (mg); Intravenous (IV); Patient Response: Unchanged; Complication: None 04:01 [MEDICATION(S)] 1:10 1 Milligrams (mg); Intravenous (IV); Patient Response: Unchanged; Complication: None 04:06 [MEDICATION(S)] 1:10 1 Milligrams (mg); Intravenous (IV); Patient Response: Unchanged Mental Status Unresponsive .Skin Cold .Cyanotic .Pale .Chest Lung Sounds .Breath Sounds - Absent A1 DISPATCHED VIA 911 FOR . (Resident #704) WHO WALKED OUT OF [Facility] AND IS MISSING. ARRIVE ON LOCATION, PD (police department) WITH CANINE UNITS HAVE BEEN SEARCHING .SINCE AROUND 2300 (11:00 PM) HRS (hours) WITH NO SUCCESS. PT (patient) APPARENTLY BROKE OUT A WINDOW AND HAS BEEN MISSING SINCE BETWEEN ,d+[DATE] (10:00 PM-11:00 PM) HRS. STAFF STATES PT HAS DEMENTIA, IS ABLE TO WALK ON .OWN BUT NOT VERY WELL AND IS AROUND 5'6 115 LBS (pounds). AROUND 0325 PT IS LOCATED BY A SEARCH PARTY APROX ,d+[DATE] MILE AWAY FROM [facility] IN AN OPEN FIELD, RESCUERS NOTIFY EMS OF A CARDIAC ARREST. EMS ARRIVES AT PT VIA ATV (all-terrain vehicle), PT IS PULSELESS AND APNEIC AND COLD TO THE TOUCH. COMPRESSIONS ARE CONTINUED AND PT IS SECURED TO BACKBOARD AND MOVED VIA ATV TO STRETCHER AND INTO AMBULANCE. CPR IS CONTINUED VIA [NAME] DEVICE AND A BVM. MONITOR SHOWS ASYSTOLE AND IV IS ESTABLISHED. PT IS INTUBATED WITH A SIZE 7.0 ET (endotracheal) TUBE AT 23 CM (centimeters), CONFIRMATION WITH BILATERAL LS (lung sounds), CONDENSATION IN THE TUBE, AND CHEST RISE .PT IS STRIPPED OF HIS COLD WET CLOTHES, WARMING OF THE PATIENT IS INITIATED WITH HOT PACKS IN THE GROIN AND UNDER THE ARMS AND MULTIPLE BLANKETS ARE APPLIED. UNABLE TO OBTAIN RECTAL OR AXILLARY TEMP, UNKNOWN IF PT IS TOO COLD OR DEVICE MALFUNCTION. PT IS GIVEN 5 ROUNDS OF 1MG (milligram) OF ,d+[DATE] EPI ([MEDICATION(S)]) THROUGHOUT TRANSPORT 5 MIN APART WITH NO CHANGE. PT REMAINS ASYSTOLE VIA 3 LEAD AND CPR IS CONTINUED. PT IS A DIABETIC BGL (blood glucose) IS AT 418. ACLS PROTOCOLS ARE CONTINUED, [Hospital] IS CONTACTED WITH NO FURTHER INSTRUCTIONS AND PT IS TRANSPORTED WITH NO CHANGE. Cardiac Arrest Yes, Prior to EMS Arrival Prearrival CPR Instructions No In Field Pronouncement Cardiac Arrest Etiology Cardiac (Presumed) First Defibrillated By Not Applicable Expired No (under In Field Pronouncement) Estimated Time of Arrest >20 Minutes Est Time Collapse to 911 180 Minutes Initial ECG Rhythm Asystole Est Time Collapse to CPR 180 Minutes Rhythm at Destination Asystole Arrest Witnessed By Not Witnessed Hypothermia No CPR Initiated By First Responder End of Event Expired in ED Time 1st CPR 03:26 [DATE] .Resuscitation Discontinued 04:08 [DATE]. On [DATE] at 12:50 PM, an interview was completed with LPN C, who was in charge of Resident #704 on the night of [DATE] through the morning of [DATE]. LPN C explained that Resident #704 was pleasantly confused and refused to take their medications that night. LPN C began to cry and stated, I even told (Resident #704) that I would be back to try to get them to take their medications and they took my hand and kissed it. LPN C further explained that she was passing medications to other residents down a different hall and did not see the Resident wander off. LPN C stated, We (with Certified Nurse Aide D) got to the 600 hall and heard the door alarm going off. We immediately opened the door and did a quick look around. Then we started looking around and found that [Resident #704] was not in their room. Around eleven I called the Administrator and she told me to call the police and keep looking. I did that, the police came, and they told us to stop looking outside because it would mess up the K9 unit scents for the dogs. The police kept telling us that usually the resident is found in another resident's bed. I feel like we wasted all that time looking inside when we should have been looking outside. LPN C was asked when was the method discovered of how Resident #704 got out (that would have alerted staff right away that the Resident was outside)? LPN C revealed, there was a resident in there that was quiet and sleeping. To be honest, we didn't realize the window was open until we turned the light on (later during the search) in the room and then we seen (sic) the window was open. LPN C was interviewed in regard to the lapse of time it took to investigate the sounding door alarm and stated, I don't know, I went down the hallway (600) with the aide and it was sounding. Once I heard it, I started looking for any missing residents. A review of the Elopement Drill dated [DATE] initiated by LPN C revealed the following information: .Comments from Observers: Screen on ,d+[DATE] pushed out. All areas searched inside and out the facility. Nursing management called .instructed to call police .police arrived, met at road by [LPN C]. A record review of CNA D's statement revealed the following: Was notified of code yellow immediately went room to room accounting for residents. Identified what Resident was missing and then went outside around the whole building and checked the old building room to room. Administrator notified and police. Came in at 10 (11:00 pm?) started doing 600 rounds and ice waters. Off unit when alarm went off. Was at front door letting in ambulance people for a return resident. A record review of the facility policy titled Unsafe Wandering & Elopement Prevention dated [DATE] revealed the following: .Every effort will be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment for residents who are at risk for elopement episodes. Nursing personnel must report and investigate all reports of missing residents . The Administrator was notified of Immediate Jeopardy on [DATE] at 02:15 PM and a plan of correction was requested to remove the immediacy that began on [DATE]. The facility provided the following removal plan. Immediate Jeopardy was removed on [DATE] and validated by the team on [DATE] Facility Removal Plan Residents currently residing in facility that are elopement risks are considered like residents. Their orders for wander guards and care plans have been audited and updated as needed. Residents in the facility have been re-assessed for Elopement risk and have had their Elopement assessments updated, any resident scored as an elopement risk, a wander guard has been given and added to the Elopement book. Elopement books have been updated as needed and are the same on each unit on [DATE] Residents that are at risk for elopement will have a securing device placed on their room window to reduce the risk of exit. Any resident at risk for elopement has a wonder guard on their person and if attempts to exit through alarming doors, staff will redirect and notify Administrator for possible 1:1 supervision needs. The Elopement policy have been reviewed and deemed appropriate by the IDT. ([DATE]) The Director of Nursing/Designee educated the facility staff on the Unsafe Wandering and Elopement Protocol and the importance of reporting elopements to the administrator as well as responding to door alarms timely. ([DATE]) Any staff not re-educated by [DATE] will be upon return to work. DON/Designee will conduct weekly random audits on elopement residents weekly X 4, then Monthly X4 or until compliance is met to ensure consistency with the Orders for wander guards, elopement books are updated and care plans are in place. All findings will be forwarded to monthly QA. Any ill findings will be corrected immediately Date of compliance: [DATE] Although the Immediacy was removed on [DATE], the facility remained out of compliance at isolated with actual harm that is not Immediate Jeopardy as sustained compliance could not be verified by the state agency.

This citation pertains in part to intake 9. Based on interview and record review, the facility failed to complete a follow-up hydration assessment and obtain lab values to monitor resident health status after a noted decline in intake and 42 pound (lbs) significant weight loss in the facility over two months, and failed to document food/fluid/snack acceptance (FARs) on every shift, for one sampled resident (R#901) of three reviewed for quality of care and nutrition concerns, resulting in inadequate and incomplete monitoring of nutritional status. Findings include: A review of the attachments associated with intake 9 were reviewed and revealed the following: .I received a call at 9:50 PM from .[facility] saying that they were sending [R#901] to ER (emergency room ) .I got a call from the ER Dr. (doctor) at [the hospital] saying that [R#901] was extremely dehydrated .lethargic .they put in an IV .had a feeding tube placed in [their] nose on September 8th, 2020 . A review of R#901's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was admitted into the facility on [DATE] and discharged to the hospital on 9/6/2020. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was cognitively intact and that the resident had impairment on their upper and lower extremities on one side, required extensive to total assistance from staff for bed mobility, transfers, dressing and hygiene/bathing, and required the supervision of one person for eating. A review of R#901's recorded weights while at the facility revealed the following: 7/1/2020 - 234.4 Lbs 7/8/2020 - 231.8 Lbs 7/22/2020 - 220.2 Lbs 7/30/2020 - 215.6 Lbs 8/5/2020 - 211.6 Lbs 8/12/2020 - 209.8 Lbs 8/19/2020 - 203.7 Lbs 8/26/2020 - 198.6 Lbs 9/2/2020 - 192.0 Lbs The weights reflect an 18.09% loss over approximately two months. R#901's Documentation Survey Reports (Point of Care documentation) for food and fluid acceptance dated July, August, and September 2020 were reviewed and revealed that intake was not documented (shown as a blank space) under food percentage acceptance and fluid intake on the following dates/shifts: NUTRITION - Amount Eaten (%) - 0900 (9:00 AM): 7/4, 7/5, 7/12, 7/13, 7/15 through 7/26, 7/29, 7/31, 8/3, 8/9, 8/15, 8/16, 8/25, 8/29 NUTRITION - Amount Eaten (%) - 1300 (1:00 PM): 7/3, 7/4, 7/5, 7/12, 7/13, 7/15 through 7/26, 7/29, 7/31, 8/1, 8/3, 8/9, 8/10, 8/15, 8/16, 8/25, 8/29 NUTRITION - Amount Eaten (%) - 1800 (6:00 PM): 7/3, 7/5, 7/6, 7/15, 7/16, 7/18 through 7/23, 7/27 through 7/31, 8/1, 8/4 through 8/7, 8/9, 8/11 through 8/16, 8/18, 8/21, 8/23, 8/29, 9/2, and 9/4. MONITOR - Fluid Intake: PO (PO=orally) (at meals/meds) 0900: 7/4, 7/5, 7/12 through 7/26, 7/29, 7/31, 8/3, 8/9, 8/10, 8/15, 8/16, 8/29 MONITOR - Fluid Intake: PO (at meals/meds) 1300: 7/3 through 7/5, 7/12 through 7/26, 7/29, 7/31, 8/1, 8/3, 8/9, 8/10, 8/15, 8/16, 8/25, 8/29 MONITOR - Fluid Intake: PO (at meals/meds) 1800: 7/3, 7/5, 7/6, 7/15, 7/16, 7/18 through 7/23, 7/27 through 7/31, 8/1, 8/4 through 8/7, 8/9, 8/11 through 8/16, 8/18, 8/21, 8/23, 8/29, 9/2, and 9/4. Multiple documented refusals of fluid intake were noted during September 2020 before the resident was transferred out of the facility. Documentation of R#901's intake of a HS (bedtime) snack (question = Did resident take snack? Y - Yes N - No) on the Point of Care reports was blank for the following dates: 7/2 through 7/8, 7/14 through 7/16, 7/18 through 7/23, 7/25 through 7/31, 8/1 through 8/16, 8/18 through 8/21, 8/23, 8/24, 8/29, 9/2 and 9/4. A review of R#901's record revealed a comprehensive metabolic panel (blood work) dated 6/29/2020 which indicated that the resident's potassium, sodium, blood urea [MEDICATION(S)] (BUN), and creatinine (all of which can be helpful in assessing nutrition/hydration status), were within normal limits. No additional blood work was found in R#901's record or provided by the facility upon request. R#901's was also noted to have a Nutrition Data Collection/Evaluation assessment dated [DATE] and a Hydration Risk Evaluation assessment dated [DATE]. No additional such assessments were found upon review of the record. On 4/6/21 at 12:41 PM, Certified Nursing Assistant (CNA) D was interviewed and queried regarding documentation of resident intake. CNA D was asked if staff is required to document a resident's food and fluid intake every shift to which she responded, Yes. We have to write down how much each resident eats and drinks every shift. CNA D indicated this information can be found in the Point of Care documentation. CNA D was then asked to review R#901's Documentation Survey Reports mentioned above and indicated that the records should not have any blank spaces. CNA D stated, There should be documented intake no matter what, so it should be filled in. When queried regarding what to do if a resident refuses fluid or food, CNA D stated, CNAs can document refusals and I tell the nurse, too. I think I might have talked with the dietitian about [R#901]. A review of R#901's provider notes revealed:8/20/2020 09:15 (AM) Transcribed NP/PA (Nurse Practitioner/Physician Assistant) Progress Note .We will .monitor [their] labs .Patient requires 24-hour supervision and assistance with all ADLs . A review of R#901's medical record revealed the following progress note written by the Registered Dietitian (RD): 8/27/2020 13:16 (1:16 PM) Dietary Progress Notes Note Text: Weekly wt (weight) obtained at 198.6# (lbs) Continues with a slow decline in weight Q (every) week. Spoke with NOD (nurse on duty) in depth re: (regarding) resident decreased appetite. Reporting some difficulty in tolerating glucerna 1.2. PO (oral) remains poor with meals. Will alert SW (social work) for possible psych services. No recent labs available at this time as well. NOD to request a recent lab check for hydration status. Continue with weekly wts. F/U (follow up) as needed. On 4/6/21 at 1:22 PM, the RD was interviewed regarding R#901's weight loss at the facility, and what interventions were implemented. The RD stated, [R#901] intake varied from 50-100% .7/22 was the start of the weight loss. When queried regarding the food and fluid acceptance records from Point of Care, the RD stated, I would expect to see that filled out every day. Breakfast, lunch, and dinner should be documented on. The RD explained that she had obtained meal preferences for the resident and started a supplemental drink. The RD stated, We didn't have [R#901's favorite] flavor (supplement) at the time so we did ensure plus .[R#901] would do good for a day or two when stuff started then would push away when people tried to help [them]. [I] switched (ensure) to the 1.2 glucerna so [they] would get more. When queried if the glucerna was entered as an intervention onto R#901's care plan, the RD stated, Just the ensure I have on the care plan .on 8/18 I did recommend to switch the ensure to the glucerna, 8/20 it was switched. When queried regarding any interdisciplinary team (IDT) regarding R#901's weight loss and decreased intake, the RD stated, I can see if there's a note, I know we talked about [R#901] multiple times in morning meeting. The RD reviewed the record and stated, We met on [R#901] for falls . and confirmed there were not IDT notes in the record related to R#901's weight loss. When queried regarding her note written on 8/27/20 that mentioned obtaining labs and why no blood work was obtained, the RD stated, I know I recommended labs. I'm not sure (what happened). I know I talked with the nurse. My guess would be [Licensed Practical Nurse (LPN) I] because she's always down there (where R#901's room was). I know I talked to the nurse about talking with the doctor to get labs. Our process has now changed. We have more IDT meetings, and I can put requests in the doctor's book. The physician did address the weight loss in the notes, I know we also involved psych. The RD was unable to provide an answer as to why labs were not ordered or recommended by the physician despite refusals of food/fluid intake and progressive weight loss. When queried regarding the completion of a comprehensive nutrition and hydration assessment after the resident's noted weight loss, the RD indicated that she completes comprehensive assessments as they come up quarterly or with a significant change. The RD stated, I don't do a comprehensive assessment with just weight loss, I just re-estimate needs and go from there. The re-estimating the needs was in the notes. The RD then proceeded to review her progress notes for R#901 and stated, I guess I didn't do it for this weight loss. I was using the estimated needs off of [R#901's] ideal body weight, but not the new weight. The re-estimate would normally be done based on the new weight. But it can vary .I did calculate what [R#901 was] eating and what it's providing. On 8/13 that [R#901] was getting about 53%. When queried whether R#901 had been able to feed themselves or required staff assistance, the RD stated, [R#901] physically fed [themselves] but needed more encouragement. When queried regarding if a hydration re-assessment was completed for R#901, the RD stated, I only see one here on 6/26/20 .I'm not sure one that does that assessment. The RD indicated nurses are responsible for completing the hydration assessments. On 4/6/21 at 1:52 PM, LPN I was interviewed with the RD and queried regarding R#901's weight loss. LPN I stated, [R#901] was not wanting to eat and refusing a lot. We tried offering options, ensure drinks. Not spiking an interesting to eat much. When queried regarding documentation of food/fluid intake, LPN I stated, As far as nurses we don't document the percentage, we will put notes in and let the doctors know to follow up. LPN I could not recall if she spoke with a doctor regarding R#901's decline in intake but stated, I think I remember holding insulin, and documented that I held it because [R#901] was refusing meals. When queried regarding nurses performing a hydration assessment, LPN I: stated, I think (nurses do that). Not positive. The RD stated, I think I recall a discussion of starting an IV and checking labs between me and [LPN I] .believe that was 8/27. I can't honestly remember why they didn't do a note on discussing [R#901] during morning meeting. [R#901] swallowed okay but was refusing a lot towards the end. On 4/7/21 at 10:54 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed regarding R#901's weight loss. The DON stated, Every time the physician was in to see [R#901], it was noted as a positive weight loss. We were most concerned with [R#901's] depression .[R#901] was overweight so weight loss was good. I know supplements were added, speech therapy was involved, we discussed with [R#901's spouse] about not wanting to eat/drink. It was more of a psychosocial issue in contrast to a nutritional issue. The NHA stated, We offered for [R#901's spouse] to come in but they were unable to due to being immunocompromised. When queried when a hydration assessment is expected to be completed, the DON stated, On admission. When queried if one would be completed when a change in hydration or nutritional status is noted, the DON stated, I don't think they are going to be pulling up a hydration assessment but there are notes from the dietitian. She puts a note in that she is monitoring the weight loss, based off of her findings and the physicians findings. [R#901] was spitting water out when the family was here. When queried regarding the frequency of obtaining lab work for health status monitoring, the DON stated, Just admission labs then every three months. When queried regarding any recommendations for labs to be drawn for R#901 due to their decline in intake, the DON stated, [R#901] was seen by the physician, plus senior wellness, and the NP (Nurse Practitioner). If they wanted labs they would've ordered labs if they felt they were needed. When queried regarding the RD's progress note from 8/27 that mentioned obtaining lab work for R#901, the DON indicated that she would have expected the RD to speak with the physician directly and stated, If the dietitian doesn't give us her recommendations then I wouldn't know, she would need to put that in the physician book. She would have to write that she was recommending labs to the physician. When queried regarding documentation of food and fluid intake, the DON indicated she expected resident intake to be documented every shift. The DON was then asked to review R#901's Documentation Survey Reports for amount eaten and fluid intake and stated, It should all be filled out, and indicated there should be no blank spaces present. When queried regarding any IDT documentation related to R#901's weight loss, the DON indicated she was not the DON at the time this weight loss occurred and that the facility had not yet started doing SOC (Standard of Care) notes. A review of R#901's care plan revealed the following: Focus: [R#901] is at nutritional risk related to recent dx (diagnosis) [CONDITION(S)]. PMH (past medical history) including CVA (stroke), DM (diabetes), and CAD (coronary artery disease). Weight loss noted since admit. Date Initiated: 6/30/2020. The amount of weight loss R#901 experienced was not found upon review of the care plan. Goal: [R#901] will receive adeq(uate) food and nutrition to meet body requirements to maintain a CBW (current body weight) of 256# +/- 2-3%. Interventions: [R#901] is taking insulin as ordered. Monitor and record meal percentage intake as needed. [R#901] is able to feed self with set up. Monitor [R#901]'s weights. Monitor labs for nutritional status. Offer [R#901] a REGULAR diet as ordered. Offer [R#901] an HS (bedtime) snack. Offer [R#901] ensure plus as ordered Date Initiated: 07/31/2020. Report any concerns to MD (doctor). SLP (speech language pathology) eval (evaluate) and treat as needed. A review of the facility's policy/procedure titled, Nutritional Management, reviewed/revised 7/31/2020 revealed, A systematic approach is used to optimize each resident's nutritional status: A. Identifying and assessing each resident's nutritional status and risk factors B. Evaluating/analyzing the assessment information C. Developing and consistently implementing pertinent approaches D. Monitoring the effectiveness of interventions and revising them as necessary. Identification/assessment: .A comprehensive nutritional assessment will be completed by a dietitian on admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Components of the assessment may include but are not limited to: General appearance, height/weight, cognitive, physical, and medical conditions, food and fluid intake, evidence of fluid loss or retention, presence of persistence hunger, poor intake, or continued weight loss, review of medication list, review of laboratory/diagnostic data .the assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/hydration. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs .Interventions will be individualized to address the specific needs of the resident .real food will be offered first before adding supplements .the care plan will be updated as needed .

This citations pertains in part to MI 473. Based on observation, interview and record review the facility failed to ensure weights were monitored and or documented for two sampled resident (R901, R902) of three reviewed for weight loss management and nutrition, resulting in a delay in the identification of significant weight loss and the likelihood of further unidentified weight loss. Findings include: R901 On 10/28/20 at 8:30 AM, R901 was observed to be in bed. The resident was covered in blankets to the chest. The head of the bed was up. R901 appeared small in stature. The face was wrinkled and the head turned toward the right side. The mouth was open and the left cheek sunk into the mouth. The jaw line was prominent. R901 appeared not to have teeth. The resident did not respond to initial queries or name. A food tray was brought in by dietary staff and set at the foot of the bed. At 8:40 staff had entered and was assisting the resident to eat. Some food acceptance was observed. At 10:17 R901 opened their eyes to their name, but then shut them and did not respond verbally. On 10/28/20 at 9:30 AM, during a phone conversation with a family member of R901, the family member reported concerns about weight loss. The family member reported R901 was more lethargic and would not eat very much. The family member was concerned that medication was given to make R901 more sleepy and less responsive. It was further reported that the facility weigh R901 and R901 weight 76 pounds. The family member reported the previous weight to be around 122 pounds. The family member reported they were in the facility for at least one meal daily to assist R901. On 10/28/20 at 10:25 Certified Nursing Assistant (CNA) A was asked about R901 and reported R901 had a wound on the bottom that cleared up and remained with a wound to the heel. CNA A added R901 ate better when they first came to the facility and will accept food at times, but will spit it out often. CNA A was asked about the weight of R901 and stated R901 had definitely lost weight and did not remember R901 having had much fluid on them. CNA A was asked about the staffing and reported terrible and the need to care for 20 or 21 residents on this day. One nurse was observed working the unit. On 10/28/20 at 10:38 AM, Nurse B was asked about R901 and reported, R901 spits out their ensure, will take some pills, but may spit them out. Nurse B was aware of the new weight for R901 and reported the doctor had been in earlier and ordered a reweigh. A review of the clinical record for R901 revealed: R 901 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated severely impaired cognition and the need for extensive assistance of one person for eating. R901 required extensive assistance of one or two persons for bed mobility, transfer, dressing, hygiene and toilet use. A review of the vitals documented weights for R901 revealed A weight of 144 pounds on 09/16/20 had been struck out as wrong chart. The next weights documented were on 09/29/20 - 123.0 pounds; 10/07/20 - 122.5 pounds; 10/27/20 - 76.1 pounds at 12:09 AM and 76.6 pounds at 12:27 PM and on 10/28/20 - 75.6 pounds. No additional weights were documented in the vital sign record. A review of the last thirty days (09/29/20 - 10/27/20) for the task Nutrition: Amounts eaten (%) revealed no documentation for the amount eaten on 10/02/20 and from 10/09/20 through 10/20/20. Amounts from 10/21/20 to 10/27/20 indicated a high of 50% times one on 10/25/20. The rest noted one or two meals out of three and intakes of zero to 20 percent. The nursing care plan revealed:(R901) is at nutritional risk related to recent diagnosis (urinary tract infection) UTI with a (prior medical history) PMH including dementia, (stroke) [MEDICAL CONDITION], (diabetes) DM, and (Irregular heart beat) Afib. Wounds on admitted Initiated: 9/22/2020 (R901)will receive adequate food and nutrition to meet body requirements to maintain a (current body weight) CBW of 123# (pounds) +/- 2-3% Date Initiated: 09/22/2020 Revision on: 10/01/2020; Monitor (R901's) weights Date Initiated: 09/22/2020; Report any concerns to MD Date Initiated: 09/22/2020; (R901) is taking [MEDICATION NAME] as ordered Date Initiated: 09/22/2020. A Nurse Practitioner noted dated 10/08/20 reported the right arm and hand to be slightly [MEDICAL CONDITION] (swollen with fluid). On 10/28/20 at 1:54 PM, R901's weight management history was reviewed with the Registered Dietitian (RD) C. The RD acknowledged the assistance of the guardian to help R901 eat. The weights in the record were reviewed with the RD. The potential weight loss from 144 to 123 (21 pounds) and 122.5 to 76.1 (46.4 pounds) was questioned and the RD agreed these would be significant weight losses. The RD reported the initial weight of 144 pounds was questioned upon observation of the resident at the facility. The RD reported a weight in the hospital record of 100 pounds prior to admission. It was noted this would show a weight loss of 23.9 pounds and remained significant. The RD noted there was fluid on the right arm of the resident on admission, but did not consider this to be the only factor in the weight loss. The RD noted R901 would not always swallow food, spit out food and had a language barrier. The RD acknowledge the weight of 76.1 pounds and the drop to 75.6 pounds. The RD then reported it was their practice to request a re-weigh for any weight in question. A review of the RD evaluation dated 09/28/20 and dietary notes revealed questions about the weights. The RD was asked about the protocol for new admits and weights and reported new admits are weighed on admission and then weekly times four. When asked about R901's missing weekly weights, and the now struck out initial weight, the RD acknowledged they were not all done and that this may have provided a better picture of R901's weight loss and more timely intervention. On 10/28/20 at 3:00 PM, the weight concerns for R901 were reviewed with the Director of Nursing (DON). The DON reported that Wednesday is the normal weight day and the CNA's complete the weights from a list provided to them. It was noted that the nurse had struck out the 144 pound initial weight and it was acknowledged that this left the resident without an admit weight. The DON also reported ongoing interactions with R901's guardian about feeding concerns, difficulties and the possibility of tube feeding. The conversation with the RD was reviewed and the DON acknowledged the missing documentation of the initial weights. R902 On 10/28/20 at 8:26 AM, R902 was observed to be in bed. A tube feeding pump was active. A review of the clinical record for R902 revealed: R902 was admitted into the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition and the need for extensive to total assistance for all activities of daily living. R902 was 70 inches tall and 161 pounds per the MDS. The nursing care plan revealed: (R902) is at nutritional risk related to recent [DIAGNOSES REDACTED]. brain damage, [MEDICAL CONDITION] .and dysphagia. Date Initiated: 07/21/2020, Revision on: 10/26/2020 (R902) will receive adequate food and nutrition to meet body requirements to maintain a IBW range of 166# +/- 10%. Monitor (R902's) weights, Date Initiated: 07/21/2020, Obtain (R902's)estimated needs and adjust (tube feed) TF/FWF as needed. Date Initiated: 07/21/2020, Report any concerns to MD. Date Initiated: 07/21/2020. A review of the vitals documented weights revealed one weight on 7/30/20 at 2:52 PM of 138.5 pounds. Additional weights were requested at 5:35 PM from the Administrator who reported there were no additional weights for R902. A review of the facility policy, Weight Assessment and Intervention Policy revised 11/18 revealed, The nursing staff and the Dietitian will collaborate to monitor, prevent and intervene for undesirable weight loss for our resident. 1. The nursing staff will measure resident weights on admission and readmission and weekly for four weeks thereafter . 2.Weights will be recorded in the individual's medical record. 3. Any weight change of greater than or less than five pounds since the prior weight will be retaken within 24 hours with the licensed nurse confirming the reweigh. If the weight is verified, nursing will notify the physician, make a referral to the Dietitian and notate on the 24 hour report for follow up. Attending physician will be notified of unplanned significant weight changes as described below. 6. Significant weight changes are defined as a. 5% or more in thirty days b. 7.5% or or more in 90 days. c. 10% or more in six months.

