Every finding on record at Medilodge of Shoreline

This citation pertains to Intakes 2999148 and 2996472.Based on observation, interview, and record review, the facility failed to transcribe and administer medications as ordered during a change in condition for one resident (R701) of three reviewed for change in condition, resulting in a delay in treatment and subsequent transfer to the hospital. Findings include:A summary of a complaint called into the State Agency revealed, [R701] was throwing up and having abdominal pain from hernia. The nursing home waited six hours to call EMS (Emergency Medical Services) . It was discovered [R701] had a perforated bowel. suffered for several hours crying out in pain and nothing was done at the nursing home other than giving [R701] Tylenol.A review of R701's medical record revealed, R701 was admitted to the facility on [DATE] readmitted [DATE] and discharged [DATE] with diagnoses of Ventral hernia without obstruction or gangrene, Morbid (severe) obesity, and Type II diabetes.A review of R701's progress note authored by Licensed Practical Nurse (LPN) A revealed, 4/21/2026 07:41 (7:41 AM) Nurses' Notes: Resident received asleep in bed. Resident awoke around 0300 (3:00 AM), verbalized c/o (complaint of) ABD (Abdomen) discomfort, reported one (1) episode of vomiting, stating [R701] ate spaghetti for dinner last night and it upset [R701's] stomach. Shortly after, resident had large loose BM (bowel movement). PRN (as needed) Tylenol admin. An hour later, resident notified writer that pain was back and hurts worse. Abdomen assessed, firm and distended, normal bowel sounds heard upon auscultation. VS (vital signs): 138/106, 109, 92% on r/a (room air), 20, 97.7. Physician and NP (Nurse Practitioner) notified, NP ordered Pepcid (a histamine-2 blocker used to treat and prevent heartburn, acid indigestion, by reducing stomach acid production), Pepto Bismol (an over-the-counter medication used to treat digestive issues, including nausea, heartburn, indigestion, upset stomach, and diarrhea) x1 (one time), stated she will be in to see resident this AM. Meds admin. LPN B notified of resident's status and NP plan to visit. Further review of R701's progress notes authored by LPN B, revealed, 4/21/2026 09:18 (9:18 AM) Nurses' Notes: Writer was called to resident room and before entering writer could hear resident vocalizing pain. Writer assessed resident and while looking at [R701] LLQ (Left lower quadrant) the hernia was pultruding from [R701's] abdomen. C/O (complaint of) pain 10/10, vitals 122/56, 100, 20, 95.6, 95%. Advised [Physician] of findings ordered to send out to hospital. DON (Director of Nursing) aware as well. A review of R701's SBAR (Situation, Background, Assessment, and Recommendation) assessment dated [DATE] 08:09 (8:09 AM), noted . Situation: ABD (abdominal) pain, distention. This started on 4/21/26. Since this started has it gotten: Worse. Things that make the condition or symptom worse are: increased pain. What do you think is going on with the resident? The resident appears to be in severe pain .On 5/7/26 at 1:00 PM, a call was made to LPN A, a voice message was unable to be made due to mailbox being full.On 5/7/26 at 12:42 PM, LPN B was asked about R701's transfer to the hospital and explained they got in the facility at 7:00 AM and could hear R701 yelling out from their room. LPN B explained they went to check on R701 and thought they would feel better if they were adjusted in bed. LPN B explained they pulled R701 up and as they pulled the resident up in the bed, they were observed to wince in pain and to grab their stomach. LPN B stated, they looked at R701's stomach and saw the resident's hernia protruding out and called the doctor. LPN B explained the doctor reported their NP was coming in but if they were not in within a timely manner to send R701 out (to the hospital). LPN B continued to monitor R701, but because of how much pain the resident was in they called the doctor back and reported the resident should be transferred to the hospital, the doctor gave orders. LPN B then called 911 for R701 to be transferred to the hospital. LPN B explained EMS did not come right away but it was approximately 9:03 AM.A review of R701's April 2026, Medication Administration Record (MAR) revealed documentation of an as needed dose of Tylenol being administered on 4/21/26 at 4:00 AM. The MAR did not reveal the NP's one time order for the administration of the Pepcid or Pepto Bismol.R701's progress notes did not reveal monitoring of R701 by LPN A regarding the pain level status of R701 after the administration of Tylenol.On 5/7/26 at 2:03 PM, the assigned Certified Nursing Assistant (CNA) C was called, a voicemail was left.On 5/7/26 at 2:32 PM, R701's roommate at the time was asked about the day R701 was transferred out to the hospital. They reported that R701 had trouble and was in consistent pain with their hernias. They said R701 told them they had two, one the size of a football and the other the size of a baseball. That night R701's family came in to visit and gave R701 spaghetti, later that night is when R701 had some trouble.On 5/7/26 at 2:13 PM, the Director of Nursing (DON) was asked for the documentation of the administration of Pepcid and Pepto Bismol as ordered by the NP on 4/21/26. During the interview the DON looked in R701's medical chart, found the Tylenol was administered at 4am, but was unable to find the one-time order and documentation for the Pepcid and Pepto Bismol.The DON was later asked about the facility's process for a resident that is experiencing a change in condition. The DON explained the nurse is to call the physician to give the clinical report, if new orders are given, the nurse is to input them into the medical record, document with a nurse's note, and follow the orders. The DON confirmed LPN A wrote a note but did not follow through with the other orders.On 5/7/26 at 3:06 PM, the Nursing Home Administrator was asked about the incident with R701 and explained after the incident they completed a timeline of what happened with R701 and found the nurse (LPN A) did not transcribe the orders into R701's medical record.A review of the facility's policy titled Medication Orders dated 10/30/20 noted, Policy This facility shall use uniform guidelines for the ordering of medication. Policy Explanation and Compliance Guidelines: 2. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility. 3. Each medication order should be documented with the date, time, and signature of the person receiving the order. A review of the facility's policy titled Notification of Changes dated, 10/30/2020 noted, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification .

Based on observation, interview and record review, the facility failed to complete annual PASARR (Pre-admission Screening and Annual Resident Review/3877) assessments for four residents (R6, R28, R32 and R61) of four residents reviewed for PASARR assessments.Findings include:Resident 6On 1/06/26 at 10:15 AM, R6 was observed sitting in a chair in their room. When asked about their care, R6 was not able to answer questions.On 1/06/26 the medical record for R6 was reviewed and revealed the following: R6 was initially admitted to the facility on [DATE] and after a brief hospitalization was readmitted [DATE] with diagnoses including Vascular Dementia, Mood Affective Disorder and Adjust Disorder with Disturbance of Conduct. A review of R6's MDS (Minimum Data Set) assessment revealed a BIMS (Brief Interview for Mental Status) assessment score of 3/15 indicating severely impaired cognition.On 1/07/26 further review of R6's medical record revealed a PASARR assessment dated [DATE] for a 30-day hospital exempted discharge. There was no updated PASARR noted in the record. Resident 28On 1/06/26 at 11:25 AM, R28 was observed resting in bed awake. On 1/06/26 the medical record for R28 was reviewed and revealed the following: R28 was initially admitted to the facility on [DATE] and after a brief hospitalization was readmitted [DATE] with diagnoses including Dementia.A review of R6's MDS (Minimum Data Set) assessment revealed a BIMS (Brief Interview for Mental Status) assessment score of 8/15 indicating moderately impaired cognition.On 1/07/26 further review of R28's medical record revealed a PASARR (3877) assessment dated [DATE] with no mental diagnoses reported. There was no updated PASARR or 3878 noted in the record acknowledging diagnosis of Dementia.Resident 32On 1/06/26 at 11:25 AM, R32 was observed resting in bed awake. Resident 32 appeared confused and stuttered trying to answer questions. On 1/06/26 the medical record for R32 was reviewed and revealed the following: R32 was initially admitted to the facility on [DATE] and after a brief hospitalization was readmitted [DATE] with diagnoses including Dementia. A review of R32's MDS (Minimum Data Set) assessment revealed a BIMS score (Brief Interview for Mental Status) assessment score of 5/15 indicating severely impaired cognition. On 1/07/26 further review of R32's medical record revealed a PASARR (3877) assessment dated [DATE] with no mental diagnoses reported on the form. There was no updated PASARR or 3878 noted in the record acknowledging diagnosis of Dementia.Resident 61On 1/06/26 at 3:05 PM, R61 was observed sitting in the chair in the dining room. R61 just nodded their head when asked if they had any concerns about their care. On 1/06/26 the medical record for R61 was reviewed and revealed the following: R61 was initially admitted to the facility on [DATE] with diagnoses including Dementia, and Alzheimer's Disease. A review of R61's MDS (Minimum Data Set) assessment revealed a BIMS (Brief Interview for Mental Status) assessment score of 3/15 indicating severely impaired cognition.On 1/07/26 further review of R61's medical record revealed a PASARR (3877) assessment dated [DATE]. There was no updated PASARR or 3878 noted in the record acknowledging diagnosis of Dementia.On 1/08/26 at 10:45 AM, the Social Services Coordinator (SSC) H was interviewed in regard to PASARR assessments. The SSC H stated resident's PASARR updates were missed (not completed). When asked what their expectation for updating Pre-admission Screening and Annual Resident Reviews, they said, residents are assessed appropriately per policy. On 1/08/26 at 2:28 PM, the Director of Nursing (DON) was interviewed. The DON stated they were unaware of the PASARR assessments not being up to date. The DON stated that their expectation is that residents will be assessed and updated as needed per the policy.A review of the PASRR - Preadmission Screen and Resident Review policy dated 10/30/23 revealed, A facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and efforts.

Based on observation, interview, and record review, the facility failed to ensure one (R8) of three residents reviewed for medication administration received the correct dose of a medication and consumed all medications provided. Findings include:Review of the medical record revealed a physician's order dated 9/25/25 for Potassium Chloride ER Tablet Extended Release 20 MEQ (milliequivalents), Give 3 tablet by mouth three times a day for supplement.Further review of the medical record revealed R8 was admitted to the facility on [DATE] with the following relevant diagnoses: Essential Hypertension, Lymphedema, Chronic Venous insufficiency and Peripheral Vascular Disease and was cognitively intact. On 1/7/26 at 7:56 AM, during an observation with Licensed Practical Nurse (LPN) A, the nurse was observed to prepare and administer medications to R8. While preparing the medication for administration, LPN A revealed R8 usually only takes one of three prescribed Potassium 20 MEQ tablets and proceeded to put one tablet into a medicine cup. R8 was not offered or asked if they would be willing to take the full prescribed dose. LPN A prepared the remainder of the medications for R8 and entered the residents' room, handing them a medicine cup with several tablets, including a narcotic. The resident set the cup on the bedside table while they obtained soda from a cooler next to their chair. R8 opened the soda, retrieved the medicine cup and remove a tablet. While still taking their medications, LPN A left the room returning to the medication cart. LPN A did not observe the resident consume any part of the medication in the cup.LPN A then documented on the Medication Administration Record (MAR) that R8 took their medications, including 3 tablets of Potassium (which only one was consumed). LPN A did not put a note in the MAR to indicate R8 did not take the full dose and did not notify the physician. On 1/7/26 at 1:54 PM, the Unit Manager (UM) F was interviewed regarding expectations regarding medication administration. UM F indicated the nurse should watch the resident consume/swallow the medication before leaving the room. UM F further indicated when part of or all of a dose of medication is refused, the nurse would document in the MAR exactly what the resident took and any other pertinent information such as education and notify the physician/nurse practitioner. On 1/8/26 at 3:00 PM, the Director of Nursing (DON) was interviewed regarding expectations regarding medication administration. The DON revealed the nurse is to ensure the resident consumes/swallows the medication and then documents in the MAR the correct doses consumed. Communication should be documented with the Physician/Nurse Practitioner when the full dose is not taken. On 1/7/26 at 2:10 PM, an interview with Nurse Practitioner (NP) G revealed they and the physician were aware of R8's medication non-compliance. NP G further revealed R8 sometimes does take all prescribed medication but often picks and chooses what they will take. NP G further revealed she reviews the MAR and did not realize full doses were not always given though were documented as given. A review of the policy titled, Medication Administration, revised 1/17/2003 revealed, 15. Observe resident consumption of medication.19. Report and document any adverse side effects or refusals.

This citation pertains to Intake 2704083. Based on observation, interview, and record review, the facility failed to provide showers for one resident (R66) of three reviewed for activities of daily living (ADLs). Findings include: A review of an Intake allegation noted, It was alleged the resident isn't provided with appropriate showers per preference.A review of R66's shower schedule noted, Bathing: Monday and Thursday dayshift.A review of R66's shower record for the last 30 days revealed, Thursday 12/11/25 documented as response not required (shower did not occur), Thursday 12/18/25 checked as one person assist, Monday 12/22/25 checked as one person assist, Thursday 12/25/25 response not required. Further review of R66's medical record revealed, was admitted to the facility on [DATE] with diagnosis of Paraplegia. A review of R66's Minimum Data Set (MDS) assessment dated [DATE] noted, R66 with an intact cognition and dependent of staff to complete activities of daily. The MDS noted R66's shower ability as Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self-partial/moderate assistance. A review of R66's care plan revealed, Focus: Resident has an Activities of Daily Living (ADL) self-care performance deficit related to Low Back pain, Paraplegia, Major Depressive disorder, Other Chronic Pain. Date Initiated: 09/20/2025. Goal: Resident's ADL needs will be met through next review. Date Initiated: 09/20/2025. Interventions: BATHING: 1 person assist Date Initiated: 12/23/2025. On 1/08/2026 at 2:52 PM, the Director of Nursing (DON) was asked to review R66's 30-day shower record and if there was any other documentation for R66's showers or refusals of showers. The DON explained, as a team they review shower documentation during the morning meeting and was not made aware of R66 currently refusing showers. After a review of R66's medical record the DON reported, she did not see any documentation regarding the refusals. The DON was asked the process for a resident that refuses a shower and explained, it should be charted under the task section by the Aide, then the Nurse would reapproach the resident, then the outcome is to be documented with a progress note. On 1/08/2026 at 3:22 PM, R66's call light was observed to be activated above the door. R66 reported the light was pressed because today is a shower day and a week ago was their last shower. On 1/08/2026 at 4:00 PM, the DON confirmed R66 is a morning shift shower on Monday and Thursday. The DON was asked why R66 shower was not documented as given for Monday 1/5/26. The DON reported they were not sure and will speak with the assigned Aide. A review of the facility's policy noted, Policy: The facility takes measures to minimize the loss of resident's functional abilities, including activities of daily living (ADLs). Activities of Daily Living include the ability to: 1. Bathe, dress, and groom Policy Explanation and Compliance Guidelines: 1. Conditions which may demonstrate unavoidable decline in ADLs include . 2. The facility provides maintenance and restorative program to assist residents in achieving and maintaining the highest practicable outcome based on their comprehensive assessment. 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 .

Based on observation, interview, and record review, the facility failed to remove expired medications from two of three medication carts reviewed. Findings include:On 1/7/26 at 1:00 PM, an observation of the Station One, medication cart 2, was a bottle of Midodrine (used to treat low blood pressure), labeled for R17 filled on 11/1/24 with a use by date of 11/1/25. On 1/7/26 at 1:22 PM, an observation of the Station One, medication cart 1, was an over-the-counter brand of sinus severe tablets with an expiration date of 8/2024. An identifying label for a specific resident was not present. On 1/7/26 at 1:54 PM, an interview with Unit Manager (UM) F revealed medication should be in the medication carts secondary to being long past their expiration dates. On 1/8/26 at 2:10 PM, an interview with the Director of Nursing (DON) revealed expired medications are to be removed from the medication carts or medication storage area and returned to pharmacy or discarded.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) meetings were held quarterly, for two of four meetings, potentially affecting all of the 103 residents currently residing in facility resulting in delayed identification and resolution of identified issues. Findings include: On 10/17/24 at 12:30 PM, a meeting was held with the Nursing Home Administrator (NHA) regarding Quality Assurance (QA) activities at the facility. A review of the sign in sheets (to confirm at least three staff were present who were knowledgable of facility systems and oversight) revealed there was no sign in sheet for March and June 2024. The NHA confirmed there were no QA meetings held during those two months. A review of the facility's policy titled, QAPI (Quality Assurance Performance Improvement) Plan, dated 10/24/22, indicates: a.The governing body and/or executive leadership is responsible and accountable for the QAPI program. The Governing oversight responsibilities include, but are not limited to: i. Approving the QAPI plan annually, and as needed. ii. Ensuring the program is sustained during transitions in leadership and staffing. (At the facility level, regional level and the corporate level.) . c. The QAA Committee shall communicate its activities and the progress of its subcommittee activities to the governing body .at least quarterly, with a formal meeting no less than annually .

This citation pertains to Intake MI00147288. Based on observation, interview, and record review, the facility failed to maintain a pest-free environment, resulting in gnats throughout the common areas of the facility and throughout residents rooms. This deficient practice had the potential to affect all 130 residents who reside in the facility. Findings include: On 10/15/24 at 9:18 AM, during initial tour room [ROOM NUMBER] bed two trash can was observed to gnats laying on and inside of the trash can. The trash can was without a liner/trash bag on the inside of the can. On 10/15/24 at 9:39 AM, during initial tour room [ROOM NUMBER] bed two trash can was observed to gnats laying on and inside of the trash can. The trash can was without a liner/trash bag on the inside of the can. On 10/16/24 at 8:02 AM, during the medication administration observation gnats were observed flying around the medications cart. The Nurse was observed to use their hands to swat the gnats away. On 10/16/24 at 8:18 AM, room [ROOM NUMBER] was observed to have a number of gants flying around in the room. The night stand drawer next to bed one was observed to be practically open with gants laying on the drawer. The Nurse was asked if the resident had food in the drawer, the drawer was observed with food itmes that had spilled into the drawer. As the Nurse opened to the drawer, a large amount of gnats were observed to begin to fly all around the room. 10/17/24 at 2:33 PM, room [ROOM NUMBER] bed one privacy curtain was observed with multiple gnats lying on the curtain. 49699 On 10/15/24 at 11:11, Housekeeper K revealed there have been gnats in many rooms. On 10/15/24 at 10:30 AM a gnat was observed flying around R72's face. On 10/15/24 at 10:32 AM Housekeeper J revealed there were gnats in several rooms because of food residents keep. 40330 On 10/15/24 at 10:07 a.m., R58 was observed in their hospital bed in room [ROOM NUMBER], bed 1. Flies and gnats were observed flying in R58's room. R58 confirmed they noticed the gnats in the room frequently. On 10/15/24 at 10:45 a.m., Flies and gnats were observed smarming above R35's bed, R58's roommate, in bed 2. R35 stated this bothered them and they reported their concerns to the facility in the past month yet they still had insects in their room. On 10/15/24 at 12:24 p.m., License Practical Nurse (LPN) R was asked about the flies and gnats in room [ROOM NUMBER]. LPN R reported a resident's family brought in fruit a few doors down, room [ROOM NUMBER], bed 2, and they believed this started the problem. LPN R acknowledged they continued to observe the gnats on the unit and in residents' rooms. On 10/17/24 at 8:13 a.m., the Housekeeping Supervisor, Staff S, was asked about the flies and gnats in residents' rooms. Staff S reported they were aware of the ongoing concern, and stated it started when a resident's family in room [ROOM NUMBER] brought fresh fruit, including ripened bananas, into the facility. On 10/17/24 at 2:20 p.m., the Director of Nursing (DON) was asked about the observations of the flies and gnats in the residents' rooms in the facility. The DON confirmed they understood the concern and planned to follow-up. Review of a pest control service report dated 9/20/24 noted: In room [ROOM NUMBER], recently cleaned due to fruit spoilage, there was a garbage can filled with food debris-milk, banana peels, and other items-without a bag .Housekeeping must ensure bags are always in trash cans. If any organic material escapes, the bins need to be cleaned and sanitized. Regular cleaning of floors is also necessary to address stickiness that can attract gnats. A review of the facility's policy titled Pest Control Program dated, 01/01/2022, noted, Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pest and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pest (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats.) .

Based on observation, interview, and record review the facility failed to change an indwelling catheter (tube inserted into the bladder to drain urine) with a urinary tract infection for one resident (R39) out of two reviewed for indwelling catheters. Findings include: On 10/15/2024 at 12:47 PM, R39 was observed to have an indwelling catheter hanging off their wheelchair. R39 stated they recently had a Urinary Tract Infection (UTI) and they were still having symptoms although they were finished with antibiotics. R39 stated they have not had their catheter changed since being admitted into the facility on [DATE]. A review of the medical record revealed R39 admitted into the facility on [DATE] with the following diagnoses, Sever Sepsis without Septic Shock and Neuromuscular Dysfunction of Bladder. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIM) score of 15/15 indicating an intact cognition. R39 also required staff assistance for bed mobility and transfers. A review of the physician orders revealed the following, Date: 8/9/2024. Directions: Change indwelling catheter 14 fr (French) balloon 30cc (cubic centimeters) r/t (related to): wounds PRN (as needed) as clinically indicated: s/s (signs/symptoms) of obstruction leakage, increased sediment, etc., infection, or if closed system was compromised as needed for catheter care. Further review of the Medication Administration Record (MAR) for August, September and October (2024) did not document R39's catheter as being changed since admisison. On 10/16/2024 at 12:47 PM, an interview was conducted with the Infection Control (IC) Nurse H. IC H stated R39 had an UTI as well as Covid. IC H stated they thought the indwelling catheter was changed and it should have been changed when they collected the urinalysis analysis sample. On 10/16/2024 at 10:53 AM, an interview was conducted with Unit Manager (UM) C. UM C stated they just ordered a new Urine Analysis for R39, however were unsure about the policy regarding changing an indwelling catheter when a resident had an infection. On 10/17/2024 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they have never changed an indwelling catheter following an UTI in the facility, only if there was sediment or if it was clogged. A review of a facility policy titled; Appropriate Use of Indwelling Catheters did not address indwelling catheter changing with infections.

Based on observation, interview, and record review the facility failed to provide care in a dignified manner, for one sample resident (R49) of seven reviewed for dignity. Findings include: On 10/16/24 at 6:50 AM, R49 reported there was an incident with two Certified Nursing Assistants (CNA) while they were receiving care. R49 continued and explained, two CNAs (CNAs F and G) entered their room to assist with care, then CNA G asked R49 about a comment R49 made about the CNAs. R49 reported they felt like CNA G was intimidating them by confronting them about their comment. R49 stated during the conversation CNA G made the comment, because they are not allowed to hit R49, she took a hygiene product and poured in down the bathroom sink. R49 stated it was reported and the CNAs were removed from their room and no longer provide care to them. On 10/16/24 at 11:05 AM, the Unit Manager confirmed that R49 reported CNA G poured out their hygiene product down the bathroom sink and the facility completed an investigation. On 10/16/24 at 11:23 AM, CNA G was called, the phone message stated the phone was disconnected. A review of CNA G's personal file noted, Performance improvement form dated 9/19/24. Reason: Resident stated employee used inappropriate language and threw away resident belongings. On 10/17/24 at 2:33 PM, the Nursing Home Administrator (NHA) reported we replaced the hygiene product and CNA G was suspended for the allegations. The NHA explained, the staff should not have brought any alleged comments up to any residents. On 10/17/24 at 2:36 PM, CNA F explained, CNA G asked for assistance with R49 and while we were helping R49 CNA G asked R49 if they made a comment about them, R49 said they did, and CNA G and R49 continued to go back and forth about the comment. CNA F explained they tried to get them to stop and to let it go but they kept going. CNA F explained they did not see CNA G pour anything out during that time. CNA F also reported CNA G did use an expletive word during the conversation with R49. A review of the facility's policy titled Promoting/Maintaining Resident Dignity dated, 10/30/23, noted, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: . 10. Speak respectfully to residents; avoid discussing about residents that may be overheard. 11. Respect the residents' living space and personal possessions .

This citation pertains to MI00147323 Based on observation, interview, and record review the facility failed to ensure communication needs were met for one resident (R10) of three residents reviewed for communication. Findings include: A review of the admission record revealed R10 was admitted on [DATE] with the following pertinent diagnoses: Dysphagia, Protein Calorie Malnutrition, Adjustment Disorder with Anxiety, Restlessness and Agitation. R10 spoke Arabic. On 10/15/24 at 9:00 AM, R10 was observed with head of bed elevated and the overbed table was across the bed with food debris visible. When R10 was queried, they were unable to respond verbally, responded with questioning look on face. On 10/15/24 at 11:40 AM, Certified Nursing Assistant (CNA) I was queried on R10's method of communication. CNA I revealed they verbalize what they are doing, use some gestures and if resident says no or becomes upset they stop and return later. CNA I revealed they were not aware of a communication board. On 10/15/24 at 11:50 AM, Unit Manager (UM) C revealed resident is unable to use a communication board. UM C further revealed R10 is often resistant to care and combative. Review of R10's Communication Care Plan, initiated 1/2/24, did not reveal an intervention for the use of a communication board. On 10/15/24 at 12:10 PM, an unknown family member was noted preparing to assist R10 with the lunch meal. Upon introduction, the family member responded, I do not speak English. Review of the Social Service Progress Note by Social Work Director M, dated 10/10/24 revealed the Social Service Director met with the resident on a 1:1 basis to complete quarterly review. Resident has a language barrier and speaks Arabic. BIMS (Brief Interview for Mental Status) and PHQ-9 (Patient Health Questionnaire-9, a diagnostic tool to screen for presence and severity of depression) unable to complete. Resident is their own RP (Responsible Person). Communication interventions do not include translators or a communication board. On 10/16/24 at 2:45 PM the Director of Social Work (SW) M revealed they have not been involved in developing any communication boards to date. They revealed they prefer family to translate, but has not used family for R10 interviews. SW M was familiar with the availability of translation companies and of staff who can provide translation. SW M revealed they conduct one to one interview by observation, interaction with family, gesturing and observation in different situations. SW M was unable to verbalize how they interview non-English speaking residents and family. Review of R10's medical record revealed there is no documentation a translator was involved when SW M completed the initial assessment or subsequent care conferences. On 10/16/24 at 3:45 PM, an email request was made to the Nursing Home Administrator (NHA) for the following items: Education provided regarding Non-English speaking residents, list of other resources such as those used for translation services, the qualifications of staff members who provide translation services, and a list of vital documents the facility may have already translated, specifically for admission. These items were not received by 5:30 PM on the last day of survey. On 10/16/24 at 4:46 PM, Social Worker M revealed there was not a translator present for the quarterly review, for BIMs, or PHQ-9. On 10/16/24 at 4:47 PM, the previous Director of Social Work (SW) N revealed the Activities Director (AD)develops specific communication boards. SW N revealed they used trusted family members, staff people, and the telephone translation companies to conduct necessary interviews. They revealed at times the Brief Interview for Mental Status (BIMS) is unable to be completed secondary to language barriers. On 10/17/2024 at 2:00 PM, R10's Family Member U was entering R10's room. Upon introduction was told, I do not speak English, I will call my son. Family Member V was called to translate the conversation and revealed that R10 is sometimes resistant to care. Family Member V further revealed they were not asked to help with providing communication to R10 in a way resident could understand. A review of the facilities policy titled Communicating with Persons with Limited English Proficiency(LEP), revised 1/1/2022, revealed the following: The Social Services Director will be responsible for obtaining access to a qualified interpreter. In the absence of the Social Services Director, the responsibility will fall to the Director of Nursing or Nurse Manager on duty. The policy further states, a. Except in emergencies, family members or friends will not be used as interpreters unless specifically requested by that individual, and after the LEP person has understood that an offer of an interpreter at no charge to the person has been made by the facility. b. The facility will document the offer of an interpreter and the resident's response in the resident's medical record .The policy also provides for communication of information contained in vital documents, including but not limited to, waivers of rights, consent to treatment forms, and financial and insurance benefit forms. 8. c. The Administrator will maintain a list of vital documents that have been translated into various languages (provide list). 9. All staff will be provided notice of this policy, and staff that may have direct contact with LEP individuals will be trained in effective communication techniques, including the effective use of an interpreter .

Based on interview and record review, the facility failed to hold medication per medication parameters for one resident (R102) out of four reviewed for medication administration. Findings include: A review of the medical record revealed R102 admitted into the facility on [DATE] with the following diagnoses, Essential Hypertension and Rheumatoid Arthritis. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) of 14/15 indicating an intact cognition. R102 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following, Amlodipine Besylate Tablet 10 MG (milligram)-Give one tablet by mouth one time a day for HTN (Hypertension) HOLD FOR SBP (Systolic Blood Pressure) <120.Start Date:7/10/2024 A review of the Medication Administration Record (MAR) for July 2024 revealed the Amlodipine was administered with a SBP <120 on the following days with the following blood pressures, 7/10-119/78,7/16-118/78,7/18-114/69,7/21-119/78,7/25-117/73, and 7/26/24-117/67. Further review of the progress notes did not show any notification to the physician regarding the medication being given despite the parameters in place. On 10/17/2024 at 10:29 AM, an interview was conducted with Unit Manager (UM) C. UM C stated they will be talking to the nurses administered the medication and doing education. UM C stated if a medication has parameters, then it should be followed. On 10/17/2024 at 1:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they expect the nurses to follow the parameters with medications. A review of a facility policy titled, Physician/Practitioner Orders-Consulting did not address medication parameters.

Based on observation, interview, and record review, the facility failed to provide and document indwelling catheter care (tube inserted into the bladder to drain urine) for one resident (R63) out of two reviewed for an indwelling catheter. Findings include: On 10/16/2024 at 8:30 AM, R63 was observed laying in bed. R63 was noted to have an indwelling catheter. R63 stated they have had a catheter since their last admission into the facility. A review of the medical record revealed R63 admitted into the facility on [DATE] with the following diagnoses, Urinary Tract Infection and Sever Sepsis with Septic Shock. A review of the Minimum Data Set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R63 also required staff assistance with bed mobility and transfers. A review of the physician orders revealed the indwelling catheter orders for catheter care were not entered until 10/14/2024 and 10/15/2024. On 10/16/2024 at 10:54 AM, an interview was conducted with Unit Manager (UM) B regarding the catheter orders being put in almost two months after admission. UM B stated they went in and entered the orders and revised them. On 10/17/2024 at 1:28 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they happened to catch the orders were not in the other day. The DON stated upon admission they go over all the orders and look at them during morning meeting and were unsure how the catheter care orders were missed. A review of a facility policy titled, Appropriate Use of Indwelling Catheters noted the following, 4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable).

Based on observation, interview, and record review, the facility failed to properly care for and document colostomy care for one (R88) of one resident reviewed for ostomy care. Findings include: On 10/15/24 at 09:15 AM, R88 revealed they have a new ostomy. R88 further revealed the appliance does not stay on, always leaks, and their skin hurts. R88 further revealed they have not been educated on how to put the appliance on because they can only use one hand. Review of the admission record revealed R88 was admitted to the facility on [DATE] with the following relevant diagnoses: Partial Intestinal Obstruction, Colostomy, Mild Cognitive Impairment, Hemiplegia and Hemiparesis affecting Right Dominant Side following Cerebral Infarction, and Aphasia. On 10/16/24 at 9:00 AM, R88 revealed their ostomy was changed by the night shift because it was leaking again. Review of R10's medical record failed to reveal any documentation of the ostomy appliance leaking, of the skin condition of the ostomy site, or that the NP (Nurse Practitioner)/MD (Medical Doctor) had been notified. On 10/16/24 at 12:30 PM, an interview with the Wound Care Nurse (WCN)Q revealed R88's skin under the ostomy wafer had declined since admission. They further revealed they were not advised or were unaware the ostomy was frequently leaking. WCN Q revealed frequent leaking could be determined by the supplies used. WCN Q revealed the ostomy site was not pictured (as wounds were) on admission. Inquiry regarding the location of documentation about the ostomy site revealed the WCN Q did not document the condition of the site. WCN Q revealed when there is an issue with an ostomy site, they would discuss with the NP/MD. WCN Q revealed education was not provided to R88 because they have communication difficulties and word finding trouble. On 10/16/24 at 1:24 PM Nurse Practitioner (NP) P revealed her examination of the ostomy site was through the appliance. NP P revealed they were unaware the appliance had been leaking or that skin under the appliance was deteriorating. Further discussion revealed they trusted the WCN Q would be able to manage the appliance and any difficulties. On 10/16/24 at 4:30 PM the Director of Nursing (DON) revealed documentation for an ostomy, should include a description of skin and surrounding area. The DON further revealed, if there are multiple appliance changes outside of the order, those should also be documented. The DON revealed that R88's family member discussed the ostomy supplies with the Nursing Home Administrator (NHA) so the correct supplies could be ordered. The DON revealed the NP/MD should be made aware of any complications with the appliance and ostomy site. On 10/17/24 at 10:00 AM an observation of R10's ostomy site with WCN Q, revealed R10's skin around the stoma was excoriated. WCN Q revealed R88 had an ostomy belt on admission that was missing and reordered. The ostomy belt was used after reapplication during this change. WCN Q revealed the appliance may not be correct for this resident and reason for the leakage. Review of R88's care plan, initiated identified interventions to include observing the skin integrity at the stoma site and report signs of irritation redness, and/or rashes to Physician/NP/PA (Physicians Assistant). Observe stoma site for complications when colostomy appliance is changed. Provide teaching to resident/family about colostomy care. Review of R88's Treatment Administration Record (TAR) the order, applying a new wafer with bag as needed, reveals no additional ostomy appliance changes were documented.

Based on observation, interview and record review, the facility failed to implement nutritional interventions for one resident (R63) out of two reviewed for nutrition. Findings include: On 10/16/2024 at 8:27 AM, R63 was observed eating breakfast. R63 was sitting leaned off to the side with visible tremors in their hand. R63 was noted to have food on the floor, as well as on their clothes. R63 stated they ate by themselves with no assistance for all meals, but they could use a little help. R63 was noted to try and drink some orange juice from a regular cup and stated they needed to put a straw in it. A two handled cup was observed on the meal tray, flipped upside down. A review of the meal ticket on the tray documented R63 was supposed to have 1:1 assistance with eating, and a two handled cup with a lid for beverages. A review of the medical record revealed that R63 admitted into the facility on [DATE] with the following diagnoses, Urinary Tract Infection and Sever Sepsis with Septic Shock. A review of the Minimum Data Set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R63 also required staff assistance with bed mobility and transfers. On 10/16/2024 at 12:12 PM, R63 was observed leaning towards their right-side eating lunch. Tremors were noted in their hands, resulting in lunch foods falling off the fork and onto their clothing. No staff were present in the room to assist with feeding. On 10/17/2024 at 11:46 AM, R63 was observed in their room with their lunch tray in front of them. R63 was observed with a cup of orange juice in their hand and sleeping. A two handled cup was noted on the tray flipped upside down. On 10/17/2024 at 11;53 AM, the Director of Nursing (DON) was brought into R63's room and asked if they were supposed to have 1:1 assistance with feeding, as well as their orange juice in the empty two handled cup. The DON looked at the meal ticket and stated they were supposed to have assistance. The DON then poured the orange juice in the empty two handled cup. On 10/17/2024 at 12:24 PM, an interview was conducted with Registered Dietitian (RD) D. RD D stated the two handled cup was put in place for independence with being able to drink and the 1:1 assistance because R63 had a decrease in intake and had lost weight. RD D stated R63 should still be receiving 1:1 assistance with feeding and the two handled cup which are interventions are on the care plan, as well as on the tray ticket. A review of a facility policy titled, Activities of Daily Living (ADLs) noted the following, 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.

Based on observation, interview, and record review, the facility failed to ensure one resident (R63) out of four reviewed for medication administration were free of any significant medication errors. Findings include: On 10/16/2024 at 9:12 AM, 9:00 AM medication administration was completed with Licensed Practical Nurse (LPN) A for R63. A review of the physician orders revealed the following, Furosemide Oral Tablet 20 MG (Milligrams) (diuretic). Directions: Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10). Time: 0900 (9:00 AM). Famotidine Oral Tablet 20 MG (antacid). Directions: Give 1 tablet by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (K21.9). Time: 0600. (6:00 AM) LPN A was observed putting medication in the cup and clicking off the medicine as yes on the Medication Administration Record (MAR) as they put the medicine in the cup. LPN A was then observed taking the Famotidine (due at 6:00 am) 20 MG cartridge and checking off the Furosemide (due at 9:00 am) 20 MG on the MAR. LPN A was then asked by surveyor what medication did they put in the medicine cup to administer, and LPN A stated they put R63's Furosemide in the medicine cup. LPN A then showed the surveyor the cartridge that was labeled Famotidine 20 MG. LPN A stated, Oh I thought that was the Furosemide, let me take that out. LPN A then removed the pill from the medicine cup. A review of the medical record revealed that R63 admitted into the facility on [DATE] with the following diagnoses, Urinary Tract Infection and Sever Sepsis with Septic Shock. A review of the Minimum Data Set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R63 also required staff assistance with bed mobility and transfers. On 10/17/2024 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they will have to do an education regarding medication pass and medication names. A review of the medical record revealed R63 admitted into the facility on [DATE] with the following diagnoses, Urinary Tract Infection and Sever Sepsis with Septic Shock. A review of the Minimum Data Set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R63 also required staff assistance with bed mobility and transfers. A review of a facility policy titled, Medication Administration noted the following, 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration .

Based on observation, interview, and record review, the facility failed to properly store and secure medications for one resident (R48) out of one resident reviewed for medication storage. Findings include: On 11/14/24 at 12:11 PM, R48 was observed lying in bed. Nystatin powder and Hydrocortisone cream were observed on R48's bedside table. R48 explained the facility staff applies the powder and cream and they leave it at R48's bedside. A review of R48's record revealed they were admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. A review of R48's Brief Interview for Mental Status revealed a score of 13, indicating mild cognitive impairment. Further review of R48's medical record revealed the following active medication order: Apply Hydrocortisone ointment 1% to left forearm and right upper chest and shoulder every day and evening shift for rash for 7 days and every 8 hours as needed for rash/itching. A review of R48's medical record also revealed the following discontinued order: Nystatin External Powder 10000 unit/gm apply to bilateral skin folds topically two times a day for skin candidiasis until 07/04/2024. On 11/14/24 at 2:56 PM, during an interview the Director of Nursing explained mediations should not be kept at a residents bedside.

Based on observation, interview, and record review, the facility failed to properly store and secure medications for one resident (R48) out of one resident reviewed for medication storage. Findings include: On 11/14/24 at 12:11 PM, R48 was observed lying in bed. Nystatin powder and Hydrocortisone cream were observed on R48's bedside table. R48 explained the facility staff applies the powder and cream and they leave it at R48's bedside. A review of R48's record revealed they were admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. A review of R48's Brief Interview for Mental Status revealed a score of 13, indicating mild cognitive impairment. Further review of R48's medical record revealed the following active medication order: Apply Hydrocortisone ointment 1% to left forearm and right upper chest and shoulder every day and evening shift for rash for 7 days and every 8 hours as needed for rash/itching. A review of R48's medical record also revealed the following discontinued order: Nystatin External Powder 10000 unit/gm apply to bilateral skin folds topically two times a day for skin candidiasis until 07/04/2024. On 11/14/24 at 2:56 PM, during an interview the Director of Nursing explained mediations should not be kept at a residents bedside.

This citation pertains to Intake MI00144522. Based on observation, interview, and record review, the facility failed to document and provide showers per resident preference and schedule for three residents (R902, R903, R904) of three residents reviewed for showers. Findings Include: R902 On 6/26/2024 at 10:30 AM, R902 was observed in their bed. R902 stated they do not receive showers as they should and they have only received two showers since being in the facility. R902 stated they do receive bed baths but would much rather have a shower. R902 stated they feel as though staff won't give them showers because they are a bit bigger and the staff do not want to do the extra work. On 6/26/2024 at 10:57 AM, R902 was observed receiving a bed bath from two certified nursing assistants (CNA). One of the CNAs stated they were getting R902 up in the chair for the day and R902's shower days were Monday and Thursday. A review of the medical record revealed that R902 admitted into the facility on [DATE] with the following medical diagnoses, Obesity and Muscle Weakness. A review at the Minimum Data Assessment set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R902 also required assistance with bed mobility and transfers. A review of the shower documentation revealed that R902's shower days were scheduled for Monday and Thursdays between the hours of 3pm and 11pm. Further review of the shower documentation for the last thirty days revealed that R902 did not have a shower documented for the following days, 6/3,6/6,6/13,6/17,6/20, and 6/24/24. 40384 R903 On 6/26/24 at 11:52 AM, R903 was asked about receiving showers and explained that it has been awhile since they received an actual shower. R903 explained their scheduled shower days are scheduled during the afternoon shift however, there is often conflict between the day shift nursing assistants that work 7am-7pm, and the afternoon shift nursing assistants that work 7pm-7am regarding whose responsible for showering her, and as a result, she doesn't receive one at all. A review of R903's medical record revealed that they were originally admitted into the facility on [DATE] with diagnoses of Lymphedema, Major Depressive Disorder, and Muscle Weakness. Further review of the medical record revealed that the resident was cognitively intact and required two-person assistance for bed mobility, bathing, and transfers requiring a Hoyer lift. Further review of R903's medical record revealed no documented showers within the last 30 days for R903. On 6/26/24 at 1:07 PM, a request for R903's showers was made to facility, and not received by the end of the survey. R904 6/26/24 at 12:02 PM, R904 was observed sitting in their room, meal tray sitting in front of them. R904 mentioned that they probably wouldn't receive their shower today, and that it had been about a week and a half since they last received one, as they don't receive them regularly. A review of R904's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Cerebral Infarction, Dementia, Heart Disease, and Muscle Weakness. Further review revealed that the resident was cognitively intact, and required two-person assistance for bathing. On 6/26/24 at 1:07 PM, a request for R904's showers was made to the facility, and not received by the end of the survey. On 6/26/2024 at 2:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated recently many of the staff aren't documenting the showers because they state they do not have access to do so. The DON stated they are telling the staff if they do not have access then they need to let a manager know so they can get access right away. A review of the facility's Activities of Daily Living (ADLs) policy was reviewed and revealed the following, 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 .

This citation pertains to Intakes MI00143495 and MI00143567. Based on observation, interview, and record review, the facility failed to float heels per physician orders for two residents (R802 and R803) out of two reviewed for skin conditions. Findings include: R802 On 4/23/2024 at 9:28 AM, R802 was observed laying in bed. R802 heels were noted to be resting on the mattress. No pillow was observed under their legs to float their heels. On 4/23/2024 at 11:23 AM, R802's heels were observed resting on the mattress. On 4/24/2024 at 9:45 AM, 10:10 AM, and 12:08 PM, R802's heels were observed resting on the mattress. A review of the medical record revealed that R802 admitted into the facility on [DATE] with the following diagnoses, Diabetes and Dysphagia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R802 also required assistance with bed mobility and transfers. Further review of the physician orders revealed the following, Start: 10/23/2023. Status: Active .Cleanse bilateral heels with Normal Saline, pat dry, apply skin prep. Keep heels floated. Further review of the Care Plan revealed the following intervention, Date Initiated: Assist to elevate heels off the mattress with pillows as tolerated. R803 On 4/24/2024 at 9:07 AM, 9:49 AM, 10:15 AM, and 11:51 AM, R803's heels were observed resting on the mattress. On 4/24/2024 at 11:51 AM, R803 was interviewed regarding their heels being floated. R803 stated that they asked the staff last night to put their legs on a pillow and float their heels, but they did not do it. A review of the medical record revealed that R803 admitted into the facility on [DATE] with the following diagnoses, Muscle Wasting and Atrophy and Diabetes. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R803 also required assistance with bed mobility and transfers. Further review of the physician orders revealed the following order, Start Date: 5/12/2023. Status: Active .Cleanse bilateral heels with NS (Normal Saline), pat dry, apply skin prep, float heels when in bed. On 4/24/2024 at 12:12 PM, an interview was conducted with Unit Manager (UM) C. UM C stated that if there is an order for their heels to be floated then they should be floated.