This Citation Pertains to Intakes: 3, 3 Based on interview and record review, the facility failed to document a comprehensive assessment for change in condition for one sampled resident (R600), resulting in lack of timely assessment, delay in emergency medical treatment, and decline in overall health status. Findings include: On 9/22/2020 at 9:05 AM, Hospital Social Worker B was called to discuss their complaint regarding R600. Hospital Social Worker B said, (R600) was admitted with the [DIAGNOSES REDACTED]. It appears that (R600) was not being cared for properly. On 9/22/2020 at 9:30 AM, R600's Family Member A was called to discuss their complaint. Family Member C stated, I had been trying to speak with (R600) several times and (they) seemed to be lethargic. I tried calling the head nurse and the doctor at the facility, but I never received a call back. On 9/22/2020 at 10:30 AM, a review of the electronic medical record noted R600 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R600 requires extensive to total, two plus person assistance with activities of daily living. A review of R600's care plan dated 6/26/2020 noted the following: Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease movement or range of motion, withdrawal or resistance to care .Monitor for changes in mental status. R600's Brief Interview for Mental Status (BIMS) noted a score of 15 (meaning cognitively intact). A review of the Skilled Daily-Neurologic dated 9/3/2020 at 12:00 AM noted the following: 1. Is resident able to be interviewed at this time? Yes .2. Is resident alert Yes. 3. Oriented to: Person, Place, Date, Time. A review of the Skilled Daily-Neurologic dated 9/4/2020 at 12:00 AM noted the following: 1. Is resident able to be interviewed at this time? Yes .2. Is resident alert Yes. 3. Oriented to: Person, Place, Date, Time. A review of the Skilled Daily-Neurologic dated 9/4/2020 at 6:00 PM noted the following: 1. Is resident able to be interviewed at this time? No. 1a Explain why resident is unable to be interviewed: Will not verbally respond at this time. 2. Is resident alert? Yes. 3. Oriented to: Person only. A review of the Skilled Daily-Neurologic created by Nurse E dated 9/5/2020 at 6:00 PM noted the following: 1. Is resident able to be interviewed at this time? No. 1a. Unresponsive. 2. Is resident alert -No. 3. Is orientation different than usual for resident? Yes. 3a. Describe change in orientation: Lethargic. The blood pressure entered on the assessment was 123/69 with the date of 8/10/2020 at 10:48 PM. A review of the medical record progress note created by Nurse D dated 9/6/2020 at 9:16 PM noted the following: On call doctor .returned call. Nurse notified (them) of resident's vital signs bp (blood pressure) 107/52, pulse ox (pulse oximeter -measures oxygen in the blood) of 86-88% (blood oxygen level at this level can result in shortness of breath, chest pain, confusion, rapid heartbeat) and heart rate of 137 (normal heart rate is 60 to 100 beats per minute). Nurse also reported resident was lethargic, nonverbal, and not responding appropriately, doctor order resident to be sent to be sent to hospital for further assessment and evaluation. On 9/22/2020 at 2:08 PM, the Director of Nursing (DON) was queried about the condition of R600 and why the resident was not sent to the hospital for unresponsiveness and lethargy. The DON said, I know (R600) was depressed and not answering questions. The nurse did not mean unresponsive. (Nurse E) was trying to say that (R600) would not answer questions. The DON was informed that Nurse E also documented that R600 was lethargic. The DON states, (Nurse E) was trying to say that (R600) would not answer questions. A review of the facility's Physician and Representative Notification-Change in a Resident's Condition or Status policy dated 10/07/2010 noted the following: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition.

This Citation Pertains to Intake 2 Based on observation, interview and record review, the facility failed to prevent falls with injury by not implementing new interventions, by not following current care plan interventions and by not updating the fall care plan following a fall, and not providing supervision to ensure a safe environment for R601 and 602, resulting in continued falls with injuries. Findings include: R601 On 9/22/2020 at 9:05 AM, Hospital Social Worker B was called to discuss their complaint regarding R601. Hospital Social Worker B said, (R601) was having a lot of falls at the facility. (R601) was hosptalized on [DATE] and 8/26/2020 due to falls .(R601) was readmitted to hospital on [DATE] after another fall. On 9/22/2020 at 11:10 AM, R601's medical record was reviewed and noted admission of 12/24/2018 and [DIAGNOSES REDACTED]. R601's Brief Interview for Mental Status (BIMS) noted a score of 3 (meaning severe cognitive impact). R601 was non-ambulatory and required extensive assistance with Activities of Daily Living (ADL). A review of the care plan interventions noted the following goal and interventions related to falls: Goal: The resident will be free of injury from falls through the review date. Date initiated: 8/8/2016. The care was revised on 8/28/20 (the date the resident returned from the hospital.) Interventions: Staff to offer res activities at night time Date initiated 8/26/20. (the date the resident was sent to the hospital.) Res to have floor mat to exit side of bed Dated initiated 8/31/20 (R601 remained hosptalized on [DATE].) returned from the hospital.) Extensive x 2 staff with mobility as needed Dated 8/28/20. On 9/22/2020 A review of R601's Fall Investigation Report and the progress notes noted falls on the following dates: 1/26/20: face and head covered in blood, laceration on top of head, sent to the hospital 4/13/20: Observed walking back to room and fall in hallway, not using walker 4/15/20: Unobserved fall in the hallway, found lying on the floor on right hip, not using walker 4/16/20: Per progress note dated 4/16/20 at 8:00 AM, Resident is sitting next to the nurses cart. (R601) states (they) has no needs at this time. 4/22/20: Unobserved fall, found sitting on the floor in the hallway. 4/26/20: Unobserved fall in the room, large bump on forehead and bleeding on left side of face. 5/3/20: Progress note dated 5/3/30 at 7:35 PM, Resident found on floor in resident's room in front of sink. 5/6/20: Unobserved fall in bathroom 7/7/20: Unobserved fall in front of bathroom, hematoma to knee 8/16/20: Observed fall in room, per CAT scan dated 8/16/20 results noted small right posterior superior scalp hematoma-sent to the hospital. Returned to facility on 8/18/20. 8/25/20: Unobserved fall in residents room, head injury, bleeding-Per hospital note, R601 with [MEDICAL CONDITION] 8/29/20: Unobserved fall in resident room, bed in high position, knee bruise, swelling, sent to the hospital. R602 On 9/22/2020 at 9:40 AM, R602 was observed sitting in their room in a wheelchair. The Certified Nurse Assistant (CNA) A was in the room assisting with ADLs. Did not observe floor mats at R602s bedside. Queried CNA A if R602 used floor mates for safety. CNA A said, (R602) does not have floor mats. On 9/22/2020 at 9:45 AM, a review R602's medical record was reviewed and noted admission of 9/25/2019 with the [DIAGNOSES REDACTED]. R602's Brief Interview for Mental Status (BIMS) noted a score of 00 (meaning severe cognitive impact).A review of R602's care plan noted the following: Interventions: Offer toileting q (every) one hrs (hours) and prn (as needed) after all meals. Date Initiated: 1/22/2020 and Revision on: 3/9/2020 .Bed at lowest position when in bed Date Initiated: 1/22/2020 .Res (resident) to have bilateral floor mats next to bed, when res (resident) is in bed Date Initiated: 1/22/2020. 1/15/2020: Observed fall in the dining room, 1/16/2020 at 3:00 AM, observed fall in the common area, 1/16/2020 at 9:45 AM, unobserved fall in another resident room 1/17/2020: Unobserved fall in the bathroom 3/7/2020: Observed fall in the common area 3/13/2020: Unobserved fall in the common area 3/15/2020: Unobserved fall in the resident's room 3/28/2020: Unobserved self transfer, resident's bed soiled 3/30/2020: Unobserved fall in the Resident's room 4/11/2020: Unobserved self-transfer out of bed 4/19/2020: Unobserved fall in the hallway 5/3/2020: Unobserved fall in the hallway-Right Hip Bruise 7/15/2020: Unobserved fall in the common area 8/6/2020: Observed fall in the common area On 9/22/2020 at 10:20 AM, the DON was interviewed and queried about R602's missing floor mats not being in the room and the DON said, Oh Wow, I will get them now. On 9/22/2020 at 2:20 PM, the Director of Nursing (DON) was queried about the number of falls and injuries for R601 and R602. The DON said, It's been a challenge caring for (R601). A review of the facility's Falls-Clinical Protocol dated 6/2018 noted the following: The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .Interventions should be developed and implemented per the assessed needs.

This citation pertains to intake: MI 182 Based on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement from the facility for one sampled resident (R900) who has a Brief Interview for Mental Status (BIMS) score of 0/15 indicating a Severely Impaired Cognition, that eloped from the facility on 8/22/2020 at approximately 3:00PM without staff being aware, resulting in the likelihood for serious injury, harm, or death. The Immediate Jeopardy (IJ) started on 8/22/2020 and was identified on 9/1/2020. The Administrator was notified of the Immediate Jeopardy on 9/1/2020 at 3:22PM and was asked for a plan to remove the immediacy. The IJ was removed on 8/22/2020, based on the facility's implementation of the removal plan as verified onsite on 9/2/2020. Although the immediacy was removed, the facility's deficient practice remained at isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: A review of the complaint information revealed the following, Resident walked out front door. (R900) passed a hospice nurse that noted (R900) was walking toward front door and alerted staff. The staff went to check on (R900). Both staff members CNA B (Certified Nursing Assistant) and CNA A saw the resident walk out the front door. The resident was brought back in the facility. Placed on 15 minute checks. Code yellow called. Residents census completed everyone was accounted for in the facility . On 9/1/2020 at 9:29AM, R900 was observed sitting in their room located on the Memory Care Unit (a specialized care unit for residents with memory issues) of the facility. The room was observed to be near the exit doors of the unit, which did not require a code to leave or enter the unit. An interview was attempted with R900 about leaving the facility. They were asked if they had ever left the building, and stated, No. Further attempts to interview the resident were unsuccessful due to their cognition. A review of R900's medical record revealed that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R900's Minimum Data Set assessment dated [DATE] revealed that R900 was Severely Cognitively Impaired, required limited to extensive assistance with Activities of Daily Living, used a walker to ambulate, and was identified as a wanderer. A review of R900's care plan revealed the following: Focus: The resident is an elopement risk r/t (related to) History of attempts to leave facility unattended, has history of leaving home prior to admission. Date Initiated: 07/18/2019. Revision on: 09/10/2019. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 07/18/2019. Revision on: 07/18/2019. Encourage resident to relax in common areas, dining rooms. Offer activities of enjoyment. Date Initiated: 09/10/2019. Identify pattern of wandering. (e.g. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise?) Intervene as appropriate. Date Initiated: 07/18/2019. Maintain consistent daily routine and consistent bedtime routine. Date Initiated: 07/18/2019. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date Initiated: 07/18/2019. If resident is restless, offer to take (R900) for walk outside, weather permitting. Date Initiated: 08/12/2019. Revision on: 08/12/2019. On 9/1/2020 at 9:32AM, CNA A was interviewed about the incident in which R900 left the facility, and stated, The hospice nurse from (Hospice Company) told me that (R900) was headed toward the front lobby. I walked toward the front and looked around, I looked in the mail room and did not see (R900). All the administrative offices were closed, and the receptionist was not at the front desk. I looked outside and saw (R900) on the sidewalk with their walker. CNA A was asked if they knew how long R900 had been outside, and stated, Based on their distance, (R900) had to have been out there for about 1 minute. (CNA B), the other CNA was walking up, so she went out to go get (R900), while I called the nurse. CNA A was asked when and what time the incident occurred and stated, It was on the weekend, in the afternoon, maybe between 2-3PM. CNA A was asked about R900's behaviors and stated, (R900) often needs redirecting. CNA A was asked if R900 had ever left the facility before, and stated, I don't know. CNA A was asked to show the surveyor the route that she took to find R900. She demonstrated exiting the memory care unit through two set of double doors, past a common area, therapy gym, mail room, administrative offices, and lobby. Once in the lobby CNA A explained that she looked out of the front window of the facility and saw R900 walking down the sidewalk. Let it be noted that the sidewalk leads to a parking lot. On 9/1/2020 at 9:40AM, CNA B was interviewed about the incident in which R900 walked out of the facility. CNA B stated, Right before the incident, (R900) had wandered to the front and the receptionist was at the desk however, when she (the receptionist) left for lunch, I brought (R900) back to the unit and put them in their room. CNA B further explained that she left to provide care for another resident and was gone between 5-10 minutes. CNA B stated, I went to check on them and they were gone. (CNA A) had gone to locate (R900) so I also went to look as well, and when I got to the front, (R900) was outside on the sidewalk. CNA B further explained that she went outside and got (R900) and brought them in. CNA B was asked if R900 said anything, and stated, (R900) was asked where they were going and they said, 'For a walk.' CNA B stated, It took some coercing, but I was able to get them to turn around and come back in. CNA B was asked how R900 had gotten out of the building and stated, I don't know, because you need a code to get out, but (R900) moves quick. On 9/1/2020 at 1:13PM, a request for all Incident and Accident reports for R900 were requested from the NHA (Nursing Home Administrator). On 9/1/2020 at 2:22PM, the Director of Nursing (DON) provided one incident and accident report related to a fall for R900. The DON was asked about R900's elopement attempts, specifically in December 2019, and indicated that she would have to look into it, but did indicate that R900 had a history of [REDACTED]. On 9/1/2020 at 3:00PM, an interview was completed with Receptionist C who was asked about the incident in which R900 exited the facility. Receptionist C stated, I was at the front desk and I had been working for 12 hours. I left for a break, but before I left, I saw a CNA sitting with (R900). I didn't see anything else. The receptionist was asked if someone is supposed to be at the front desk at all times, and stated, They told me that I should have a CNA cover me when I go on breaks, but we are short staffed and if someone is up here, there is no one to help with the residents. Receptionist C was asked if they had ever witnessed R900 attempting to exit the facility and stated, I've seen them try to push the door open and pull on the windows. A review of R900's medical record revealed the following progress notes: 8/22/2020 18:23 (6:23PM) Nurses' Notes Note Text: At 1450 (2:50PM) writer was notified by hospice nurse that (R900) was heading to the front lobby after she attempted to redirect them unsuccessfully. (CNA A) proceeded to the front lobby to redirect them and (CNA B) went to assist as well. (CNA A) returned to notify me (R900) had gotten outside the building. (CNA B) successfully brought (R900) back inside the building. No injuries noted. Administrator, daughter, and team health notified. 15 min (minute) checks started immediately and staff to keep resident from exiting 500 hall. 12/29/2019 16:37 (4:37PM) Nurses' Notes Note Text: Resident walked around without pants in hall way to caring connects dinning (dining) room at noon, then at 1620 (4:20PM) resident was found outside unattended, resident left building with other family members, CNA assisted resident back into building, 15 min checks started. 10/27/2019 19:49 (7:49PM) Nurses' Notes Note Text: Resident attempted to go out the front door after dinner. Redirected back to 500 hall. A review of R900's Quarterly Risk assessment dated [DATE] revealed the following: 2. Elopement history. B: Leaving facility without supervision, when supervision is required. Yes. B1. # of times. 3. C: Leaving facility without informing staff. Yes. C1. # of times. 3. Summary of review: A: Resident is at risk for elopement/wandering at this time. Yes. B. Elopement/wandering risk as evidenced by. Resident frequently exit seeks. Resident has left building in the past. Comments. Resident has wanderguard on right ankle. A review of the incident and accident report dated 8/22/2020 revealed the following: Time of incident: 2:50PM Incident Type: Unobserved Location: Parking Lot Brief Description: Resident walked outside the front door. Resident was unattended at the time. Was a mobility device used: Yes, Walker. Action Taken: 15 Minute Checks. On 9/2/2020 at 12:10PM, the Nursing Home Administrator was asked about the facility's Wanderguard system (an alarm used to alert staff when a resident attempts to leave), and explained that there isn't an audible alarm that alerts when a resident attempts to exit the facility, rather, beepers are worn by CNAs to alert them that a resident is near an exit. The NHA also explained that the Wanderguard system only works if the door is closed, and in this case, the door was already open when R900 exited the facility. On 9/2/2020 at 12:18PM, the Director of Nursing (DON) was asked about the criteria for a resident to be placed on the memory care unit and explained, A CNA and nurse will come to a morning meeting and have identified a resident who they think would benefit from the unit. She further explained that the difference between that unit and other units is programming, and that there are more individualized activities, and it is a slower pace. The DON was asked about coverage at the front desk and explained, Due to covid, we had to temp (tempersture) everyone out, so there is someone at the front desk at all times. Usually a CNA is there on their off shift and is supposed to let someone know they need a replacement. On 9/2/2020 at 12:29PM, the video footage of R900 exiting the facility was reviewed with the Maintenance Director. At 1:11PM, R900 was observed coming down the hallway leading to the lobby and sitting in a chair. At 2:00PM, the receptionist is seen exiting the facility, and CNA B is seen taking R900 away from the lobby. At 2:16PM, R900 is seen walking back to the lobby unattended, and again sits down in a chair. At 2:19PM, a staff member is seen walking into the facility, looks back at R900, and keeps walking as R900 exited through the door. At 2:21PM, R900 is seen being brought back into the facility by CNA B. A review of the facility's Unsafe Wandering & Prevention Protocol. Missing Resident Protocol revealed the following, Policy Statement: Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement .Reporting practices: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the licensed nurse in charge as soon as practical. Facility Abatement Plan: Resident # (R900) immediately assessed by a licensed nurse including Skin assessment. She was re-assessed for elopement risk on 8/22/2020 and 15 minute checks were initiated immediately and were continued until the IDT reviewed and revised the care plan on 8/24/2020. Elopement Assessment completed on 9/1/20. Incident reports were reviewed for the last 30 days by the administrator to identify other elopement incidents, none identified. (Completion Date: 9/1/2020). Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. 1. A resident roster was obtained and all residents' whereabouts were accounted for on 8/22/2020. 2. Current residents were re-assessed via elopement assessment by a licensed nurse on 8/24/2020. Five residents have Wander guards attached to their person or equipment. Current care plans were reviewed and revised if necessary by the IDT on 9/1/2020. 3. The front door and door alarms were checked for function by the Director of Environmental Services and Administer on 8/22/2020. All door alarms were functioning correctly. 4. Wander guard system was checked for function by the Director of Environmental Services and Administer on 8/22/2020. The Wander guard was functioning correctly. 5. A secondary alarm (audible alarm) was activated and will sound when any person breaks the beam and walks in the main hallway towards the front door on 8/24/2020. 6. The Elopement Risk Binders were reviewed by the Social Worker to assure all residents at risk for elopement are listed in the book and have a Resident Wandering Elopement Risk Identification sheet which was confirmed by the Administrator on 9/1/2020. 7. These books are located at the front desk, nursing stations and photos are posted in the employee break room. 8. An Elopement Drill was performed on 8/22/2020 and staff responded to the door alarm appropriately. 9. Elopement Assessments completed for all residents on 9/1/2020, 5 out of 104 were deemed to be at risk for elopement. Care plans updated as indicated.

This Citation Pertains to Intake Numbers MI 907, MI 947, and MI 023. Based on observation and interview and record review, the facility failed to prevent physical and verbal abuse for three sampled (#'s 701, 703, and 704) and one unsampled (discharged Resident #1) reviewed for abuse, resulting in a facility staff member verbally and physically abusing facility Residents including willfully and forcibly grabbing the back of Resident #701's neck and pushing them forward while verbally calling them an Fuc#ing idiot and saying, Are you Fuc#ing stupid. This deficient practice resulted in an Immediate Jeopardy , hospitalization related to physical injury, unnecessary pain, and psychosocial distress. Findings include: The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:48 PM. A plan to remove the immediacy was requested. The IJ began on [DATE] and was removed on [DATE] based on the facility's implementation of the plan removal as verified onsite on [DATE]. Although the IJ was removed, the facility's deficient practice remained at pattern. Actual harm that is not immediate jeopardy. Findings include: An interview was conducted with Confidential Witness B on [DATE] at 8:35 AM. When queried regarding Resident #701, Witness B revealed they worked at the hospital where the Resident had been transferred following the incident. Witness B stated, (Resident #701) said they had been abused (at the facility). With further inquiry, Witness B revealed Resident #701 had told them a (facility) worker got mad when they spilled their meds and threw them on the bed. When asked, Witness B was unable to provide a date in which the incident occurred. When asked why the Resident had been hospitalized , Witness B indicated it was due to an injury which occurred because of the assault. Witness B was asked about Resident #701's injury and replied, Something with their neck but was unable to recall the specific injury. On [DATE] at 9:45 PM, Resident #701 was observed in their room, in bed, with their eyes closed. An interview was conducted with the Resident at this time. When queried regarding their stay in the facility, Resident #701 indicated they just got back from the hospital. When asked why they were in the hospital, Resident #701 closed their eyes and did not respond. Resident #701 was then asked how they were treated by facility staff and replied, Okay now. When queried regarding care prior to going to the hospital, Resident #701 stated, Registered Nurse (RN) A picked me up by the legs and the back of the neck. I don't want to talk about it. It was scary. Resident #701 was then asked if they were scared now and replied, I was. Resident #701 then revealed Registered RN A hurt their neck when they grabbed them. When queried if they were still having pain, Resident #701 replied, More discomfort in my neck now. Resident #701 was then asked if anything else occurred that they would be comfortable talking about and replied, RN A yelled at me. Called me names. I don't want to talk about it anymore. On [DATE] at 10:05 AM, an interview was completed with RN C. When queried regarding Resident #701, RN C revealed the Resident had recently returned from the hospital. RN C was asked why the Resident had been sent to the hospital and replied, (Resident #701) had an X-Ray of their spine and were sent out for a CAT Scan (Computed Tomography- Radiology diagnostic test which produces more detailed images than X-Rays). When asked if the Resident had an injury to their spine at the facility, RN C replied, I don't know. With further inquiry regarding the Resident and if they had any special care needs, RN C stated, (Resident #701) has a hard time swallowing pills. They always have. When asked if Resident #701 was displaying any different behaviors since their return to the facility, RN C replied, This is my first time seeing (Resident #701). RN C was then asked if they had worked with RN A and replied, No, they work nights and I would days. An interview was conducted with Nursing Assistant D on [DATE] at 10:10 AM. When queried regarding Resident #701, Nursing Assistant D revealed the Resident had just got back from the hospital. Nursing Assistant D further stated, (Resident #701) has been tired since they got back. Nursing Assistant D further revealed being excessive sleepy is abnormal for the Resident. Record review of Resident #701's medical record revealed the Resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment and required extensive to total assistance to perform Activities of Daily Living (ADLs) with the exception of eating. Additional review of the resident's medical record revealed [REDACTED]. Additional review of Resident #701's medical record revealed no documentation pertaining to the incident on [DATE]. Detailed review revealed the following progress note documentation: -[DATE] at 10:15 AM: Transcribed physician progress notes [REDACTED]. Patient being seen after a report from staff that patient had head and neck shoved forward by a staff member . Patient initially complained of neck pain . -[DATE] at 9:06 AM: Transcribed NP (Nurse Practitioner)/PA (Physician Assistant) Progress Note . Chief Complaint / Nature of Presenting Problem: Neck pain . History Of Present Illness: This patient is being evaluated per nursing request with above concerns . underwent a cervical spine x-ray due to possible injury. The Plan: post evaluation the patient's RN called reporting x-ray shows anterior dislocation of C2 (Second cervical vertebra of spine) on C1 (First cervical vertebra of spine) recommending a CAT scan. Due to the patient's multiple medical condition and recent trauma will send to the emergency room for evaluation . nursing to call 911 . -[DATE] at 1:55 PM: Discharge plan . On [DATE] X-ray results of c-spine showed a c-2 displacement. Results reviewed with (Nurse Practitioner) . order given to send resident to ER for CT scan. Resident has had . (complaints of) pain in the neck region or back in the last 5 days . Resident made aware of results and order to send to Hospital of choice . Administrator notified of plan of care. EMS (Emergency Medical Services called at 1350 (1:50 PM) for transfer to ER (emergency room ). No documentation from Resident #701's hospitalization from [DATE] until [DATE] was present in the medical record at the facility. An interview was conducted with Nursing Assistant E on [DATE] at 10:47 AM. When queried regarding Resident #701 on [DATE], Nursing Assistant E stated, (Resident #701) called me into their room because (RN A) left their pills on the on bedside table for (Resident #701) to take themselves. Nursing Assistant E then revealed, I have seen (RN A) take meds in and drop off for Residents to take by themselves very frequently so that was not alarming to me. When asked what occurred, Nursing Assistant E stated, (Resident #701) said 'Honey, I think I dropped some of my pills and I can't find them. Nursing Assistant E revealed they searched the Resident's bed and floor but were unable to find the pills. When asked what happened next, Nursing Assistant E stated, I went and told (RN A) and (RN A) went ballistic. Nursing Assistant E revealed (RN A) stormed into (Resident #701's) room and grabbed (Resident #701's) lemonade out of their hand. Nursing Assistant E stated, (RN A) was swearing at (Resident #701). Nursing Assistant E was asked what RN A was saying to the Resident and replied, Fu#k this and fu#k that, and I'm going to get in trouble. (Nurse A) called (Resident #701) a 'Fuc#ing idiot' and said, 'Are you Fuc#ing stupid?' Nursing Assistant E then stated, Then (RN A) grabbed the blankets (off Resident #701) and yanked them. (Nurse A) grabbed (Resident #701's) neck and bent them forward. When asked how and where RN A grabbed Resident #701, Nursing Assistant E explained RN A put their hand around the back of the Resident's neck and forcefully pulled them forward by their neck towards their feet. Nursing Assistant E described that when RN A grabbed the Resident and forcefully yanked them, Resident #701 cried out, OW, OW, OW, Stop and You're hurting me. When queried regarding their actions when this was occurring, Nursing Assistant E replied, I said (RN A) WHAT ARE YOU DOING? loudly to RN A in (Nursing Assistant E indicated they said it loudly to get RN A's attention.) When asked, Nursing Assistant E revealed RN A then Slammed (Resident #701) back down in the bed and threw the blankets at (Resident #701) and said 'I can't believe this princess has to have lemonade with their pills'. When asked about Resident #701's reaction, Nursing Assistant E stated, (Resident #701) was so upset. (Resident #701) said, 'Honey, they almost broke me in half' and indicated they stayed with the Resident for approximately 10 to 15 minutes to provide emotional support. When queried if the Resident complained of pain following the incident, Nursing Assistant E specified the Resident complained of pain in their neck. When asked what transpired when they left the Resident's room, Nursing Assistant E stated, After I went out of (Resident #701's) room, (RN A) asked how upset (Resident #701) was. I told (RN A) that they hurt (Resident #701) and (RN A) said, 'I have to go back in there and smooth things over so I don't get reported'. When asked if RN A went back into Resident #701's room, Nursing Assistant E revealed they did. When asked if RN A entered Resident #701's room alone, Nursing Assistant E replied, Yes. Nursing Assistant E was then asked if they saw the Resident again after RN A entered their room alone and replied, Yes. (Resident #701) said '(RN A) came to apologize but it was inexcusable and unforgivable'. Nursing Assistant E then disclosed, (Resident #701) is a very slow person. This really affected them- for this to happen to them. (Resident #701) is such as sweetie, just a kind person and specified the Resident should not have been treated the way they were by RN A. When asked if there were any other staff observed what occurred, Nursing Assistant E replied, No and indicated they were the only staff assigned to work on the unit. When queried if the Resident had a roommate and/or if any other Residents saw what happened, Nursing Assistant E stated, No roommate and further revealed there were no other Residents in the proximity of the Resident. At this time, Nursing Assistant E was queried if they had worked with RN A prior to the shift on [DATE] and stated, Yeah, (RN A) is a very crude person. They get angry real quick. When asked what they meant, Nursing Assistant E stated, It was hard for me to tell (them) about the meds because (RN A) always gets so frustrated and pissy. Nursing Assistant E was asked to elaborate regarding RN A's behavior. Nursing Assistant E revealed they had only worked at the facility a few months but had observed numerous instances in which they observed RN A treat Residents without dignity and respect but had never observed them physically harm a Resident prior to Resident #701. With further inquiry related to specific Residents, Nursing Assistant E revealed they frequently worked on the 800 unit with RN A which had a high turnover and could not recall first and last names of Residents. At this time, Nursing Assistant A was asked who and when they reported the observed abuse and stated, I reported. I didn't understand how to report it right away. I didn't know I had to call Administrator and I didn't want to tell the other nurse working on Friday because they are friends with (RN A). With additional inquiry related to reporting, Nursing Assistant E stated, I wanted to talk to a nurse I could trust and indicated they contacted another facility nurse via phone to ask what to do. Nursing Assistant E revealed the nurse they contacted instructed them to contact the Director of Nursing and gave them their phone number. Nursing Assistant E stated, I left a voicemail and went to bed. With further inquiry, Nursing Assistant E stated, I went to work that night and (RN A) was there. At this time, Nursing Assistant E disclosed another Resident, who was now discharged (discharged Resident #1), that RN A had been verbally abusive toward. When asked, Nursing Assistant E stated, I was sitting in the room talking to (discharged Resident #1). They were so concerned and crying about the infection that developed in their leg when (RN A) came in with their pills. (discharged Resident #1) said, 'I'm not taking my antibiotic' and (RN A) said, 'Oh yes, you are' with a mean tone. Nursing Assistant E explained they recalled (discharged Resident #1) explaining to RN A that they were leaving the facility in two days and wanted to follow up with a different doctor. When asked what happened, Nursing Assistant E stated, (RN A) told (discharged Resident #1) that if 'they don't take the meds that their family would end up visiting them in the morgue'. Nursing Assistant E explained that RN A did the same thing both Friday ([DATE]) and Saturday ([DATE]) nights and stated, (discharged Resident #1) ended up taking the meds because (RN A) bullied them into it. When asked how discharged Resident #1 responded to the interaction with RN A, Nursing Assistant A replied, (discharged Resident #1) was just crying and crying. With additional inquiry regarding abuse reporting, Nursing Assistant E stated, On Monday I told another nurse I trust what had happened (regarding Resident #701) and they had the Administrator on the phone and knew exactly what to do. When asked why they did not call anyone else or say more to RN A when the incident with Resident #701 occurred, Nursing Assistant E stated, I was afraid that (RN A) would start messing with me. Nursing Assistant E elaborated, I didn't want repercussions to happen to myself and (Resident #701). (Resident #701) was scared to report it because (the Resident) said they were scared. When asked if they had reported the verbal abuse to (discharged Resident #1), Nursing Assistant E revealed they had not but indicated they already reported the abuse towards Resident #701 by RN A. When queried regarding education and training received at the facility related to abuse and reporting abuse, Nursing Assistant E stated, It was very vague, didn't go over who to report to. When asked what was covered in the training, Nursing Assistant E stated, The seven different types of abuse but didn't specify who to report to just to report to someone higher up. Nursing Assistant E then stated, After the incident (with Resident #701), I have been educated by the Administrator and now I know who to go to. When asked if the facility Abuse Coordinator/Administrator phone number was posted in the facility, Nursing Assistant E replied, No. A phone interview was conducted with RN A on [DATE] at 12:00 PM. When asked if they worked midnight shift at the facility on [DATE] and Resident #701's assigned nurse, RN A indicated they were. At this time, RN A indicated they were aware of the reason for the phone call. When queried regarding the care they provided Resident #701 on [DATE], RN A replied, I put (Resident #701's) meds (medications) on the bedside table and then the CNA (Nursing Assistant E) came and got me because the Resident said they dropped them. When asked why they left the Resident's medications on their bedside table, RN A stated, I knew (Resident #701) wouldn't take them. I know I shouldn't have done that. RN A then revealed they entered the Resident's room to look for the medications and stated, I pushed (Resident #701) down on their shoulder. RN A was then asked where Resident #701 was at this time and revealed the Resident was in their bed. When queried why they pushed the Resident down by their shoulder if the Resident was bed, RN A did not immediately answer and then stated, I mean I pushed (the Resident) up to look behind them. (Resident #701) yelled out so I put them down. When asked if they yelled or used profanity when speaking to the Resident, RN A indicated they did not recall doing that. When asked about their tone and demeanor when they entered the room and if they were frustrated or spoke to the Resident in a snippy or rude tone, RN A stated, I can come off that way but most Residents laugh about it. RN A was then asked if they were mad or frustrated with the Resident when they went into their room to look for the medications and stated, I was frustrated. RN A was queried regarding being frustrated and stated, It's always something. We are short staffed. With further inquiry, RN A stated, I had a lot going on. I hurt my knee and wasn't even supposed to be working. My knee hurt. My AC (Air Conditioning) quit, my car quit and my cat died . RN A was then asked if they were experiencing feelings of burnout and replied, Could have been getting burned out- always short staffed. With further inquiry regarding Resident #701 yelling out when they pushed them, RN A stated, I tried to make it up to (Resident #701). I did hurt (the Resident) but I didn't really mean it. RN A was then queried regarding abuse education received at the facility and indicated they completed education assigned by the facility. When asked if abuse education included signs and symptoms of burn out, RN A did not provide a direct response and then stated, I could have been getting burned out. We are always short staffed. Review of facility provided Investigation documentation did not include a staff schedule and/or mental health assessment for Resident #701. Detailed review of documentation included in the provided investigation revealed the following: -[DATE]: Incident and Accident Form . Date of Incident: [DATE] . Time: 2130 (9:30 PM) . Condition prior to incident: alert . Location: Resident room . Incident type: Observed . Staff to Resident: Abuse/Neglect . CNA reported to this writer on [DATE] at 2230 (10:30 PM) that on [DATE] they witnessed the nurse verbally yelling at (Resident #701) and then grab them by their neck and slam them forward. DON (Director of Nursing) and Administrator notified immediately after incident reported to (Nurse F) . -Undated Written Summary: RN A went into (Resident #701) to administer evening medication . Nursing Assistant E then reported to (RN A) that the resident dropped some pills. (RN A) appeared upset per (Nursing Assistant E) . Upon interview, (Resident #701) also got the impression the nurse was upset . Upon interview the Resident pain in their neck was a '5' out of ten. Prior to (RN A) leaning them forward, (Resident #701) did not have any pain in their neck . Conclusion . (RN A) admitted they may have been frustrated at the time they entered the Resident's room The resident instructed (spouse) not to speak to anyone about the incident because they were afraid of retaliation . The (Physician) ordered a cervical spine X-ray, which was abnormal . The Resident was sent to the hospital for further evaluation . Conclusion: Substantiated for mistreatment . -Nursing Assistant E written statement, dated [DATE]: On [DATE], (RN A) went in and gave (Resident #701) their pill without administering them and walked away. I was paged into the room about 9:10 PM. (Resident #701) was upset and asking me to help because they dropped their pills and couldn't find them. I began looking . and did not find them . (Resident #701) was visibly upset . I approached (RN A) and they were furious. They started yelling and swearing and stomped into (Resident #701's) room. (RN A) yelled at (Resident #701) and grabbed their lemonade out of their hand and slammed it on the dresser. Continuing to yell at (the Resident), (RN A) ripped all the blankets off of (Resident #701) and shook them out then I was standing on the right hand side of the bed and (RN A) was on the left. (RN A) reached up and grabbed (Resident #701) by their neck and slammed them forward yelling at me to help move her. I, out of reflex, yelled 'What the hell are you doing?!' (RN A) put their hand on (the Resident's) shoulder and pushed (Resident #701) back into bed. The whole time yelling at (Resident #701( and being belligerent). (RN A) slammed the table back at (Resident #701). (RN A) then threw their hands up in the air and stormed out of the room. I stayed behind because I needed to comfort (Resident #701). (Resident #701) looked at me with terror in their face and said '(RN A) almost broke my back!' I told (Resident #701) don't you worry, I will take care of this. I am so sorry and sat there comforting (the Resident) for 15 minutes. About an hour later, (RN A) asked me, was (Resident #701) really upset. I said yes- you were so cruel. (RN A) said I better go in there and smooth things over so (Resident #701) doesn't report me. -[DATE] at 11:30 AM, RN A Interview: 1. Tell me what happened on [DATE] . '(Resident #701) dropped their pills. I went in to see about the pills . I put my hand on (The Resident's) shoulder and pulled them forward . The Resident stated, 'You are hurting my back.' . I let the Resident seat back. I felt bad that I hurt them . 4. Did you raise your voice to the Resident? 'I wasn't angry. I might have been frustrated.' . 7. Did the Resident complain of pain? Resident stated, 'Back hurt,' I gave them Tylenol. 8. Did you go back to check on the Resident? 'Yes, several times' . 18. Did you use any profanity in the presence of the (Resident #701)? . don't remember saying any profanity. 19. Did the Resident seem upset after you moved them forward? . 'Complained of pain in back.' 'Hurt.' (RN A) stated, 'I felt bad for hurting (Resident #701) . (The Resident) didn't seem bad'. The interview was signed by the facility Administrator and DON but not by RN A. -A skin assessment for Resident #701, dated [DATE]. The skin assessment indicated no new abnormal skin areas were observed. -A pain assessment for Resident #701, dated [DATE] at 3:31 PM. The pain assessment indicated the Resident has pain at three out of 10 on a zero to 10 scale at that time. -Radiology Report, dated [DATE]: Cervical Spine 2 or 3 Views . Results: C2 appears anterior displaced relative to the skull base and C1 . Conclusion: Apparently displaced C2 . Review of Resident #701's hospital documentation from [DATE] to [DATE] included the following: -Date of Service: [DATE]. Patient admitted : Final Diagnoses: [REDACTED]. Xarelto (prescription medication to prevent blood clots) Coagulopathy . History of Present Illness . present to emergency department with complaint of neck injury . patient was assaulted by nursing home staff member, who 'handed the patient like a doll' . The patient states . they accidentally dropped a cup with medication pills provided by the caregiver and the caregiver became extremely furious and mad . The patient is currently taking Xarelto and aspirin . Radiological studies were also reviewed . revealing impression: 1. Newly developed bilateral CSF (Cerebral Spinal Fluid) density, extra-axial fluid collections layering along the frontal and parietal convexities measures up to 9 mm (millimeters), causing mild mass effect on the frontal and parietal lobes (fluid build up around lobes of brain) . The patient will be admitted to ICU (Intensive Care Unit) as per trauma recommendations . An interview was conducted with the Administrator on [DATE] at 1:50 PM. When queried regarding RN A's interview statement not being signed by them, the Administrator stated, I didn't have (RN A) sign it because I was so frustrated. With further inquiry, the Administrator revealed RN A had been fired. When asked if RN A had worked with Resident #701, the Administrator did not answer the question and stated, We began investigating as soon as we were made aware of the allegation. When queried regarding the delay in reporting, the Administrator acknowledged the delay and indicated (Nursing Assistant E) attempted to report the abuse to the Director of Nursing (DON) but the DON had been diagnosed with [REDACTED]. On [DATE] at 8:45 AM, an interview was conducted with Nursing Assistant G. When asked if they had worked with RN A, Nursing Assistant G revealed they had. Nursing Assistant G stated, My first time working in the building, (RN A) was just not helpful. They were always complaining and always had an attitude. When asked what they meant by attitude, Nursing Assistant G revealed RN A acted like, I have too many things to do and didn't have time for the Residents. Nursing Assistant G proceeded to discuss an incident they were aware involving Resident #703 and RN A. Nursing Assistant G stated, (Resident #703) is a tough Resident. (The Resident) is blind and confused but they can tell you want they want. (Resident #703) would yell out 'God help me' repeatedly and (RN A) would shut the door. Nursing Assistant G expressed they did not feel shutting the Resident's door was appropriate because that was how the Resident expressed their needs. Nursing Assistant G then revealed they were informed, by another facility Nursing Assistant that Resident #703 was overhead asking RN A why they slapped them. When asked if they reported the incident, Nursing Assistant G revealed they did and that the DON was aware. Nursing Assistant G was asked when the incident occurred and replied, Maybe a month or a month and a half ago. Record review revealed Resident #703 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited to extensive assistance to completed ADLs with the exception of supervision with eating. On [DATE] at 10:35 AM, Resident #703 was observed in their room, in bed. An interview was attempted to be completed with the Resident at this time. When asked questions, Resident #703 was pleasant but unable to provide meaningful responses to questions responding, I don't feel good today to questions asked. On [DATE] at 10:55 AM, Resident #704 was asked about interactions with staff at the facility and reported there was one nurse (RN A), that a couple of months ago, dropped them in the bathroom and bumped (Resident #704's) head and there was one young girl (nurse aide) working with the nurse. Resident #704 stated, They were supposed to get me on and off the pot. They had put me on and left me for a couple of hours and my legs had gone to sleep. I told them to give me a minute, butt they decided I was getting up then. (RN A) had the belt way up (around chest). (They) went and lifted me up and my legs were giving out, my feet slid and I went back and caught the toilet with one butt cheek. Resident #704 indicated the aide had tried to help with Resident #704's legs during the fall, but The nurse just looked at me. Resident #704 also noted the fire department had to come and get Resident #704 off the floor. Resident #704 continued, RN A was terrible. One night the nurse shoved pills in my mouth with (their) hand. I had been given the wrong medications which caused me to break out so I like to make sure what I am taking is right. Resident #704 reported it happened a second time (shoved pills in Resident #704's mouth), but was more awake and told (RN A) never to do that again. When asked why the pills were shoved in their mouth Resident #704 indicated they believe they had nodded off and stated, That nurse is just nasty. (It's the attitude and tone). (RN A) would screech at you . Further record review indicated Resident #704 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated intact cognition. The resident needs activities of daily living assistance nursing care plan dated [DATE] indicates Resident #704 is able to eat independently and requires a two person assist for bed mobility and transfer. An interview was conducted with Licensed Practical Nurse H on [DATE] at 11:00 AM. When queried regarding observations of RN A, LPN H stated, They were not always kind and patient (with Residents). LPN H stated, (RN A) says things loud and with a tone, like 'You're fine' and 'You got what you needed'. When asked if they had ever witnessed RN A use profanity towards or verbally abuse a Resident, LPN H revealed they observed RN A being disrespectfully. LPN H stated, (RN A) would roll their eyes. An interview was conducted with Nursing Assistant I on [DATE] at 8:56 AM. When queried regarding the facility, Nursing Assistant I revealed they only worked two shifts at the facility on [DATE] and [DATE]. When asked why they only worked two shifts, Nursing Assistant I explained, I did not like the facility at all. They were so short staffed and detailed the two days they worked ended up being 16 hour shifts. Nursing Assistant I further revealed they were left alone on the unit their first day working. Nursing Assistant I was then asked if they worked with RN A and stated, I didn't really see (RN A) all night except for when I had a patient have a fall. I was warned about (RN A). When queried regarding being warned, Nursing Assistant I revealed they were told by other facility nursing assistants that RN A is very difficult to find and can be rude. On [DATE] at 9:26 AM, an interview was completed with Nursing Assistant K. When asked if they had worked with RN A, Nursing Assistant K replied, Yes. Nurse Assistant K stated, I was in the room when (RN A) gave meds because they said they needed a witness. When asked about RN A's interaction with the Resident, Nursing Assistant K replied, (RN A) was kind of pushy. When asked what they meant, Nursing Assistant K stated, Did not greet (the Resident). Went in and said 'Here's your medicine' and walked out. Nursing Assistant K then stated, (RN A) always had smart remarks and would say rude things about the Residents. When asked what type of rude things, Nursing Assistant K replied, Glad we are out of that room. When queried if RN A treated Residents with dignity and respect, Nursing Assistant K stated, No. (RN A) didn't treat them like they were a person like (RN A) just wanted to get their job done and go home. Nursing Assistant K then stated, Sometimes (RN A) was unavailable- like no where to be found and seemed short-tempered. When queried if any other staff had similar concerns and/or observations of RN A, Nursing Assistant K stated, Everyone knew, us CNAs had talked about it quite a few times. a few times. (RN A) was quite honestly, no other way to put it, a bit#h- just rude. When asked if they had reported their concerns regarding RN A's treatment of [REDACTED]. there long enough but looking back I should have. It had been going on a long time. I think one of the senior CNAs would h (TRUNCATED)