This citation pertains to Intake MI00143567. Based on observation, interview, and record review, the facility failed to get residents out of bed per their preference for two residents (R803 and R806) out of two reviewed for resident rights. Findings include: R803 On 4/23/2024 at 9:30 AM, R803 was observed laying in bed. R803 was interviewed regarding their care in the facility. R803 stated that they enjoy being at the facility, however they (facililty staff) do not get them up like they should R803 stated they prefer to get up before breakfast and be up for all meals. R803 stated they do not like eating their meals in the bed. R803 stated that they also don't like to miss bingo. On 4/24/2024 at 10:15 AM, R803 was observed still in bed. R803 stated they asked to get up before breakfast, but no one got them up. R803 stated they hope they are up by lunch. On 4/24/2024 at 11:51AM, R803 was observed eating lunch in their bed. R803 stated they were informed they would be getting up after lunch. On 4/24/2024 at 12:06 PM, an interview was conducted with Certified Nursing Assistant (CNA) D. CNA D stated that R803 is supposed to get up on midnights so that R803 would be up for breakfast. CNA D stated they were unable to get R803 up before lunch because of something going on in the facility. CNA D stated they informed R803 they would get them up after lunch. A review of the medical record revealed R803 was admitted into the facility on [DATE] with the following diagnoses, Muscle Wasting and Atrophy and Diabetes. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R803 also required assistance with bed mobility and transfers. R806 On 4/24/2024 at 9:45 AM, R806 was heard crying in their room. R806 stated they have been trying to get out of the bed and attend activities for the last two days. R806 stated that no one will get them up and they keep being told they are short staffed. R806 stated they get depressed sitting in the room and laying in bed all day. R806 stated the Activities Director came and stated that they would make sure they got up today and attended activities. A review of the medical record revealed that R806 admitted into the facility on [DATE] with the following diagnoses, Edema and Major Depressive Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental statsu score of 15/15 indicating an intact cognition. R806 also required assistance with bed mobility and transfers. On 4/24/2024 at 11:27 AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated that it is resident preference when they get up. The NHA stated some people like to get up early, and some like to get up late. It all depends on what the resident prefers, and they accommodate. A review of a facility policy titled, Activities of Daily Living noted the following, .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.

This Citation pertains to Intake Number: MI00131987. Based on observation, interview, and record review, the facility failed to prevent sexual abuse of a resident by a staff member for one resident (Resident #801) of three residents reviewed for abuse, resulting in an Immediate Jeopardy to the health and safety of the resident when a staff member witnessed a Certified Nursing Assistant (CNA) in R801's room with his penis exposed, R801 without a brief, and R801 was assessed to have vaginal bleeding. R801 was transported to the hospital and started on Post Exposure Prophylaxis (PEP) coverage (medicine prescribed after possible exposure to HIV - Human Immunodeficiency Virus) and antibiotics. The sexual abuse resulted in serious harm and/or injury to the resident using the reasonable person concept. Immediate Jeopardy: The Immediate Jeopardy began 10/14/2022. The Immediate Jeopardy was identified on 10/18/2022. The Administrator was notified of the Immediate Jeopardy on 10/18/2022 at 4:13 PM and a plan to remove the immediacy was requested. The immediacy was removed on 10/19/2022 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Findings include: Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 1/1/22, revealed, in part, the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Sexual Abuse' is non-consensual sexual contact of any type with a resident . Review of a Facility Reported Incident (FRI) submitted to the State Agency revealed on 10/14/22, Facility staff member reported to charge nurse she observed employee (CNA 'A') in R801's room with his pants unzipped and his private parts out. An unannounced, onsite investigation was conducted from 10/18/22 through 10/25/22. On 10/18/22 at 11:33 AM, R801 was observed in her room, lying on her back in the bed. The privacy curtain was pulled part way and R801's calves and feet were visible from the doorway. When addressed, R801 smiled. R801 was no able to answer questions with appropriate responses and appeared pleasantly confused. When asked questions, R801 stated, Praise the Lord repeatedly. When asked about care in the facility and if anything ever happened that made her feel uncomfortable or unsafe, R801 stated, Only when it's up. Praise the Lord. R801 was unable to be interviewed. Review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Alzheimer's Disease and schizophrenia. Review of R801's Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had severely impaired cognition, no behaviors, and was totally dependent on at least two staff members for physical assistance for bed mobility, transfers, and toilet use. Review of R801's progress notes revealed the following: A Nurses' Notes progress note, dated 10/15 22 at 2:30 AM, written by Nurse 'C' that noted, .Res (resident) transferred per (county sheriff) orders to (hospital) for alleged abuse . A Nurses' Notes progress note dated 10/15/22 at 2:30 AM that noted, .Skin assessment performed on resident on 10/15/22 around 12 am with nurse and CNA. A small amount of bright red blood was seen on the residents brief . On 10/18/22 at 12:27 PM, a telephone interview was conducted with Nurse 'C'. When queried about what occurred with R801 on 10/14/22, the following was reported: Nurse 'C' explained she gave a very detailed explanation to the facility on the day the incident happened and described the reaction from CNA 'B' as brutal, shocking, and reported she had nightmares from the trauma. Nurse 'C' reported that around 11:45 PM on 10/14/22, CNA 'B' came down the hall to the nurses' station and was agitated, hyperventilating, hysterical, and could not catch her breath or get words out to tell us what was going on, but we could tell it was urgent. Nurse 'C' followed CNA 'B' down the hall and CNA 'D' and CNA 'G' came with her. Nurse 'C' asked CNA 'B' to tell her what was wrong because she was crying and could not speak and stopped at R801's door. Nurse 'C' reported she saw R801 lying in bed on her back, covered with a blanket, and was wearing a gown. CNA 'A' was standing to the right side of the bed by the window. Nurse 'C' stated, I can't remember everything (CNA 'B') said but I do know what she said indicated that (CNA 'A') did something sexual to (R801). Nurse 'C' explained she asked CNA 'A' to leave the room and sit by the nurses' station and she took CNA 'B' into the medication storage room to try to understand what happened. Nurse 'C' stated, (CNA 'B') explained to me what happened but I don't remember all the details (Nurse 'C' explained the lapse in memory was due to a medical issue but that she gave a full detailed statement to the police and the facility administration on the day the allegation was made). I do know that she indicated it was sexual in nature and that she walked in and (CNA 'A') was on (R801's) bed, he jumped up, and (CNA 'B') saw part of (CNA 'A's) penis and he tucked it away. Nurse 'C' described CNA 'B' as being in total shock and had a total meltdown and was crying throughout the whole conversation. Nurse 'C' reported CNA 'A' asked her what was being said about him and she had him stay at the nurses' station until the Director of Nursing (DON) and/or the Administrator arrived at the facility. Nurse 'C' further explained she had Nurse 'E' perform a skin assessment without removing any potential evidence and Nurse 'E' assessed R801 with CNA 'G' present and there was a small amount of blood in the brief. Nurse 'C' reported the police were called by the Administrator and R801 was taken to the hospital for an examination. On 10/18/22 at 2:48 PM, a telephone interview was conducted with CNA 'B' (the witness to the incident). When queried about what happened with R801 on the night of 10/14/22, CNA 'B' explained she worked a double shift from 3:00 PM until 3:00 AM and was assigned to a different set of residents beginning at 11:30 PM when the afternoon shift left. CNA 'B' reported she began the second part of her shift around 11:30 PM and went to put eyes on her new set of residents. CNA 'B' explained she observed a supply cart that contained linens and briefs placed in front of R801's door and the door to the room was closed. CNA 'B' moved the cart and opened the door, there was nobody in the first bed in the room and the privacy curtain was pulled which obstructed the view to the bed near the window. CNA 'B' walked toward R801's bed and observed CNA 'A' jump from the bed suddenly and was trying to put his penis back in his pants. CNA 'B' reported she saw CNA 'A's penis outside of his pants. CNA 'B' further reported R801 was positioned on her left side facing the door with the privacy curtain drawn and her back side was naked with no brief on. CNA 'B' reported she could not see R801's face because of the privacy curtain. CNA 'B' reported CNA 'A' was aware that she entered the room and after he jumped up and tucked his penis into his pants he was standing right by CNA 'B' at the foot of the bed. CNA 'B' ran out of the room and got Nurse 'C' and Nurse 'C' had CNA 'A' come out of the room. On 10/19/22 at 9:44 AM, CNA 'B' was further interviewed via the telephone. CNA 'B' reported she did not exchange any words with CNA 'A' when she saw him in R801's room. CNA 'B' explained she had worked with CNA 'A' before and had nothing against him. CNA 'B stated, I saw what I saw. I just happened to walk in at that time. When queried about whether it was facility protocol to place the supply cart in front of the door and CNA 'B' reported it was not. Review of a Field Case Report completed by the local police department revealed they were contacted at 10/15/22 at 12:24 AM. The Narrative section of the report documented, On October 15, 2022, I was dispatched to (facility) located at (address) for an employee sexually assaulting a resident, later identified as (R801). Upon arrival, (officer name), and I spoke with the Administrator of (facility) .(Administrator) said one of his medical aides, later identified as (CNA 'B'), walked in on another employee with his pants down. (Administrator) stated that the employee, later identified as (CNA 'A'), was in the front office .(Administrator) advised that (R801) had dementia and was unable to speak for herself. (Administrator) introduced officers to (CNA 'B'). (CNA 'B') was visibly upset about what had happened. (CNA 'B') was shaking as she was describing what had happened .I spoke with (CNA 'B') who explained that she just got on shift and was checking out her patients for the night. (CNA 'B') went to (room number) where a patient changing cart (a cart that held patient care supplies) was in front of the closed room door. (CNA 'B') opened the door to check on the patient. When (CNA 'B') went inside the room the first bed was empty and the curtain was drawn. (CNA 'B') went to (R801's bed) where she witnessed (CNA 'A') getting off the bed with his pants undone. (CNA 'B') said she saw (CNA 'A's) penis and he was tucking it back in his pants. (CNA 'A') zipped up his pants and put his belt back on. (CNA 'B') saw that (R801) was on her left side with the back of her gown open and no brief on. (CNA 'B') ran out of the room screaming and to get the nurse, later identified as (Nurse 'C'). I spoke with (Nurse 'C') who explained that she had a hard time calming (CNA 'B') down. (CNA 'B') was screaming and could not make out words. (Nurse 'C') thought at first a resident had passed away. (Nurse 'C') was able to calm (CNA 'B') down to understand her. (Nurse 'C') went back into (R801's room number) to tell (CNA 'A') he needed to leave the room now and wait in the dining area until advised otherwise. (Nurse 'C') stated (CNA 'B') was in so much shock that she told (Nurse 'C') 'All the people out there he could have sex with. He picks disabled helpless people.' .(Police officer) transported (CNA 'A') to (police department) for an interview .(Fire department) arrived on scene to transport (R801) to (hospital) . On 10/18/22 at 2:20 PM, a telephone interview was conducted with CNA 'D'. When queried about what happened with R801 on 10/14/22, CNA 'D' reported CNA 'B' was assigned to R801 and was taking over CNA 'A's residents at shift change (afternoon shift going into midnight shift). CNA 'D' reported CNA 'B' was doing rounds and went into R801's room and CNA 'A' was in there and CNA 'B' came out of the room crying and could barely speak. CNA 'D' reported CNA 'B' was so upset she could not explain what she saw. CNA 'D' reported she went down to R801's room with Nurse 'C' and CNA 'B' and CNA 'A' was just finishing up care and asked me to help him boost the resident up in bed. CNA 'D' was not clear about what the allegation was and said she thought CNA 'B' said CNA 'A's belt was loose, but I guess she told (Nurse 'C') more. It should be noted that when CNA 'B' observed the alleged abuse, she left the room and CNA 'A' was still present in the room until the rest of the staff (CNA 'D', CNA 'G', and Nurse 'C') arrived. On 10/18/22 at 3:19 PM, a telephone interview was conducted with the alleged perpetrator, CNA 'A'. When asked, What information can you provide me regarding the allegation of sexual abuse against (R801)?, CNA 'A' reported he was aware there was an allegation that he sexually abused R801. CNA 'A' did not make any statements that sexual abuse did not occur. He reported R801 was very far into dementia, can't move at all on her own, and that he provided incontinence care to R801 without assistance of other staff even though she required at least two people to provide care because I don't like to bother other people for help. CNA 'A' reported he had his knee behind R801's legs and his arm on R801's back to hold R801 onto her side and as I was coming out of the bed, (CNA 'B') comes in and sees me while I was adjusting my pants and I guess I was in a precarious position because here we are! On 10/18/22 at 3:59 PM, a telephone interview was conducted with Nurse 'E'. When queried about what occurred with R801 on the midnight shift of 10/14/22 going into 10/15/22, Nurse 'E' reported an employee (CNA 'B') was crying at shift change (afternoon shift going into the midnight shift) and later I found out that alleged abuse took place. Nurse 'E' explained that she was asked by the charge nurse who was assigned to R801, Nurse 'C', if she could complete a skin assessment on R801. Nurse 'E' reported CNA 'G' was present during the skin assessment and a couple spots of bright red blood were in R801's brief. Nurse 'E' explained she kept the same brief on R801 due to the allegations that were made. On 10/19/22 at 9:18 AM, a telephone interview was conducted with R801's resident representative (RR 'F'). When queried about whether he was notified about any allegations of abuse against R801, RR 'F' reported he was notified on the day of the allegation that there was a witness from the facility that saw an aide pulling up his pants and his penis was out and R801 was in the bed without a brief on. RR 'F' reported R801 had dementia and cannot recall anything. RR 'F' further explained that he was concerned that past sexual abuse could have occurred because R801 had episodes of having blood in her diaper. RR 'F' explained that R801 had ultrasounds done to see if there was a medical explanation, but nothing was determined. Review of R801's hospital record revealed R801 arrived to the Emergency Department (ED) on 10/15/22 at 2:24 AM. The Arrival complaint was documented as Sexual Assault .Pt (patient) was seen by aide at (facility name) . Review of the ED Provider Notes dated 10/15/22 at 2:28 AM revealed .presenting to the ED today with the chief complaint of sexual assault. Patient is A&O (alert and oriented) x 1 (to person only) at baseline. Patient was brought to the ED by EMS (Emergency Medical Services) with police present upon evaluation. They state that they were called to her facility .for suspected sexual assault. Per staff, an aide walked into the patient's room and found another resident (staff) tucking his penis back into his pants while the patient was lying on her bed with her night gown open without any underwear or briefs on. They brought her to the ED for evaluation .Mental status is at baseline. She is disoriented and confused .4:30 AM Spoke with the SANE (Sexual Assault Nurse Examiner) nurse after completion of their examination. They provided recommendation for STI (Sexually Transmitted Infections)/PEP (Post-Exposure Prophylaxis) coverage . Further review of R801's clinical record revealed the following physician's orders initiated on 10/15/22 upon R801's return from the hospital: Bictegravir-Emtricitabine-Tenofovvir (an antiviral medication prevents HIV from multiplying in your body) 50-200-25 mg (milligrams) every morning Dolutegravir 50 MG (an antiviral medication used with other medications to treat HIV) daily Doxycycline Hyclate 100MG (an antibiotic medication used to treat sexually transmitted diseases such as chlamydia, syphilis, gonorrhea, pelvic inflammatory disease) two times daily for seven days Metronidazole 500 mg (an antibiotic medication used to treat conditions including bacterial vaginosis) two times daily for seven days HIV to be drawn on 11/15/22 for antiviral surveillance On 10/17/22, an infectious disease consultation was ordered. Further review of R801's progress notes revealed the following: On 4/22/22 at 10:23 PM, a Nurses' Notes progress note documented, .Observed mild vaginal bleeding, notified (physician) with order for pelvic ultrasound ASAP (as soon as possible) . On 4/23/22, a Nurses' Notes progress note documented, .Had vaginal bleeding during night but not large amount and not saturated. Will be having a pelvic ultrasound . On 4/23/22, a Nurses' Notes progress note documented, .Small amt (amount) brown discharge from vagina . On 4/28/22, a Nurses' Notes progress note documented, .Residents pelvic ultrasound report in, Conclusion: Very limited study. Anatomy poorly delineated. Probable large myomatous uterus (non-cancerous growths/fibroids). Possible asymmetric tissue towards the left side could represent uterine tissue. Pelvic mass/malignancy difficult to exclude. Consider endovaginal scan or MRI (magnetic resonance imaging). Echogenic material with in the bladder may represent debris/clots. Underlying mass difficult to exclude. Notified (physician) with order for Gynecology appointment to be taken . On 4/29/22, a NP(Nurse Practitioner)/PA (Physician Assistant) Progress Note documented, .Late Entry: .Patient is being seen today for evaluation from abnormal pelvic ultrasound .At this time staff report no additional of abnormal vaginal discharge, unit manager is contacting (radiology company) to see if a transvaginal ultrasound can be done in facility . On 5/4/22, a NP/PA Progress Note documented, .Patient continues with no abn (abnormal) vaginal discharge . On 6/13/22 (approximately two months after the first and only episode of vaginal bleeding/brown discharge documented on 4/22/22), a NP/PA Progress Note documented, .On 6/9 patient went for abd (abdominal)/trans vag (transvaginal) U/S (ultrasound) .no results are posted .No concerns from staff at this time . ON 6/24/22, a NP/PA Progress Note documented, .Received message from (community health care program NP), She stated that the trans/vag u/s done at the hospital did not 'show much' and she inquired if it was felt an OB/GYN (obstetrics/gynecology) consult should be done. Based off the pelvic ultrasound done at (facility), I am recommending patient still seen by OB/GYN. The ultrasound at facility showed probable large myomatous uterus .There has been no additional vaginal bleeding but with two different results it would be in patient best interest to still have a specialist examine her . On 8/1/22, a NP/PA Progress note documented, .There have been no additional reports of vaginal bleeding . On 9/8/22 at 8:44 AM, a Nurses' Notes progress note documented, .At 0645 (6:45 AM) CNA notified nurse of resident scratching her virgina <sic> during am care. Nurse went to assessed <sic>resident little blood noted was wiped and cleaned protected <sic> cream applied was effective .endorsed to Am nurse to monitor for virginal <sic> bleed. Safety maintained . There was no documented evidence that a physician was contacted regarding R801 scratching her vagina or the little blood noted. On 9/15/22, a NP/PA Progress note documented, .There have been no additional reports of vaginal bleeding . Review of CNA 'A's time punches for 4/21/22 revealed he clocked in at 3:04 PM and closed out at 11:41 PM. Review of CNA 'A's time punches for 9/7/22 revealed he clocked in at 3:10 PM and clocked out at 7:49 AM. Assignment sheets for nursing staff for the above dates were requested. However, they were difficult to interpret. The assignment sheets for 4/21/22 revealed a CNA was assigned to R801 until 7:00 PM and CNA 'A' was assigned to a set that did not include R801. CNA 'A's name was next to the CNA's name assigned to R801 until 7:00 PM but it was crossed out and it did not indicate who was assigned to the resident after 7:00 PM. The assignment sheets for 9/7/22 revealed four different assignment sheets for the afternoon shift with one that documented CNA 'A' assigned to R801. Review of R801's September 2022 Documentation Survey Report, a report that showed care documented by CNAs, revealed CNA 'A' provided bed mobility, dressing, and personal hygiene with no other staff present (indicated by documentation of 4, which according to the legend, meant total dependence and 2, which according to the legend, meant one person physical assist). On 10/18/22, the Administrator, who was the facility's identified Abuse Coordinator, was queried about the facility's findings from the alleged incident. The Administrator reported he was still in process of investigating the allegation. Any information the facility had regarding the allegation thus far was requested at that time. The Administrator provided the following staff statements handwritten by the DON and signed by the staff member being interviewed to indicate accuracy: A Statement of Witness from CNA 'B' taken on 10/15/22 at 2:50 AM by the DON documented, At approximately 11:30 PM, I walked into (R801's) room. The privacy curtain was pulled to the end of the bed. I saw (CNA 'A') jump up out of the bed. I saw the upper part of (CNA 'A's) penis and he was trying to tuck it back into his pants. He was trying to cover himself. I ran out of the room and started yelling for (Nurse 'C'). A Statement of Witness from Nurse 'C' taken on 10/15/22 at 3:00 AM by the DON documented, I was at the nursing station at approximately 11:45 PM when (CNA 'B') was frantic and was having a hard time talking, was hyperventilating. (CNA 'B') took us down to (R801's) room. Myself and (CNA 'D') went into room. (CNA 'A') was standing by the right side of the bed. I asked (CNA 'A') to leave the room. A second Statement of Witness from Nurse 'C' taken on 10/17/22 at 4:00 PM documented, I instructed (CNA 'A') to go into the dining room after I asked (CNA 'A') to come out of the room. (CNA 'A') walked up to the nurses' station and (CNA 'A') asked what was going on and I said I can't say anything until the Administrator and DON came in. I have been trying to remember everything that happened that night. (CNA 'B') did say that (CNA 'A') was lying in bed to the side of the resident. A Statement of Witness from CNA 'A' taken on 10/15/22 at 12:30 AM by the DON documented, At approximately 11:30 PM I was in (R801's) room. I had my right knee on the bed as resident often will push back when trying to change her. Resident was on her left side. I had removed her brief. I saw (CNA 'B') out of the corner of my eye walk into the room. Approximately few minutes later (Nurse 'C') and (CNA 'D') walked into the room. I asked them to help me pull the resident up. (Nurse 'C') asked me to step outside of the room. (Nurse 'C') asked me not to leave. I did adjust my pants after taking my knee off the bed. My pants slide down a bit and I'm always adjusting my pants. A Statement of Witness from CNA 'D' taken on 10/15/22 at 3:45 AM via the telephone by the DON documented, When I went into the room, the resident was laying on her back, wearing a gown and brief and blanket was over the resident. (CNA 'A') asked for help boosting resident up. (CNA 'A') did not appear nervous. A second Statement of Witness from CNA 'D' taken on 10/17/22 at 4:45 PM documented, I was at the nurses station when (CNA 'B') walked up and said I went into the room and (CNA 'A') was doing something with his belt. I walked into the room first then (Nurse 'C'). (CNA 'A') was on the side of the bed by the window. (CNA 'A') was finishing up cares. (CNA 'A') asked for assistance boosting resident up. (CNA 'A') did not seem distressed. Resident had a gown and brief on and (CNA 'A') was putting the covers on top of her. After we walked out (CNA 'A') asked why did she pull me out of the room. I said (CNA 'B') saw you putting your belt buckle up. A Statement of Witness from Nurse 'E' on 10/15/22 at 3:30 AM documented, Someone said that (CNA 'B') was crying. So I went over to station 1 I saw (Nurse 'C') in the med (medication) room with the door partially open. (Nurse 'C') asked me to do a skin assessment on (R801). When I went into the room resident was laying flat she was wearing a gown and a brief. I did a full skin assessment, looked under her breasts and I undid her brief checked groin area and vaginal area. I noticed a 2 small spots of bright red blood. Myself and (CNA 'G') rolled resident over and I noticed 2 small spots of bright red blood on the back of the brief. A Statement of Witness from CNA 'G' taken on 10/17/22 documented, We were standing at the nurses station waiting for set assignments. (CNA 'B') came to the nurses station and was having a hard time getting her words out. (CNA 'B') said that he's having sex with her. We asked who. (CNA 'B') said that woman. We went into the room and I only went part way in and the curtain was closed. I did not see (CNA 'A'). A Statement of Witness from CNA 'H' via the telephone documented, I was getting ice water on station 1 at approximately 11:45 PM. I saw (CNA 'B') crying and I asked what was going. (CNA 'B') said I came in there and pulled back the curtain and I saw him buckling his belt and pulling his pants up. (CNA 'D') said (CNA 'A') they're talking about you. I said to (CNA 'A') do you have a belt on. (CNA 'A') lifted his shift and (CNA 'A') did not have a belt on. (CNA 'A') was wearing pull up scrubs. (CNA 'A') appeared to be shocked. [NAME] said I put my knee on the bed and that's what she probably saw . Review of a Report of Consultation dated 10/20/22 revealed R801 was seen for a Gynecology consultation. The consultation documented, .history of vaginal spotting in June 22 (2022). No pain, no discharge. Ultrasound - unremarkable. Unable to examine well. Vagina, clean, normal. Speculum examination - limited due to large stool in rectum. Blind PAP taken. Can't see cervix or feel uterus .Advised to watch for recurrence, if so - recommend EUA (exam under anesthesia) and possible endometrial biopsy. The consultation did not mention the alleged sexual assault from 10/14/22 and the presence of bright red blood in R801's brief. On 10/25/22 at 9:58 AM, a telephone interview was conducted with Detective 'I'. Detective 'I' reported he was going to contact the prosecuting attorney to discuss their next steps. The facility presented the following Immediate Jeopardy Abatement or Removal Plan on 10/18/2022 at 1730 hours: Medilodge of Shoreline Removal Plan For F 600 Date 10/18/2022 Time 5:30 PM 1. Alleged staff member was immediately removed from the resident's room and place at the nurses' station with other staff member. Alleged staff member remains suspended pending investigation 2. Sterling Heights Police were immediately notified of the allegation by on 10/15/2022 at 12:24 AM. Resident 801 was immediately sent to hospital for evaluation and treatment if necessary on 10/15/2022 at 2:30 AM. Resident 801 returned to the facility on [DATE] around 1:30 PM and remains in the facility at this time. 3. Police interviewed alleged staff member and then transported said staff member to the police department for further questioning. Alleged staff member was released by police later that morning. 3. Current residents on the unit were questioned by the DON with no further concerns noted on 10/14/2022. 4. Current residents on the unit had skin assessment completed by a Licensed Nurse on 10/15/2022 with no abnormal findings 5. Current staff have been reviewed for Michigan Back ground check and no staff flagged. 6. Current staff will be re-educated on the Abuse policy by the DON/designee on 10/18/2022. No staff will work past 10/18/2022 if not re-educated. The Abatement Plan was verified on site on 10/19/2022. The Immediate Jeopardy Abatement or Removal Date is 10/18/2022. Although the immediacy was removed the facility's deficient practice was not corrected and remained Isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency.

This citation pertains to intakes: MI 815. Based on observation, interview and record review, the facility failed to prevent non-consensual sexual contact, and monitor a male Resident (R701-Brief Interview for Mental Status [BIMS] score of 15/15=intact cognition) with a known history of inappropriate sexual behaviors towards residents and staff (2022: 7/15, 7/17, 7/18 and 7/19), resulting in R701 performing a sex act with a female Resident (R702-BIMS of 4/15=severe cognitive impairment) on 8/26/2022 at approximately 4:45 PM. R701 was observed by a visitor walking by R702's room, with the bare breast of R702 in their mouth. R701 was kissing, touching and had their hands in R702's pants. The visitor alerted staff by asking if R701 and R702 were a couple and that the lady (R702) looked resistive. Upon staff entering the room, R701 was observed kissing and touching R702's breasts. According to staff R701 did not stop right away with R702. This deficient practice resulted in an Immediate Jeopardy (IJ) and the likelihood for serious physical and/or psychosocial harm, injury, impairment, or death. Findings include: A review of the complainant intake noted, Complainant states an unknown male resident entered the residents' room and started kissing and [R702's] lifting up [R702's] shirt . Details: It was alleged that the resident was kissed and groped by another resident. On 8/31/22 at 11:55 AM, during a tour of the facility R701 was observed in their room, in bed sleeping, with a one-to-one staff (Sitter E) in a chair at the foot of their bed. Sitter E was asked the reason R701 was on a one-to-one with them and stated, [R701] allegedly assaulted someone Friday. On 8/31/22 at 11:55 AM, R701 was observed in bed sleeping and did not wake for the interview. The roommate of R701 was awake and was asked about the incident with R701 coming into their room. R703 explained, I heard things. [R701] 'Can I F**k you' and [R702] said 'Yes.' That's when I said you get out of here, I'm in this room too, and [R701] didn't. R701 asked 'If it felt good, [R702] said 'Yes.' R703 continued and stated, that [R701] asked to get in the bed with R702, then started to hear heavy breathing. R703 stated, It really blew my mind. R703 continued and said, that they had pressed the button for a Nurse, but they came because of a person walking by. On 8/31/22 at 1:41 PM, Ward Clerk A was asked about the incident with R701 and R702. Ward Clerk A explained, last Friday (8/26/22) near the time for her to go home for the day. A resident's family member that was being discharged home; said they didn't know the facility allowed couples in rooms. Ward Clerk A explained, that is when she asked in what room for clarification. Ward Clerk A stated, The visitor pointed to the left side of the hallway and said, 'Well go check it out because [R701] has [R701] ti**y in [R701's] mouth.' I grabbed my Nurse (Nurse B) and said we have an emergency. Ward Clerk A stated, We heard the roommate [R703] screaming before making it to the room. The door was open upon arrival. [R702's] wheelchair was on the left side of the bed, so [R701] was partially on top of [R702]. [R701] mouth was on [R702's] breast. Ward Clerk A explained that [R702] was making a grunting sound and moving their arms in a resistive manner. Ward Clerk A was asked, how did R702 look and said, R702's shirt was half on and may have been behind R702's head. Ward Clerk A was asked if R702 had on pants and stated, the left side of [R702's] pants were down and [R701's] hand was down [R702's] pants. Ward Clerk A was asked, what happened when [R701] was told to stop and stated, [R701] seemed upset that we interrupted and didn't stop right away, we had to say stop again. Ward Clerk A explained, they tried to keep [R701] near but [R701] pushed them out of the way and went towards [R701's] room, walking fast and yelled that 'I (R701) was supposed to be in there.' Ward Clerk A was asked how R702 was after R701 left the room and stated, [R702] was confused and really had to be redirected to keep [their] shirt down, [R702] kept pulling it up, asking if [they] were supposed to have it up. Ward Clerk A was asked if R702 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/31/22 at 1:12 PM, the Nursing Home Administrator was asked about R701's sexual behavior and explained, one of the previous incidents from his understanding, was on a national hug day and that some of staff felt uncomfortable by the hug and kiss attempts. The NHA explained that is when R702 got a one-on-one. On 8/31/22 at 3:41 PM, a phone interview was conducted with Nurse B, Nurse B was asked about the incident with R701 and R702 and stated, I was sitting behind the desk and the secretary (Ward Clerk A) came and got me and didn't say too much, only 'I need you to come with me it's important.' There were two family members at the desk. One of them said, 'There is a guy down the hallway, sucking on this [R702's] ti**es. Nurse B continued and stated, [R701] was in the room, shirt around [R702's] neck area, [R701] was on [R702's] breast. After [R701] was caught, [R701] tried to hurry and get out of the room and was hitting me and the [Ward Clerk A] with the walker, bumping us to get out the room because we were in the doorway. Nurse B was asked how R702 was during the incident and explained, R702's shirt was up, and wasn't sure if R702 knew what was going on. R702 had their hands up when they saw R701 on R702. Nurse B was asked if she had witnessed other incidents with R701's sexual behavior and stated, [R701] used to be on my unit. I had an incident with [R701], I was standing at my med cart [R701] tried to kiss me. And I told [R701] it wasn't appropriate. On 9/1/22 at 9:35 AM, Guardian G (of R702) was asked about the incident with R701 and R702. The guardian explained that they had seen R701 that day (8/26/22). The Guardian stated, [R701] is very talkative and roams around a lot. I was with [R702] talking outside on the patio and [R701] followed us. [R701] was talking about everything, we came back in and [R701] came in also. We went to [R702's] room and [R701] said, 'Oh that's [R702's] new room.' The Guardian explained, they received a call from the facility's Nursing Home Administrator (NHA) that explained the incident with R701 and R702. The Guardian stated, Then a detective called me and said that they are viewing it as a sexual assault. I pictured them interrogating [R701] and [R701] crying, I didn't want that, I talked it over with my sister and my husband. We didn't want to press charges and told them (facility) to keep [R701] away. The Guardian was asked if they had visited their family since the incident. The Guardian said that they did, and they talked to R702 and R703 about it. The Guardian was asked what they told them and stated, [R702] told me that it made [them] feel scared and nervous. The roommate (R703) told me [R703] told [R701] to get the hell out of there, but [R701] wouldn't leave. A review of the facility's written wittiness statement revealed, Name and Position of Witness: [R701]. Date: 8/26/22. Statement of Witness: I walked into a room and assisted [R702] into bed. [R702] asked me for a kiss so I bent over and kissed [R702]. I was asked to leave the room I did not touch [R702's] breasts. I was not in bed with [R702]. Signature of Witness: Resident refused to sign. 8/26/22. Signature of Interviewer: DON (Director of Nursing). 8/26/22. Name and Position of Witness: [R702] Date: 8/26/22. Statement of Witness: A Gentleman came into my room, and we were very friendly. We were kissing and stuff like that. We didn't get it on [R701] asked me if [they] could come into my room. [R701] never came into my room before. I gave [R701] approval to come into my room. It felt so good. I didn't pull my pants down [R701] touched my leg and arm. We were kissing. We didn't have sex. I haven't done that in a long time. We were both laying down in bed, but no clothes came off. I am not upset over the incident. Resident denies pain. Signature of Witness: R702. 8/26/22. Signature of Interviewer: DON. 8/26/22. Name and Position of Witness: [R702] Date: 8/26/22. Name and Position of Witness: [R703]. Statement of Witness: I was on the phone with my daughter and heard [R701] come into the room. [R701] said [to R702] let me get in bed with you, Then I heard some huffing and puffing. [R702] said, that feels good. I said you guys' better stop or I'm calling the nurse. Signed [R703] 8/31/22. Interviewer: SW (Social Worker). Name and Position of Witness: [Nurse B]. Date: 8/26/22. Statement of Witness: I was sitting at the desk and overheard a family member telling the ward clerk there is a man down the middle hall sucking on a ladies ti**y. [Ward Clerk A] and I ran down the hallway to room [ROOM NUMBER] and saw [R701] with [their] face on [R702]. [R702] was laying in the bed making hand gestures and I said [R701] what are you doing? It startled [R701] and then we told [them] to get off [R702] and [R701] hit both (Ward Clerk A) and I trying to get out of the room. We notified the DON and [R701] ran down the hallway back towards [R701's] room. Signature of Witness: [LPN B]. Signature of Interviewer: [Unit Manager Nurse D] 8/26/22. Name and Position of Witness: [Ward Clerk A]. Date: 8/26/22. Statement of Witness: I was at the nursing desk and the sons of another resident. [Visitor] approached me and asked. Is that a couple down there? I said, what side? He pointed to the right side of the hallway and said [R701] has [R702's] ti**ies in [R701's] mouth and [R702] seemed resistive, you might want to check that out. I immediately grabbed nurse [Nurse B]. We took off. Running down the hall, checking all the rooms. We approached 218 (room) and saw the resident [R701] on top of the resident, [R702]. [R701's] mouth was on [R702's] breasts and [R701's] hand was down [R702's] pants. With [R702's] left side of pants partially pulled down. [R702] was fanning [their] arms, making grunting noises. The nurse and I scream stop and get off. He got up, look at myself and the nurse stating what did I do wrong? I'm supposed to be with [R702]. We called the DON and unit manager and resident [R702] started running away down the hallway toward [their] room. Signature of Witness: [Ward Clerk A] Signature of Interviewer: [Unit Manager Nurse D] 8/26/22. Resident #701 (R701) A review of R701's medical record revealed, R701 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R701's MDS, noted a 15/15 BIMS indicating intact cognition and required limited assistance for locomotion off unit. A review of R701's care plan revealed, Focus: The resident exhibits inappropriate social behavior of kissing, hugging, touching, and making sexual comments to staff and residents. Date Initiated: 07/19/2022 Revision on: 08/29/2022. Goal: The resident's inappropriate behaviors will be managed through the next review date. Date Initiated: 07/19/2022 Target Date: 11/22/2022. Interventions: Observe for change or increase in behavior and report to charge nurse, social worker, doctor, and psychiatric staff. Date Initiated: 07/19/2022. Revision on: 07/19/2022. Resident assigned to 1:1 Date Initiated: 08/26/2022. Focus: The resident receives antipsychotic medication(s) ([MEDICATION(S)], [MEDICATION(S)]) r/t (related to) hx (history) of hallucinations & [CONDITION(S)] Date Initiated: 05/11/2022 Revision on: 05/12/2022. Goal: No increase in symptoms of emotional discomfort or strain Date Initiated: 05/11/2022. Revision on: 06/20/2022. Target Date: 11/22/2022. Intervention: Administer medications as ordered (see MAR for specific instructions. Observe for adverse drug effects and notify MD PRN (as needed). Date Initiated: 05/11/2022 Further review revealed, Progress notes of Behavior: 6/24/2022 17:49 (5:49 PM) Behavior Management Monthly Meeting Note Late Entry: Comment: Behavior meeting held with DON, psych NP (Nurse Practitioner), unit manager and LMSW (Licensed Master Social Worker). [R701] has [CONDITION(S)] with dementia. [R701] has wandering behaviors and has a Wanderguard. [R701] is on [MEDICATION(S)] and [MEDICATION(S)]. [R701] is followed by (local behavioral health group) and [R701] AIMS (Abnormal Involuntary Movement Scale) was completed on 5/27/22. 7/15/2022 10:36 (10:36 AM) Transcribed Psychiatric Note Late Entry: Note Text: Send Note Print & Close Window (local behavioral health group) . Complaint: Now visit requested due to making sexual statements towards, touch of staff breasts, and sexual requests from staff. Resident has Psychotic features of Hallucinations/delusions . 7/15/2022 23:45 (11:45 PM) Pertinent Charting-Behavior Note Text: Event Date: 07/15/2022. Behavior Displayed: Inappropriate sexual behavior noted, resident trying to kiss female staff and other patients on the lips, trying to grab female staff breast and stated that He wants to make love to female staff and other female patients. Precipitating factors/events: Resident walked out of room with walker, walked up to staff/other female residents and started being sexually inappropriate, [R701] was not provoked. Intervention(s) attempted: Writer asked resident to behave [R701] self, informed [R701] that this behavior was not appropriate and asked [R701] to go to leave staff/female patients alone and to go to [R701's] room. Intervention results: Unsuccessful, Resident walked away and tried to kiss a female resident on [R701] way to is room. Pharmacologic Intervention required: Psych NP . was onsite and notified. 7/19/2022 17:16 (5:16 PM) Pertinent Charting-Behavior Note Text: Event date: 07/18/2022 Pt. (patient) was in hallway in front of female patients room. [R701] invited female patient back to [R701's] room. CNA easily redirected Pt. back to [R701's] room. 1:1 maintained. 7/22/2022 11:52 (11:52 AM) Transcribed Psychiatric Note Late Entry: Note Text: Send Note Print & Close Window (local behavioral health group) . Complaint: Continues to have periods of making sexual statements and request toward staff. Resident has Psychotic features of Hallucinations/delusions Continues to have periods of making sexual statements towards staff. Resident denies and sexual behaviors. Oriented to self only . Increase [MEDICATION(S)] to 20 mg. Schedule [MEDICATION(S)] 0.5 mg BID (twice per day). Keep PRN (as needed) for now, plan GDR (gradual dose reduction) soon. Consents obtained. Continue to monitor . 8/10/2022 09:56 IDT -Interdisciplinary Progress Note Note Text: Resident with no recent behaviors. Resident does ambulate with walker throughout the building periodically. [R701] attends activities with no inappropriate sexual behaviors. Will remove 1:1. 8/26/2022 16:45 (4:45 PM) Nurses' Notes Late Entry: Note Text: Resident was observed in room [ROOM NUMBER]-1 with a female (R702) resident kissing. Resident was asked to leave the room. The DON assisted resident back to room and a 1:1 was immediately implemented. 8/26/2022 18:00 (6:00 PM) Pertinent Charting-Behavior Late Entry: Note Text: Event Date: 08/26/2022 Behavior Displayed: Resident was observed on top of a female resident in the female's resident's bed. Precipitating factors/events: Intervention(s) attempted: Nurse went into room [ROOM NUMBER]-1 and asked to stop and resident was asked to get off of resident in room [ROOM NUMBER]-1. Resident immediately got up and resident using walker left the room and returned to [R701's] room. Intervention results: Resident complied with request and without confrontation returned to [R701's] room. Pharmacologic Intervention required: Comments: DON followed resident back to [R701's] room and 1:1 was immediately implemented. DON contacted resident's wife and reported the situation to the wife. 8/29/2022 17:50 (5:50 PM) Social Services Progress Note Text: Resident remains on behavior charting and on 1:1. Met with resident today, who verbalized being concerned about where [R701] will live next. Continues to verbalize [R701] position that the incident with the female resident didn't warrant the attention it has received. It wasn't serious, [R701] states . A review of the facility's document titled, Decision Making Determination Form noted, I have evaluated this resident, [R701], and have made the following determinations regarding decision making abilities. The resident is: Incapable of making decisions regarding medical treatment. This determination is based upon: Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed Psychologist . 8/31/22. Resident #702 (R702) On 9/1/22 at 2:54 PM, R702 was observed lying in bed. R702 was asked about the incident with R701 and if they remembered it. R702 stated, Yes I think so. R702 was asked if R701 hurt them and stated, I don't remember. A review of R702's medical record noted, 8/26/2022 17:30 Nurses' Notes Late Entry: Note Text: DON was notified at approximately 4:45 pm that there was a [R701] resident in room [ROOM NUMBER]-1 kissing resident and touching [R702's] breasts. Staff stated that they were notified by a family member who was walking by the resident's room that they witnessed a [R701] resident kissing and touching resident's (R701) staff stated that they were notified by a family member who was walking by the resident's room that they witness and had asked if they were a couple. Staff immediately went to room [ROOM NUMBER] and witnessed male resident kissing resident and touching her breasts. Nurse immediately removed resident from the room and resident was assisted back to his room. Administrator, (Name of local) Police Department notified, Guardian Notified, Physician notified. Skin assessment was completed with no injuries, bruising noted. Resident denied pain. -DON A review of R702's medical record revealed, R702 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R702's admission and most recent quarterly MDS assessment noted, R702 with a severely impaired cognition of 04/15 and required the need of staff for extensive to total assistance with Activities of Daily Living (ADLs). Skin assessment. 8/26/22 . Comments: No skin issues noted. no abnormal marks or, no redness no scratches noted. Buttocks and peri and vaginal area no marks noted. Social Services Progress Notes. Date: 8/29/22 Met with resident today, who verbalized feeling safe and having no concerns other than wanting to move out into her next community housing placement. A review of facility's policy titled, Abuse, Neglect and Exploitation dated, 7/28/202 noted: Policy. It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Sexual Abuse is non-consensual sex contact of any type with a resident . III. Prevention of Abuse, Neglect and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting and intervening in situation in which abuse neglect, exploitation, and/or misappropriation of resident property is more likely to occur with deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the resident and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . The Administrator was notified of the Immediate Jeopardy on 08/31/2022 at 4:15 PM and a plan of correction was requested to remove the immediacy that began on 8/26/2022. The facility provided the following removal plan. Immediate Jeopardy was removed on 9/1/2022 and validated by the team on 9/1/2022. Removal Plan Date 8/31/2022 Time 4:20PM Resident 701 remains on 1:1 supervision since incident on 8/26/22 Resident 702 has been assessed by Social Services 8/29/22 and Guardian has been notified on 8/26/22. Local Police have been notified on 8/26/22 and are not pressing charges against resident 701. Resident 701 remains on 1:1 supervision. Care plan has been revised related to sexual behaviors Resident has been assessed by Psych services on 8/26/22 for additional interventions as needed. Resident 702 has been assessed for psychosocial distress by the Social Services on 8/29/22. The care plan had been revised to include Social Service visits for potential psychosocial distress. Psych services assessed on 8/26/22 with no further recommendations needed. Residents with BIMS score of 10 or above will be assessed for psychosocial concerns related to sexual abuse by the SSW. Completed by 8/30/22 Residents with BIMS score of 9 or below will have a complete skin assessment completed by licensed nursing staff to rule out sexual abuse. Completed by 8/30/22 The Administrator/designee provided in person verbal re-education to staff on the abuse policy and procedure, specifically related to perpetrators. Facility staff members that have not been re-educated by 8/31/22 will not be allowed to work until education is received. DON/designee will review 24 hour report Monday-Friday to identify any residents having sexual behaviors towards staff or residents. Identified residents plan of care will be reviewed, will be placed on 1:1 and remain on a 1:1 until reviewed and evaluated by the IDT and medical provider as no longer a risk for sexual behaviors toward staff or residents. Date of compliance 8/31/22. Although the immediacy was removed on 8/31/22, the facility remained out of compliance at pattern with actual harm that is not Immediate Jeopardy as sustained compliance could not be verified by the state agency.