This Citation Pertains to Intake Intake MI 947. Based on interview and record review, the facility failed to ensure chemical restraints were not utilized for staff convenience for one (Resident #702) reviewed for chemical restraints resulting in Resident #702 being administered a psychoactive medication ([MEDICATION NAME]) without a healthcare provider order on 8/2/20 at approximately 11:00 PM because the Resident was just going crazy and would not calm down. This deficient practice resulted in an Immediate Jeopardy , Resident #702 experiencing excessive lethargy and the likelihood for harm. The Administrator was notified of the Immediate Jeopardy on 8/12/20 at 2:48 PM. A plan to remove the immediacy was requested. The IJ began on 8/2/20 was removed on 8/12/20 based on the facility's implementation of the plan removal as verified onsite on 8/13/20. Although the IJ was removed, the facility's deficient practice remained at isolated. Actual harm that is not immediate jeopardy. Findings include: Record review of a Facility Reported Incident submitted by the facility related to an allegation of abuse, unrelated to Resident #702, included the following in the undated, narrative summary: During the investigation another concern was brought by a nurse receiving report from (RN A) on another Resident. (RN A) stated that they gave a nursing dose of [MEDICATION NAME] to (Resident #702) . The oncoming nurse assessed (Resident #702) and found them to be drowsy . (Resident #702) was not prescribed [MEDICATION NAME] . During the interview with (RN A), I asked them if they gave the [MEDICATION NAME] to (Resident #702). (RN A) admitted they gave the [MEDICATION NAME] with no order . On 8/12/20 at 9:58 AM, Resident #702 was observed in their room in bed. An interview was completed with the Resident at that time. When asked how they were treated by facility staff, Resident #702 stated, I don't ([***] ) about anything. The Resident did not provide further explanation. When queried if they had any concerns regarding medications and/or medication administration within the facility, Resident #702 indicated they were not aware of any problems. Review of Resident #702's medical record revealed the Resident was recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required none to extensive assistance to perform Activities of Daily Living (ADLs). Review of Resident #702's progress note documentation in the medical record revealed Resident #702 experienced a fall within the facility on 8/1/20. There was no documentation of behaviors and/or agitation on 8/2/20. The documentation included the following: -8/3/20 at 5:27 PM: Nurses' Notes . Resident had an episode of being dizzy with therapy . -8/4/20: Transcribed physician progress notes [REDACTED]. The patient was very lethargic yesterday reports they think everything was fuzzy all day long and does not remember much that happened . -8/5/20: Nurses' Notes . Resident fell on [DATE]. X-ray of left hip ordered and shows displacement. (Doctor) notified and received orders to transfer resident to (Hospital) . Patient transferred via EMS. Review of Resident #702's healthcare provider orders and MAR indicated [REDACTED]. An interview was completed with the facility Administrator on 8/12/20 at 11:30 AM. When queried regarding Resident #702 receiving a [MEDICATION NAME] when they did not have an order for [REDACTED].#702) a nursing dose. The Administrator was asked what a nursing dose was, the Administrated stated, (RN A) said they couldn't get a hold of the Doctor so they just gave it (medications). When asked where RN A obtained the controlled, narcotic medications they administered to Resident #702, the Administrator replied, (RN A) said they gave (Resident #702) (an un-sampled Residents) meds. Review of facility provided investigation documentation pertaining to Resident #702 included the following: -Interview with RN A, dated 8/6/20 at 11:30 AM: 1. Can you tell me what happened you gave report to a nurse and stated you gave (Resident #702) a 'nursing dose' and (the Resident ) was really sleeping all day. Could not do therapy. (RN A) stated, '(Resident #702) thought they were in a hotel, trying to get out of bed. I gave them a [MEDICATION NAME] . 2. (Resident #702) does not have an order for [REDACTED]. 3. Do you know what mg (milligram)? (RN A) stated, 'No.' 4. Did you sign out the medication? (RN A) stated, 'Yes, in the narc book for (un-sampled Resident)' . 5. Did you chart on (Resident #702)? (RN A) stated, 'No.' 6. Why didn't you call the doctor? (RN A) stated, 'I put it in the doctors book.' 7. What did you think was going on with the Resident? (RN A) stated, 'I thought their ammonia level (may be elevated in kidney or liver disease and can cause coma and death if untreated) off' . -Undated, written statement by Nursing Assistant G: On 8/3/20, (RN A) was the nurse (on night shift) . (RN A) came down to finish passing meds then went into (Resident #702's) room. I asked what they were doing . I had just checked on them and they were sleeping. (RN A) ;looked and me and said you're not a narc are you. I then said no. (RN A) said okay- you don't look like one anyway . I gave (Resident #702) something good . (Resident #702 ) asked (RN A) if it would make them sleep, that they didn't want anything that made them pass out and (RN A) told them No. (RN A) said they felt bad but (Resident #702) was bad all night they couldn't do it no more . I went in at 7:30 AM and yelled their name four times, I got louder and louder with each name call and (Resident #702) never moved) . didn't eat breakfast . did the same at lunch . When I left at 2:00 PM, (Resident #702) was still immobile. -Statement by Nurse M dated 8/3/20: (Nurse M) stated to this author that in am . (RN A) stated they gave (Resident #702) a 'nursing dose' and will be 'sleeping all shift. (Nurse M) asked what is a nursing dose? (Nurse M) stated (RN A) responded I gave them an [MEDICATION NAME] and a [MEDICATION NAME] because (Resident #702) is almost 300 pounds. (Nurse M) liked to see a [MEDICATION NAME] and ordered and stated (Resident #702) didn't have either ordered. -Medication Discrepancy Report dated 8/3/20: Unauthorized Drug (drug administrated without a physician's orders [REDACTED]. Nurse for Resident received report from midnight nurse on 8/3/20 that Resident received a 'nursing dose, will sleep all shift' . Outcome to Resident . Resident c/o (complain of) feeling dizzy during therapy . -Individual Resident's Controlled Substance Record for August 2020 Medication Administration Record [REDACTED]. A phone interview was conducted with RN A on 8/12/20 at 12:00 PM. When asked if they provided care to Resident #702 on 8/2/20, RN A revealed they were and indicated the facility Administrator had already spoke to them. When queried what occurred during the shift related to Resident #702, RN A stated, (Resident #702) was just going crazy and would not calm down. When asked why the Resident was upset and/or agitated, RN A did not provide an explanation but stated, (Resident #702) thought they were in a hotel. When asked if the behaviors were new for Resident #702 and what assessment and interventions were taken, RN A indicated the behaviors were new and that the Resident did not have any orders for medications for behaviors. When asked what non-pharmacological interventions were attempted to calm the Resident, RN A revealed they did not attempt any non-pharmacological interventions. When asked if they contacted the Resident's physician, RN A replied, No because you get an online system so I gave them (an un-sampled Resident's) [MEDICATION NAME]. When asked why they would purposely administer a controlled substance, psychoactive medication to a Resident that it was not ordered for, RN A reiterated their previous statement that Resident #702 was just going crazy. RN A then stated, I shouldn't have done it. I picked up some bad habits. No further explanation was provided. When asked why they did not document Resident #702's new and unusual behaviors in the Residents medical record, RN A did not provide a response. An interview was completed with the Director of Nursing (DON) on 8/13/20 at 8:32 AM. When queried regarding Resident #702 receiving a [MEDICAL CONDITION] medication not ordered for them, the DON revealed they were aware of the incident. When asked how they were made aware of the incident, the DON revealed the day shift nurse who received report from RN A informed the Unit Manager of what occurred. When queried why an Incident and Accident Report was not included in the provided investigation, the DON reviewed the investigation file, confirmed there was not an Incident and Accident Report in the file and stated, I know there was one. Upon request, the DON indicated they would look for the Incident and Accident Report. An interview was conducted with Licensed Practical Nurse (LPN) H on 8/13/20 at 11:00 AM. When queried, LPN H revealed they did not provide care to Resident #702 on 8/2/20 or 8/3/20. When asked if they had worked with RN A, LPN H indicated they worked day shift and RN A worked night shift and stated they would follow RN A. LPN H was then asked if they noted any discrepancies with narcotic and/or psychoactive medications for Residents after RN A worked and replied, Yes, like a narc (narcotic/controlled substance medication) would be signed out in the book (facility narcotic count book) but not documented in the MAR (Medication Administration Record). When asked about facility policy/procedure related to this and if they reported the inconsistencies, LPN H indicated they did not report the discrepancies. When asked about the Resident's condition following the unauthorized administration, LPN H revealed the Resident was very lethargic and indicated they were assessed by the Health Care Provider. When asked why the provider documentation did not indicate Resident #702 received a non-prescribed medication and why they were not seen until 8/4/20 for lethargy, LPN H stated, The Doctor saw the Resident (on 8/3/20) before they were notified (about the medication) and the Nurse Practitioner saw them the next day (8/4/20). On 8/13/20 at 8:45 AM, an interview was conducted with Nursing Assistant G. When queried regarding Resident #702 on 8/3/20, Nursing Assistant G stated, I was doing room to room checks and (RN A) came around and peeked in (Resident #702's) room. I asked what they were doing. (RN A) came out and said to me, 'You're not a narc are you?' and 'You didn't look like one.' (RN A) told me they gave (Resident #702) two little pills. When asked if RN A told them the names of the pills they gave the Resident, Nursing Assistant G revealed they could not remember and stated, I'm not good with the names. Nursing Assistant G then stated RN A told them that they told (Resident #702) it was Tylenol. Nursing Assistant G revealed that RN A told them Resident #702 had asked if the pills were going to knock them out and RN A said they felt guilty but told (Resident #702) no. When asked if anything else occurred, Nursing Assistant revealed RN A then told them they gave (Resident #701) some good stuff and the Resident should be out for awhile. Nursing Assistant G was asked what they did next and replied, I left the hall because I felt very uncomfortable. I honestly didn't know what to do with the info. I told (Nurse M). Nursing Assistant G revealed Nurse M told them that was not okay and that Resident #702 was not even prescribed that. Nursing Assistant G was asked about Resident #702 during their shift and stated, I went in there (room) for breakfast about 7:30 AM and said (Resident #702's) name progressively louder with no response at all. With further inquiry, Nursing Assistant G revealed they went back into the Residents room around 10:30 AM and Resident #702 was slurring. Nursing Assistant G revealed the Resident did not eat their lunch and stated when they went in around 2:00 PM, Resident #702 was still sleeping. Nursing Assistant G then stated, (Resident #702) was drinking their own urine. They were not in a normal state of mind and hadn't been awake for more than 15 minutes all day. Review of facility provided Incident and Accident Report for Resident #702 revealed the following, Date of Incident: 8/3/20 . (Nurse M) for 8/3/20 was getting report from midnight nurse (RN A) who stated . that they gave (Resident #702) a 'nursing dose', (the Resident will be sleeping all shift. (Nurse M) asked what is that and (RN A) responded, I gave [MEDICATION NAME] and [MEDICATION NAME] and both because (the Resident) is almost 300 pounds. (Nurse M) later realized that the Resident doesn't have either medication ordered . Treatment: Assessment/Neurochecks . Resident (notified) . 8/10/20: Returned from Hospital . Documentation of neurochecks for Resident #702 were not provided nor noted in the Residents medical record documentation. Review of facility provided policy/procedure entitled, Abuse Prevention Program (Revised: 2/22/18) revealed, Our residents have the right to be free from abuse, neglect . and any physical or chemical restraint not required to treat a Resident's symptom . Our facility will not condone resident abuse by anyone, including staff members . Facility Abatement Plan: 1. Affected Resident Resident #702 was assessed by the Physician on (8/3/2020) to determine any unwanted effects of Receiving medication on 8/2/2020. And again assessed by the NP for unwanted effects on 8/4/2020. No adverse effect were noted. The interdisciplinary team has reviewed resident #702 to ensure care plans and interventions are Based on assessments for behaviors. Updates were made to the plan of care on (8/12/2020) Identification of other residents Residents with noted behaviors have been reviewed by Social Services to ensure no [MEDICAL CONDITION] medications are needed on a PRN basis on 8/12/2020. Any resident requiring PRN [MEDICAL CONDITION] medication currently have a current physician order. Residents receiving PRN [MEDICAL CONDITION] medications have been reviewed by the interdisciplinary team to assure proper [DIAGNOSES REDACTED]. (8/12/2020) The DON has reviewed current resident's narcotic sign out sheets to ensure administration of said medications match the sign out sheets. No further concerns have been noted. On 8/13/2020 2. Actions to Prevent Occurrence/Recurrence: The Administrator and DON have reviewed the Abuse policy and have deemed it appropriate on 8/12/2020. 13 out of 42 licensed nurses have been re-educated by (The DON /Designee) on proper use of prn medications for behavior & that a Physician order [REDACTED]. On 8/12/2020, No Licensed Nursing staff will work past (8/12/2020 at midnight) without first receiving re-education. 3. The DON will audit the narcotic sign out sheets weekly to ensure administration of medications are accounted for in the MAR's Audits will be brought to QAPI monthly for review and recommendations until sustained compliance is achieved The Administrator is responsible for sustained compliance

This citation pertains to intake 8. Based on observation, interview, and record review the facility failed to safely transfer two (#30 and #104) sampled residents of two reviewed for accidents, from a wheelchair to bed using a hoyer lift, resulting in deep skin tears to the legs of both residents and sutures to resident # 30. Findings include: On 10/14/19 at 9:46 AM, Resident #30 was observed laying in bed with a low air loss mattress with their legs elevated. Resident #30 was asked about an incident that occurred on 10/2/19 and stated, Skin healed, I don't remember how it happened. On 10/15/19 at 11:15 AM, the resident's medical record revealed, Progress Note: 10/2/2019 05:21 Nurses' Notes: CNA (Certified Nursing Assistant ) was transferring resident from w/c (wheelchair) to bed and resident acquired a deep skin tear to left lateral lower. Adipose extremity tissue is exposed . NP (Nurse Practitioner) was notified and ordered to send resident to hospital for evaluation and treatment. Progress Notes: 10/2/19 10:01:37. IDT (Interdisciplinary Team) met to go over res (resident) skin tear. Res was being transferred back to bed after being toileted, back to bed. This happened at 0500 (5:00 AM). Cena (CNA) transferred res back into bed, res stated my leg, my leg, cena noted blood on bed and went and got charge nurse. Nurse assessed res and called MD (Medical Doctor) on call and NP gave verbal order to send res out to hospital for evaluation and treatment. Will have maintenance examine wheel chair for any sharp edges. On 10/15/19 at 10:00 AM, a review of the facility's incident and accident report revealed, 10/2/19 (Resident #30). Witness ((CNA J)), Incident Type: Observed, Location: Resident room, Injury type: Skin Tear. Treatment: Call 911. Assessment, First Aid, Sent to Hospital. Action taken: Assistive Device, Staff Re-education. Attached was a form titled Nursing Home To Hospital Transfer Form that noted, (Resident #30), Key Clinical Information: to left lower extremity - skin tear (deep) adipose. Most recent Pain level: 10/10. A review of CNA J's hand written statement revealed: Around 5:00 am (unknown resident) . was calling as (they) normally dose (does) . Afterwards (unknown resident ) roommate (Resident #30) asked to go the bathroom. I got (Resident #30) up toileted (them). Afterwards took (Resident #30) back to (their) bed. I pulled the chair up to the bed pivoted (Resident #30) to the bed, It was then (Resident #30) said 'My leg my leg' I looked down there was blood on the floor and a tear on (Resident #30's) leg. I put (Resident #30) in bed and went and got the charge nurse. I'm guessing (Resident #30's) leg got caught on the back of the wheelchair while I was transferring (them). Signed CNA [NAME] On 10/16/19 at 10:25 AM, a wound care observation was completed with Physician G, Nurse H, and Nurse I. Physician G reported the measurements as the following, Length 3.3 centimeters (cm), Width .5 cm, No depth, and 30% necrotic tissue. On 10/16/19 at 12:25 PM, the Director of Nursing (DON) was asked for the facility's investigation regarding the incident. The DON stated, The I/A (incident and accident) report and the statement from the CNA is the investigation. We got a statement and he (CNA J) reenacted what happened with the nurses. The resident's leg was hit while pivoting to the bed on the leg rest of the wheelchair. At that time the phone number for the staff involved with the incident was requested. On 10/16/19 at 1:10 PM, CNA J was called, the person that answered the phone stated that he was not CNA J and that he did not work at this facility. On 10/16/19 at 2:35 PM, Nurse K was interviewed via phone and was asked about the incident with Resident #30. Nurse K stated, The CNA (CNA J) came to get me, and when I went into the room (Resident #30) was in bed. I asked what happened. He reenacted what happened. (Resident #30) hit (their) leg. The w/c has a part on it that (Resident #30's) leg got caught on. It was during standing motion when it happened. Nurse K was asked if CNA J was moving fast. Nurse K stated, I don't know, but (Resident #30) was upset and said that he (CNA J) was moving fast. On 10/16/19 at 2:40 PM, further review of Resident #30's medical record revealed, Progress Note: 10/2/2019 11:50 Nurses Note Text: Patient returned from . hospital @ (at) 1150 via EMS (emergency medical services ) . Patient received 4 sutures to left lower leg, to be removed by facility in 7-10 days. Physician notified of arrival. Resident #30 was admitted into the facility on [DATE], with a [DIAGNOSES REDACTED]. Resident #30's Care plan noted, Care plan: Focus: The resident has actual impairment to skin to left shin, bilateral buttocks, mid upper back Date Initiated: 8/3/2019. Revision on: 10/11/2109. Interventions: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 08/02/2019. On 10/16/19 at 1:36 PM, the Administrator was asked about the incident with Resident #30. The Administrator stated, (Resident #30's) skin is very frail. It happened during a transfer. The Administrator was asked if it was reported that CNA J was moving too fast. The Administrator stated, No it was not. The Administrator was asked had CNA J ever had complaints from residents. The Administrator stated, Yes. We have had to educate him about moving too fast, we had a complaint about it. Resident #104 On 10/14/19 at 9:32 AM, R104 was observed in bed wearing oxygen via nasal canula. R104 was asked if they had any wounds and stated, I have a bad cut on my leg. The Nurse was getting me out of bed with the lift and hit my leg with it. It really hurt when that happened. R104 was observed with a dressing on their right lower leg. On 10/15/19 at 3:15 PM, a review of R104's medical record noted a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated , 7/23/19 noted, that R104 required extensive assistance of two plus persons with all activities of daily living. The care plan initiated 7/24/19 and revised on 10/10/19 noted, The resident will be free of serious injury . Resident is able to transfer with Hoyer . A review of the progress note dated 10/8/19 at 2:57 PM, Created by Nurse L, noted, Resident being transferred via hoyer lift, residents Right shin hit battery on hoyer skin tear occurred, care plan updated to reflect three person transfer. Wound order written . A review of the Skin Progress Note created by Nurse Q, on 10/10/19 at 5:19 PM noted, Right shin-3.1x2.7xUtD (unable to determine depth), Resident obtained skin tear from Hoyer transfer. The Incident report dated 10/8/19 noted that R104 was being transferred via hoyer lift, and R104 right leg hit the battery on the hoyer and a skin tear occurred. On 10/15/19 at 11:00 AM, the Administrator was interviewed regarding the hoyer lift and R104. The Administrator stated, I think it was two CNA's (Certified Nursing Assistant) that were transferring (R104). The Nurse writes the Incident report. No additional information was reported about the skin tear and the hoyer lift. On 10/16/19 at 9:49 AM, R104's wound care was observed with Nurses H and I. The wound was observed as an open laceration exposing beefy redden tissue, and a large fold of non-intact skin pulled to the right. On 10/16/19 at 11:57 AM, CNA R was interviewed regarding the hoyer lift and R104. CNA R stated, The bed was up a little too high, when we were moving (R104) with the hoyer lift, (R104's) leg hit the hoyer battery. On 10/16/19 at 1:48 PM, Nurse L was interviewed regarding the hoyer lift and R104. Nurse L stated, We were transferring the resident to a chair and (CNA R) raised the bed too high and (R104) hit their leg on the battery. A review of the facility's policy titled Quality of Care undated, noted, .The resident's plan of care will address the risks involved with the resident . The policy did not address the procedure for a hoyer or wheelchair transfer.

This citation pertains to 2 Based on interview and record review, the facility failed to initiate preventative measures to prevent the development and worsening of a pressure ulcer of one (R200) of three sampled residents reviewed for pressure ulcers, resulting in the development, worsening, and infection of a pressure wound. Findings include: On [DATE] at 8:40 AM, an interview was conducted with family member A regarding R200's stay in the facility. Family member A said, (R200) was admitted into the facility for therapy. How did they develop such a bad wound on their bottom while in their care? (R200) had only a little redness to their bottom when admitted . There should do something with the nursing home laws. (R200) lived alone and was able to take care of themselves before this. The facility did not tell us that (R200's) wound was so bad. We told the facility to send (R200) to the hospital, but they kept saying that they can take care of the wound there. We demanded that they send (R200) to the hospital. Family member A was asked if R200 was currently in the hospital. Family member A said. No. (R200) died a few days ago. On [DATE] at 10:15 AM, a review of R200's medical record noted an admission on [DATE] with a primary [DIAGNOSES REDACTED]. R200's medical history included [MEDICAL CONDITIONS] (respiratory disease), [MEDICAL CONDITION], and [MEDICAL CONDITION] Infarction ([MEDICAL CONDITION]). R200's Brief Interview for Mental Status (BIMS) score was ,[DATE] indicating a moderately intact cognition. The Minimum Data Set (MDS) assessment noted that R200 required extensive assistance with activities of daily living (ADLs) such as: Two plus persons physical assistance with bed mobility (turning and repositioning), and transferring from the bed, chair, wheelchair. A review of the care plan dated [DATE] and revised on [DATE] noted: The resident has impairment to skin integrity. Intervention: Follow protocols for treatment of [REDACTED]. A review of the Initial Skin assessment dated [DATE] noted the following: Coccyx [DIAGNOSES REDACTED] (redness). Other: Bilateral lower arms multiple areas of discoloration, left calf scab area, right inner ankle [DIAGNOSES REDACTED] and left heel, right temple area of discoloration and scab area. No treatment plan was initiated. A review of the progress note dated [DATE] at 11:17 AM by the Physician Assistant B noted the following: History Of Present Illness: Patient is being evaluated per nursing request due to nausea and dry heaves. Patient also reports of burning sensation in feet and heels Skin: No new sores or pruritus no abnormal [MEDICAL CONDITION] . Skin: Incision right hip clean dry and intact no drainage is noted on dressing, normal to inspection no suspicious [MEDICAL CONDITION] or rash noted, Warm and dry. A review of the progress note dated [DATE] at 12:35 PM by the Physician C noted the following: Skin: No new sores or pruritus no abnormal [MEDICAL CONDITION] .Will float heels while in bed no open areas noted to heels . Continue patient's pain medication for pain control. A review of the Skin assessment dated [DATE] at 11:39 PM noted the following regarding the coccyx area: Left gluteal fold-[DIAGNOSES REDACTED], quarter sized open area with yellow colored tissue present. Right gluteal fold-[DIAGNOSES REDACTED], 3 small open area. Bilateral heels [DIAGNOSES REDACTED]/boggy. There was no documentation located that the skin assessment was communicated to the physician, and no treatment plan was initiated. A review of the progress note dated [DATE] at 12:26 PM by the Physician C noted the following: Skin: Incision right hip clean dry and intact no drainage is noted on dressing, normal to inspection no suspicious [MEDICAL CONDITION] or rash noted, Warm and dry, no open areas to heels. A review of the progress note dated [DATE] at 12:50 PM by the Physician Assistant B noted the following: Skin: Incision right hip clean dry and intact no drainage is noted on dressing, normal to inspection no suspicious [MEDICAL CONDITION] or rash noted, Warm and dry. A review of the Skin assessment dated [DATE] at 7:28 PM noted the following: Right trochanter (hip)-post hip drsg (dressing) intact. No additional documentation on the Skin Assessment regarding the coccyx area noted on this date. A review of the progress note dated [DATE] at 10:15 AM by the wound care physician [NAME] noted the following: R200 seen by wound care for a new wound discovered to (their) coccyx. Wound care was asked to evaluate and treat. (R200) is currently lying in bed general weakness. (R200) is alert and oriented x2 (person and place) and cooperative. (R200) is incontinent of bowel and bladder .Wound Location: Coccyx, Type: Pressure unstageable. Description: Pale yellow slough is appreciated loosely situated periwound areas clean and moist no odor scant serous exudated is appreciated. Wound is nontender. No flocculence. There is some mild excoriation to the periwound area reminiscent of moisture associated skin damage. However the base of this area is still [MEDICATION NAME] with some dry and flaking of skin. Size: 1.5 cm 9 (centimeters) x 2.3 cm by UTD (unable to be determined). No tunneling or undermining .Plan 1. Cleanse wound with wound cleanser and dry. 2. Apply silvakoliagen to the wound base and cover with 6x6 border foam .change daily. 3. Keep area clean and dry. Reposition patient frequently. Pressure flow mattress. Wheelchair cushion. Reviewed with nursing. 4. Nutrition support hydration. A review of the progress note dated [DATE] at 2:48 PM by the Wound Care Nurse F noted the following: Resident admitted with coccyx wound 1.5x2.3 x UTD . A review of the progress note dated [DATE] at 6:51 AM by Nurse G noted the following: Cleanse right and left buttock w (with) wound cleanser and apply silvakollagen to wound (every) day and as needed. A review of the progress note dated [DATE] at 1:14 PM by the Physician Assistant B noted the following: Skin: Positive tenderness coccyx region with positive drainage on (R200) dressing and foul odor. A review of the medical orders ordered by Physician Assistant B on [DATE] noted culture coccyx wound r/t (related to) odor. A review of the progress note dated [DATE] at 12:10 PM by the wound care physician [NAME] noted the following: Location: Coccyx. Type: Pressure unstageable. Description: Pale. Infection is appreciated this is easily debrided at bedside sharp debridement (removal of dead tissue with a scapal). Once debrided, granulation tissue was noted. Also no undermining standing cephalad. Is mildly tender. Moderate to heavy purulent drainage which was expressed .There is an area extending in a butterfly pattern on either side wound opening showing early slough formation. Wound edges are not attached because of the underminining noted .Size: 1.7 cm x 6.4 cm by UTD. There is undermining appreciated 4cm 12:00 to 2:00 . 1. Cleanse wound with wound cleanser and dry. 2. Sharp debridement to remove devitalized tissue and liquefaction tissue. In the undermining area apply [MEDICATION NAME] gauze gently packed .3. Reposition patient frequently. Pressure offload strategies including sharp mattress,wheelchair cushion. A review of the progress note dated [DATE] at 4:00 PM by the Infection Disease Nurse Practitioner H and Physician [NAME] noted the following: Wound noted to be infection (infected) with heavy drainage. Wound culture is pending. Patient complains of increasing pain and discomfort. Surrounding skin is red and inflamed, wound base with slough tissue, wound is deep. Will start [MEDICATION NAME] and [MEDICATION NAME] (antibiotics), pending final culture results. A review of the wound culture report dated [DATE] noted the following: Aerobic Culture wound: Organism 1. Heavy growth Escherichia Coli. Organism 2. Heavy growth [MEDICATION NAME] Faecalis. A review of the progress notes dated [DATE], [DATE], [DATE], [DATE] and [DATE] noted the following by Nurse J, Encouraged resident to stay off backside. Per the MDS, R200 requires two or more-person assistance with positioning. A review of the progress note dated [DATE] at 11:04 AM by wound care physician [NAME] noted the following: 1. Coccyx wound measurement: 2.8 cm x 5.5 x 2.0 .undermining noted 9:00 to 1:00 at a depth of 3.0 cm. 2. Left heel blister-The blister is intact and serous filled .size 2.0 cm x 4.0 cm. A review of the progress note dated [DATE] at 7:07 PM by Nurse J noted the following: Resident sent to (hospital) per family request for wound care treatment at 1500 (3:00 PM). Family took all belongings at the time of discharge. On [DATE] at 1:10 PM, the DON was interview regarding the wound of R200. The DON said, I don't remember that wound without looking at the chart, I will check with my unit manager. On [DATE] at 1:21 PM, Unit Manager K was interviewed regarding the wound of R200, I only rounded once and cannot tell you anything about (R200) wound. The wound care nurse quit. They walked out around [DATE]. They never came back (to the facility). Should I ask the DON to come back in and speak with you? On [DATE] at 1:27 PM, the Unit Manager L was interviewed regarding the wound of R200. Nurse L said, There are two initial skin assessments, so, I'm assuming the second one (skin assessment) is the correct one. Unit Manager L was asked how they came to that conclusion. Unit Manager L said, the second one is more thorough. On [DATE] at 1:41 PM, the DON was interviewed regarding the wound of R200. The DON said, I believe that an infection disease physician saw (R200). The DON and Unit Manager L were asked if they completed an initial assessment and did R200 enter the facility with a wound. The DON said, I'm not sure. The wound care nurse walked out and never came back. The DON was asked who took the place of the wound care nurse. The DON said, The Unit Managers and I covered wound care. The Norton Plus Pressure Ulcer Scale (used to assess the risk for pressure ulcer in adult patients) noted the following scores: [DATE]: 15-Moderate Risk for wound [DATE]: 14- Moderate Risk for wound [DATE]: 16-Low Risk for wound On [DATE] at 2:20 PM, the wound care policy Pressure Ulcers/Pressure Injury Prevention and Treatment - Clinical Protocol was reviewed with the Administrator, DON, Unit Managers K and L: 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. The Administrator, DON, Unit Managers K and L were asked if the facility followed their policy. The Administrator said, Well, according to the documentation in the medical record, the nurses did not follow the policy for (R200). The Administrator was asked where did the breakdown occur. The Administrator said, The wound care nurse was having difficulty. We noticed it during a QAPI (Quality Assurance Performance Improvement) meeting. Unit Manager K said, We wanted (the wound care nurse) to be successful. We tried to assist. The DON was asked how long the wound care nurse in that position. The DON said, For a few months. On [DATE] at 2:41PM, The Wound Care Nurse M was called and interviewed regarding the wound of R200. Wound Care Nurse M said, I did not care for (R200) wound until the end of my employment at the facility. (R200) wound was a stage two. The position became very overwhelming for me. On [DATE] at 3:05 PM, Physician C was called and interviewed regarding the wound of R200. Physician C said, From my understanding, the wound developed somewhere after (MONTH) 2. The wound continued to worsen and then (R200) was sent to the hospital. On [DATE] at 3:15 PM, Physician Assistant B was called and interviewed regarding the wound of R200. Physician Assistant B said, I don't remember the day, however, I was walking down the hall and saw (R200) in (their) room. When I walked in, I noticed a horrible smell. I asked (R200) if I can look at (R200) bottom. There was a lot of drainage and the smell was bad. I ordered a wound culture and (R200) was started on antibiotics.

Based on observation, interview, and record review, the facility failed to ensure appropriate care and management to prevent infection of an indwelling suprapubic catheter (catheter inserted into the bladder by means of a surgically placed incision in the abdomen) for one of one sampled Residents (#708) reviewed for catheter care, of a total sample of 24 Residents, resulting in Resident verbalization of dissatisfaction with care, repeated urinary tract infections, and the potential decline in overall health status. Findings include: Record review on 4/24/17 at 12:00 PM revealed Resident # 708 was originally admitted to the facility on [DATE] and was most recently readmitted to the facility 2/22/17 with [DIAGNOSES REDACTED]. The Resident #708's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete Activities of Daily Living (ADL's). Additional record review revealed that Resident #708 had been discharged and readmitted to the facility multiple times due to hospital admissions. Dates included: discharged [DATE] and Readmitted [DATE] discharged [DATE] and Readmitted [DATE] discharged [DATE] and Readmitted [DATE] discharged [DATE] and Readmitted [DATE] discharged [DATE] and Readmitted [DATE] discharged [DATE] and Readmitted [DATE] On 4/24/17 at 2:30 PM, Resident #708 was observed lying in bed in their room. The Resident's positioning in the bed was not straight, with the Residents head tilted slightly down and to the right side. The Resident's suprapubic catheter tubing was observed with large amounts of sediment. The tubing also had a large amount of a white colored substance that appeared to be thick in consistency. When queried, Resident #708 stated, I feel awful today, I can't seem to catch my breath. I asked the aid to get the nurse for me. Nurse Q entered the Resident's room at this time. On 4/24/17 at 3:00 PM a record review of Resident #708's medical record revealed that the Resident was sent to the emergency room (ER). On 4/25/17 at 6:10 AM, an interview was conducted with Nurse A. When queried regarding Resident #708, Nurse A stated, (Resident #708) was transferred out for chest pain and pressure yesterday. When queried further, Nurse A replied, The ER said (the Resident's) potassium (electrolyte that effects muscles and cardiac function) was high and I think (the Resident) is going to be admitted . On 4/25/17 at 11:00 AM, additional record review of Resident # 708's medical record revealed an intervention within the Residents Active Care Plan to Change suprapubic catheter on the 15th of every month and prn (Date Initiated: 01/27/2017). Documentation within the Resident's medical record revealed the last time that Resident #708's suprapubic catheter had been changed was on 2/15/17. During an interview with Nurse A on 4/25/17 at 11:30 AM, when queried regarding the condition of Resident #708's suprapubic catheter and changing the catheter, Nurse A replied, I'm not sure off the top of my head but I will look. Should be in the TAR (Treatment Administration Record). Nurse A proceeded to review documentation within Resident #708's medical record and stated, I don't see any documentation that it was changed. I will have to get back to you. An interview occurred with Nurse A on 4/26/17 at 8:00 AM. When queried, Nurse A stated, (The Resident) is back from the hospital. When queried regarding Resident #708's suprapubic catheter, Nurse A stated, I found the order for it to be changed on the 15th of every month but that order was discontinued on 2/22/17. When queried why the order was discontinued, Nurse A was unable to provide a response. When queried regarding facility policy pertaining to indwelling catheters including care and changing, Nurse A replied, I believe our policy is that we only change them if there is a reason to change them. When asked if a catheter with a large amount of sediment in the tubing and a large amount of a thick appearing, white colored substance would be an indication to change the catheter, Nurse A stated, I would think so. On 4/26/17 at 9:00 AM, Resident #708 was observed in their room lying in bed. The Resident's catheter tubing was clear and draining clear yellow urine with a small amount of white colored sediment noted in the tubing. Record review on 4/26/17 at 11:00 AM of Resident #708's Health Care Provider orders revealed the order to change the Residents catheter the 15th of every month was discontinued on 2/22/17 with the reason listed in the notes section of the order as discharged to hospital. On 4/26/17 at 1:30 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding care and maintenance suprapubic catheters within the facility, the DON stated, Catheter changes are completed as needed. When queried if a catheter with a large amount of sediment and a large amount of a thick appearing, white colored substance in the tubing would be an indication to change the catheter, the DON replied, Absolutely. When queried regarding the discontinued order to change Resident #708's catheter, the DON stated, (Resident #708) went to the hospital and was then readmitted to the facility. I cannot say why the order was discontinued. The only orders in there now are the normal protocol orders. When queried regarding how many urinary tract infections that Resident #708 has had while at the facility, the DON reviewed the medical record and stated, Well, there are two positive UA's (urinary analysis- indicating infection) in March and two positives in April. (The Resident) was in and out of the hospital a few times in January and February. When queried if the Resident was being treated for [REDACTED]. Record review with the DON at this time revealed that the results of Resident #708's most recent urinalysis with culture and sensitivity were received by the facility on 4/16/17 and revealed the Resident had a urinary tract infection caused by the bacterium Pseudomonas Aeruginosa. When queried if Resident #708's urinary tract infections are connected to the catheter care provided in the facility, the DON replied, Yes, I see what you are saying and the connection. We definitely have work to do with staff education here. I haven't been here that long and we just hired a new in-service director too. An interview was conducted with Resident #708 on 4/26/17 at 2:45 PM. When queried regarding the suprapubic catheter, Resident #708 stated, The aide changed the tubing part today. With further inquiry, the Resident stated, All they (facility staff) ever do is change the tubing or the bag part. They never change this part (the Resident pointed to the actual catheter that is inserted into the abdomen), isn't this the part that really matters? Resident #708 additionally stated, I always have infections, could that be why? When asked if the aid unhooked the catheter tubing (drainage system) from the catheter that is inserted into the abdomen to change the tubing, the Resident replied, Yeah. An interview was conducted with Nurse N on 4/26/17 at 3:00 PM. When queried if aides change catheter tubing or drainage bags due to sediment or build up in the bag/tubing, Nurse N stated, Yes, if they think they need to be changed. When queried why the catheter is not changed, Nurse N did not provide a response. When questioned when the last time that Resident #708's suprapubic catheter had been changed, Nurse N reviewed the Resident's medical record and stated, I guess not since February. That upsets me, should have been done. Record review of facility policy entitled Catheter Care, Urinary (Revised Date 03/23/2011) revealed Never disconnect the catheter drainage system. A facility policy and/or protocol pertaining to changing indwelling catheters and drainage systems was requested but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to identify and implement interventions, including reassessment, updating food preferences and providing nutritional supplements to prevent significant weight loss for 2 (#'s 702, 704) of 6 residents reviewed for weight loss from a total sample of 21 residents, resulting in significant unplanned weight loss and the potential for the residents to not maintain their highest level of well being. Findings include: On 4/24/17 at 10:30 am, a record review indicated, Resident #704 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The resident also sustained a right [MEDICAL CONDITION] after falling at the facility on 7/28/16 and severe unplanned weight loss. The Minimum Data Set assessment (MDS), dated [DATE] indicated, the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. The resident required extensive 1 person assistance with transfers, dressing, hygiene and toileting and was able to feed self with set up assistance. The resident did not walk. An observation and interview on 4/24/17 at 12:40 PM revealed, Resident #704 was sitting in bed watching TV. When queried about lunch, the resident stated, It was ok. A record review of the resident's weight on 4/24/17 at 2:30 PM revealed the following: 12/7/16 93.8 pounds (lbs). 1/4/17 87.6 lbs. 1/31/17 85 lbs. 2/1/17 85 lbs. 2/9/17 83.6 lbs. 2/22/17 82.8 lbs. 3/2/17 82 lbs. 4/10/17 77 lbs. 4/24/17 The Dietitian documented a weight of 79.4 lbs, but it could not be located elsewhere in the medical record. The resident lost 16.8 lbs., between December 7, 2016 and April 10, 2017. On 4/25/17 at 2:35 PM, a review of the Nutrition Data Collection/Evaluation's, completed by the Registered Dietitian revealed: Nutritional assessment dated [DATE] indicated, the resident weighed 90.4 lbs., Ideal Body Weight (IBW) 90-110 lbs. with a regular diet and approximately 75 percent (%) intake of meals, meeting estimated nutrient needs via meals .continue current plan of care. Nutritional assessment dated [DATE] indicated, Resident #704 weighed 85 lbs. and was on a physician prescribed weight loss program, because she received a diuretic, but had No [MEDICAL CONDITION] (swelling). Resident is underweight (BMI 17). Resident is triggering significant weight loss x 90 days. Meds reviewed: diuretic may contribute to weight fluctuations. [MEDICATION NAME] (an antidepressant may stimulate appetite .continue current plan of care. Nutritional assessment dated [DATE] indicated, Resident #704 weighed 82 lbs, with IBW 99-110 lbs., the resident was Not on a physician prescribed weight loss program and there was no [MEDICAL CONDITION]. The resident ate approximately 75% of meals. 6.8% loss noted within 1 week .Current diet remains appropriate to provide estimated needs. Will continue to monitor and make diet adjustments PRN (as needed). A review of the medical record on 4/25/17 at 15:00 PM indicated, no diet adjustments had been implemented prior to 4/24/17. A Nutrition Progress Note, dated 4/24/17 at 1:03 PM revealed, CBW (current body weight) 79.4 lbs, .has had 12% loss x 6 months .Due to noted loss, Two Cal supplement added 120cc BID (twice a day) with (medication) Rx pass to promote stability. Will continue to monitor . No diet preferences obtained. On 4/26/17 at 8:45 am, the resident was observed in their room and the breakfast tray was approximately 90% complete. The resident had a bag of cheese popcorn on the bed and stated, I love that popcorn. My daughter brings it for me. On 4/26/17 at 9:00 am, a review of the Nutrition Care Plan, initiated on 12/27/16 and revised on 4/14/17 for Resident #704 revealed: Monitor and report signs/symptoms (s/s) of dysphagia (difficulty swallowing) on 12/27/16, Monitor/record/report to MD s/s of malnutrition on 12/27/16, obtain monitor lab/diagnostic work on 12/27/16, provide and serve diet as ordered: Regular on 12/27/16, Monitor intake and record q (every) meal on 12/27/16, RD (Registered Dietitian) to evaluate and make diet change recommendations PRN on 12/27/16 and on 4/24/17-Two Cal 120 cc BID (twice a day). An interview with Dietitian C on 4/26/17 at 11:05 am provided, I am new here. The previous dietitian left in March, when asked if the Dietitian was familiar with Resident #704 and that the resident only weighed 77 lbs. Dietitian C further stated, A supplement was started for (Resident #704) on 4/25/17. It's 2 Cal 120 milliliters (ml) BID (twice a day). Dietitian D was also interviewed and said she had requested the reweigh of Resident #704 on 4/24/17, but wasn't sure who provided the weight of 79.4 lbs. or why it was not documented in the medical record. The Dietitians provided a document indicating Resident #704 had experienced the following significant weight losses: 6.1 % in 30 days, 10.9% in 90 days and 16.6% in 180 days. At 3:00 PM on 4/26/17, Dietitian C was interviewed and provided a copy of an additional Nutrition Progress Note, dated 4/26/17 which indicated, on that date, the resident's food preferences were reviewed, including adding Sherbet for lunch and dinner, as the resident indicated liking this. The note further indicated, Current intake with supplements and additional food items likely to meet/exceed est (estimated) needs. On 4/26/17 at 2:10 PM, an interview with the Administrator and Director of Nursing provided, There are a variety of things we do to address weight loss. It's discussed at our weekly meetings. Supplements can be ordered. The resident's likes and dislikes can be obtained. Medications can be reviewed. When asked why there were no new interventions, including updating food preferences or providing a nutritional supplement, since the resident was noted to have significant weight loss with the most recent quarterly Nutrition assessment dated [DATE], the Administrator indicated the Dietitian had reevaluated Resident #704 on 4/24/17. On 4/26/17 at 3:15 PM, a review of the policy titled, Weight Assessment and Intervention, dated 3/21/2011, revealed, The nursing staff and the Dietitian will collaborate to prevent, monitor, and intervene for undesirable weight loss for our residents .Weights will be recorded in the individual's medical record, any weight change of greater than or less than 5 pounds since the prior weight will be retaken the next day for confirmation .the dietitian will be notified and respond within 24 hours of written notification, negative trends will be assessed and addressed by the Dietitian .Interventions for undesirable weight loss should focus first on food ex. Extra food, snacks, calorie-dense food, liquid nutritional supplements . Resident #702 On 4/24/17 at 1:20 p.m., a record review of the medical record for Resident #702 was completed. According to the face sheet, Resident #702 was admitted to the facility on [DATE] and then readmitted on [DATE] with the [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #702 needed extensive assist with transfers, limited assist with eating and was severely cognitively impaired. On 4/25/17 at 6:45 a.m., a record review of Resident #702's weights had revealed that he was admitted to the facility with a weight of 144.4 pounds (lbs) (10/10/16) and was 5 foot 10 inches in height. On 11/2/16, a weight of 121.2 lbs was documented in the Electronic Medical Record (EMR). A supplement was ordered for nutritional support according to the Nutrition Data notes dated on 10/31/16 at 10:54 a.m. On 2/1/17, Resident #702 had a documented weight of 110.4 lbs On 4/25/17 at 8:35 a.m., 9:35 a.m. and 9:45 a.m., Resident #702 was calmly sitting in the dining room with a plate of scrambled eggs and an unidentifiable brown substance on it. The two items of food on his plate were about the same size as the diameter of a base ball. There was a small glass of what appeared to be milk in front of him. During each observation, Resident #702 was barely eating his food. At 9:45 a.m., a staff member had picked up his food to place it in a caddy to take back to the kitchen. Resident #702 had ate 25% of his breakfast. On 4/26/17 at 9:25 a.m., Resident #702 was observed to be calmly sitting in the dining room. He had a bowl of oatmeal and a glass of orange juice in front of him. He was occasionally taking a bite of his oatmeal. During this time, Certified Nursing Assistant (CNA) X was queried in regards to how Resident #702 eats. According to CNA X,according to his mood, they may or may not assist him with his meals. CNA X explained that at times, Resident #702 does not want to eat and will not let people assist him with feeding. An interview on 4/26/17 at 11:05 a.m. with the Registered Dietician (RD) C was completed. During this interview, the RD had explained that Resident #702 had supplements ordered that were served by the dietary staff. According to RD C, Resident #702 had a milk shake that is ordered to provide additional calories and nutritional support. The milk shake is [MEDICATION NAME] given at breakfast time. RD C also stated that because of his weight loss, he was placed on double portions with his meal and that would also be listed on his meal ticket. When queried in regards to his breakfast he had received on 4/25/17 and 4/26/17 and the lack of milk shake for the 4/26/17 breakfast meal, RD C offered no explanation. On 4/26/17 at 11:30 a.m., an interview with Dietary Manager L was completed. During the interview, a copy of the meal ticket for Resident #702 with the date of 4/26/17 was reviewed. the meal ticket confirmed that Resident #702 was to receive double portions and have a milk shake served during breakfast time. Dietary Manager L was unable to explain why Resident #702 did not receive double portions for breakfast on 4/25/17 or 4/26/17 and did not receive a milk shake on 4/26/17. On 4/26/17 at 12:00 p.m., RD C had provided and explanation about Resident #702 not receiving his diet as ordered and stated that Resident #702 had gotten up late and that his original breakfast tray had been thrown away that was why he was no given his milkshake. RD C further explained that Resident #702 would be offered his milk shake at lunch time. On 4/26/17 at 2:30 p.m., the Administrator was queried as to the type of diet Resident #702 was served for breakfast on 4/26/17. The Administrator had reconfirmed what RD C had stated that Resident #702 had woke up late and that he was given his nutritional supplement at lunch time. On 4/26/17 at 3:20 p.m., a record review of the care plan initiated 12/20/16 for Nutritional Deficits had an intervention revised on 4/12/17 that stated, provide and serve the diet as ordered: Mech soft (a mechanically altered diet to allow for easier chewing and swallowing); Mighty shake (a supplement to provide additional calories and nutrients) per order. On 4/26/17 at 3:30 p.m., a review of the policy titled, Weight Assessment and Intervention revised 3/21/11 revealed the following: 10. Interventions for undesirable weight loss should focus first on food .Liquid nutritional supplements may be considered if resident caloric intake remains inadequate to stabilize or increase weight .

Based on observation, interview, and record review the facility failed to provide adequate supervision and implement safety device interventions as listed on the care plan for 1 (#701) of 3 residents reviewed for falls from a total sample of 19, resulting in a left hip fracture that required surgical repair. Findings include: Resident #701 was observed on 3/15/2016 during the lunch meal service in the dining room being fed by a facility staff member. Resident #701 was alert but unable to carry on a meaningful conversation. Review of the undated facility admission record, Resident #701 was a [AGE] year old female admitted to the facility on [DATE]. The electronic medical record reflected Resident #701 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] Resident #701 had a brief interview of mental status (BIMS) score of 12 out of 15 indicating moderately impaired cognition, and required 1 person extensive assist with transfers and ambulation. The MDS further reflected Resident #701 had 2 or more falls without injury. The fall risk assessment dated [DATE] reflected Resident #701 scored a 13. The fall risk assessment form reflected If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential FALLS. A prevention protocol should be initiated immediately and documented on the care plan. A review of Resident #701's care plan dated 02-18-2016 reflected Resident has had falls with a goal of Minimize injury with falls. Interventions included: resident not to be left alone unattended while in wheelchair in room related to impulsive self transfers, appropriate foot wear--non-skid socks or rubber soled shoes, resident will be encouraged to lay down after lunch, after all meals, activities and leave of absence per her preference. Hipsters on at all times was an added intervention to the care plan on 6-02-2015. The nurses notes dated 2-13-2016 reflected Resident laying on floor on E hall, on her left side in fetal position, nurse assessment--resident has small laceration on left forehead and to the right hand index finger, areas cleaned and small islands applied, resident complains of left leg/hip pain, no limb rotation . Resident #701 was transferred to the hospital on 2-13-2016. The x-ray report dated 2-13-2016 reflected a fracture of the neck of the left femur. Hospital records dated 2-16-2016 reflected Resident #701 required the left hip to be surgically repaired on 2-14-2016. A review of the fall investigation report dated 2-18-2016 reflected on 2-13-2016 Resident #701 was observed on the floor in a fetal position on her left side Resident has small laceration to left forehead and to right hand index finger. x-ray of bil (sic) hips ordered then resident sent to hospital. Page 7. of the investigation reflected Resident has a history of unsafe transfers. Hipsters were not on, taken off earlier in shift for shower. Current interventions: Hipsters, Not to be left in room when up in w/c (wheelchair) unattended, Non-skid socks/shoes, Non-skid pad, w/c cushion. Resident transferred to ER for fx (sic) left hip. A review of Resident #701's physical therapy evaluation dated 2/18/2016 reflected .decline in ability to perform bed mobility, transfers, and inability to ambulate since most recent hospitalization [DATE] where resident was transferred s/p (status [REDACTED]. On 3-16-2016 at approximately 2:30 p.m., during an interview with Certified Nursing Assistant (CNA) F, whom was assigned to care for Resident #701 on 2-13-2016, CNA F reported that Resident #701 was Very agitated that day and CNA F had ambulated her several times during her shift. CNA F further reported she had showered Resident #701 after dinner and was pushing her in the wheelchair back to Resident #701's room to lay her down when she saw that a call light was on in another residents room. CNA F reported she left Resident #701 in the hallway unattended to answer the call light and stated, It was only a matter of seconds. Upon her return from assisting the unidentified resident Resident #701 was on the floor. When queried if Resident #701 was wearing hipsters CNA F replied No, when queried if Resident #701 was wearing nonskid footwear CNA F replied No. When queried if any other staff were present in the hallway when she left Resident #701 CNA F replied No. On 3-17-2016 at 1:47 p.m., Licensed Practical Nurse I whom was assigned to Resident #701 on 2-13-2016 was telephoned for an interview but was unavailable. On 3-17-2016 at approximately 2:10 p.m. CNA J, who assigned to care for Resident #701, was interviewed regarding the residents current functional status. CNA J stated, (Resident #701) is no longer able to walk and now she's a 2 person transfer with a gait belt. On 3-17-2016 at 2:15 p.m., during an interview with Unit Manager Registered Nurse G, whom authored the fall investigation, stated that she thought CNA F left Resident #701 with Nurse I when CNA F answered another residents call light, and then Nurse I left Resident #701 in the hallway unattended to attend to a separate medical emergency. When queried about what medical emergency entailed and the resident involved, RN G was unable to provide an answer. The investigation did not entail any statements from CNA F or LPN I. Nurse G stated she obtained all the information regarding Resident #701's fall from the Director of Nursing(DON),and that Resident #701 was readmitted to her unit on 2-18-2016 after Resident #701's hospitalization for hip surgery, but did not reside on her unit at the time of the fall. On 3-17-2016 at 3:30 p.m., during an interview with the DON she reported being aware that Resident #701 had 4 falls since December 2015 and was aware Resident #701 was at high risk of falls. The DON agreed that Resident #701's care plan was to have hipsters on at all times but reported that the hipsters were soiled. When queried if the facility had more that 1 pair of hipsters available she replied, Yes. The DON reported Nurse G was in charge of the fall investigation because Resident #701 was readmitted to her unit and thought she had interviewed staff involved/on duty at the time of Resident #701's fall. The facility's fall policy titled Falls-Clinical Protocol with a reviewed/revised date of February 2013, reflected 1. Based on the assessment an initial plan of care (ipoc) will be developed and implemented to address identified risk. This will be revised as necessary. 2. The Minimum Data Set (MDS) and subsequent Care Assessment Areas (CAAs) will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls. 3. a. Goals may include, but are not limited to, reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. 4. Interventions should be developed and implemented per the assessed needs. ( )