This citation pertains to Intake: MI 717 Based on observation, interview and record review, the facility failed to provide adequate supervision and monitoring to prevent an elopement from the facility for one sampled Resident (R350), who had severe cognitive impairment and eloped from the facility on 5/17/2022 at approximately 12:00 AM, in cold night-time temperatures of 48 degrees Fahrenheit, without facility staff being aware of the resident's whereabouts for approximately 2 hours, which required police and familial assistance to determine location. This deficient practice resulted in an immediate jeopardy, with the likelihood of serious injury, harm, impairment, or death. Findings include: On 6/07/2022 at 10:31 AM, an interview was completed with the Nursing Home Administrator (NHA) regarding the elopement of R350. The NHA explained that he received a phone call indicating that a resident was missing, and that a code yellow and head count had been conducted. The NHA further explained that the police and family were contacted, and upon his arrival to the facility, the police advised him to remain inside the building as the police brought a drone and a K9 unit to assist in the search of the resident. The NHA explained that the resident was located approximately 2 hours later in an unknown location to him, and that the resident's family immediately took the resident with them and refused assessments and transportation by the facility. The NHA was asked how the resident exited the facility and explained that they had exited out of the door on the Pathways unit, the unit the resident resided on. The NHA was asked if the door the resident exited out of was alarmed and indicated that it was a working alarmed door. At this time, the NHA was asked to show the surveyor the door. Two sets of double doors were observed. The first set had two alarms, a fire door alarm and a wanderguard alarm. The second set of doors did not have alarms, and lead out to a wooded, grassy area. According to www.accuweather.com, on 5/17/22 at around 1:45 AM it was a low of 48 degrees Fahrenheit. A review of R350's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] (brain disease), Muscle Weakness and Unspecified Abnormalities of Gait and Mobility. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5/15 indicating a severe cognitive impairment and required limited assistance with Activities of Daily Living (ADLs). Further review of R350's medical record revealed that they had an Elopement Assessment completed on 5/12/2022 in which the following was noted: 3. Summary of review: a. Resident is at risk of wandering/elopement at this time. 1. Yes. b. Wandering/elopement risk as evidenced by: poor safety awareness, wandering aimlessly, attempting to open exit doors. Further review of R350's medical record revealed the following progress notes: 5/12/2022 13:23 (1:23 PM) Physician Progress Note. Late entry: Note Text: HPI (History of Present Illness): This is [identifying information] with a PMH (past medical history) significant for the below. Patient was brought in [local hospital] ER (emergency room ) by family due to AMS (altered mental status). Patient is a poor historian and still has confusion .Per hospital papers daughter had found patient wandering on [NAME] Avenue and attempting to get into another persons car . 5/12/2022 14:34 (2:34 PM). Nurses' Notes Note Text: This resident noted to have gone to an outside door in an attempt to open the door several times since admission. [family member] notified and it was discussed with [family member] about the use of a Wander Guard for safety, [daughter] agreed that [their family member's] safety was more important and stated that we could apply the Wander Guard with [their] permission] . A review of R350's medical record revealed the following physician's order for the Wanderguard dated for 5/13/2022: Check function and expiration of wanderguard one time a day Check function and expiration date of wanderguard/electronic bracelet. A review of the Treatment Administration Record (TAR) for R350 revealed that the physician order was not followed on the 5/15/2022, 5/16/2022 and 5/17/2022. On 6/07/2022 at 11:15 AM, a phone interview was completed with Confidential Family Member M about the elopement of R350. They explained that they had provided permission for a wanderguard to be placed on R350, after they were informed that R350 had made attempts to leave the facility causing the door alarms to go off. Confidential Family Member M explained that they received a call on 5/17/2022 from the [local police department] informing them that R350 had left the facility, and that no one saw them go out because staff was busy with a resident who had a [CONDITION(S)] that was pulled out. Confidential Family Member M explained that the facility informed them that the cameras located inside the facility were not working, and that the last time they had seen R350, they were in the common area wearing pajama bottoms, socks, and a t-shirt, they did not know what direction R350 had gone, and that the alarms were not working. Confidential Family Member M further explained that after they received the call, they along with two other family members went to the facility and witnessed a drone and a K9 unit dog looking for their loved one. Confidential Family Member M explained that at about 1:45 AM, the police had stopped looking for R350, and indicated that they would wait until sunrise to start looking again, but upon insistence of the family, the local police indicated they would contact the Michigan State Police for assistance with a helicopter. Confidential Family Member M explained that they and their family members continued to look for R350, and at about 3:15 AM, one of their family members went into the woods facing the front of the facility, and 15 minutes later, began to scream that they had located R350. Confidential Family Member M explained that R350 was wearing pajamas pants, a t-shirt, house shoes, was crying, shaking and cold because it was chilly outside. Confidential Family Member M explained that they took the resident home. Confidential Family Member M was asked about R350, and explained that since the elopement, they have become incontinent and have night terrors. On 6/07/2022 at 11:32 AM, an interview was completed with Nurse N about the elopement of R350. Nurse N explained that they were not the assigned nurse for R350 that night and that the last time they had seen R350, they were in the common area with another resident (R338), who they would often wander around the unit with. Nurse N explained that they, R350's assigned nurse, along with R350's assigned Certified Nurse Assistant (CNA P), were in another resident's room as they had a [CONDITION(S)] emergency which involved them vomiting in their [CONDITION(S)] and having a bowel movement. Nurse N explained that when they learned of the door alarms going off, they went to the Pathways door and did a scan and did not see anyone and continued with their room sweep. Nurse N explained that the alarm was going off on the hospice wing as well, and R338 was located on that unit, by the exit door. On 6/07/2022 at 11:50 AM, the NHA was asked if the cameras in the facility were working the day of the elopement and explained that they were not working, and randomly go out for no reason. On 6/07/2022 at 11:54 AM, a phone interview was completed with the assigned nurse of R350 the night of the elopement, Nurse O. Nurse O explained that R350 was a resident that did not sleep at night, was restless, and would often stay at the nurses' station at night. Nurse O explained that the night of the elopement, they needed assistance from Nurse N and CNA P for a resident with a [CONDITION(S)]. Nurse O explained that after they were finished with the resident, they went back to the nurses' station and was notified that their resident (R350), had gone missing. Nurse O was asked if they could hear the alarm doors from inside the resident's room and explained that they could not. Nurse O further explained the process of locating the resident, and recalled looking at the Pathways door, which was slightly ajar, which they believe was the door R350 exited out of. On 6/7/2022 at 12:02 PM, an attempt to contact the assigned CNA (CNA P) for R350 the night of the elopement was made to no avail. However, a review of their written statement revealed the following, .After taking the soiled linen to the utility room, I heard a page overhead to check the Pathways doors. Noticed the resident that was at the nurses station was no longer there. I started to round and complete a headcount on Pathways, Couldn't locate the resident so we went to the 300 unit. There was a resident there, so we redirected [them] back to Pathways Nurse N rounded outside . On 6/07/2022 at 12:09 PM, and interview was completed with the Director of Nursing (DON) regarding R350's elopement. The DON explained that they received a call at 12:15 AM indicating that R350 had gone missing, in which she advised them to call the police immediately. She reported that when she arrived at the facility, the police were there, along with a K9 and drone. The DON explained that a couple of hours later, R350 was found and observed walking toward her and another officer and was unsure where R350 had been located. The DON explained that R350 was observed as cold, and that the family decided to take the resident to the hospital on their own. A review of the facility's Past Non-Compliance documentation did not indicate a compliance date, nor did it address the supervision and monitoring of residents at risk of elopement. On 6/07/2022 at 2:21 PM, the DON and NHA were asked for the root cause of the elopement and explained that it was the staff's reaction to the door alarms. They further explained that the door alarm was sounding, they read the panel however, they initially went to the staff entrance door which was secured. They then looked back at the panel again and saw it was the Pathways door. The DON and NHA were asked about the lack of supervision for R350, who was an elopement risk. They explained that those at risk of elopement have wanderguards, and that there are always people walking around however, if there is a particular resident that is exit seeking, we get them an activity, get them a 1:1 to de-escalate their seeking behavior Regarding R350, they explained that they ambulated with no assistance, had a history of being awake at night and would provide snacks. They were asked to provide the amount of time; the nurses and CNA were in the [CONDITION(S)] resident's room. The NHA and DON revealed that they were not sure on the amount of time, but thought it was 5 minutes because the nurse came out and checked the doors. On 6/07/2022 at 3:37 PM, an interview was completed with Nurse Q. Nurse Q explained that they were giving report the midnight nurse at Station #1 at 11:45 PM when they heard the alarm, which sounded and had red lights blinking. Nurse R called overhead that two alarms were going off, one of them being on the Pathways unit however, once the Pathways door was cleared, the alarm would not stop. Nurse Q explained that they walked around and heard the hospice alarm door going off and observed R338 standing at the door which was unlocked. R338 was escorted back to their unit however, a head count was completed and that is when they were notified that someone was missing on the Pathways unit, and everyone started to look for the resident, R350. A review of the facility's policy Unsafe Wandering & Elopement Prevention dated 1/1/2021 revealed the following: Policy: Every effort will be made to prevent unsafe wondering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Nursing personnel must report and investigate all reports of missing residents. Policy Explanation and Compliance Guidelines: 1. All residents who are at risk for harm because of unsafe wandering will be assessed by the interdisciplinary care planning team. 2. The resident's care plan will be modified to indicate the resident is at risk for elopement episode. Staff will be informed at shift change of the modifications to the resident's care plan. 3. Interventions for unsafe wandering and elopement attempts will be entered into the resident's care plan and medical record. 4. Should an elopement episode occur, the contributing factors, as well as the interventions' tried, will be documented on the nurses' notes . The Administrator was notified of Immediate Jeopardy on 6/7/2022 at 4:19 PM and a plan of correction was requested to remove the immediacy that began on 5/17/2022. The facility provided the following removal plan. Immediate Jeopardy was removed on 6/7/2022 and validated by the team on 6/8/2022 Removal Plan: Immediate Facility Action: F689 Elopement Resident R350 no longer resides in the facility. 1. A resident roster was obtained and all residents' whereabouts were accounted for on 6/7/22. Current residents were re-assessed via a new elopement assessment by a licensed nurse on 6/7/2022. Residents deemed at risk for elopement, their care plan has been reviewed and updated by a licensed nurse on 6/7/2022 at 7 PM 2. The Elopement Risk Binders will be reviewed by SW (Social Workers)/Licensed Nurses to assure that 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 DON on 6/7/2022. 3. Licensed nurses, Certified Nursing assistants, and ancillary staff will be Re-educated on the Unsafe Wandering and Elopement Prevention Protocol / Missing Resident Protocol by the DON/SDC/Designee in person on 6/7/2022. Any staff not educated by 6/7/22 by midnight will be provided with in person education prior to shift start. 4. The Unsafe Wandering and Elopement Prevention Protocol / Missing Resident Protocol was reviewed by the Regional Director of Operations, VP of Clinical services, DON, and Administrator on 6/7/22 and deemed it appropriate. System change: Residents deemed at risk for elopement who attempt to leave the building unattended will be placed on a 1:1 for increased supervision and have their care plan updated. Resident will be reviewed in morning clinical M-F by the IDT, and placed in behavioral SOC. Monitoring 1. The Administrator/ DON / Designee will review the 24-hour report M-F, to identify any unreported attempts to leave the building by residents at risk for elopement weekly x 4 weeks, and monthly there after until substantial compliance is met, and audits are discontinued by QAPI. The administrator is responsible for sustained compliance. Alleged compliance 6/7/2022. Although the Immediacy was removed on 6/7/22, 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 to Intake: MI 649 Based on observation, interview and record review, the facility failed to implement appropriate fall interventions and supervision to ensure a safe environment for one resident (R507) who has [DIAGNOSES REDACTED]. Findings include: Review of Intake MI 649 revealed the following, My (family member) has fallen a couple of times. R507 is at high risk for falls. R507 fell on [DATE]th and was sent to the hospital and released back to the facility. This last fall happened this morning (September 17th) and R507 was admitted . On 9/24/2020 at 10:26AM, R507 was observed in their room with the door closed sitting in their wheelchair. The front of R507's shirt and shorts were observed to be saturated in spilled coffee. R507's right arm was observed in a splint. Attempts were made to interview R507 however, they appeared confused, and was actively hallucinating and talking to people who were not there, therefore, they were unable to answer questions related to their hospitalization . A review of R507's medical record revealed that they were admitted into the facility on [DATE] for [DIAGNOSES REDACTED]. R507's most recent Minimum Data Set assessment dated [DATE] revealed that they were moderately cognitively impaired and required limited to extensive assistance with Activities of Daily Living (ADLs). Further review of R507's medical record revealed the following progress notes related to 10 unwitnessed falls: 3/20/2020 20:54 (8:54PM) Pertinent Charting-Falls Note Text: Date of Fall: 03/20/2020 Situation Details: Resident is alert and oriented x (times) 2 to 3. slightly confused at the time of fall. Resident try to take out (off) the brief. Possibly slide (slid) down from the wheel chair . Assessment: Resident does not have any injury will continue to monitor. No injury noted. Mitigating Factors: Environmental Factors: Interventions: CNA (Certified Nursing Assistant) need to q 2 hours (every 2 hours) check residents brief and change brief. 3/26/2020 15:20 (3:20PM) SOC (standard of care)-Falls New Fall/Follow-Up: observed on floor Situation (where/when/what/who): observed on floor in front of bed sitting on buttock Injury/No injury: no injury noted Factors involved (acute condition/environment, etc.): resident likes to be independent and complete most of (R507) adl's. attempted to change brief and lost balance. Notifications: family and physician Analysis of interventions to implement: offer toileting at HS (bedtime). offer assistance as needed. 3/30/2020 03:40 (3:40AM) Pertinent Charting-Falls Note Text: Date of Fall: 03/30/2020 Situation Details: Resident was observed sitting on buttocks on floor, back against the bed, both legs are extended on floor. Assessment: No reddened areas noted on skin. ROM (range of motion) of all extremities WNL (within normal limits). Neuro checks initiated. No apparent injury noted. Mitigating Factors: Environmental Factors: Interventions: MD Notification: (Physician B) Responsible Party Notification: (Family Member) Comments: Resident was observed sitting on her wheelchair at the beginning of the shift. Resident noted with confusion . 4/13/2020 11:48 (11:48AM) Pertinent Charting-Falls Note Text: Date of Fall: 04/13/2020 Situation Details: Writer in hallway, heard thump, entered residents room, noted res (resident) laying on floor between bed and doorway laying in fetal position on L (left) side. Assessment: Res (resident) alert/verbal with no change in cognition noted, res stated (R507)was looking for gum. ROM performed with no s/s (signs and symptoms) of pain, skin assessment negative for any new skin tears/abrasions bruising though multiple red/purple/green bruises noted on B (both) arms/hands and legs . Mitigating Factors: Res has deficit with both short/long term memory, can forget quickly, low safety awareness with hx (history) of falls Environmental Factors: n/a Interventions: Low bed with floor mats on B sides of bed MD Notification: (Physician B) . Comments: Re-educated res on use of call light though res forgets quickly. 4/24/2020 10:44 (10:44AM) SOC-Falls New Fall/Follow-Up: observed on floor Situation (where/when/what/who): observed on floor next to bed Injury/No injury: no injury noted Factors involved (acute condition/environment, etc.): resident attempted to transfer self to wheelchair. Notifications: family and physician Analysis of interventions to implement: staff to ask resident if (R507) would like to get up in wheelchair for breakfast. Referrals: Comments: no further falls noted. 6/2/2020 07:35 (7:35AM) Pertinent Charting-Falls Note Text: Date of Fall: 06/02/2020 Situation Details: Pt (patient) found on the floor next to bed as (R507) tried to go to the bathroom. Assessment: no injury noted Mitigating Factors: Pt need it to be toiled (toileted) Environmental Factors: none Interventions: update the care plan, pt toiled it (toileted) MD (medical doctor) Notification: yes Responsible Party Notification: yes. 6/11/2020 00:00 (12:00AM) Pertinent Charting-Falls Note Text: Date of Fall: 06/11/2020 Situation Details: Resident was observed sitting on their buttocks on floor mat, back against the bed, bilateral legs slightly flexed & crossed. Assessment: Assessed skin, ROM of all extremities WNL, neuro checks initiated. Reddened area noted on right cheek. Mitigating Factors: Environmental Factors: Interventions: MD Notification: (Physician) left msg. via voicemail . Comments: Resident states (R507) was sleeping in bed & when turning on side rolled out of bed & fell on the floor mat. Also (R507) states (R507) hit face on the dresser, noted reddened area on the right cheek. Resident c/o (complain of) pain on bilat (bilateral) knees & lower leg, (R507) states they had that pain since after previous fall (6/2/20), noted swelling on both areas Tylenol given @ (at) 12:15am with good effect. Later in the morning resident states (R507) hit their head on the dresser, no bump or open area noted on the head. Resident slept well. 6/11/2020 13:01 (1:01PM) Nurses' Notes Note Text: Resident in hallway in w/c (wheelchair). Right side of cheek reddened area and dark bruising just below the reddened area. Palpated area, resident with no complaints of pain. Resident with fall earlier in the am . 6/12/2020 09:49 SOC-Falls New Fall/Follow-Up: Pt (patient) had fall on 6/2 with no injury Pt had fall on 6/11 in which (R507) hit their face on dresser. Situation (where/when/what/who): Resident states (R507) was sleeping in bed & when (R507) was turning on their side they rolled out of bed & fell on the floor mat. Also (R507) states they hit their face on the dresser, noted reddened area on the right cheek. Resident c/o pain on her bilat. knees & lower leg, states they had that pain from previous fall (6/2/20), noted swelling on both areas . Injury/No injury: x-rays negative, pt now without pain Factors involved (acute condition/environment, etc.): Pt with mild confusion, rolled out of bed. both falls in AM Analysis of interventions to implement: pt to be offered and encouraged to get up earlier in AM . 8/2/2020 16:00 (4:00PM) Nurses' Notes Note Text: resident was up in w/c (wheelchair) and self propelling w/c in the hall way. alert with confusion. incoherent talk. not very clear. observed hallucination also. encouraged oral fluids. (R507) stated that (R507) wants to call their mother, mother was at door side . 8/24/2020 14:33 (2:33PM) Pertinent Charting-Falls Note Text: Date of Fall: 08/24/2020 Situation Details: pt found kneeling next to bed on knees. no injury noted. Assessment: pt had legs out of bed and knees on floor. monitor for injury. none Mitigating Factors: Environmental Factors: Interventions: MD Notification: yes Responsible Party Notification: message left. 9/13/2020 07:25 (7:25AM) Pertinent Charting-Falls Note Text: Date of Fall: 09/13/2020 Situation Details: Resident was observed laying on the right side on floor next to bed. (R507) stated they hit their head on the floor, no bruise or bump noted. Small bruise noted on right shoulder approx. 2cm (centimeters) X 3cm. Assessment: Assessed skin, small bruise noted on right shoulder approx. 2cm X 3cm. ROM of all extremities WNL. Neuro checks initiated. Small bruise noted on right shoulder approx. 2cm X 3cm. Mitigating Factors: Environmental Factors: Interventions: MD Notification: (Physician) Responsible Party Notification: (Family Member) Comments: Resident denies pain . Received order from (Physician) to send resident to hospital for CT scan of head. Called 911, resident left the facility @ (at) 8:50am accompanied by the EMS (Emergency Medical Services) staff. 9/14/2020 18:35 (6:35PM) Pertinent Charting-Falls Note Text: Date of Fall: 09/14/2020 Situation Details: Resident was observed on the floor in a sitting position,and stated that they hit their head on the wall and (R507) also landing (landed) with right wrist, the right wrist is swollen and the (there) is a bruise noted, the Dr was notified and a stat X-ray was order. Assessment: swollen right wrist and a bruise on right wrist bruises Mitigating Factors: Environmental Factors: Interventions: MD Notification: Responsible Party Notification . 9/15/2020 08:30 (8:30AM) Nurses' Notes Note Text: (Nurse Practioner) notified of x-ray results, [MEDICAL CONDITION] right radius, which appears old, though clinical correlation is necessary, and a more recent injury cannot be excluded if there is pain at this location and no prior documentation of injury . 9/15/2020 12:20 (12:20PM) SOC-Falls New Fall/Follow-Up: Patient has had multiple falls. Patient had a fall on 8/24/20, 9/13/20 and 9/14/20. Situation (where/when/what/who): All falls took place in the resident's room. During the fall incident on 8/24/20, patient was observed kneeling next to their bed on their knees. Resident was attempting to put on their pants and they appeared too tight and when struggling to put pants on they lost their balance and fell . On 9/13/20, the resident was observed lying on the floor next to their bed on their right side. On 9/14/20, patient was observed sitting on the floor of their room on their buttocks in front of the foot of their bed. Patient was not sure what (R507) was doing but stated that they did not have their glasses so (R507) was probably looking for them and that's why (R507) was ambulating in their room. Injury/No injury: No apparent injury for the fall on 8/24/20, patient did state that they hit their head during the fall on 9/13/20 and was sent to the hospital for a CT scan . On 9/14/20, patient c/o (complaint of) right wrist pain. (R507) told staff that when they fell , they put their arm out and hurt their wrist. (R507) also stated that they hit their head on the wall as they fell . Factors involved (acute condition/environment, etc.): Patient has Dementia and poor safety awareness. Patient requires a one person assist for transfers. Patient does not use their call light regularly. Notifications: Family and physician notified Analysis of interventions to implement: For the fall incident on 8/24/20, the resident was to get proper fitting clothing. For 9/13/20, staff will encourage patient to be up and dressed and in their wheelchair prior to breakfast. For the fall incident on 9/14/20, resident will be provided with an eyeglasses lanyard . 9/16/2020 12:30 NP/PA (Nurse Practioner/Physician Assistant) Progress Note Late Entry: Note Text: Subjective: Patient is being seen today due to results of right wrist xray. Reports came back showing possible old right wrist fracture. Per radiology reports if clinically warranted it was recommended to repeat xray with oblique views. On examination patient and point tenderness and is unable to perform ROM to wrist. Staff have also reported that patient has 4 falls in past 24 hours. Attempts have been made to contact patients family with messages left. Bruising is present to wrist and thumb .Mental status - alert oriented times 1 with short term memory loss; poor historian - Mechanical Fall: Fall precautions - 9/15: R Wrist Xray shows possible old fx (fracture) recommend to clinically correlate with repeat and oblique views - 9/16: Repeat R wrist xray with oblique views 9/16/2020 22:41 (10:41PM) Nurses' Notes Note Text: X-ray report came back and it shows that patient has acute fracture involving right distal radius with mild displacement 9/17/2020 03:32 (3:32AM) Nurses' Notes Note Text: Transferred to (emergency room ) for evaluation of right wrist fracture via (EMS) .right wrist/arm with swelling and purple bruising. 9/18/2020 19:02 (7:02PM) Nursing Evaluation Summary Note Text: Patient arrived by the transporter from (hospital) Patient came in with a slide and their right wrist is bruise, swollen and fracture . On 9/24/2020 at 12:11AM, LPN A was asked about R507's frequent falls and stated, (R507) needs a 1:1, but they (facility) need more CNAs (Certified Nursing Assistant) because there is not enough help. No one sets up their food, and they are often left alone. I would suggest that R507 be placed in a room where they can be frequently supervised. A review of R507's fall care plan revealed the following: The resident is at risk for falls related to: Deconditioning, Unsteady gait, acute exacerbation of Asthma, generalize weakness, history of falls. Date Initiated: 06/20/2018, Revision on: 09/21/2020. Check and change every 2 hours, Date Initiated: 03/20/2020 Offer toileting ac (before meals), pc (after meals), hs (bed time) and prn (as needed). Date Initiated: 03/23/2020. Floor mats next to exit side of bed. Date Initiated: 04/13/2020 Non-skid socks to be worn. Date Initiated: 06/02/2020 Remind the resident to not get up without assistance. Date Initiated: 06/29/2018. Revision on: 06/02/2020 Resident attempting to pull up pants, staff observed pants being tight. SW (social work) will assist resident with obtaining new clothes. Date Initiated: 08/25/2020 Resident will be provided with an eyeglasses lanyard. Date Initiated: 09/15/2020 Staff to get patient up and dressed and into her wheelchair prior to breakfast. Date Initiated: 09/15/2020 Ensure that personal items are within reach. Date Initiated: 09/16/2020. A review of the facility's Falls-Clinical Protocol outlined the following, Monitoring and Follow-up: 1. The staff will monitor and document the individuals response to interventions intended to reduce falling or the consequences of falling. 2. Residents will be reviewed though Standards of Care at a determined time frame after new interventions are implemented to determine if effective or revision is necessary .If the individual continues to fall the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and re-evaluate the continued relevance of current interventions. Let it be noted that there was no documentation that the resident's care plan has been followed by staff, or that the care plan interventions have been re-assessed following each fall. On 9/24/2020 at 3:34PM and 3:55PM, R507's room door was closed. Upon entry, the resident was sitting in their wheelchair, in the same spot, wearing the same soiled clothing from 10:26AM. On 9/24/2020 at 4:08PM, the Nursing Home Administrator (NHA) was interviewed and asked the facility's expectation in the prevention falls, and stated, We try to limit falls as much as possible; We try to put interventions in place to prevent falls. The NHA was asked if they were aware of R507's most recent fall in which they fractured their wrist and their thoughts on their fall, the NHA stated, (R507) was recently switched to a private room for isolation and was looking for their glasses and rolled out of bed.