This citation pertains to intake number MI 192 and MI 721. Based on interview and record review, the facility failed to provide adequate staffing levels in the dining area to ensure the safety of one Resident (#604) of four residents reviewed for falls from a total sample of four, who was assessed by the facility as a high risk for falls and repeatedly known to attempt self transfers, resulting in a fall with a skin tear and head trama with a subdural hematoma (bleeding in the brain) requiring emergent transfer to an acute care hospital. Findings include: On [DATE] at 1:43 p.m., during the pre survey phone interview with the complainant, the complainant stated that on admission ([DATE]) to the facility she had spoken to the Director of Nursing (DON) and the Certified Nursing Assistants (CNA)'s and informed them (Resident #604) was a fall risk and was at the facility because of a fall at another facility with a fracture of his back. The complainant stated they (staff) told her they would "keep a close eye on him." The complainant stated receiving a call by the facility staff about 6:00 p.m. on [DATE] and was informed (Resident #604) had fallen and had a small bump on his head, but was fine. Then at 3:00 a.m. they (facility staff) called to say (Resident #604) was being sent to the hospital. At the hospital the doctors said (Resident #604) was bleeding so bad in his brain that they couldn't do surgery or anything and placed him on hospice and he died . The complainant said the death certificate stated the cause of death as "acute subdural and intraparenchymal hemorrhage (a type of hematoma, usually associated with traumatic brain injury)." The complainant stated "I saw him at the hospital, it wasn't a little bump it was a big bump and bleeding in his brain (daughter heard crying)." A review on [DATE] at 10:30 a.m., of the closed electronic medical record (EMR) for Resident #604 revealed an admission to the facility on [DATE] at approximately 6:00 p.m. with [DIAGNOSES REDACTED]. A review of the admission nursing assessment dated late entry [DATE] documented Resident #604 was awake, alert times one (person), combative, incontinent of bowel and bladder, able to move all extremities with unsteady gait. An admission fall assessment documented "intermittent confusion, history of ,[DATE] falls in past 3 months, chair bound, balance problem while standing, takes one to two medications which may increase fall risk, with a total score of 11 . . .10 or greater, the resident should be considered at High Risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." Additional nursing notes dated [DATE] and [DATE], documented Resident #604 was "at risk for falls due to history of multiple falls/sp (status [REDACTED]." A facility Nurse Practitioner note dated [DATE] at 9:20 a.m., documented "Resident (#604) up in wheelchair confused conversation. . . attempting to stand up from wheelchair placed back in and now in common area for close observation." The "Falls" care plan dated [DATE], documented "Resident (#604) at risk for falls d/t (due to) history of multiple falls." Interventions wheelchair at full tilt back, rear anti tip bars, adjust bed height to low position, non skid socks or rubber soled shoes when up, wing mattress in place." A review of the medication administration records (MAR) documented Resident #604 had received scheduled anxiety medication (Ativan) at 2:00 p.m. (Side effects include drowsiness, dizziness, lightheadedness and dry mouth). On [DATE] at 11:00 a.m., a review of the incident report dated [DATE] at 6:00 p.m., documented Resident (#604) had impaired memory, physical impairment, hearing impairment and impaired decision making. (Resident #604) was "observed by a visitor walking in dinning room fell and hit elbow and head on another resident's chair. . .Injury: skin tear right elbow, hematoma/bruise right side top of head, abrasion left side/top of head. . . assessment, first aid and neuro checks initiated. . .on call physician notified, family member notified." Listed under interventions in place prior to fall documented "Resident (#604) at risk for falls due to falls/history of falls." Resident statement "Oh, I don't remember." The investigative statement from the visitor/witness (unable to be contacted by phone) documented "Resident (#604) was behind observer in wheelchair in dining room. He got up and began walking out of dining room. He fell back hit his elbow first then right side of skull then left side of skull on another residents wheelchair tire." Further review of the EMR revealed a Nurse's note dated [DATE] at 4:25 a.m., signed by Staff Registered Nurse "B" documented, Nurse "B" received shift change report that (Resident #604) had hit his head during an attempt to walk (unassisted) in the dining room at 6:00 p.m. and was receiving vital signs and neuro checks (an evaluation of a person's nervous system, alertness, pupil response to light, grip strength) per protocol. Nurse "B" documented she preformed assessments and neuro checks that were with in normal from 8:00 to 10:00 p.m. per protocol. . .During next rounding check Resident (#604) noted to 'non responsive', pulses present and strong. . . Nurse noted chest rise and fall with no signs of respiratory distress. . .sternal rub produced no response, pupils fixed and non-responsive, vital signs blood pressure ,[DATE] (normal ,[DATE]), pulse 83, respirations 20, temperature 98.6, O2 (oxygen saturation) 90%, blood sugar 142, bruising on head noted unchanged. . .911 called. . . Resident escorted out by EMS at 0300 (3:00 a.m.). Family notified." During a phone interview on [DATE] at 1:10 p.m. with CNA Staff "D" she stated she had cared for Resident (#604) one time on his second day at the facility and noted he was "tense and seemed fearful of falling. . .I was told he would try to self transfer. . ." During an interview on [DATE] at 4:00 p.m., Staff Nurse "A" stated, Resident (#604) was a new admit and this ([DATE]) was the first time she was assigned to him . Staff "A" stated it had been reported to her by night shift that Resident #604 had anxiety and attempts to stand. Staff "A" stated he was alert with confusion and did receive Ativan (antianxiety medication) that afternoon (2:00 p.m.) as scheduled related to anxiety and "continually trying to stand up." He was laid down then until dinner (approximately 5:00 p.m.) when he was taken to the dining room by CNA staff "C". Staff "A" stated she was not in the dining room (when Resident #604 fell ) but heard someone call for a Nurse to the dining room. When she entered the dining room two other Nurses were there. (Resident #604) was on the floor his head against another Residents wheelchair. His head had a tiny area with blood and a quarter size bump. He had a skin tear to the right elbow. An assessment was done and Resident #604 was at his baseline prior to the fall. Neuro checks were done every 15 minutes until 7:00 p.m. and were normal. On [DATE] at 4:20 p.m., Staff Registered Nurse "E", stated she did Resident (#604)'s admission assessment and no family was present at the time. Staff "E" said he was alert one-two, (person, place) and his fall assessment was done, and the hospital transfer paperwork noted multiple falls. That made him at risk for falls. Staff "E" stated on [DATE] she responded to call for help in the dining room about 6:00 p.m. and found Resident (#604) on his left side on the floor. A family member for another Resident said he stood and fell and said he bumped his head. He (Resident #604) could talk, was confused. . .a little dazed like "what happened", no mental status changes, no signs of pain and assisted in getting up. He had a small abrasion like a rug burn on his head. His Nurse "A" came in and took over. On [DATE] at 10:05 a.m., the Director of Nursing stated staff were in the dining room at the time of the fall, one activity staff person, three dietary staff, one CNA in the room and one CNA in and out of the room. The DON said three CNA's were assigned the dining room at that meal. On [DATE] at 11:15 a.m., Activity Staff "G" was interviewed per phone and stated, "We (activity staff) assist in the dining room at meals, have trivia, serve coffee, cut up and set up trays. . .I move around and keep an eye on Residents. CNA's are in the room to sit and feed Residents. . .I was the only activity person and was serving trays. He (Resident #604) was way in the back by the piano. I didn't know him. I looked up and saw him walking wobbling back and forth and he fell . . .the CNA's were sitting and feeding and looking at there Residents on the side of the room by the kitchen and that is where I was (near the kitchen). There was no staff on the side of the room where he (Resident #604) was. . ." On [DATE] at 11:55 a.m., Staff CNA "F"was interviewed per phone and stated, she was assigned to the dining room on [DATE]. She stated she was on the other side of the room (near the front by the kitchen) sitting feeding a Resident and heard "him (Resident #604) screaming and crying in pain and someone said get a Nurse. . . I saw him after the fall, he was laying on the ground crying and holding his head. . . It was Halloween and only two CNA's were (assigned) in the dining room with one activity staff and the kitchen staff who aren't facility staff. . .We were really short staffed. I wanted to walk out. I had an entire hall to my self ,[DATE] Resident's and the dining room. The other two CNA's each had a hall with 22 Residents. We had trick or treaters, I felt very overwhelmed and ready to cry. That was the worst day I have ever had in my years at the facility. We usually have ,[DATE] Residents each. I was the only one (CNA) in there (dining room) when he (Resident #604) fell . Staff CNA's "H' and "L" were taking Resident's out of the dining room. Activity Staff "G" was in there and dietary staff all at the kitchen area. No one was on that side of the room where he was sitting and fell . . .We try to keep a look out , but I am really helping to feed Residents." On [DATE] at 12:05 p.m., CNA staff "H" stated per phone she had been assigned to the dining room on [DATE] but was not in the room when (Resident #604) fell . Staff "H" stated one CNA should stay in the dining room all the time, but that doesn't happen. We feed Residents then take them back to there rooms. . . We are not able to monitor the Residents because we are in and out." When asked if enough CNA staff are scheduled to meet Resident needs Staff "H" answered "absolutely not. . . we have ,[DATE] Residents per CNA. . .we can't take care of the Residents. . . I didn't feel I could do my job that day." On [DATE] at 12:45 p.m. per phone, Staff CNA "I" stated she was assigned to (Resident #604) on [DATE]. Staff "I" stated he was very fidgety. . .before the fall he did try to get up a couple of times from his wheelchair. . .we kept him in view at the Nurse's station. . .after the fall he did try to get up from bed, and would turn around (head at foot of bed). I checked him every ,[DATE] minutes to make sure he was not trying to get up. . .( he was) awake at times and asleep other times. . ." On [DATE] at 1:05 p.m., Staff CNA "J' stated per phone, "I worked [DATE] from ,[DATE] p.m., we were short staffed. . .Each CNA on Unit 1 (Hall A, B & C) had 22 to 23 Residents each. . .If assigned the dining room you go in and sit and feed Residents and watch the other Residents. Activity and kitchen staff are in the (dining) room, we don't have enough staff to monitor the dining room and halls. . .I was out in the hall, I didn't see him fall, I saw him on the floor and an activity staff yelled for me to get a Nurse." On [DATE] at 1:20 p.m., dietary Staff "K", stated per phone, he was in the dining room during dinner on [DATE]. Staff "K" stated, "I try to keep an eye on Residents . . .Usually 3 kitchen staff, ,[DATE] activity staff and ,[DATE] CNA's (are in the dining room). . .only the activity staff stay in the room . . .everyone else is in and out. . .The CNA's have a habit of leaving the dining room after the Resident's are served, (they) feed Residents then leave. . .I don't think there is enough staff in there (dining room). I have to baby sit and I'm not really trained for that. I feel I'm going to be held liable if someone falls. I'm not really trained for that. . ." On [DATE] at 2:00 p.m., the facility DON, stated the facility did not have a policy on supervision in the dining room and she could not locate the daily assignment sheets for [DATE]. The DON said three CNA's , one activity staff, and three dietary staff were assigned in the dining room on [DATE] for dinner. The DON said "I'm not sure who was in the room at the time (Resident #604 fell ) but only ( activity Staff "G" ) saw him. She was not close enough to him when he fell ." The DON provided names of the CNA's who worked Unit 1. When questioned the DON stated, "Yes, the three CNA's had 22 -23 Residents through dinner." On [DATE] at 2:10 p.m., CNA Staff "L" stated per phone, that she had never been assigned to care for Resident #604 but worked [DATE] and remembered "he tried to stand up often", we kept him in view. . . We would tell him to sit and sometimes have to go to him to make him sit. On [DATE] for dinner (CNA "I") brought him (Resident #604) to the dining room about 5:00 p.m., he was sitting way in the back by the piano. . ." An observation of the dining room on on [DATE] at approximately 3:00 p.m., revealed the room was approximately 54 feet long by approximately 37 feet wide (by counting the 12 x 12 floor tiles) . The piano and kitchen were noted to be at opposite ends in the long direction kitty corner to each other. The DON stated that staff reported (Resident #604) was sitting at one of the tables at the back of the room near the piano and fell near the last table (observed to be approximately 15 -20 feet apart.) During a phone interview with Staff Nurse "B" on [DATE] at 6:00 p.m., she stated, on [DATE] from 7 p.m. to 7 a.m. was the first time she was assigned to Resident #604. Nurse "B" stated she was informed he would attempt to get up on his own and had fallen about 6:00 p.m. and hit his head. Staff "B" stated, Resident #604 was up in his wheelchair at the start of her shift (7:00 p.m., approximately one hour after he had fallen) "he was able to talk but drowsy, which was normal for him because he went to bed early." Nurse "B" said she preformed a quick assessment which did not reveal any concerns. Nurse "B" stated the neuro checks from 8:00 to 10:00 p.m., were normal and resident could answer yes no questions as was normal for him. Nurse "B" stated per protocol the next neuro check was due at 2:00 a.m. but she was with another Resident at the time and did Resident #604's neuro check at approximately 2:45 a.m. "I noticed his head was at the foot of the bed. . .I took his hand to take his blood pressure he didn't open his eyes. . .I did a sternal rub (application of a turning pressure to the sternum) a couple of times. . .his pupils were fixed. . .I knew he had fallen. . . I called 911 and stayed with him. . .ambulance left and I called his family. . ." A review on [DATE] at 3:15 p.m., of the facility "Falls- Clinical Protocol" dated ,[DATE], revealed the following: "As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. . .The falls section (fall risk evaluation) is inclusive of; history of falls, cognitive status/behavioral symptoms, vision status, continence mobility, balance, vital signs and orthostatic blood pressure evaluation, age, heath conditions/risk factors and medications. Staff will ask the resident and the caregiver or family about a history of falling. . .Based on the assessment and initial plan of care will be developed and implemented to address identified risk. . .Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. . .Residents who have fallen and have been witnessed to hit their head, suspected to have hit their head, or the fall was un-witnessed and the the resident has cognitive impairments or not a reliable historian should have neuro checks per MD (Medical Doctor) orders or protocol. . ."

This citation pertains to intake number MI 865. Based on interview and record review, the facility failed to respond in a timely manner to a Resident's request for assistance for a Resident known to be at risk of falls and known to attempt self transfer for one (#501) of three sampled Residents reviewed for falls from a total sample of three, resulting in a fall with head injury including laceration and requiring emergent transfer to an acute care hospital. Findings include: During the pre-survey phone interview with the complainant on [DATE] at 1:50 p.m., the complainant stated that "(Resident #501) had a fall with hip fracture prior to entering the facility and was there for rehabilitation. She was a fall risk. At the time of the fall on [DATE] (Resident #501) hit her head and had a cut (laceration). At the ER (emergency room ) they did a CT scan (Computerized Tomography) and informed (complainant) that (Resident #501) had three brain bleeds from the trama. There were no fall interventions at the facility. . ." The Complainant stated the copy of the death certificate she had been given documented the "cause of death as 'a consequence of or due to subdural hematoma, as a consequence of or due to blunt head trama. . . . She (Resident #501) was placed on hospice and we took her home. She died on [DATE]." On [DATE] at 11:30 a.m., a review of the closed electronic medical record (EMR) for Resident #501 revealed an original admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment ((MDS) dated [DATE], documented Resident #501's cognition was eight (,[DATE] equals moderately impaired) and Resident (#501) required extensive assistance of two persons for bed mobility and transfer and extensive assistance of one person for toileting, hygiene and bathing. Resident #501's "Balance During Transition and Walking" section documented she was "not steady" (only able to stabilize with human assistance) for "moving from seated to standing potion, turning around, moving on and off toilet and for surface to surface transfers (between bed and chair or bed and wheelchair)." A facility fall risk assessment dated [DATE], documented a score of 13 (a score of 10 or higher equals high risk) with risks which included intermittent confusion. A [DATE] fall risk assessment documented a score of nine (9) with risk factors which included the following: History of fall (,[DATE]) in past three months, medications which increased risk of falls, chair bound, balance problems standing and sitting, and decreased muscular coordination. A "Resident at risk for falls" Care Plan dated [DATE], documented interventions which included, extensive assist times two (2 person) with bed mobility, transfers and toileting. . . Non skid socks or rubber soled shoes when up, non skid strips to floor on right side of bed (added [DATE]). A review of Resident (#501) medications dated [DATE], documented the following: Warfarin Sodium/Coumadin 4 milligrams (mg) every day (an anticoagulant normally used to prevent the formation of blood clots in the blood vessels and their migration elsewhere in the body), Asprin 81 mg every day, Lasix 40 mg (dieretic) every day, and Ativan 0.5 mg (antianxiety) every day among other medications. Laboratory results for Coumadin monitoring dated [DATE], documented Resident #501's PT (prothrombin time in seconds) and INR (international normalized ratio) (blood tests that are used to determine the clotting tendency of blood), were as follows: "INR 2.8 H (high) and PT 28.8 H (high) (reference range for INR Moderate-intensity warfarin therapy 2.0 -3.0 and PT 9.0- 11.5 seconds), High intensity warfarin therapy INR 3.0 -4.0." On [DATE] at 12:00 noon, a review of the facility incident report dated [DATE] at 4:15 a.m., documented "Resident (#501) was observed on the floor in her room with a noted skin tear to the right elbow. Resident stated 'I just wanted to get up'. Interventions in place at time of fall, low bed, non skid socks, call light with in reach. Resident last toileted ,[DATE] hour prior to fall, not incontinent at time of fall. Immediate intervention "every 15 minute checks." Investigation finding 'Resident (#501) attempted self transfer.' Neuro checks initiated. Non skid strips applied to floor on right side of bed." Review of the incident report dated [DATE] at 8:55 p.m., documented "Resident (#501) observed laying on the floor in front of the closet in room. Resident on right side bleeding from a 1" laceration on right side of head. Positive pelvic/coccyx pain. No loss of consciousness. Resident able to stand with assist of two (2). No neuro deficits. Resident noted with 'head injury/laceration'. Interventions in place at time of fall 'non skid socks, bed in low position, call light in reach.' Resident stated 'Well, I had to go to the bathroom, so I got up myself instead of waiting'. Level of assistance resident requires, 2 (two persons) extensive. Additional information Resident does not use call light. Yells when wants something then is often sleeping when staff arrives in room. Resident has been shown the use of the call light multiple times." Further review of the EMR revealed a progress note dated [DATE] at 6:58 a.m., that documented "Resident agitated all shift getting up and down every ,[DATE] minutes. CNA (Certified Nursing Assistant) reports Resident going to void more frequent than normal. Resident denies pain/burning with voiding, does complain of lower back pain. . . 7:29 a.m. Resident restless all shift and discomfort across lower back." A progress note dated [DATE] at 8:55 p.m., "Resident (#501) observed lying on right side on floor. . .Noted 1" laceration on scalp on right side of head. Laceration bleeding profusely. Pressure applied. . .Resident cried out when her buttocks touched the bed. Resident states severe pain in coccyx that goes down into groin. . .Dr (doctor) called and ordered Resident sent to hospital. Bleeding controlled. No loss of consciousness, Resident oriented ,[DATE]." A review of the (hospital) transfer sheet dated [DATE], documented [DIAGNOSES REDACTED]." Addition information, "8:55 p.m., Resident attempted to transfer self, slipped and fell . Positive 1 inch laceration to right side of head, resident is on Warfarin 4 mg every day and ASA (Asprin). Bleeding controlled and resident assisted into bed. Resident crying out in pain when attempting to sit. Pain in pelvis and groin. Pulses palpable. No loss of consciousness. No nausea/vomiting. No neuro deficits. Resident given Tylenol 650 mg oral for pain at 9:05 p.m." On [DATE] at 3:10 p.m., Registered Nurse (RN) Staff "A", was interviewed per phone and said she recalled Resident #501. Staff "A" stated "She (Resident #501) would not use her call light. . . you could be in her room and ask if she needed anything and then leave and she would get up as soon as you walked out of the room. . . That night ([DATE]) I had gone past her room and she yelled out and I said I will be right there. . .'She yelled I need some help' She usually wanted the bed pan. I had seen her as I went by and she was in bed. The call light was not on. I was on my way to another room with water. I came out less than two minutes later and was walking towards her room and heard her fall. . . When I went into her room she was at the foot of the bed, head bleeding. She kept pushing me away saying she was fine. I called for help and applied pressure, controlled the bleeding. I knew she was on Coumadin. She (Resident #501) stayed alert and oriented with no change, no loss of consciousness, no symptoms of stroke and was out by ambulance in less than 10 minutes. . .She (Resident #501) said, she was going to the bathroom." On [DATE] at 3:40 p.m., CNA Staff "B", was interviewed and stated, "She (Resident #501) would not use the call light, often self transferred in her room. Occasionally she stood from the wheelchair in the hall. She had daily self transfers, often. . . she was confused a lot at the end (of her stay). . .I was not assigned to her but had toileted her about 10 minutes before she fell (on [DATE]). I asked her what she wanted to do and she wanted to go to bed (after toileting). CNA Staff 'C' and I had both taken her to the bathroom several times that night. Sometimes she was able to go (urinate). . .She was a little more confused and really agitated. . . Once she began to get more mobility in that hip she did it (self transfer) a lot. She (Resident #501) was not safe to self transfer. . . When you found her self transferring and would tell her not to. She would say I know I don't care I am gong to do it anyway." On [DATE] at 4:10 p.m., Staff "C" stated, Resident #501 was "A very independent woman, if she got it in her head she would just do it (self transfer). I would see her up in the bathroom or chair, and say (name of #501) you need to wait for help. She would say 'my light was on.' Sometimes it was sometimes it wasn't. I told (RN Staff "D") you need to chart she (Resident #501) is forgetting to lock her wheelchair and getting up on her own and going to the bathroom. . .I think she (Resident #501) new what she was doing. She kept getting stronger and it was getting worse (more attempts to self transfer). On my shift (,[DATE] p.m.) it was constant (attempts to self transfer). She was constantly getting up. . . I would tell activities staff to leave her with eyes on. . ." When asked about the events of [DATE] at the time of the fall, Staff "C" stated "I was up and down the hall and put her to bed between ,[DATE]:00 p.m.,. . .The next thing I heard someone yell help and I went in and the Nurse "A" was in there tending to her. . .She was on her side blood coming from her head and complaining of tail bone hurting. . .They asked what she was trying to do and she said 'I wanted to get out of bed.' The call light was not on." On [DATE] at 11:05 a.m., RN Staff "D" stated "(Resident #501) came here (facility) for a left hip fracture from a fall and was extensive assistance of two persons then was downgraded to extensive assistance of one person. She didn't always have it all (related to cognition). She didn't like to use the call light. We would keep her close and educate her on the use of the call light, but she liked to call out (for assistance). I had her on days and she was up a lot unassisted. . . She did attempt to self transfer often. As she got stronger she attempt more often, she wasn't steady. I would try to keep her out of the room where I could see her." When asked if she had been informed about concerns of self transfer from CNA's, Staff "D" said yes a CNA had reported that she (Resident #501) was trying to put herself to bed, or get up from bed to chair. I would hope I documented it in episodic progress notes." Review of progress notes did not reveal documentation by Staff "D" of Resident #501's attempted self transfers. On [DATE] at 11:30 a.m., The Facility Director of Nursing (DON) was queried regarding Resident #501's fall and self transfer attempts. The DON stated, "(Resident #501) was alert and oriented ,[DATE] most of the time. It was not until about the 26th ([DATE]) that she was more confused. She was working with therapy and had non skid socks and non skid strips on the floor. We rarely use alarms or mats because studies have shown they don't prevent falls and only alert you after (the fall). Resident (#501) fell on [DATE] and it was the first fall she had here. We added non skid strips to the floor. On [DATE] she had more frequent urination without burning or pain, urine was clear yellow was she was alert and oriented times two (generally person and place), per progress notes. A urinalysis with culture and sensitivity was ordered and would have been done on midnights but she fell prior. Until that point staff was supervising and managing her fall risk. We felt on [DATE] she slipped during a self transfer. It just started that evening ([DATE]) that she had more urgency and was trying to get up unassisted more often." The DON was informed that when interviewed the RN Staff "A" said that Resident #501 had called out for assistance and (Staff "A") told her she would be right back. The DON responded stating "At that moment the Nurse must have felt telling her (Resident #501) she would be back was enough and she had returned in a moment. I'm assuming she didn't think she (Resident #501) would self transfer at that point." On [DATE] at 2:05 p.m., CNA Staff "E" and Staff "F" were interviewed and queried about Resident #501 attempting to self transfer. Staff "E" stated "I caught her myself two times when she got up from chair to bed, usually after lunch. She did not use the call light. Usually she would just call out for what she wanted. If you didn't come right away she would do it (self transfer) herself. Most of the time she was alert and oriented with a little confusion. We just learned to get to her quickly. If she called out she wanted to go to bed or to the bathroom. Any Resident that self transfers is at risk for falls. She did self transfer, but wasn't safe to do it." When asked the time frame for self transfers in relation to when Resident #501 was sent to the hospital Staff "E" stated "A few weeks before the fall." Staff "F" stated "She (Resident #501) would self transfer. She would use the call light at times but I did catch her trying to self transfer and assisted her. She was alert and oriented with confusion sometimes. Once her call light was on abut five minutes and by the time I got to there she was trying to get up on her own. She was a fall risk." On [DATE] at 2:20 p.m. The DON was queried regarding Resident #501's fall risk and whether the Care Plan or progress notes addressed Resident #501's attempts to self transfer. The DON stated "It was a new behavior for (Resident #501), I did not see it in notes or the Care Plan." On [DATE] at 9:00 a.m., the facility fall policy dated February 2013, documented the following: "As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task; Admission evaluating data form, which includes the falls risk evaluation. . .History of falls, cognitive status/behavioral symptoms, vision status, continence, mobility, balance, vital signs and orthostatic blood pressure evaluation, age, health conditions/risk factors, and medications. Staff will ask the resident and the caregiver or family about a history of falling. Based on the assessment an initial plan of care will be developed and implemented to address identified risk. This will be revised as necessary. The Minimum Date Set (MDS) and subsequent CAAs (Care Area Assessment) will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls. . . Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. Interventions should be developed and implemented per the assessed needs. . . For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. . .An accident/incident report will be completed and forwarded to the DON as part of the facility's internal Quality Assessment and Assurance Program. . . The staff will monitor and document the individuals response to interventions intended to reduce falling or the consequences of falling. Residents will be reviewed through Standards of Care at a determined time frame after new interventions are implemented to determine if effective or revision is necessary. If interventions have been successful in prevention falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention has resolved. If the individual continues to fall, the interdisciplinary team should reevaluate the situation and consider other possible reasons for the resident's falling. an will re-evaluate continued relevance of current interventions."

Based on observation, interview and record review, the facility failed to provide supervision and assisted transfers for a Resident with a history of poor safety awareness, and failed to implement corrective actions following falls for one (#911) of 12 residents assessed for needing assistance with transfers from a total of 22 sampled residents, resulting in falls with bruises, abrasions and fractures. Findings include: On 4/22/14 at 12:50 p.m., Resident #911 was observed lying in bed. The Resident's right side of the face was observed to be covered with purple and magenta colored bruising surrounding the right eye. When queried what happened, Resident #911 stated, "I fell ." On 4/23/14 at 9:10 a.m., Resident #911 was observed sitting up on the side of the bed. The Resident stated, "I can't talk now. I have to use the bathroom." Certified Nursing Assistant/Housekeeper, CNA "K" was cleaning Resident #911's room. Resident #911 yelled, "I have to use the bathroom! I have to go! Why does this always happen every time! I can't even use my own bathroom!" During this time CNA "K" continued to clean the Resident's room, went into the bathroom and continued to clean. Resident #911 continued to yell, "(CNA "K" name)! What's taking so long! Come on! You can let me go to the bathroom for Christ's sake! Why every time I have to go!" CNA "K" then went over to Resident #911 and assisted the Resident with transfer to her wheel chair and assisted the Resident to the bathroom. On 4/23/14 at 9:32 a.m., Resident #911 was queried regarding the incident earlier that morning and stated, "I have a kidney infection. When I have to go I have to go. They tell me I need assistance with transferring." When queried as to why she became so upset with CNA "K," Resident #911 stated, "She just kept cleaning. I had to go!" On 4/23/14 at 9:55 a.m., CNA "K" was queried regarding the incident and stated, "I am a CNA as well as a housekeeper. I am expected to assist the Residents if needed. She (Resident #911) has to use the bathroom a lot but she does not always go." On 4/24/14 at 7:20 a.m., Resident #911 was observed self transferring from the bed to the wheelchair. The Resident proceeded to wheel into the bathroom and shut the door. The toilet flushed, the sink water was turned on then off. CNA "L" was then overheard saying "You are not to be going to the bathroom yourself. You need to use the call light. You don't want to fall." CNA "L" wheeled Resident #911 out of the bathroom and assisted the Resident back into bed. CNA "L" was queried as to what Resident #911 was doing and stated, "I was in the other room and I heard someone in the bathroom. I went in and (Resident #911) had used the bathroom (transferring self) and was washing her hands." When queried as to if the Resident self transfers often, CNA "L" stated, "Yes." On 4/25/14 at 1:40 p.m., Resident #911's medical record and Incidents and Accident (I & A) Reports were reviewed with Nurse Manager "E" and revealed the following: Resident #911 was admitted into the facility on [DATE] and most recent re-admission was 4/7/14 with [DIAGNOSES REDACTED]. The Resident's Minimum Data Set Assessment (MDS), dated [DATE] revealed that the Resident's cognition was moderately impaired and required extensive assistance with one staff for most activities of daily living (ADL) including toileting and transfer. I & A dated, 11/17/13, revealed "Resident was returning to room after outing with daughter, shoes were wet, slipped on tile in room, fell on right side and hit back of head." Radiology report, dated 11/17/13, revealed "Intertrochanteric fracture of the right hip." The Resident had surgery and returned to the facility. The following twelve I & A's were reviewed and revealed that Resident #911 had unobserved falls after attempting to self transfer in most cases to use the bathroom without assistance. During this time Resident #911 was assessed as needing assistance with transfers and toileting. : 12/7/13, 12/21/13, 1/5/14, 1/12/14, 1/14/14, 1/15/14, 1/23/14 at 1:30 p.m. (assisted to floor), 1/28/14, 1/31/14, 3/14/14, 3/16/14, and 3/22/14. I & A, dated 1/17/14 at 0210 (2:10 a.m.), revealed "Attempted to get up on own to toilet. Plan of action: Restorative program for bowel and bladder. Toilet at HS (hour of sleep) approximately 2 am-5 am. Bladder scan to rule out retention." Progress note, dated 1/17/14 at 4:06 a.m., revealed "Unsteady gait with poor balance. Resident educated on use of call light. Wheelchair placed at bedside." Skilled Nursing Assessment, dated 1/17/14 at 4:13 a.m., revealed "Transfer: Extensive assistance, 1 (one) person." Nurse Manager "E" was queried regarding the bladder scan and stated, "There is no record of the bladder scan." Safety Meeting Note, dated 1/17/14 at 11:13 a.m., revealed "Safety team is looking into getting a bedside toilet." Nurse Manager "E" was queried regarding the bedside toilet and stated, "I don't know. We don't use them." I & A, dated 1/18/14 at 1515 (3:15 p.m.), revealed "Resident was in bed, attempted self transfer. Resident is impulsive and is not using the call light. Resident has had an increase of frequency and urgency." Safety meeting note, dated 1/20/14 at 11:25 a.m., revealed "Restorative to begin a bowel and bladder program to assess times for toileting." Nurse Manager "E" was queried regarding the documentation of the bowel and bladder program indicated but was unable to provide any documentation and provided no comment. I & A, dated 1/23/14 at 2315 (11:15 p.m.), revealed "Resident needed to use restroom. She did not use call light. She got out of bed unassisted and walked to the bathroom and fell on the way. Pain left side of head, small lump left side of head. Plan of action: Resident will use walker for ambulation." Safety Meeting notes, dated 1/27/14 at 9:28 a.m., revealed "Brought up in safety meeting related to self transfers without assist. Therapy is working with resident on walking with rolling walker and having it in her room for assist with ambulation." Nurse Manager "E" was queried regarding transfer devices being put in front of the Resident and at bedside would this be confusing to the Resident while documentation indicated that the Resident needs extensive assistance with transfers but provided no comment. I & A, dated 2/1/14 at 4:30 a.m., revealed "Resident self transferred from bed to bathroom. She did not use call light to ask for assistance." Progress notes, dated 2/7/14 at 7:25 p.m., revealed "Resident continues to state that she needs to be toileted after being toileted...Resident had multiple attempts to self transfer self to the toilet. Resident reminder that she needs help to transfer and to use call light." Resident #911's physician order, dated 2/7/14, revealed "X-Ray knee left tomorrow pain." Nurse Manager "E" was queried regarding the radiology report and stated, "We have no record of the left knee X-Ray." I & A, dated 2/12/14 at 2350 (11:50 p.m.), revealed "Resident self transferred from bed to toilet, while transferring back to bed from toilet, resident fell . Plan of care: Walker to be at bedside at all times." Care plan titled, "Inability to complete ADL tasks independently related to dementia," dated 1/8/14 through 4/7/14, revealed 1/27/14-4/7/14: Resident may transfer and ambulate to bathroom with rolling walker extensive times one with gait belt. Extensive assist times one for bed mobility and toileting." I & A, dated 2/21/14 at 10:00 a.m., revealed "Self transferred from bed to standing. Walker was at bedside, she did not use. While ambulating she fell to floor. She did not use call light or ask for help." Progress notes, 2/21/14 at 7:05 p.m., revealed "Resident states 'I was trying to go to the bathroom and I lost my balance; she states that she scraped her back against the heater. Writer observed a slight red area on center of back. Resident was extensive assist times 2 (two) into wheelchair." I & A, dated 3/31/14 at 1300 (1:00 p.m.), revealed "Resident was taken to room to be toileted then put to bed for nap Resident then attempted to self transfer from bed to bathroom. Rolling walker was not next to bed." I & A, dated 4/2/14 at 2200 (10:00 p.m.), revealed "Resident self transferred from bed to standing, walked to bathroom and fell to floor. Resident was sent to hospital due to right rib fractures. Returned from hospital 4/7/14. Comments: Bruise to right eye. Nose bleed. Rib pain right side." Radiology Report, dated 4/3/14, revealed "Acute complete nondisplaced fractures of the 8 th to 11 th ribs. In comparison to prior chest study, findings are new." Radiology report, dated 4/3/14, revealed "Acute fractures of the superior nasal bone right lateral margin." Radiology report, dated 4/3/14, revealed "Superior mild subluxation of the right humerus with moderate degenerative changes of the glenohumeral joint suggests chronic tear of the right rotator cuff." I & A, dated 4/10/14 at 4:20 a.m., revealed "Resident observed using bathroom by CNA, CNA went to assist resident back to bed, resident refused assist pulled self back and fell after stating 'I can do this myself.' Resident continues to want to be independent." Unit Manager "E" was queried regarding Resident #911's continued falls due to unassisted transfers and the appropriateness of interventions and stated, "She's getting up regardless (of interventions). She is working with therapy so self transfers are as safe as can be." When queried regarding safety care plan and behaviors such as not using call light, not using assistive devices etc. Nurse Manager "E" stated, "I don't see anything about those behaviors." On 4/25/14 at approximately 3:10 p.m., Resident #911's care plans were reviewed and revealed the following: Care plan titled, "Resident is newly admitted he/she will require staff assistance with all ADL's," dated 11/22/13 through 12/02/13. Extensive assist with toileting." Care plan titled, "Resident is newly admitted he/she will require staff assistance with all ADL's," dated 12/6/13 through 12/30/13. Resident will be assisted with all ADL's daily and prn (as needed). Requires extensive assistance times one for transfer." Care plan titled, "Inability to complete ADL tasks independently related to dementia," dated 1/8/14 through 4/7/14, revealed "Resident will be assisted with all ADL's daily and prn. 1/8/14-1/21/14 Resident requires extensive assistance times two for transfers, weight bearing as tolerated right lower extremity. 1/21/14-1/27/14 I will ambulate only with therapy at this time for safety. 1/27/14-4/7/14: Resident may transfer and ambulate to bathroom with rolling walker extensive (assist) times one with gait belt. Extensive assist times one for bed mobility and toileting." Care plan titled, "Inability to complete ADL tasks independently related to dementia," dated 4/14/14, revealed, "Provide extensive assist times two with transfers and toileting no gait belt at this time due to new rib fractures." Care plan titled, "Behavior," dated 12/20/13 through 12/30/13 and 12/31/13 through 4/7/14, revealed "(Resident name) will utilize her call light when she is in her room. Staff will observe her and try to anticipate her needs." On 4/25/14 at 5:25 p.m., the facility Administrator was queried regarding Resident #911's history of falls, lack of documented interventions and supervision and stated, "We are aware. We have improved and are making progress." On 4/25/14 at approximately 5:50 p.m., the facility's policy titled, "In-Depth Investigation of Incident/Accident Reports," no date, was reviewed and revealed "To identify causative factors and reduce the opportunity for repetition of a similar event. Care plans for the resident will be developed and/or revised to reflect the action to be taken. All staff involved with the resident must be aware of the steps identified to eliminate the potential for repetition of a similar event." ( )