This citation pertains to intake 6 Based on interview and record review the facility failed to ensure and maintain an environment free from physical abuse and verbal abuse for one (R600) of three sampled residents reviewed for staff to resident abuse, resulting in unprovoked physical contact, physical injury and mental anguish. Findings include: On 6/25/20 at 10:17 AM, Police Officer A was interview via phone call and queried about the incident on 6/1/20 with CNA B, CNA C, (Certified Nurse Aides) and R600. Police Officer A said, Dispatch was called on 6/1/20 between 4:00AM and 4:30 AM. Two aides (CNA B and CNA C) came into R600's room to change (their) brief. (R600) said (CNA C) was rough while having the brief changed and left bruises on the top part of both of arms. We are still investigating this incident. A review of the electronic medical record noted R600 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of R600's Minimum Data Set ((MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) of 15 (Intact cognitive response). R600 requires extensive assistance with activities of daily living. On 6/25/20 at 11:59 AM, CNA B was called via phone and interviewed regarding the incident on 6/1/20 with R600 and CNA C. CNA B said, (R600) needed to be changed. I told the nurse (Nurse D) that I needed help and (Nurse D) sent (CNA C) to help. We were very short and (CNA C) did not want to help. When I was turning (R600) toward me to change the linen, (CNA C) grabbed (R600) and pulled (R600) over real hard without letting the patient know. (R600) told (CNA C) to stop being so rough like that. (CNA C) left the room and then came back and told (R600) that (they) didn't want to come in to help anyway and said (they) better not get fired. On 6/25/20 at 12:10 PM, attempted to call Nurse D via phone, left voice message. On 6/25/20 at 12:22 PM, attempted to call CNA C via phone, the phone line was disconnected. On 6/25/20 at 1:52 PM, R600 was interviewed about the incident with CNA B and CNA C. R600 said, The (CNAs) came into my room to change my diaper because I was wet. The one aide (CNA C) was very mean and roughed me up. I had bruises. (CNA C) told me that (they) did not come in for me, (CNA C) said (they) only came in to help the other aide. The staff are all mad and mean to us (residents). But that is not a reason to put bruises on me. That made me very mad. A review of R600's Incident Report noted on 6/1/20 at 04:00 AM reported bruising to .R600 statement noted as follows: Patient reports that (CNA C), was too rough with (R600) and would not stop care when requested. PT (patient) reports that (they) was hurt during care .Policy and Procedures, staff education for abuse reporting, turning and reposition of residents teaching .(R600) was interviewed by the Administrator and the Director of Nursing and was noted to have slight bruising on (their) bilateral biceps and right shoulder .(CNA B) stated in (their) interview that (CNA C) was rough while assisting with care .(CNA C) Turning (R600) quickly without notifying (them) of the change in position. On 6/25/20 at 2:15 PM, the Administrator was interviewed and queried about the incident. The Administrator said, I was notified that (R600) was treated rough by (CNA C) on the midnight shift. We went in to speak with (R600) and (R600) said (CNA C) was rough with care while changing the brief. The nurse (Nurse D) and (CNA B and CNA C) were all suspended. After the investigation (CNA C) was terminated. A review of the Abuser Prevention Program dated 2/22/18 noted the following: Our residents have the right to be free from abuse, neglect .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff.

This pertains to intakes MI 060 and MI 813 Based on observation, interview, and record review, the facility failed to provide appropriate transfer assistance for one (#701) of three sampled residents reviewed for injuries of unknown origin, from a total sample of six, resulting Resident #701 sustaining a distal left tibia and fibular shaft fractures. Findings include: On 7/2/18 at 10:20 AM, Resident #701 (R701) was observed in the family lounge. She was observed sitting in a geri chair. R701 had a cast on her left lower leg. On 7/2/18 at 10:15 AM, a review of R701's clinical record and facility incident report was begun. R701 was originally admitted into the facility on [DATE] with a readmission date of [DATE]. Her [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented severe cognitive impairment and extensive two+ person physical assistance for transfers. Radiology report for R701, dated 4/30/18, documented the following: Conclusion: acute oblique distal left tibia and fibular shaft fractures with subcentimeter step-offs, respectively. The facility incident report on R701 with a date/time of 4/30/18 at 12:00 PM documented the following: -Condition prior to incident: the incident was not witnessed; location of observation was the dining room; skin injury; injury of unknown origin -Brief Description: Walked in dining room to take another resident inside and noticed a green, purple, red bruise to left lower leg. -Treatment: resident sent to hospital -Other information that is important to know: Resident is non ambulatory. Requires 2 person assist for transfers. Has osteopenia. Geri chair for out of bed locomotion. Exhibits episodes of restlessness. Has been observed by staff and family (to) swing legs over side of geri chair legs; scooting self sideways in chair. Transfer changed to mechanical lift. Padding applied to geri chair and tray prongs. On 7/3/18 at 11:00 AM, a review of the facility's investigation report on R701 revealed the following: -CNA (Certified Nurse Aide) Z interview (worked 4/29/18 day shift): I got (R701) dressed and up for breakfast. I didn't see anything on her legs. I lifted her up and put her in her chair After lunch I saw her in the geri chair. I moved her legs over the left side of the foot part of the geri chair. I moved the legs over into the chair and placed pillows to her side. Her pants were on and I didn't notice anything. I laid her down in bed after lunch. She didn't grimace or seem like she was in pain when I put her legs in bed . -CNA W interview (worked 4/29/19 afternoon shift): R701 was left in her bed during this shift. .I checked her to see if she was wet .I cleaned her and turned her .She was perfectly fine. She had her Pjs on already so I didn't get her undressed .I pulled her pants down to her knees so I didn't see below her knees. She was the same talking in her own way and reaching for me. -CNA F interview (worked 4/29/18 midnight shift): I didn't notice a bruise on her leg. I wasn't looking for it. I changed her during the night. (R701) was leaning toward her left side when I was putting her pants on in the morning .She wasn't whining or crying was just talking as usual. I used the (brand name of mechanical lift) to get her up. I didn't really look at her leg. -CNA E interview (worked 4/30/18 day shift): I saw (R701) in the geri chair in the dining room during breakfast .I was sitting at the table with her and saw a bruise on her left lower leg .I reported it to the nurse . On 7/2/18 at 3:07 PM, when CNA E was queried about the bruise she observed on R701 leg, she said, (R701) moves her legs from side to side. She can be feisty in the chair and bed. You need two people to change her brief and to transfer her using the (brand name of mechanical lift). I told (Nurse D) right after breakfast about the bruise which was about four inches long. On 7/2/18 at 3:30 PM and 7/3/18 at 10:19 AM, the Director of Nursing (DON) was interviewed regarding the events associated R701's injury. R701's MDS assessments of 1/11/18 and 4/11/18 were reviewed and both documented that R701 required two-plus person physical assistance for transfers between surfaces including to or from her bed and wheelchair. The DON said, The MDS nurse should have updated (R701's) care plan to reflect two-plus person physical assist for transfers as indicated on the MDS. A mobility/activities of daily living care plan was initiated on 4/24/18 which was revised to include Transfers with full body mechanical lift with 2 person assist on 5/7/18. When the DON was queried if she believed R701's leg movement in her geri chair caused her injury, she said, No. The DON stated it was an improper transfer when the CNA used the mechanical lift by herself. When queried about the potential problem of using the mechanical lift improperly, the DON said, Some type of injury could occur. I did a past non-compliance related to transfer issues. The facility's investigation packet revealed that CNA Z was issued a Performance Improvement Form dated 5/1/18. The counseling/corrective action documented: CNA transferred resident (a two person assisted) alone. The DON stated staff were in-serviced on how to transfer residents properly. The facility performed audits related to resident transfers. When the DON was queried about concerns identified during the facility audits, she said, Yes, staff did not always know where to look for resident transfer information.

Based on observation, interview and record review, the facility failed to implement interventions and provide care per professional standards of practice to ensure 1 (#39) of 5 sampled Residents reviewed for pressure ulcers (wounds caused by pressure), from a total sample of 21, did not develop new-onset and re-occurring facility acquired pressure ulcers resulting in the development of two unstageable pressure ulcers (full thickness tissue loss), two Stage II pressure ulcers (open ulcer with partial thickness tissue loss), pain and the potential for infection, delayed healing, and decline in overall health status. Findings include: On 3/13/18 at 9:02 AM, Resident #39 was observed in their room sitting in a wheelchair. The Resident's feet were on the floor and a Posey boot was observed on the right foot. An interview was completed with the Resident at this time and when queried regarding the Posey boot on their right foot, Resident #39 stated, I got a big blister on the back of my heel. The resident further stated, I got a couple sores on my bottom that they (staff) are trying to get rid of. When asked,the resident stated, They (sores) started about three weeks ago. When asked if they are able to reposition themselves in bed and the wheelchair, Resident #39 indicated they did not have the strength. When asked regarding the frequency that facility staff assist them to reposition in their chair and in bed, Resident #39 stated, Not as often as I need it. I'm not supposed to be up more than two hours. Resident #39 indicated they often sit up in their wheelchair for five to six hours at a time and are frequently the last person to get put back to bed at night. When asked again about the frequency that they are repositioned in their chair and in bed, Resident #39 indicated they are only repositioned when they are transferred with the Hoyer lift (mechanical lift) from their bed to their chair and back to their bed. When asked regarding pain from the pressure ulcers, Resident #39 stated, I couldn't sleep last night because of the pain. On 3/13/18 at 10:37 AM, an interview was completed with Nurse E. When queried regarding Resident #39, Nurse E stated, (The Resident) had two open areas on their coccyx. They also have Unna boots (compression dressing) and they also have a treatment for [REDACTED]. With asked about the Unna boots, Nurse E was unable to provide an explanation for use and indicated the wound care nurse completed the Unna boot treatment. On 3/13/18 at 11:37 AM, Resident #39 was observed sitting in their wheelchair in the doorway of their room. The Posey boot was in place to the Resident's right foot. When queried, Resident #39 indicated they were waiting for assistance to go to the dining room for lunch. Nurse E was then observed taking the Resident to the dining room in their wheelchair. On 3/13/18 at 1:31 PM, the Resident #39 was observed in their room in the facility. The Resident was laying in their bed, positioned on their back. When queried, Resident #39 indicated they just laid down. The Posey boot was in place to the Resident's right foot and the Resident's left foot was laying directly on the mattress. Record review on 3/13/18 at 3:45 PM revealed Resident #39 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, had an indwelling urinary catheter, and required extensive to total assistance to perform Activities of Daily Living (ADL's). On 3/14/18 at 8:20 AM, Resident #39 was observed in their room. The Resident was positioned on their back in their bed. The head of the Resident's bed was elevated at approximately 45 degrees. The Resident's eyes were closed. An overbed table with the Resident's breakfast tray was positioned over the bed in front of the Resident. At 8:44 AM on 3/14/18, Resident #39 was observed laying in their bed, positioned on their back with the head of the bed elevated at approximately 45 degrees. The Resident's breakfast tray remained in front of the Resident on the overbed table and the Resident was eating. When queried, Resident #39 indicated staff did not offer to get them out of bed yet. The Posey boot was in place to the Resident's right foot and the Resident's left foot was laying directly on the mattress. On 3/14/18 at 10:11 AM, Resident #39 was observed sitting in their wheelchair in their room. When queried, Resident #39 stated, They (staff) just got me up. The Posey boot was in place to the Resident's right foot. On 3/14/18 at 12:43 PM, Resident #39 was observed sitting in the same position in the wheelchair in their room with the Posey boot was in place on their right foot. Resident #39 was observed in their wheelchair with the Posey boot was in place on their right foot in their room on 3/14/18 at 3:00 PM. Record review of Resident #39's Gentel wound care documentation on 3/14/18 at 3:15 PM revealed the most recent documentation of the pressure ulcers occurred on 3/8/18. The documentation indicated the following: -Left Medial Buttocks, Facility Acquired, Stage II, Size: 0.6 centimeters (cm) X 2.5 cm -Right Medial Buttocks, Facility Acquired, Stage not indicated, Size: 1.0 cm X 0.3 cm X 0.1 cm -Right Achilles, Facility Acquired, Unstageable, Size: 1.0 cm X 1.0 cm -Right Heel, Facility Acquired, Unstageable, Size: 4.0 cm X 3.0 cm -Left Great Toe, admitted , Unstageable, Size: 0.8 cm X 0.8 cm Wound documentation dated 3/6/18 revealed the following measurements: -Left Great Toe, Size: 0.6 cm X 0.8 cm Wound documentation dated 3/5/18 revealed the following measurements: -Left Medial Buttocks, Size: 2.5 cm X 2.0 cm -Right Medial Buttocks, Size: 2.5 cm X 1.5 cm Wound documentation dated 3/1/18 revealed the following measurements: -Right Achilles, Size: 1.0 cm X 1.0 cm -Right Heel, Size: 3.0 cm X 4.0 cm Review of Resident #39's care plans on 3/14/18 at 3:25 PM time revealed a care plan entitled, Risk for impaired skin integrity R/T (related to) advanced age, altered circulation, comorbidities, exposure to moisture, limited mobility. admitted with mult (multiple) abrasions to the left elbow & penis, Stage 2 pressure injury to the lateral left heel, skin tear to the right great toe, history of skin breakdown to the buttocks, eschar to the left great toe. Stage 2 to the left heel resolved 11/2/17. Noted with abrasion to foreskin 11/27/17. Unstageable: Left heel 3.0 X 4.0, Unstageable Right Achilles 3 X 3 2/15/2018. Recurrent dti's (Deep Tissue Injuries) to left medial buttock 2.5 X 2 and right 2.5 X 1.5 3/05/2018,, improving bilateral medial buttock wounds upstaged to stage 2's Left medial buttock 0.6 X 2.5 and Right medial buttock 1 X 1.3 on 3/08/2018 (Initiated: 10/11/17, Revised: 3/14/18). Care plan interventions included: -POPA (Positioning .Offer Food and Fluids, Peri-care, Apply Ointments .) (Initiated: 2/9/18, Revised: 3/1/18) -Prafo boot to right foot while in bed .Heel lift boot to left foot while in bed as tolerated (Initiated: 2/9/18, Revised: 3/1/18) -Reposition as indicated and PRN (as needed) as tolerated (Initiated: 10/11/17) -Treatment as ordered (Initiated: 10/11/17) Review of the Resident's orders and Treatment Administration Record (TAR) for (MONTH) (YEAR) at this time revealed the following: -Bil (bilateral) buttocks: apply [MEDICATION NAME] every shift (facility has three shifts) and PRN (Dated 12/12/17). Documentation indicated the treatment was not completed on: 3/3/18 Afternoon, 3/4/18 AM, 3/7/18 Afternoon, 3/9/18 PM, 3/11/18 PM, and 3/14/18 Afternoon. There was no documentation of PRN application. -Rt (right) heel: Apply Allevyn foam then Unna boot weekly (Dated 2/10/18) -Soft booties to Lt (left) foot as tol. (tolerated) (Dated 1/30/18). No documentation indicating the treatment was completed. -Apply AF (Anti-Fungal) powder, apply [MEDICATION NAME] to bilateral medial buttocks q (each) shift and PRN (as needed) (Dated 3/6/18). Documentation indicated the treatment was not completed on: 3/6/18 Afternoon, 3/7/18 AM, 3/7/18 Afternoon, 3/9/18 PM, and 3/14/18 Afternoon. There was no documentation of PRN application. -Skin Prep Spray: R (right) 1st and 2nd toe: Apply topically per plan of treatment every shift. Documentation indicated the treatment was not completed on: 3/3/18 Afternoon, 3/5/18 Afternoon, 3/7/18 Afternoon, 3/9/18 Afternoon, and 3/14/18 Afternoon. On 3/15/18 at 8:10 AM, observation occurred of Resident #39 sitting in their wheelchair in their room with the Posey boot was in place on their right foot. On 3/15/18 at 10:30 AM, Resident #39 was observed sitting in the same position in their wheelchair in their room. The Posey boot was in place to the Resident's right foot. On 3/15/18 at 11:38 AM, observation of wound care for Resident #39 occurred with Wound Care Nurse F and Nursing Assistant G. Resident #39 was laying in their bed in their room. When queried, the Resident indicated they were put back in bed by staff in order to complete the dressing change. The Resident had a Posey boot in place to their right leg. Upon removal of the Resident's brief by Nurse F and Nursing Assistant G, the Resident's brief was noted to be wet and visibly soiled with bright red and brown colored drainage. The Resident was observed to have an open, irregularly shaped wound on their left buttocks that was approximately one inch long by one centimeter (cm) wide. The wound bed was red, white, and black in color. The black colored area within the round was approximately the size of a pencil eraser. The wound was actively draining a small amount of light red colored serosanguinous drainage. A separate open area was observed on the Resident's left buttocks. The wound was irregularly shaped and approximately two centimeters long by 0.5 cm wide. The wound bed was noted to be light pink in color. Observation occurred of Nurse F applying [MEDICATION NAME] (skin protectant drug) and then sprinkling anti-fungal powder over the [MEDICATION NAME]. Nurse F did not cleanse the wound bed prior to applying the cream and powder and the wound was not covered with a dressing. At this time, Nurse F and Nursing Assistant G placed a brief on the Resident. When queried if the wounds on their buttocks hurt, Resident #39 stated, When I sit on it. Nurse F then removed the Resident's socks and the Posey boot from their right foot. A dark black colored ulcer was observed on the Resident's right heel. The black area was irregularly shaped and approximately the size of a half dollar. Another area, on the back of the Resident's right foot in the Achilles area was observed to be dark black in color, irregularly shaped and approximately 1 inch long by 1 cm wide. A dark black area, approximately the diameter of a pencil was observed on the Resident's right great toe. The Resident had an area of red colored skin on the medial (inside) of their right foot over a bony prominence. The Resident's left foot was observed to have a dark black colored spot of the medial aspect of the left great toe that was irregularly shaped and approximately the size of a pencil eraser. The Resident's heel on their left foot was red in color. When queried if the heel was blanchable, Nurse F pressed the area. No blanching was observed. Nurse F applied an Allevyn dressing to the Resident's right heel followed by the Unna boot dressing wrapped with Coban (self-adherent wrap utilized to secure dressings and apply compression). Nurse F proceeded to apply an Unna boot dressing and Coban to the Resident's left lower extremity. Nurse F was observed wrapping the Coban tightly around both of the Unna boot dressings on the Resident's legs. When queried regarding the Coban and if the Coban becomes tighter the longer it is on, Nurse F replied, Yes, it tightens. When queried further regarding monitoring of the neurological status of the Resident's feet with the compression dressing in place, Nurse F did not provide a response. The ulcers on the Resident's toes on both of their feet did not receive treatments and were not covered with a dressing. Nurse F did not cleanse the wounds prior to application of the Unna boot dressings. After the dressing, Nurse F and Nursing Assistant G placed socks on both of the Resident's feet and the Posey boot was placed on the Resident's right foot. Following the dressing change, Resident #39 was positioned on their back in bed. An interview was completed with Nurse F on 3/15/18 at 12:19 PM. When queried why the wounds were not cleansed prior to applying a new treatment or dressing, Nurse F stated, I don't know. The doctor doesn't do it. When asked if Resident #39 developed the pressure ulcer on their right heel and Achilles while the Unna boot was in place, Nurse F replied, Yes, that is why we got the Allevyn (dressing under the Unna boot). When queried regarding the Resident's toes and if the wounds were caused from pressure, Nurse F stated, Yes. With further inquiry regarding why a dressing or treatment was not in place, Nurse F did not provide an explanation. When asked if placing the Resident's socks over the pressure ulcer would cause rubbing and additional pressure, Nurse F stated, Yes. When queried regarding the Resident's left heel being non-blanchable, red, and positioned directly on the bed, Nurse F did not provide an explanation. With inquiry pertaining to assessment of the Resident's skin and heels when the Unna boots are in place, Nurse F indicated the Unna boots stay on for one week. When asked how the Resident's skin is assessed when the Unna boots are in place as the Resident has already developed two pressure ulcers when the boots were in place, Nurse F was unable to provide an explanation. When queried regarding wound measurement documentation occurring on various dates and facility policy/procedure related to wound measurements, Nurse F indicated the dates were related to the recent system change at the facility. When asked if more recent measurements were available, Nurse F indicated the wound care physician saw Resident's within the facility early in the morning and documentation was not available. On 3/15/18 at 1:00 PM, an interview and record review was completed with Nurse F. When queried regarding the treatment of [REDACTED]. When queried regarding the onset dates of the Resident's pressure ulcers, Nurse F provided the following: -Left Medial Buttocks, 3/5/18 -Right Medial Buttocks, 3/5/18 -Right Achilles, 2/15/18 -Right Heel, 12/21/17 -Left Great Toe, admitted , Unstageable When queried regarding the observed ulcer on the Resident's right great toe not being included in facility documentation of pressure ulcers, Nurse F indicated the pressure ulcer was small and was not continued in the new wound system. Upon request, Nurse F reviewed their wound log documentation and stated, The onset date was 2/18/18. With further inquiry, Nurse F stated, The last measurements were 0.4 cm X 0.4 cm. An interview was completed with the facility Administrator on 3/15/18 at 2:40 PM, when queried regarding Resident #39's pressure ulcers and left heel not being elevated or having a heel boot in their room, the Administrator stated, I will find out. On 3/15/18 at 3:39 PM, Resident #39 was observed lying in their bed positioned on their back. The Resident was in the same position they were placed in following the dressing change. An interview was completed with the Director of Nursing (DON) on 3/15/18 at 3:40 PM. When queried regarding the Resident's facility acquired pressure ulcers, the DON replied, (The Resident) has a lot of co-morbidities. With further inquiry regarding the statements and observations of the Resident not being repositioned every two hours, a heel boot not being present in the Resident's room and not being utilizing a for their left foot while in bed, and lack of documentation of treatment completion the DON stated, I can see where you are coming from. No further explanation was provided. Record review on 3/15/18 at 5:30 PM of facility policy/procedure entitled, POPA- Prevention of Pressure Areas (Revised 10/17/12) revealed, Purpose . To prevent the occurrence of pressure areas. Staff will identify those Residents at high risk for development of pressure areas and implement the POPA protocol . 8. P= Positioning and Turning . Turn and reposition every 2 hours when in bed or wheelchair; Use positional devices to keep pressure off bony prominence's .Avoid friction and shearing when moving Residents .