THIS CITATION HAS TWO DEFICIENT PRACTICES: DEFICIENT PRACTICE #1 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND CONSISTENTLY IMPLEMENT PLANNED SAFETY INTERVENTIONS FOR TWO (#401 AND #413) OF 15 RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 22, RESULTING IN FALLS WITH INJURY. FINDINGS INCLUDE: ON 4/30/13 AT 11:00 A.M., REVIEW OF RESIDENT #413'S CLINICAL RECORD REVEALED A TRANSFER FORM (AMBULANCE RECORD) DOCUMENTING RESIDENT #413 WAS TRANSFERRED TO THE hospital on [DATE] BECAUSE SHE "fell , HIT HEAD, LANDED ON LEFT HIP AND PELVIC PAIN NOTED." A HOSPITAL X RAY REPORT DATED 4/7/13 AT 9:03 P.M., REVEALED RESIDENT #413 HAD, SUSTAINED AN "ACUTE LEFT HIP FRACTURE (BROKEN BONE). TRAUMA (ACCIDENT). " ON 4/30/13 AT 2:25 P.M., CERTIFIED NURSING ASSISTANT (CNA) "H" AND CNA "D" WERE OBSERVED TRANSFERRING RESIDENT #413 INTO BED. THE RESIDENT CRIED OUT, "OW, OW, OW, THAT HURTS", GRIMACED AND CRIED OUT, "OW, OW, THAT'S SO SORE" DURING THE TRANSFER. AS THE CNAS LIFTED HER LEGS UP ONTO THE BED. CNA "D" AND CNA "H" REPORTED THAT RESIDENT #413 HAD THE LAP TRAY RESTRAINT ON HER WHEELCHAIR TO PREVENT HER FROM FALLING. THE CNAS STATED, "SHE (RESIDENT #413) WAS IN A WHEELCHAIR WITH A LAP TRAY. THEN SHE WENT ON HOSPICE AND HOSPICE CHANGED HER TO A HIGH BACK WHEELCHAIR WITHOUT THE LAP TRAY. A FEW DAYS LATER, SHE GOT UP AND fell AND BROKE HER HIP. SHE WAS A HIGH FALL RISK." ON 5/1/13 AT 10:00 A.M., NURSE "A" WAS INTERVIEWED ABOUT RESIDENT #413'S FALL ON 4/7/13 AND STATED, "IT WAS DURING SHIFT CHANGE, ON A SUNDAY. I WAS WALKING OUT THE DOOR (TO GO OFF DUTY) WHEN SHE fell . IT WAS WELL DOCUMENTED IN THE NURSING NOTES (CHART) THAT SHE TRIED TO GET UP BY HERSELF ALL THE TIME. SHE WAS IN A GERI CHAIR (WHEELED RECLINER) WITH A TRAY TABLE. HOSPICE CAME IN AND DISCONTINUED (D/C) HER TRAY TABLE (RESTRAINT) AND CHANGED HER INTO A HIGH BACK WHEELCHAIR. WE HAD CALL-INS (STAFF CALLING IN SICK) THAT DAY, SO WE WERE SHORT (LESS STAFF). WE BROUGHT EVERYONE INTO THE HALLWAY WHILE WE WERE DOING REPORT (CHANGE OF SHIFT). WE FOUND HER ON THE FLOOR 20 MINUTES LATER. WHEN WE DID THE INVESTIGATION (INTO THE FALL), THERE WAS NO DOCUMENTATION OF WHY HOSPICE GOT RID OF THE TRAY TABLE. THE FALL OCCURRED LESS THAN A WEEK AFTER THEY GOT RID OF THE TRAY TABLE. SHE (RESIDENT #413) IS VERY UNSTEADY AND VERY IMPULSIVE. SHE WAS ALSO VERY COMBATIVE AND COMPULSIVE BEFORE SHE BROKE HER HIP". ON 5/2/13 AT 11:45 A.M., RESIDENT #413'S CLINICAL RECORD AND INCIDENT AND ACCIDENT REPORTS WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON), AND REVEALED THE FOLLOWING: ACCORDING TO THE FACE SHEET RESIDENT #413 WAS ORIGINALLY admitted INto the facility on [DATE], AND readmitted INto the facility on [DATE] AFTER TRANSFER TO hospital on [DATE] FOR SURGICAL REPAIR OF A LEFT HIP FRACTURE. OTHER [DIAGNOSES REDACTED]. REVIEW OF INITIAL ADMISSION RECORDS REVEALED RESIDENT #413 WAS ORIGINALLY admitted INTO THE FACILITY AFTER A hospitalization IN A GERIATRIC PSYCHIATRIC UNIT FOR "AGITATED BEHAVIOR." THE MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT #413 HAD SEVERE COGNITIVE IMPAIRMENT (DEMENTIA), DIFFICULTY UNDERSTANDING AND COMMUNICATING, NEEDED EXTENSIVE ASSISTANCE FROM TWO STAFF FOR TRANSFER TO THE WHEELCHAIR AND WALKING, AND HAD MULTIPLE INDICATORS OF UNDESIRABLE BEHAVIORS, AND UNSTEADY BALANCE. A PHYSICAL THERAPY SCREENING assessment dated [DATE], IDENTIFIED RESIDENT #413 NEEDED, "FALL PRECAUTIONS" AND REQUIRED ONE PERSON PHYSICAL ASSISTANCE FOR TRANSFERS AND AMBULATION. A FALL RISK ASSESSMENT, DATED 11/2/12 DOCUMENTED RESIDENT #413 WAS AT HIGH RISK FOR FALLS WITH A SCORE OF 11. (THE ASSESSMENT NOTED, "IF THE TOTAL SCORE IS 10 OR GREATER, THE RESIDENT SHOULD BE CONSIDERED AT HIGH RISK FOR POTENTIAL FALLS. A PREVENTION PROTOCOL SHOULD BE INITIATED IMMEDIATELY AND DOCUMENTED ON THE CARE PLAN.") A NURSING CARE PLAN FOR FALLS, DATED 1/17/13 FOR RESIDENT #413, REVEALED THE FOLLOWING SAFETY INTERVENTIONS, "RESIDENT TO BE MOVED TO HIGH VISIBILITY AREAS WHEN UP AND OUT OF BED (START 1/27/13), RESIDENT TO HAVE A GERI CHAIR WITH LAP TRAY AND BILATERAL SUPPORT SYSTEM TO KEEP RESIDENT FROM HARMING HERSELF AND OTHERS (STARTED 11/9/12, DISCONTINUED 4/8/13, AFTER THE FALLWITH FRACTURE)." AN I&A DATED 1/10/13 AT 2:15 A.M., DOCUMENTED, "CNA WALKED DOWN HALLWAY, SEEN EMPTY BED, OBSERVED RESIDENT ON FLOOR." "PLAN OF ACTION" WAS NOTED AS, "FREQUENT CHECKS, RESIDENT TO BE PLACED IN HIGHLY VISIBLE AREAS WHEN UP AND OUT OF BED." AN I&A DATED 4/7/13 AT 6:30 P.M., DOCUMENTED, "LOCATION: HALLWAY. RESIDENT WAS OBSERVED LAYING ON FLOOR NEXT TO WHEELCHAIR (W/C) ON HER LEFT SIDE. HIT LEFT SIDE OF FOREHEAD. ICE APPLIED. RESIDENT COMPLAINED OF (C/0) PAIN AND WAS TRANSFERRED TO HOSPITAL. RESIDENT WAS IN HALLWAY SITTING IN W/C, WHICH WAS NEW, WITHOUT RESTRAINT. RESIDENT ATTEMPTED TO AMBULATE AND fell . RESIDENT HAD HIP FRACTURE." A NURSING NOTE FOR RESIDENT #413 DATED 4/7/13, DOCUMENTED, "RESIDENT NOTED LAYING ON HER LEFT SIDE. BUMP ON LEFT FOREHEAD. RESIDENT SCREAMING OUT IN PAIN, HELP ME, I'M HURT". REVIEW OF A PAIN assessment dated [DATE], DOCUMENTED RESIDENT #413 WAS ASSESSED AS HAVING NO PAIN TO MILD PAIN ON AVERAGE (PRIOR TO HIP FRACTURE). REVIEW OF A PAIN assessment dated [DATE] (AFTER THE FRACTURE) REVEALED RESIDENT #413 HAD MODERATE TO SEVERE PAIN, ASSESSED AS 10 ON A PAIN SCALE( SCALE OF 1-10 WITH 10 REPRESENTING WORST PAIN). THE ASSESSMENT DOCUMENTED PAIN HAD A NEGATIVE IMPACT ON RESIDENT #413'S MOOD, ACTIVITY, APPETITE AND NORMAL SOCIAL ROUTINE. WHEN QUERIED AT THIS TIME, THE DON STATED RESIDENT #413 WALKED WITH STAFF ASSISTANCE PRIOR TO FRACTURING HER HIP ON 4/07/13, BUT WAS NO LONGER ABLE TO DO SO. WHEN QUERIED, THE DON STATED, "SHE WAS HIGH RISK FOR FALLS. WE STARTED OFF WITH A LAP TRAY AND GOT A CHAIR FROM HOSPICE. THE NEW CHAIR DIDN'T HAVE A TRAY AND THE ONE WE HAD DIDN'T FIT. THAT'S WHEN SHE GOT UP AND fell . IT WASN'T A PLANNED RESTRAINT REDUCTION AS IT SHOULD HAVE BEEN. IT WAS A MISCOMMUNICATION WITH HOSPICE." ON 5/3/13 AT 1:30 P.M., THE HOSPICE CLINICAL COORDINATOR "J" WAS INTERVIEWED BY TELEPHONE AND STATED, "WE DID ORDER A GERI CHAIR FOR HER (RESIDENT #413). HER DAUGHTER IS A NURSE AND WANTED THE TRAY TABLE AND GERI CHAIR TO KEEP HER MOTHER SAFE." ON 5/6/13 AT 9:30 A.M., THE HOSPICE CLINICAL COORDINATOR "J", AND RESIDENT #413'S HOSPICE NURSE WERE INTERVIEWED BY TELEPHONE CONFERENCE. HOSPICE CLINICAL COORDINATOR "J" REPORTED, "INITIALLY SHE (RESIDENT #413) HAD A STANDARD WHEELCHAIR WITH A LAP BUDDY. THE FACILITY SAID IT WASN'T WORKING FOR HER, AND CHANGED HER TO A GERI CHAIR WITH A TRAY TABLE, PROBABLY BECAUSE SHE WAS COMBATIVE AND CONFUSED. WE CHANGED HER TO A HOSPICE ISSUED GERI CHAIR WITH TRAY TABLE ON 4/3/13. WE FOUND OUT THAT THE FACILITY CHANGED HER INTO A HIGH BACK WHEELCHAIR WITHOUT A TRAY TABLE WITHOUT TELLING ME. THEY ARE SUPPOSED TO GO THROUGH HOSPICE BEFORE MAKING ANY CHANGES LIKE THAT, BUT WE FOUND OUT AFTER THE FACT. I TALKED TO THE DON AND SHE SAID THE FACILITY WAS GOING RESTRAINT FREE, AND THE GERI CHAIR AND LAP TABLE WERE A DOUBLE RESTRAINT. SHE (RESIDENT #413) WAS SUPPOSED TO BE MONITORED UNDER THE RESTRAINT FREE PLAN. IN THIS CASE, THE CNA DIDN'T GET THERE IN TIME." ( ) ON 4/30/13 AT 12:25 P.M., RESIDENT #401 WAS OBSERVED AT LUNCH IN A GERI CHAIR (WHEELED RECLINER) WITH LEGS ELEVATED. THE RESIDENT'S KNEES AND HIPS WERE CONTRACTED (FROZEN INTO BENT POSITION). THE RESIDENT WAS ALERT BUT DID NOT RESPOND WHEN SPOKEN TO, AND WAS FED BY STAFF. ON 5/1/13 AT 9:10 A.M., RESIDENT #401 WAS OBSERVED IN THE SHOWER ROOM WITH CERTIFIED NURSING ASSISTANT (CNA) "C" AND HOSPICE CNA "B". BOTH CNAS REPORTED THAT RESIDENT #401 "DOESN'T MOVE MUCH. SHE'S PARALYZED FROM THE WAIST DOWN." CNA "C" STATED, "SHE'S DECLINED A LOT IN THE LAST YEAR. SHE NEVER MOVED MUCH, BUT SHE USED TO MOVE HER ARMS A LITTLE BIT AND TRY AND HIT YOU DURING CARE. SHE WAS ALWAYS PRETTY THIN AND FRAIL, SO SHE NEVER REALLY MANAGED TO REALLY HIT HARD." ON 5/1/13 AT 9:40 A.M., NURSE "A" STATED, "SHE (RESIDENT #401) fell OUT OF BED A WHILE BACK. WE FOUND HER ON THE FLOOR. I DON'T KNOW HOW IT HAPPENED. WE DIDN'T THINK THAT SHE COULD MOVE." ON 5/1/13 AT 9:45 A.M., CNA "D" WAS INTERVIEWED AND STATED, "SHE (RESIDENT #401) fell OUT OF BED JUST AFTER THEY DISCONTINUED HER BOLSTERS (SOFT SIDE RAIL BED RESTRAINTS). WE BECAME A RESTRAINT FREE FACILITY AND THEY GOT RID OF ALL THE BOLSTERS AND ALARMS. SHE DIDN'T HAVE A FALL MAT THEN. THEY DIDN'T THINK SHE COULD MOVE." ON 5/2/13 AT 10:10 A.M., OCCUPATIONAL THERAPIST (OT) "O " WAS INTERVIEWED AND REPORTED, "SHE HASN'T BEEN MOBILE FOR YEARS. " ON 5/2/13 AT 11:00 A.M., RESIDENT #401'S CLINICAL RECORD AND ACCIDENT AND INCIDENT REPORTS (I&A) WERE REVIEWED WITH THE DIRECTOR OF NURSING AND REVEALED THE FOLLOWING: A FACE SHEET DOCUMENTED RESIDENT #401 WAS INITIALLY admitted INto the facility on [DATE], WITH MOST RECENT READMISSION ON 11/23/12. [DIAGNOSES REDACTED]. A QUARTERLY MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] (PRIOR TO THE FALL WITH FRACTURE), DOCUMENTED THAT RESIDENT #401 HAD SEVERE COGNITIVE IMPAIRMENT, SEVERE DIFFICULTY UNDERSTANDING AND COMMUNICATING, DID NOT WALK, AND NEEDED EXTENSIVE STAFF ASSISTANCE FOR MOVEMENT IN BED, TRANSFERS TO THE WHEELCHAIR, EATING, AND ALL ACTIVITIES OF DAILY LIVING. THE MDS ALSO DOCUMENTED THAT RESIDENT #401 HAD LIMITED JOINT MOVEMENT ON BOTH SIDES OF THE UPPER BODY. REVIEW OF NURSING CARE PLANS FOR RESIDENT #401 REVEALED AN ACTIVITY FOR DAILY LIVING (ADL) CARE PLAN DATED 5/26/11 (DISCONTINUED 9/27/12) WITH THE FOLLOWING INTERVENTION, "TO HAVE BILATERAL BOLSTERS RELATED TO (R/T) HAVING AIR LOSS MATTRESS, MATTRESS RUNS RISK OF ROLLING OUT OF BED WITH AIR FLUCTUATION (STARTED 4/25/12, DISCONTINUED 9/27/12)". REVIEW OF THE CLINICAL RECORD AND NURSING CARE PLANS FOR RESIDENT #401 WITH THE DON FAILED TO REVEAL A FALLS PREVENTION CARE PLAN OR A FALLS RISK ASSESSMENT SINCE 2008. A PHYSICAL RESTRAINT INFORMED CONSENT DATED 4/26/12 FOR RESIDENT #401, NOTED "BILATERAL BED BOLSTERS (RESTRAINTS) TO SIDES OF BED FOR BOUNDARY AWARENESS FOR SAFETY." A FACILITY INCIDENT AND ACCIDENT REPORT (I&A) FOR RESIDENT #401, DATED 7/20/12 AT 2:40 A.M., DOCUMENTED, "RESIDENT OBSERVED LAYING ON FLOOR ON RIGHT SIDE. ON THE RIGHT SIDE OF FOREHEAD THERE IS A LARGE (4.5 CENTIMETERS (CM) BY 5 CM) LUMP/BRUISE." THE I&A NOTED THAT NO RESTRAINTS OR ENABLERS WERE IN USE AT THE TIME OF THE FALL. ON 5/2/13 AT 11:00 A.M., REVIEW OF RESIDENT #401'S CLINICAL RECORD AND THE I&A INVESTIGATION WITH THE DON REVEALED NO DOCUMENTATION INDICATING THAT THE BED BOLSTERS WERE PROPERLY APPLIED AND IN PLACE AT THE TIME OF THE FALL. WHEN QUERIED, THE DON WAS UNABLE TO EXPLAIN WHY THE I&A DOCUMENTED THAT NO RESTRAINTS OR ENABLERS WERE IN USE AT THE TIME OF THE FALL. ADDITIONAL INFORMATION WAS REQUESTED BUT NOT PROVIDED BY SURVEY EXIT. WHEN REQUESTED, THE DON WAS UNABLE TO EXPLAIN HOW A RESIDENT WHO WAS UNABLE TO MOVE THE LOWER BODY, HAD DECREASED RANGE OF MOTION OF THE UPPER BODY, AND WAS UNABLE TO MOVE INDEPENDENTLY IN BED (REQUIRING EXTENSIVE ASSISTANCE OF STAFF) COULD CLIMB OVER THE BED BOLSTERS AND FALL OUT OF BED. WHEN ASKED WHY RESIDENT #401 HAD NO FALLS RISK ASSESSMENT DOCUMENTED SINCE 2008, THE DON STATED, "ALL OUR RESIDENTS ARE AT RISK FOR FALLS." ON 5/3/13 AT 1:50 P.M., THE TREATMENT NURSE "G" WAS INTERVIEWED. NURSE "G" REPORTED SHE REMEMBERED RESIDENT #401 PRIOR TO HER FALL IIUUUUUUUN JULY 2012, AS SHE HAD TREATED THE RESIDENT FOR A PRESSURE SORE. NURSE "G" STATED, "SHE WAS ABLE TO FLAIL HER ARMS WEAKLY WHEN SHE GOT AGITATED, BUT SHE WAS NOT ABLE TO MOVE FROM ONE TROCHANTER (HIP) TO ANOTHER. I CAN'T SEE HER CLIMBING OVER A BOLSTER." REVIEW OF THE UNDATED FACILITY POLICY ENTITLED "FALL PREVENTION", REVEALED THE FOLLOWING STATEMENTS: "PURPOSE: TO ASSURE ONGOING ASSESSMENT AND IDENTIFICATION OF RESIDENTS AT RISK FOR FALLS. TO ASSURE APPROPRIATE INTERVENTIONS ARE IN PLACE TO DECREASE RISK OF FALL AND INJURY. NURSING: INITIATE FALL RISK ASSESSMENT UPON ADMISSION AND QUARTERLY THEREAFTER." ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SAFELY SECURE 70 DISPOSABLE RAZORS IN THE "B" HALL SHOWER ROOM, AS WELL ONE DISPOSABLE RAZOR AND ONE PAIR OF SCISSORS WITH SHARP EDGES IN THE "D" HALL SHOWER ROOM, RESULTING IN THE POTENTIAL FOR ACCIDENTS IN TWO OF THREE SHOWER ROOMS. FINDINGS INCLUDE: DURING A TOUR OF THE FACILITY WITH THE MAINTENANCE SUPERVISOR ON 5/2/13 AT 9:05 A.M., THERE WERE 70 DISPOSABLE RAZORS OBSERVED STORED IN AN UNLOCKED CABINET IN THE UNLOCKED "B" HALL SHOWER ROOM. ALSO, DURING THE SAME TOUR, THERE WAS ONE DISPOSABLE RAZOR AND ONE PAIR OF SCISSORS WITH SHARP EDGES OBSERVED STORED IN AN UNLOCKED PLASTIC STORAGE CONTAINER IN THE UNLOCKED "D" HALL SHOWER ROOM. THE MAINTENANCE SUPERVISOR STATED HE WAS UNAWARE THAT THE RAZORS AND SCISSORS WITH SHARP EDGES WERE TO BE STORED IN A SECURE LOCATION. REVIEW OF THE FACILITY'S POLICY, "SHAVING - RESIDENT CARE", DATED 05/3/13, DOCUMENTED, "THE SHAVERS ARE (TO BE) LOCATED IN THE LOCK BOX IN THE SHOWER ROOM CABINET. GO TO NURSE'S CART AT STATION ONE OR TWO AND GET KEY FOR LOCK BOX . . . DISPOSABLE RAZORS MUST BE DISPOSED OF IN A SHARPS CONTAINER". THIS POLICY DID NOT ADDRESS THE STORAGE OF SCISSORS WITH SHARP EDGES. ( / )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ASSESS, CARE PLAN OR IMPLEMENT INTERVENTIONS FOR PAIN FOR ONE (#401) SAMPLED RESIDENT OUT OF FOUR RESIDENTS REVIEWED FOR PAIN OUT OF A TOTAL SAMPLE OF 20 RESIDENTS, RESULTING IN CRYING OUT IN PAIN WHILE RECEIVING CARE. FINDINGS INCLUDE: ON 5/23/12 AT 9:35 A.M., OBSERVATION OF CATHETER CARE WITH CERTIFIED NURSE ASSISTANT (CNA) "B", REVEALED THE CNA WIPING THE TIP OF RESIDENT #401'S PENIS WITH A DISPOSABLE CLOTH. RESIDENT #401 YELLED OUT AND BEGAN CRYING. CNA "B" CONTINUED TO WIPE THE CATHETER TUBING WITH ANOTHER DISPOSABLE CLOTH, AND RESIDENT #401 CONTINUED CRYING AND YELLED OUT "AWE, AWE, AWE, AWE..." THE URINARY MEATUS (TIP OF THE PENIS) WAS SPLIT OPEN AND TORN DOWNWARD. CNA "B" WAS QUERIED IF RESIDENT #401 HAD RECEIVED ANY PAIN MEDICATION PRIOR TO THE PROCEDURE AND SHE STATED "YES, THE NURSE GAVE HIM SOMETHING BEFORE I PUT HIM IN THE BED." AT 9:45 A.M., STAFF NURSE "A" ENTERED THE ROOM AND PERFORMED WOUND CARE ON RESIDENT #401'S COCCYX (UPPER BUTTOCKS) AREA. THE WOUND WAS A STAGE IV (EXPOSED MUSCLE, FASCIA AND UNDERLYING LAYERS) MEASURING 4.8 CENTIMETERS (CM) X 3.5.CM X 1.2 CM. WHILE NURSE "A" WAS CLEANING THE WOUND, THE RESIDENT YELLED OUT "AWE, AWE, AWE", AND FACIAL GRIMACING WAS OBSERVED. NURSE "A" WAS QUERIED AS TO WHEN THE RESIDENT LAST WAS MEDICATED FOR PAIN, NURSE "A" STATED, "THE MIDNIGHT NURSE GAVE HIM SOMETHING AT AROUND 2:30 THIS MORNING." RECORD REVIEW REVEALED THAT RESIDENT #401 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #401'S MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] INDICATED THE RESIDENT'S COGNITION WAS SEVERELY IMPAIRED AND RELIED EXTENSIVELY UPON THE STAFF FOR ACTIVITIES OF DAILY LIVING, TRANSFERS AND BED MOBILITY. THE MDS RATED THE RESIDENTS PAIN AS BEING A "6" IN A NUMERIC RATING SCALE OF 0-10 WITH ZERO BEING NO PAIN AND TEN BEING THE WORST PAIN, WITH A FREQUENCY OF OCCASIONALLY. ON 5/23/12 AT 10:00 A.M., REVIEW OF THE MEDICATION ADMINISTRATION RECORDS (MAR) DOCUMENTED, "[MEDICATION NAME] HCL (PAIN PILL) 50 MILLIGRAM (MG) ONE TABLET AS NEEDED, BY MOUTH EVERY 6 HOURS FOR PAIN." IN A COURSE OF 22 DAYS RESIDENT #401 RECEIVED ONLY 6 DOSES OF PAIN MEDICATION. THE LAST DOSE OF PAIN MEDICATION ADMINISTERED TO RESIDENT #401 WAS ON 5/22/12 AT 9:58 A.M., ALMOST 24 HOURS PRIOR TO THE OBSERVED CATHETER AND WOUND CARE. WHEN NURSE "A" WAS QUERIED ABOUT THE PAIN MEDICATION, SHE SAID "OH HE DIDN'T GET ONE EARLY THE MORNING? I THOUGHT HE DID." REVIEW OF THE ACTIVE MEDICAL RECORD REVEALED A BLANK PAIN ASSESSMENT AND NO PAIN CARE PLAN. ON 5/23/12 AT 12:20 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING THE PAIN MANAGEMENT FOR RESIDENT #401. THE DON STATED THAT SHE WAS AWARE OF THE RESIDENT "URETHRAL EROSION" AND THAT HE HAS BEEN SEEING A UROLOGIST. SHE STATED THAT THE PHYSICIAN "JUST CRINGED" WHEN SHE SAW IT LAST AND "I AGREE HE SHOULD HAVE SOMETHING ON BOARD FOR PAIN PRIOR TO TREATMENT AND CARE". WHEN ASKED ABOUT THE LACK OF PAIN ASSESSMENT OR PLAN OF CARE, THE DON STATED "WE JUST CHANGED OVER TO A NEW COMPUTER SYSTEM, AND SOME OF OUR ASSESSMENTS GOT LOST". REVIEW OF THE FACILITY'S POLICY TITLED "PAIN MANAGEMENT PROTOCOL", DATED 9/9/08; "UPON ADMISSION A SEVENTY-TWO (72) HOUR PAIN ASSESSMENT WILL BE PERFORMED BY ATTENDING NURSES (EVERY SHIFT FOR THREE DAYS) AND A PAIN ASSESSMENT WILL BE PERFORMED MONTHLY THEREAFTER, AND FOR NEW ONSET OF PAIN, READMISSION, WHEN NEW BEHAVIORS ARISE, TO ENSURE ONGOING INDIVIDUALIZED PAIN ASSESSMENTS AND PAIN MANAGEMENT FOR EACH RESIDENT. NURSING WILL INITIATE A CARE PLAN FOR RESIDENTS WHO EXHIBIT SIGNS OR SYMPTOMS OF PAIN". ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE COORDINATION OF CARE TO PREVENT THE DEVELOPMENT OF A PRESSURE SORES FOR ONE (#403) OF ONE SAMPLED RESIDENT WEARING A KNEE BRACE OF SIX RESIDENTS REVIEWED FOR PRESSURE SORES OUT OF A TOTAL OF 20 SAMPLED RESIDENTS, RESULTING IN AN INFECTED PRESSURE SORE. FINDINGS INCLUDED: ON 5/23/12 AT 1:40 P.M., TREATMENT NURSE "P" WAS OBSERVED PROVIDING WOUND CARE TO RESIDENT #403 THREE PRESSURE SORES: THE PRESSURE SORE TO THE LEFT FRONT CENTER OF KNEE WAS A CIRCULAR STAGE 3 PRESSURE SORE, THE INNER CIRCLE WAS WHITE, AROUND THE WOUND WAS RED. THE WOUND MEASURED 2.2 CENTIMETERS (CM) IN LENGTH (L) BY 1.1 CM IN WIDTH (W). (STAGE 3 PRESSURE SORE. TISSUE LOSS SUBCUTANEOUS FAT VISIBLE) THE PRESSURE SORE TO THE LEFT OUTER ASPECT OF HEEL (LATERAL). THE STAGE 3 OVAL SHAPED RUPTURED BLISTER. THE AREA AROUND THE WOUND WAS WHITE AND PEELING FROM THE SKIN. THIS WOUND MEASURED 1.2 CM L X 1.0 CM W. THE PRESSURE SORE ON THE INNER ASPECT OF ANKLE AREA WAS A STAGE 4. IT WAS ESCHAR (BLACK) AREA WHICH MEASURED 1.0 CM L X 0.8 CM W. NURSE "P" WAS QUERIED REGARDING THE DEVELOPMENT OF RESIDENT #403'S PRESSURE SORE, NURSE "P" STATED, "THE PRESSURE SORES DEVELOPED WHILE HE WAS WEARING A LEFT KNEE BRACE." THE RESIDENT WAS INTERVIEWED REGARDING THE KNEE BRACE AND STATED "THE BRACE WAS UNCOMFORTABLE AT TIMES." THE RESIDENT WAS NOT WEARING THE BRACE. ON 5/23/12 AT 2:00 P.M., RECORD REVIEWED REVEALED THAT RESIDENT #403 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED, THE RESIDENT WAS INDEPENDENT IN DECISION MAKING AND WAS DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING EXCEPT EATING. REVIEW OF THE BRADEN SCALE (TOOL FOR MEASURING PRESSURE SORE RISK) DATED 9/11/11, REVEALED THE SCORE WAS 14, WHICH INDICATED THE RESIDENT WAS AT MODERATE RISK FOR DEVELOPING PRESSURE SORES. REVIEW OF A PHYSICIAN'S ORDER DATED 2/29/12 DOCUMENTED, " LEFT KNEE ORTHOSIS (BRACE) FOR KNEE FLEXION CONTRACTURE." REVIEW OF THE PHYSICAL THERAPIST "I" NOTES DATED "FROM 2/28/12 TO 3/5/12" DOCUMENTED, "ORTHOSIS FITTING AND TRAINING BOTH CAREGIVER AND PATIENT FOR PROPER APPLICATION." REVIEW OF THE WOUND CARE PHYSICIAN'S NOTES REVEALED THE FOLLOWING: 1. 3/19/12, "LEFT GLUTEAL STAGE 3 ULCERATION MEASURING 1.0 CM X 0.8 CM X 0.3 CM. RIGHT GLUTEAL STAGE 3 ULCERATION MEASURING 1.3 X 1.0 X 0.3. WE WILL START BIOSTEP AND COVER WITH A BORDER GUAZE. HEELS NO EVIDENCE OF ULCERATION." 2. 3/26/12, "HEELS NO EVIDENCE OF ULCERATION." 3. 4/2/12, "HEELS NO EVIDENCE OF ULCERATION." 4. 4/9/12, "HEELS NO EVIDENCE OF ULCERATION." 5. 4/23/12 DOCUMENTED, " THE PATIENT ALSO HAD A LEG BRACE IN PLACE THAT CREATED A LEFT GLUTEAL STAGE 3 ULCERATION. WOUND MEASUREMENT 4.0 CM X 2.5 CM X 0.3 CM. THERE IS A SKIN BRIDGE OF 2.5 CM. LEFT KNEE SKIN TEAR MEASURING 2.0 X 1.3 CM. THE SURROUNDING TISSUE HAS SEVERE [DIAGNOSES REDACTED] WITH [MEDICAL CONDITION]. LOCAL TISSUE TEMPERATURE IS ELEVATED. BACTRIM DS (ANTIBIOTIC) ONE TABLET THREE TIMES A DAY FOR 21 DAYS" LEFT HEEL STAGE 3 ULCERATION MEASURING 2.7 CM X 1.2 CM X 0.3 CM SKIN BRIDGE OF 0.7 CM ." WOUND CARE NURSES NOTES REVEALED THE FOLLOWING: 1. 2/1/12, "RESIDENT WITHOUT A WOUND." 2. 3/26/12, " WOUND PRESENT AT SACRUM STAGE 2, MEASURING 0.8 CM X 0.8 X 0.2 CM. WOUND BASE ZERO SLOUGH NOTED. DRAINAGE IS SMALL AMOUNT, SEROSEROUS. ZERO ODOR." 3. 4/2/12, " WOUND PRESENT AT SACRUM STAGE 2 MEASURING 0.8 CM X 0.8 X 0.2 CM. WOUND BASE ZERO SLOUGH NOTED. DRAINAGE IS SMALL AMOUNT SEROSEROUS. ZERO ODOR." 4. 4/16/12, "STAFF NURSE VERBALLY REPORTS A REDDENED AREA TO LEFT PATTELLAR (KNEE) AND LEFT HEEL WITH SCABBED AREA. MEASURED 0.5 CM X 0.3 CM X 0.1 CM. RESIDENT HAS BRACE NOTED TO SAME AREA." REVIEW OF THE CARE PLANS/CARE GUIDE REVEALED NO INFORMATION ON MONITORING FOR SKIN CARE WHILE WEARING A KNEE BRACE. ON 5/23/12 AT 2:10 P.M., THE DIRECTOR OF NURSING (DON), RESTORATIVE NURSE "H", WOUND CARE NURSE "E", AND PHYSICAL THERAPIST (PT) "I" WERE INTERVIEWED. PT "I" STATED THAT RESIDENT #403 WAS MEASURED FOR THE BRACE, BUT WAS UNABLE TO PROVIDE DOCUMENTATION OF THE MEASUREMENTS UPON REQUEST. PT "I" ALSO STATED SHE HAD INSERVICED RESTORATIVE STAFF AND THE CERTIFIED NURSING ASSISTANTS (CNA) REGARDING BRACE APPLICATION, BUT WAS UNABLE TO PROVIDE DOCUMENTATION OF THE INSERVICES UPON REQUEST. PT "I" ALSO STATED SHE HAD OBSERVED RESIDENT #403 WITH THE BRACE ON FROM 3/5/12 TO 3/30, BUT DID NOT CHECK FOR PROPER FITTING. THERE WAS NO DOCUMENTATION INDICATING WHEN THE BRACE WAS APPLIED, OR OF RESIDENT #403'S TOLERANCE OF THE BRACE. PT "I" STATED, "THE RESIDENT WAS TRANSFERRED TO RESTORATIVE ON 3/30/12." RESTORATIVE NURSE "H" STATED, "I NEVER RECEIVED INFORMATION REGARDING THE BRACE." THE DON STATED, "THERE WAS LACK OF COORDINATION OF CARE." THE MANUFACTURER'S INFORMATION LITERATURE REGARDING THE BRACE WAS REVIEWED. THE BRACE WAS SHAPED LIKE A LEG SPLINT WITH METAL LIKE SUPPORTS ON BOTH SIDES ON THE RIGHT SIDE WAS AN ADJUSTMENT CONTROL FOR TIGHTENING AND LOOSENING THE BRACE. THE BRACE WAS LINED WITH A PADDING AND HAD A PADDING DEVICE THAT WAS FITTED FOR THE KNEE CAP. THE STRAPS WERE USED TO SECURE THE BRACE IN PLACE. THE DEVELOPMENT OF THE PRESSURE SORES WERE CONSISTENT WITH THE PRESSURE POINTS ON THE BRACE, THE KNEE, HEEL AND GLUTEAL AREA. THE LITERATURE DOCUMENTED THE FOLLOWING NURSING ACTIONS: "CHECK CUFFS EVERY 2 HOURS TO ENSURE NO PRESSURE POINTS OCCURRED", AND, "NURSING ALERT: CHECK FOR REDNESS OR [MEDICAL CONDITION]." REVIEW OF THE FACILITY'S UNDATED POLICY ENTITLED, SPLINTING/ CONTRACTURES MANAGEMENT DOCUMENTED," WHEN WEARING SPLINTS CHECK FOR PRESSURE AREAS, ESPECIALLY AROUND BONY PROMINENCES. WEARING TIMES SHOULD BE REGULATED AND REDNESS SHOULD NOT LAST MORE THAN 5-10 MINUTES. IF REDNESS OCCURS FOR MORE THAN 10 MINUTES THE SPLINT SHOULD BE DISCONTINUED. ( ) DEFICIENT PRACTICE STATEMENT #2: BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ONE (#408) OF SIX RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 20, RECEIVED AN APPROPRPIATELY SIZED DRESSING FOR A PRESSURE ULCER, RESULTING IN EXACERBATION OF AN EXISTING WOUND. FINDINGS INCLUDE: ON 5/23/12 AT 10:00 A.M., DURING AN OBSERVATION OF WOUND CARE FOR RESIDENT #408 BY NURSE "A", THE FOLLOWING FIVE PRESSURE ULCERS WERE NOTED: 1. RIGHT HEEL - THERE WAS A SILVER DOLLAR SIZED WOUND COVERED WITH HARD DRY BLACK BROWN ESCHAR (DEAD TISSUE) SURROUNDED BY PALE WHITISH BOGGY SKIN. THERE WAS MOTTLED BLUE DISCOLORATION OVER THE VENTRAL AND PLANTAR SURFACES OF THE RIGHT FOOT. 2. LEFT HEEL - THERE WAS A NICKLE SIZED SUPERFICIAL ULCER WITH CURLING WHITE EDGES AND A BLUE-BLACK NON BLANCHABLE CENTER. 3. SACRUM (LOWER BACK) - THERE WAS A 8.8 CENTIMETER (CM) BY 9.5 CM CIRCULAR BEEFY RED MOIST OPEN AREA WITH AREAS OF TAN SLOUGH (MOIST DEAD TISSUE) AND AREAS OF HARD DARK BROWN ESCHAR, SURROUNDED BY A 4 CM BY 2.3 CM AREA OF MOIST RED EXCORIATED SKIN WITH A SMALL AMOUNT OF SEROSANGUINOUS DRAINAGE (TISSUE FLUID.) 4. LEFT BUTTOCK, THERE WAS A 3 CM BY 3.7 CM MOIST REDDISH BROWN OPEN AREA WITH MOIST PINK CURLED EDGES. 5. THE LEFT HIP BONE - THERE WAS A 12 CM BY 4 CM REDDENED BLANCHABLE AREA WITH A DARK BROWN, FIRM, NON BLANCHABLE CENTER. WHEN NURSE "A" FINISHED WOUND CARE, SHE APPLIED AN ALLEVYN DRESSING (SPECIALIZED DRESSING TO PROMOTE WOUND HEALING, MINIMIZE BACTERIAL CONTAMINATION AND ABSORB DRAINAGE FROM THE WOUND) TO RESIDENT #408'S SACRAL PRESSURE ULCER. THE ALLEVYN DRESSING WAS HEART SHAPED, AND WAS NOT LONG ENOUGH OR WIDE ENOUGH TO COVER THE ENTIRE WOUND, PARTICULARLY AT THE SMALLER END OF THE DRESSING. NURSE "A" PRESSED THE ADHESIVE EDGES OF THE DRESSING INTO PLACE DIRECTLY ONTO THE DEEP OPEN AREA AT THE LEFT SIDE OF THE WOUND, AND ONTO THE WEEPING MACERATED AREA OF THE RIGHT SIDE OF THE WOUND. WHEN ASKED WHETHER THE DRESSING WAS THE APPROPRIATE SIZE FOR THE WOUND, NURSE "A" STATED, "IT'S NOT BIG ENOUGH TO COVER THE WOUND, BUT IT'S THE BIGGEST ALLEVYN DRESSING WE HAVE." ON 5/23/12 AT 10:45 A.M., THE DRESSING ON RESIDENT #408'S SACRAL PRESSURE ULCER WAS INSPECTED WITH TREATMENT NURSE "E". TREATMENT NURSE "E" REPORTED THAT THE PRESSURE ULCER ON RESIDENT #408 WAS CONSIDERED "UNSTAGEABLE" (DEPTH AND SEVERITY COULD NOT BE DETERMINED.) TREATMENT NURSE "E" STATED, "YOU'RE ABSOLUTELY RIGHT, THIS DRESSING IS TOO SMALL. IT DOESN'T EVEN COVER THE WHOLE WOUND, AND THE ADHESIVE AREA IS ON THE WOUND AND ON THE EXCORIATED AREA. THE ADHESIVE IS IRRITATING AND SHOULDN'T BE PLACED ON DAMAGED OR OPEN SKIN. THE WOUND HAS GOTTEN LARGER SINCE I LOOKED AT IT TWO DAYS AGO. THE EXCORIATED AREA IS NEW." ON 5/23/12 AT 1:00 P.M., NURSE "A" WAS QUERIED ABOUT RESIDENT #408 AND REPORTED, "SHE WAS SENT TO THE HOSPITAL BY THE WOUND NURSE BECAUSE HER WOUNDS HAD GOTTEN SO MUCH WORSE SINCE MONDAY (5/21/12)." ON 5/25/12 AT 10:40 A.M., TREATMENT NURSE "E" MEASURED THE SAME SIZE ALLEVYN DRESSING THAT WAS USED BY NURSE "A" TO COVER RESIDENT #408'S SACRAL WOUND ON 5/23/12. THE DRESSING MEASURED 11.5 CM LONG AT THE SHORTEST POINT AND 3.5 CM WIDE AT THE NARROWEST POINT. RESIDENT #408'S SACRAL WOUND WAS 12.8 CM LONG BY 11.8 CM WIDE ON 5/23/12. THUS, RESIDENT #408'S WOUND WAS 1.3 CM LONGER AND 8.5 CM WIDER THAN THE DRESSING AT THE NARROWEST AND SHORTEST POINTS. WHEN QUERIED ABOUT THIS, TREATMENT NURSE "E" STATED, "THIS IS THE LARGEST ALLEVYN WE HAVE. NURSE "A" SHOULD HAVE NOTIFIED ME THAT THE WOUND HAD GOTTEN BIGGER AND SHOULD HAVE GOTTEN A PHYSICIAN'S ORDER TO USE A GAUZE DRESSING, IF WE DIDN'T HAVE AN ALLEVYN DRESSING BIG ENOUGH FOR THE WOUND." ON 5/25/12 AT 1:30 P.M., THE DIRECTOR OF NURSING WAS INTERVIEWED AND STATED THAT NURSE "A" SHOULD NOT HAVE DRESSED RESIDENT #408'S WOUND WITH A DRESSING THAT WAS TOO SMALL TO COVER THE WOUND, BUT SHOULD HAVE CONTACTED THE TREATMENT NURSE FOR FURTHER INSTRUCTIONS. RESIDENT #408'S MEDICAL RECORD WAS REVIEWED AND REVEALED A FACE SHEET THAT INDICATED THAT SHE WAS admitted to the facility on [DATE]. HER PHYSICIAN ORDER SHEET, DATED MAY 2012, WHICH LISTED ALL PHYSICIAN ORDERS FROM 3/13/12 THROUGH 5/23/12 REVEALED THE FOLLOWING: DIAGNOSES- [MEDICAL CONDITION] AND LATE EFFECT CEREBRAL VASCULAR DISEASE. HER MINIMUM DATA SET ASSESSMENT, DATED 3/29/12, REVEALED THAT HER COGNITION WAS MODERATELY IMPAIRED AND THAT SHE REQUIRED EXTENSIVE STAFF ASSISTANCE FOR BED MOBILITY, TRANSFER AND BATHING. REVIEW OF THE FACILITY POLICY ENTITLED "WOUND CARE/TREATMENT GUIDELINES", REVISED 9/1/11 REVEALED NO STATEMENT INDICATING THAT THE DRESSING SHOULD BE LARGE ENOUGH TO COVER WOUND." ( )