This citation pertains to Intake # MI 475: Based on interview and record review, the facility failed to ensure that one (#901) of three sampled residents reviewed with dysphagia (swallowing impairment), from a total sample of three, was served Polish sausage in a form prescribed by the physician (chopped), resulting in an immediate jeopardy when resident # 901 choked on a piece of sausage and subsequently died . This deficient practice has the potential to place all residents with swallowing impairment at risk for harm, serious injury and/ or death from choking. The immediate jeopardy (IJ) was identified on [DATE] at 10:30 am. The Administrator was notified of the immediate jeopardy on [DATE] at 2:30 p.m., and a plan of correction to remove the IJ was requested. The IJ was removed on [DATE], based on the provider's implementation of corrective action on [DATE] as verified on-site on [DATE], during the completion of extended survey. Although the IJ was removed, the facility's deficient practice remained isolated with potential for more than minimal harm that was not immediate jeopardy. Findings include: On [DATE] at 9:45 a.m., the facility's Administrator and Director of Nursing (DON) were interviewed in relation to the Facility Reported Incident # MI 475. The (DON) stated, "This is the sequence of events based on our investigations so far. On [DATE] at approximately 5:00 pm to 5:45 pm time frame, (name of resident--for purposes of the citation, will be referred to as Resident #901) was in the dining room eating dinner. Resident #901 was able to feed himself independently. Afternoon shift supervisor #1 entered the Cardinal dining room and observed that Resident #901 appeared to be sleeping. Supervisor #1 wiped saliva off of his lips and noticed an outline (of the lips) that appeared to be quite cyanotic (bluish color). Two other nurses noticed supervisor #1 wheeling (Resident 901) away to remove him from the dining room. The Supervisor performed eight to nine [MEDICATION NAME] maneuvers (abdominal thrusts) and a piece of sausage came out (of the resident's mouth). At that time the resident took three breaths and was wheeled back to his room. He continued to decline while being suctioned and oxygen administered at 10 liters. The primary care physician was in the building, pulled (Resident #901's) chart, and realized the resident was a 'NO CODE'. The Physician called resident #901's wife for clarification and status evaluation. At that time the resident's wife changed her mind, 911 was called, and the nurse began cardiopulmonary resuscitation (CPR). When 911 arrived, they took over (CPR), shocked and intubated the resident, and pulled out another piece of sausage. (Resident #901) was transported to the hospital." When the administrator and DON were asked the reason for Resident #901's admission to the facility, the (DON) responded, "This resident choked at home while eating a hamburger and was admitted to the facility for rehabilitation." On [DATE] at 11:25 a.m., during an interview with the facility's registered dietician (RD) about Resident # 901's choking incident, the RD stated, "Resident #901 has been at the facility for six months and came in with [MEDICAL CONDITION] (lack of adequate oxygen supply to the brain) secondary to airway obstruction, dysphagia, dementia, [MEDICAL CONDITION], paralysis agitans (muscle rigidity and tremors), debility, and protein calorie [MEDICAL CONDITION]. (Resident #901) choked on a hamburger at home and was brought to facility. This last Sunday [DATE], during the dinner meal, Resident #901 was served polish sausage cut into three pieces--so the resident could use his hands--as finger food--to feed himself." Review of Physician order [REDACTED].#901 was prescribed a regular diet with chopped (cut into small pieces) meat. The dietitian was asked if the three pieces served was the same as "chopped" and said, "no". On [DATE] at 12:05 pm, during an interview with the speech therapist (ST) regarding resident #901's choking incident, she stated, "Resident #901 was first seen on [DATE], and he came in on National Dysphagia Diet (NDD#1 diet)..." The ST provided an undated document that defined several types of "national dysphagia diets". The definition of the NDD#1 diet was as follows: "NDD#1--PUREE. Purpose: resident is unable to chew and/or swallow textured foods; Foods are pureed into a smooth consistency; Nearly all items on the menu can be pureed". The ST stated, "Resident #901 was prescribed nectar thickened liquids. Assessed resident to have little residue on his tongue, no signs or symptoms of aspiration with nectar thickened liquids." The ST indicated Resident #901 was provided speech therapy services for 4 weeks, and during that time different food consistencies were introduced. The ST stated, "Resident # 901's strength improved and posture got better--able to sit up better. I tried (to train) staff and caretakers for safe swallow strategy for 4 weeks and resident able to tolerate a regular (NO MODIFICATION: all foods are allowed) chopped (cut into small pieces) foods from the kitchen. I discontinued dysphagia goal on [DATE] because (Resident #901) was tolerating his meals without any signs and symptoms of aspiration. I still recommend nectar thickened liquids at all times." The (ST) also stated, "I saw (Resident #901) again on [DATE], because the family requested--the resident was having trouble feeding himself so I moved him to assisted dining room. Resident #901 tolerated regular chopped foods with mildly extended but adequate mastication (chew) and swallow--two swallows to clear a bolus (mouthful) with mild residuals (amount of food left in the mouth after swallowing) during meals." This was consistent with the physician's orders [REDACTED]. The ST was asked on [DATE] at 12:25 pm, if she received any verification and feedback since assessing Resident #901 on [DATE], from direct care staff (certified nursing assistants, restorative nursing staff, and others) about Resident #901's eating/swallowing patterns when she was not at the facility during all meals and she said, " I did not." The ST was asked about training and evidence of caretaker and staff training for safe swallow strategy, and she stated, "I have none to show. I did not document educating any family member, and I have no documentation of staff members trained on signs and symptoms of aspiration/choking." The ST was asked if she met with the interdisciplinary team (IDT) namely nursing, occupational therapist (OT), restorative nursing, and physician to address Resident #901's progress, and she stated "No". There was no documentation that during the IDT meetings that the diet consistency and resident's ability to ingest food was discussed prior to the diet recommendations being implemented. The ST was asked about the cognitive status of resident #901. She indicated she was not aware Resident # 901 had a [DIAGNOSES REDACTED]. On [DATE] at 3:15 pm, during an interview with the occupational therapist (OT), she indicated that on [DATE] Resident #901 was referred to her because of increased difficulty feeding self and that she worked with the resident through [DATE] and discharged patient to restorative program for self-feeding. On [DATE] at 3:26 pm, the restorative nurse #2 was interviewed about Resident #901's self-feeding and swallowing abilities and stated, "A nurse came to me and reported (Resident #901) was observed having difficulty eating and unable to feed himself in the dining room, so I picked-up the resident in the Rehab Dining Program. At this time, the document entitled, "Rehab Dining Program Log Sheet" for Resident #901 was reviewed with Restorative Nurse #2. ( ) The log revealed the first section of the form "Compensatory Swallow Strategies/Guidelines" was "Blank". The next section, entitled, "Other Instructions:" was the following hand-written documentation: "1.) verbal cues for pacing, alternating solids/liquids and to use left hand for feeding. FYI (for your information) provide nosey cup, scoop plate, curved fork." The section entitled, "Meal Time Record" revealed the interventions identified in "other instructions" was completed for all three meals on [DATE], [DATE], [DATE] -[DATE], [DATE] and [DATE]. The log documented two meals recorded (either breakfast and lunch or lunch and dinner) on [DATE], [DATE]-[DATE], [DATE] -[DATE], and ,[DATE] (no year documented). Cues and redirection provided by staff members who initialed the bottom of the record revealed Resident #901 required extensive assistance (defined as 6 or more times) to minimal assistance (defined as ,[DATE] cues during a meal) each day recorded. The section entitled "Tolerated diet" indicated "Y" (yes) for all breakfast meals recorded and "Y/R" for lunches and dinners recorded from ,[DATE]-[DATE] (R stands for "runny nose"). "Coughing" episodes were documented on at lunch time on ,[DATE] -[DATE], and dinner on [DATE]. ( ) Restorative Nurse 2 was asked about Resident #901's plan of care when the resident was discharged from the Rehab Dining Program, she stated, "nothing was done--and there was no (IDT) input related to resident #901's therapeutic nutritional care prior to resident #901 choking incident on [DATE]". Restorative nurse #2 also stated, "in my notes of [DATE], this resident was unable to lift his arm and move the fork to his mouth--instead he put his head down to the plate of food. He would not follow directions, no matter how much he was cued". On [DATE], Restorative Nurse 2 documented: "Everyday resident attempts to put too much food in his mouth even with constant cues to alternate liquids with food. Again today he would not lift (his) hand to mouth. He kept leaning over the plate to get his foods". On [DATE], Restorative Nurse #2 documented: "Resident attempted to not use his arm to eat. He was trying to bend over--(words crossed out)---to the plate. Needs constant vc's (verbal cues) with raising fork to moth. He also needs constant vc's to alternate food with liquids and to slow down with eating." During a subsequent interview with the Speech Therapist on [DATE] at 3:50 pm, the (ST) reported she was unaware of all noted documentation's from restorative nursing and offered no further explanations relating to residents #901's ability to feed himself independently in a safe manner. On [DATE] at 4:20 pm, the nurse supervisor #1 on duty the day resident #901 choked was interviewed. She confirmed she was on duty on the day of the incident and she stated, "I entered the Cardinal dining room and observed 2 staff serving food to some residents. I know this resident (Resident #901)--whenever he gets served his meals he eats very fast. When I saw this resident, one piece of his sausage was not on the plate. He was drooling--thick secretions were coming out of his mouth. No staff were observed at his table during that time. I used tissue to remove the secretions and observed his lips were becoming blue. I wheeled (Resident #901) out of the dining and performed 8 to 9 [MEDICATION NAME] maneuvers. Thick secretions mixed with food particles came out from his mouth. Resident was leaning forward--the resident was wheeled out of the dining room and started on oxygen while being suctioned. Chest compressions were started on the resident and permission was obtained from his wife." On [DATE] at 9:15 am, certified nurse assistant (CNA 'A') was interviewed by telephone. She confirmed she was on duty on the day of the incident. CNA 'A' reported the following: "The cardinal dining room is for all residents that need help with feeding. When I saw this resident, he was already eating with no staff assistance. I observed the afternoon nurse supervisor come and say to him (Resident #901) "sit up and eat your food. The resident was slumped down in his chair all the time--he leans forward and sideways. (Resident #901) was choking and the supervisor went to him and said "come on let's eat" then realized the resident was choking and took him out of the dining room. I then realized the resident was choking when nurse supervisor #1 rushed him out of the dining room with two other staff members to perform [MEDICATION NAME] maneuver. There was no staff feeding resident #901. Resident #901 eats in that dining room all the time by himself without any assistance." On [DATE] at 1:45 pm, a review of resident #901's clinical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], indicated had a Brief Interview for Mental Status (BIMS) summary score of 04 out of 15, and required one person physical assistance with bed mobility, transfers, eating and toilet use. In section K of the MDS "Swallowing Disorder", Resident #901 was assessed with [REDACTED]. The resident had no difficulty or pain when swallowing and did not hold food in mouth/cheeks or have residual food in mouth after meals. The resident was described with no "loss" (falling out of mouth) of liquids or solids during and after eating or drinking; however, Resident # 901 was assessed to require a mechanically altered diet--change in texture of food or liquids (e.g. pureed food, thickened liquids). Documented under section O of the MDS revealed the resident's time recorded spent with Speech and Occupational Therapy was "0" (zero) minutes. Review of the speech language pathology plan of care dated [DATE], on [DATE], at 4:45 pm, documented Resident #901 exhibited "new or declining deficits in thought processing and reasoning, effecting ability to: attend (pay attention), recall (short-term memory), problem solve, orient and sequence (ordering). (Resident #901) demonstrated impaired oral and pharyngeal difficulties during swallowing. Applicable goals were as follows: increased safety and adequate intake with least restrictive diet, independent use of safe swallow strategies, increased problem solving abilities for safe functioning, able to identify safety issues in his environment, independent use of compensatory strategies, increased orientation times 3, and increased ability to recall new information and sequence tasks". The approaches were "deficit awareness training, simulated problem solving tasks, environmental cues and orientation training, diet analysis and modification, establish and implement safe swallowing strategies namely: must be 90 degrees, cue/give very small bites, slow rate of intake, check mouth for pocketing, alternate liquids and solids, resident to remain upright 20- 30 minutes after intake, patient family and staff indication, and staff training". On [DATE] at 5:54 p.m., review of the rehab services dysphagia evaluation dated [DATE], indicated resident #901 was admitted on (NDD1) with honey thickened liquid (HTL). Review of the nutrition risk assessment dated [DATE], on [DATE] at 4:56 pm., revealed the dietitian recommended a regular diet with consistency of NDD2. According to documentation provided by the facility, undated, a NDD# 2: Ground was defined as follows: Purpose: minimize chewing and/or increase ease of swallowing. Foods are finely minced/ground and are moistened. Vegetables that can be mashed with a fork are included. Bread is not included unless the ticket reads "bread OK". On [DATE] at 4:59 pm, review of the nursing progress notes revealed the following: "[DATE] at 5:40 pm, resident eating in cardinal dining room; self feeding. Observed lips turning blue, non-verbal, thick secretions from mouth. [MEDICATION NAME] given at least 8 times. Food particles fell out of mouth, resident's tongue protruding, turning blue, non-responsive, CPR started. EMS able to aspirate particle. Observed sausage 3.5 X 2.5 cm..." (2.54 cm is equal to one inch) The facility submitted a plan of correction (POC) dated [DATE] that indicated the following: Resident #901 choked on a piece of sausage and later died at the hospital. 1) The Corrective Action that has been or will be accomplished for those residents affected by the deficient practice: Resident # 901 was admitted to the facility on [DATE]. On Sunday [DATE], resident #901 was eating his dinner meal when at 5:42 pm he was observed by the RN Nurse Supervisor to be slumped in his chair. When she approached him she observed his lips to be cyanotic and immediately removed resident from the dining room. Outside the dining room door two (2) LPN Charge Nurses responded immediately and the [MEDICATION NAME] maneuver was performed. Resident did expel food during the emergency response and took (3) three deep breaths. Resident was taken to his room placed on oxygen via mask and suctioning attempted. Resident was awake but unresponsive and color had improved during this time. Vitals signs were temperature 97.3, pulse 57, respirations 2 and gasping, blood pressure ,[DATE] and pulse oximetry was 51% on 10 liters of oxygen via mask. At 5:45 pm, Residents primary care physician who was in the facility contacted the resident ' s wife to alert her of the event and change in his status and to confirm resuscitation desires. The wife expressed verbally to his physician that she wanted his Advanced Directive designation changed from Medical Treatment at the Facility or at the Hospital if necessary-No Cardiopulmonary Resuscitation to Full Treatment- Cardiopulmonary Resuscitation/hospitalization . At 5:50 pm, Cardiopulmonary Resuscitation was initiated per wife ' s request, 911 was called and at 5:57 pm Emergency responders arrived and took over care of the resident. Resident expired at the acute care hospital on Monday [DATE] at 6:00 pm. 2) How the facility has identified or will identify other residents who have the potential to be affected by the same deficient practice: A complete review of therapeutic and altered diets occurred for all residents/patients on [DATE]. (126 in total) All of the residents/patients (51 residents/patients out of 126 total) that are on NDD1, NDD2, NDD 3 and chopped diets have been screened by speech therapists and occupational therapists (if appropriate) beginning at 6:00 pm on [DATE] and continuing through 6:00 am on [DATE]. If a screen resulted in a need for a full therapy evaluation and the admission of a resident/patient for therapy treatment, an interdisciplinary team was created to work through the communications regarding the specifics of the treatment plan for the resident. In total 51 screens were completed in a 24 hour period beginning on [DATE]. 3) The measures that have been or will be put into place, or systemic changes made to ensure the deficient practice will not recur: On [DATE] 9:00 pm, a Dining Room Assistance/Checklist form was created as a permanent form for all three meals. This form will provide evidence and documentation that staff that are working in the dining room provide appropriate meal time supervision. Monitoring includes proper posture, the ability to feed or take verbal cueing, the determination that food is not being pocketed in the resident/patients mouth, and that adequate chewing and swallowing occurs. If a resident/patient dines in his or her room this same checklist will be completed by the staff person delivering the meal tray and providing supervision or assistance. Also, at the dinner meal on [DATE] a new enhanced tray card system was fully implemented for all residents/patients. The new tray card system will assist staff to identify the type of assistance the resident/patient will need in terms of set up, supervision, swallowing or cueing by staff during meal times. All staff, all departments have been in serviced on the new ticket system All Staff beginning with afternoon shift (3 pm-11 pm) on [DATE] have been in serviced and re-educated to: Types of National Dysphasia Diets which are known as a type of modified diet. Types of " Set Up " Diets such as Regular Chopped The use and implementation of the Dining Room Assistance/Checklist form for dining room and patient room dining. Types of Assistance and Supervisor that is needed during a resident ' s placement in the various levels of dining experience at Evangelical Home Sterling Heights such as Hummingbird Hut, Sterling Cafe and the Cardinal Cafe. Hummingbird Hut- Independent dining room and food is plated and residents are free to choose items from posted menus at the point of service. Sterling Cafe- Cafe experience for our short term rehabilitation patients. Food is plated at point of service and individuals are free to choose items from posted menus. Cardinal Cafe- Primarily designated for those residents/patients that are in the rehab/restorative nursing dining program and for those residents who need supervision, assistance, with plate set up and food placement or cueing. Food is plated at the point of service and individuals are free to choose items from posted menus as appropriate. The enhanced tray card system identifying supervision needs became effective [DATE]. All staff, all department have received this in service and re-education prior to working their next scheduled shift. A Dysphasia Committee was formed and held their first meeting on [DATE]. The committee will consist of Registered Dietitians, Speech Therapists, Occupational Therapists, Dining Services Director, Nursing Supervisors and the Director of Clinical Nursing Services to ensure the interdisciplinary team has reviewed at least quarterly all residents/patients on the above modified diets. The Corporate RN, Vice President of Process Improvement will assist the facility team with the initial coordination of the meetings and to assure that the clinical, nursing and therapy needs of the resident/patient are addressed. Educational sessions were held on [DATE] with all kitchen production staff, cooks, and Dining services staff. The education sessions included the preparation of foods for altered (chopped) diets and information on the specifics of each therapeutic diet. The staff also received education on the new Dining Room Assistance/Checklist for use in the dining rooms and for meals delivered in a resident/patient room and the new enhanced tray card system. All staff were educated before beginning work on [DATE]. On [DATE] at 4:30 pm an Interdisciplinary Team meeting was held with supervisory clinicians, therapists and administrative staff to discuss and re-educate on the importance of documenting interdisciplinary team meetings and progress notes in the clinical record. 4) A. How the facility will monitor its corrective actions to ensure that the deficient practice is corrected and will not recur: What QA pieces were put into place? A daily audit tool has been implemented to verify the use of the Dining Room Assistance/Checklist. The tool will be used to ensure any concerns noted in the previous day meals have been addressed and documented by the Interdisciplinary Team. Tray Card ticket system will be reviewed weekly at the Interdisciplinary team meeting to ensure all current modifications are updated and accurately reflects the current status of the residents/patients and the type of assistance required for meal times. The Director, Clinical Operations and the facility Executive Director/Administrator will compile audit results and report to the QAPI committee monthly for three months and then quarterly or as directed by the committee. B. Who Is Responsible For Sustaining Compliance: The Executive Director, Health Care Services/Administrator and the Director, Clinical Operations have ultimate responsibility to ensure compliance is attained and maintained in this area." ( )

THIS CITATION PERTAINS TO INTAKES MI 264; MI 392; AND MI 325 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 OF 3 SAMPLED RESIDENTS (#101) WAS PROVIDED ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS WHEN RESIDENT #101 WAS NOT SEATED IN HER WHEELCHAIR WITH A SENSOR ALARM PAD AND WAS LEFT UNATTENDED IN THE DINING ROOM. THE ACCIDENT RESULTED IN A FRACTURED RIGHT FEMUR. FINDINGS INCLUDED: REVIEW OF THE ADMISSION RECORD FORM FOR RESIDENT #101 INDICATED AN admission date of [DATE]. THE FORM INDICATED [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) COMPLETED ON 1/14/13, INDICATED THAT RESIDENT #101 WAS AMBULATORY AND PERFORMED MOST PERSONAL CARE ACTIVITIES WITH SUPERVISION. ON 5/14/13, AT 10:00 A.M., OBSERVATION REVEALED THAT RESIDENT #101 WAS IN A WHEELCHAIR WITH AN ALARM SEAT SENSOR PAD. INTERVIEW WAS ATTEMPTED WITH RESIDENT #101 BUT HER IMPAIRED COGNITION IMPEDED HER ABILITY TO COMPREHEND QUESTIONS AND GIVE RELIABLE RESPONSES. ON 5/14/13, AT 10:15 A.M., INTERVIEW WITH THE DIRECTOR OF NURSING, KNOWN AS EMPLOYEE #7, REVEALED THAT RESIDENT #101 HAD RECENTLY DISPLAYED A SIGNIFICANT CHANGE IN CONDITION. EMPLOYEE 7 ALSO REPORTED THAT THE RESIDENT HAD TWO FALL INCIDENTS THAT RESPECTIVELY OCCURRED ON 4/01/13 AND 4/20/13. EMPLOYEE #7 REPORTED THAT RESIDENT #101 CURRENTLY DISPLAYED IMPAIRED GAIT MOBILITY WITH POOR BALANCE AND REQUIRED A WHEELCHAIR WITH A SENSOR PAD TO ALERT STAFF WHEN SHE ATTEMPTED TO ELEVATE FOR AMBULATION. REVIEW OF THE RESIDENT'S CLINICAL RECORD INDICATED IN THE "INTERDISCIPLINARY TEAM PROGRESS NOTES" DATED 4/01/13, AT 11:20 A.M., "RESIDENT (#101) WAS FOUND SITTING ON THE FLOOR IN ROOM." REVIEW OF AN INCIDENT REPORT DATED 4/01/13, INDICATED THAT "RESIDENT (#101) SITTING ON THE FLOOR NEAR BED, BETWEEN THE CHAIR AND TV STAND." THE INCIDENT REPORT INDICATED A CORRECTIVE MEASURE FOR PREVENTION OF SIMILAR INCIDENTS TO INCLUDE "SENSOR PAD ALARM FOR WHEELCHAIR; AND THERAPY SCREEN." ON 4/01/13, INTERVIEW WITH THE PHYSICAL THERAPIST KNOWN AS EMPLOYEE #1 REVEALED THAT A PHYSICAL THERAPY SCREEN COMPLETED ON 4/02/13, WHEN RESIDENT #101 HAD BEEN ASSESSED AND DISPLAYED IMPAIRED GAIT MOBILITY. EMPLOYEE #1 STATED THAT RESIDENT #101 WAS EVALUATED FOR USE OF A MERRIWALKER AND DUE TO HER POOR MOTOR SKILLS AND SAFETY ISSUES. RESIDENT #101 WAS AT RISK FOR INJURY AND THEREFORE, A MERRIWALKER WAS NOT RECOMMENDED. THE THERAPIST STATED THAT THE RESIDENT WAS APPROVED TO USE THE MERRIWALKER ONLY UNDER DIRECT SUPERVISION, OTHERWISE SHOULD USE A WHEELCHAIR WITH AN ALARM SENSOR PAD FOR MOBILITY. REVIEW OF THE COMPREHENSIVE CARE PLAN IN THE RESIDENT'S CLINICAL RECORD INDICATED THAT ON 4/01/13, A REVISION TO THE "FALL RISK" CARE PLAN WAS CREATED TO INCLUDE THE INTERVENTION FOR A "SENSOR PAD ALARM TO WHEELCHAIR AND BED." FURTHER REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED IN THE "INTERDISCIPLINARY TEAM PROGRESS NOTES" DATED 4/20/13, AT 7:05 P.M., "RESIDENT (#101) FOUND ON FLOOR IN CARDINAL CAFE." REVIEW OF AN INCIDENT REPORT DATED 4/20/13, INDICATED THAT "RESIDENT (#101) SITTING ON BUTTOCKS ON FLOOR IN DINING ROOM." THE CORRECTIVE MEASURE ON THE INCIDENT REPORT INDICATED THAT, "RESIDENT NOT TO BE LEFT IN DINING ROOM UNATTENDED." FURTHER INTERVIEW WITH EMPLOYEE #7 REVEALED THAT RESIDENT #1 fell FROM SITTING IN A STRAIGHT BACK CHAIR AT THE DINING ROOM TABLE. EMPLOYEE #7 FURTHER REPORTED THAT RESIDENT #101 WAS NOT SITTING IN HER WHEELCHAIR WITH THE SENSOR PAD AND WAS FOUND IN THE DINING ROOM UNATTENDED BY STAFF AND ALONE. REVIEW OF THE FACILITY'S INTERNAL INVESTIGATION REGARDING THE FALL INCIDENT ON 4/20/13, INDICATED THAT THE RESIDENT WAS ASSESSED FOR INJURIES AND THERE WAS NO COMPLAINTS OF DISCOMFORT OR EVIDENCE OF PHYSICAL TRAUMA. THE INVESTIGATORY REPORT INDICATED THAT THE ASSESSMENT WAS COMPLETED BY TWO LICENSED PRACTICAL NURSES KNOWN AS EMPLOYEES #2 AND #3. ON 5/14/13, AT 2:00 P.M., INTERVIEW WITH EMPLOYEE #2 REVEALED THAT ON 4/20/13, AT APPROXIMATELY 7:00 P.M., SHE WAS SUMMONED TO THE CARDINAL CAFE BY A CERTIFIED NURSING ASSISTANT, KNOWN AS EMPLOYEE #4, WHO REPORTED THAT RESIDENT #101 WAS ON THE FLOOR. EMPLOYEE #2 STATED THAT SHE OBSERVED RESIDENT #101 IN A SITTING POSITION ON THE FLOOR AND IMMEDIATELY ASSESSED THE RESIDENT FOR INJURIES, COMPLETING RANGE OF MOTION ON THE UPPER AND LOWER EXTREMITIES. EMPLOYEE #2 STATED THAT RESIDENT #101 DID NOT COMPLAIN OF ANY PHYSICAL DISCOMFORT OR REPORT HITTING HER HEAD. EMPLOYEE #2 STATED THAT SHE (#2) WAS ASSISTED BY OTHER STAFF MEMBERS IN ELEVATING RESIDENT #101 INTO A WHEELCHAIR AND THEN TRANSPORTED THE RESIDENT TO HER ROOM. EMPLOYEE #2 STATED THAT SHE ALSO NOTIFIED THE AFTERNOON NURSE SUPERVISOR, KNOWN AS EMPLOYEE #3. EMPLOYEE #3 STATED THAT RESIDENT #101 WAS ALONE IN THE DINING ROOM. ON 5/15/13, AT 10:30 A.M., INTERVIEW WITH EMPLOYEE #3 REVEALED THAT HE ALSO ASSESSED RESIDENT #101 FOR INJURIES DURING THE AFTERNOON SHIFT AND STATED HE DID NOT OBSERVE ANY SIGNS OF PHYSICAL TRAUMA NOR DID RESIDENT #101 COMPLAIN OF PAIN OR DISCOMFORT ASSOCIATED WITH THE FALL. ON 5/15/13, AT 11:30 A.M., INTERVIEW WITH EMPLOYEE #4 REVEALED THAT AT APPROXIMATELY 7:00 P.M., SHE WAS PASSING BY THE "CARDINAL CAFE" DINING ROOM; HEARD SOMEONE CRYING, AND OBSERVED RESIDENT #101 ON THE FLOOR APPROXIMATELY 3 FEET FROM THE TABLE AND CHAIR. EMPLOYEE #4 STATED THAT THE RESIDENT WAS ALONE IN THE DINING ROOM AT THE TIME OF HER OBSERVATION. EMPLOYEE #4 STATED THAT SHE IMMEDIATELY SUMMONED FOR HELP AND EMPLOYEE #2 RESPONDED TO THE DINING ROOM AND IMMEDIATELY ASSESSED RESIDENT #101 FOR INJURIES. RESIDENT #101 DID NOT REPORT ANY COMPLAINTS OF PAIN OR DISCOMFORT. EMPLOYEE #4 STATED THAT THE RESIDENT WAS NOT SITTING IN HER WHEELCHAIR WITH THE SENSOR PAD BUT HAD BEEN PLACED AT THE DINING ROOM TABLE IN A STRAIGHT BACK CHAIR, DESPITE THE FACT SHE WAS A FALL RISK. EMPLOYEE #4 STATED THAT RESIDENT #101 DID NOT COMPLAIN OF ANY PAIN OR DISCOMFORT FOR THE REMAINDER OF HER SHIFT THAT ENDED AT 11:00 P.M., ON 4/20/13. FURTHER REVIEW OF THE RESIDENT #101'S CLINICAL RECORD REVEALED IN THE "INTERDISCIPLINARY TEAM PROGRESS NOTES" DATED 4/21/13, AT 8:00 A.M., "RESIDENT EXHIBITED PAIN IN HER RIGHT LEG. PHYSICIAN NOTIFIED AND STAT X-RAY OF RIGHT HIP, RIGHT FEMUR, AND RIGHT TIBIA/FIBULA ORDERED." FURTHER REVIEW OF THE PROGRESS NOTES INDICATED, AT 2:21 P.M., "RIGHT EXTREMITY FRACTURE INVOLVING PROXIMAL FEMUR WITH MINIMAL DISPLACEMENT. THE RESIDENT WAS TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER TREATMENT AND EVALUATION." THE PROGRESS NOTE ENTRY WAS DOCUMENTED BY EMPLOYEE #5, A LICENSED PRACTICAL NURSE. ON 5/15/13, AT 1:30 P.M., INTERVIEW WITH EMPLOYEE #5 REVEALED THAT AT APPROXIMATELY 8:00 A.M., SHE WAS NOTIFIED BY A CERTIFIED NURSING ASSISTANT, KNOWN AS EMPLOYEE #6 THAT RESIDENT #101 WAS COMPLAINING OF PAIN IN HER RIGHT LEG WHEN SHE ATTEMPTED TO DRESS HER. EMPLOYEE #5 STATED THAT SHE IMMEDIATELY ASSESSED THE RESIDENT AND THE RESIDENT EXHIBITED PAIN WHEN MOVEMENT OF THE RIGHT LEG WAS ATTEMPTED. EMPLOYEE #5 STATED THAT THE RESIDENT WAS ADMINISTERED TYLENOL AND SHE IMMEDIATELY NOTIFIED THE PHYSICIAN AND RESIDENT'S FAMILY. EMPLOYEE #5 STATED THAT WHEN THE X-RAY REVEALED A RIGHT FRACTURED FEMUR THE RESIDENT WAS IMMEDIATELY TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER TREATMENT. REVIEW OF THE HOSPITAL RECORD REVEALED THAT ON 4/23/13, THE RESIDENT HAD A "RIGHT HIP PINNING ATTRIBUTED TO A RIGHT IMPACTED FEMORAL NECK FRACTURE, S/P PERCUTANEOUS SCREW FIXATION." THE HOSPITAL RECORD INDICATED THAT THE RESIDENT WAS discharged AND RETURNED TO THE NURSING HOME ON 4/25/13. CONSEQUENTLY, THE FALL INCIDENT THAT RESULTED IN A RIGHT FEMORAL FRACTURE WAS AVOIDABLE WHEN RESIDENT #101 WAS SEATED IN THE CARDINAL CAFE DINING ROOM IN A STRAIGHT BACK CHAIR AT THE DINING ROOM TABLE RATHER THAN HER WHEELCHAIR WITH THE SENSOR PAD AS CARE PLANNED. FURTHERMORE, THE ABSENCE OF SUPERVISION IN THE DINING ROOM WAS AN ATTRIBUTING FACTOR FOR AN ACCIDENT TO OCCUR.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 823. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT 1 OF 8 RESIDENTS (#103) FROM FALL RELATED ACCIDENTS, IN A TOTAL SAMPLE OF 10 RESIDENTS, WHEN RESIDENT #103'S BED ALARM MALFUNCTIONED, RESULTING IN RESIDENT #103 FALLING TO FLOOR SUSTAINING HEMATOMA TO BACK OF HEAD, PELVIC FRACTURES (PUBIC RAMUS) AND INCREASED PAIN. FINDINGS INCLUDE: REVIEW OF THE RECORD REVEALED A FACE SHEET DATED 12/04/12 THAT INDICATED RESIDENT #103 WAS A [AGE] year OLD FEMALE ORIGINALLY admitted to the facility on [DATE] WITH THE MOST RECENT REadmission date of [DATE]. THIS FACE SHEET ALSO INDICATED RESIDENT #103 HAD [DIAGNOSES REDACTED]. REVIEW OF THE RECORD REVEALED A NURSING CARE PLAN FOR FALL RISK INITIATED 08/23/12, THAT INTERVENTIONS TO ADDRESS RESIDENT #103'S FALL RISK INCLUDED USE OF A CHAIR/BED ELECTRONIC ALARM, LOW BED, AND FLOOR CUSHION MAT AND FOR NURSING STAFF TO ENSURE THE DEVICE IS IN PLACE AS NEEDED. REVIEW OF THE RECORD REVEALED A MINIMUM DATA SET (MDS) assessment dated [DATE] INDICATING THAT RESIDENT #103 REQUIRED EXTENSIVE ASSISTANCE FROM ONE PERSON FOR TRANSFERS, AND WALKING IN THE ROOM. REVIEW OF THE RECORD REVEALED physician's orders [REDACTED]. REVIEW OF THE RECORD REVEALED AN INCIDENT REPORT SIGNED 12/03/12 THAT INDICATED, ON 12/01/12 AT 7:10 AM, RESIDENT #103 WAS OBSERVED LYING ON FLOOR INSIDE HER ROOM IN A SUPINE POSITION, WITH A HEMATOMA TO BACK OF HER HEAD. THIS REPORT INDICATED RESIDENT #103 HAD COMPLAINTS OF PAIN TO LOWER BACK AND WAS TRANSFERRED TO AN OUTSIDE HOSPITAL. REVIEW OF THE RECORD REVEALED A QUALITY ASSURANCE INVESTIGATION REPORT DATED 12/01/12 THAT INDICATED RESIDENT #103 fell FROM A LOW BED DURING AN UNASSISTED TRANSFER AND STATED SHE WAS "GOING TO THE BATHROOM." THIS REPORT INDICATED RESIDENT #103 HAD A HISTORY FALLS, UNSTEADY GAIT, AND HAD A SENSOR ALARM SAFETY DEVICE ORDERED. THIS REPORT INDICATED RESIDENT #103'S ALARM DID NOT SOUND. THIS REPORT INDICATED THAT WHILE PERFORMING CARE FOR ANOTHER RESIDENT THE NEXT ROOM, CERTIFIED NURSING ASSISTANT (CNA) #6 HEARD A LOUD NOISE AND HEARD RESIDENT #103 CALLING FOR HELP. THIS REPORT INDICATED CNA #6 "RUSHED OVER" AND OBSERVED RESIDENT #103 ON FLOOR NEAR BATHROOM DOOR. THIS REPORT INDICATED LICENSED PRACTICAL NURSE (LPN) #8 HEARD CERTIFIED NURSE AIDE (CNA) #6 CALL FOR HELP AND WHEN ENTERING THE ROOM, LPN #8 OBSERVED RESIDENT #101 LYING ON FLOOR IN A SUPINE POSITION WITH A HEMATOMA TO BACK OF HER HEAD. RESIDENT #101 WAS COMPLAINING OF PAIN TO HER LOWER BACK. THIS REPORT INDICATED THAT CNA #7 ALSO HEARD CNA #6 CALL FOR HELP AND CAME TO THE ROOM OBSERVED RESIDENT #103 ON FLOOR NEAR BATHROOM DOOR WITH A "BUMP" TO BACK OF HEAD AND COMPLAINING OF PAIN "ON HER BUTTOCKS." REVIEW OF THE RECORD REVEALED PHYSICIANS ORDER DATED 12/01/12 THAT INDICATED RESIDENT #103 WAS TRANSFERRED TO AN OUTSIDE HOSPITAL FOR EVALUATION. REVIEW OF THE RECORD REVEALED A PATIENT TRANSFER FORM DATED 12/01/12 THAT INDICATED RESIDENT #103 WAS TRANSFERRED TO AN OUTSIDE HOSPITAL FOR FALL FROM LOW BED, COMPLAINT OF LOW BACK PAIN AND HEMATOMA TO OCCIPITAL REGION. REVIEW OF OUTSIDE HOSPITAL RECORDS REVEALED emergency room DOCUMENTATION DATED 12/01/12 AT 12:03 PM THAT INDICATED RESIDENT #103 REPORTED SHE SLIPPED ON FLOOR ON WAY TO BATHROOM AND fell AND HAS COMPLAINTS OF BACK AND HIP PAIN. REVIEW OF OUTSIDE HOSPITAL RECORDS REVEALED emergency room DOCUMENTATION DATED 12/01/12 AT 1:20 PM THAT INDICATED RESIDENT #103 HAD OBVIOUS HEMATOMA TO OCCIPUT AND GENERALIZED BACK TENDERNESS. REVIEW OF OUTSIDE HOSPITAL RECORDS REVEALED IMAGING AND DIAGNOSTIC RADIOLOGY REPORT DATED 12/02/12 AT 12:56 PM THAT INDICATED RESIDENT #103 HAD FRACTURE DEFORMITIES OF THE LEFT HEMIPELVIS WITH A FRACTURE THROUGH THE POSTERIOR MID SHAFT OF THE LEFT INFERIOR PUBIC RAMUS WITH SOME COMMINUTION AT THE FRACTURE SITE AND WITH A SMALL AMOUNT OF PERI-FRACTURE HEMATOMA. THIS REPORT ALSO SAID RESIDENT #103 HAD AN ADDITIONAL FRACTURE AT THE SYNCHONDROSIS OF THE LEFT PUBIC RAMUS WITH THE LEFT ISCHIUM WITH MILD HEMATOMA SEEN ADJACENT TO THIS FRACTURE DEFORMITY. REVIEW OF OUTSIDE HOSPITAL RECORDS REVEALED emergency room DOCUMENTATION DATED 12/02/12 AT 3:38 PM THAT INDICATED RESIDENT #103 HAD FRACTURE DEFORMITIES INVOLVING THE LEFT INFERIOR AND SUPERIOR PUBIC RAMI. REVIEW OF OUTSIDE HOSPITAL RECORDS REVEALED DISCHARGE SUMMARY DATED 12/03/12 THAT INDICATED RESIDENT #103 HAD PRINCIPAL [DIAGNOSES REDACTED]. DURING AN INTERVIEW WITH RESIDENT #103 ON 02/27/13 AT 11:15 AM, RESIDENT #103 SAID, IN REFERENCE TO HER FALL ON 12/01/12, SHE TRIED TO "GET UP AND WALK TO THE BATHROOM" AND "SLIPPED ON SOMETHING." RESIDENT #103 SAID SHE WAS IN A LOT OF PAIN AFTER THE FALL AND HAD TO GO TO THE HOSPITAL. RESIDENT #103 WAS UNABLE TO RECALL ANY OTHER INFORMATION REGARDING HER INJURIES. DURING AN INTERVIEW WITH CNA #7 ON 02/28/13 AT 9:20 AM, CNA #7 SAID THAT ON 12/01/12, SHE DID NOT WITNESS RESIDENT #103 FALL BUT HEARD CNA #6 CALL FOR HELP FROM RESIDENT #103'S ROOM. ACCORDING TO CNA #7, SHE OBSERVED RESIDENT #103 LYING ON HER BACK ON THE FLOOR IN HER ROOM NEAR BATHROOM DOOR AND HAD A "BUMP" ON BACK OF HER HEAD AND WAS COMPLAINING OF BUTTOCKS PAIN. CNA #7 SAID SHE DID NOT HEAR RESIDENT #103'S BED ALARM SOUNDING WHEN SHE ENTERED THE ROOM. CNA #7 SAID RESIDENT #103 HAD THE BED ALARM IN PLACE BECAUSE SHE had a history of [REDACTED]. CNA #7 SAID THE BED ALARM WAS PRESSURE SENSITIVE AND DESIGNED TO TRIGGER WHEN THE RESIDENT SHIFTED HER WEIGHT OR LIFTED OFF THE BED. DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) #8 ON 02/28/13 AT 9:45 AM, LPN #8 SAID ON 12/01/12 AT 7:10 AM SHE HEARD CNA #6 CALLING FOR HELP AND UPON ENTERING THE ROOM OBSERVED RESIDENT #103 LYING ON HER BACK ON FLOOR AT THE BATHROOM DOOR. LPN #8 SAID RESIDENT #103 HAD COMPLAINTS OF HEAD AND BACK PAIN. LPN #8 SAID RESIDENT #103'S BED ALARM WAS IN PLACE ON THE BED BUT WAS NOT SOUNDING. LPN #8 SAID THERE WAS NO EVIDENCE THE BED ALARM HAD BEEN MANIPULATED. LPN #8 SAID CNA #6 TOLD LPN #8 THAT RESIDENT #103'S BED ALARM WAS NOT SOUNDING WHEN CNA #6 ENTERED THE ROOM. DURING OBSERVATIONS OF RESIDENT #103'S ROOM ON 02/28/13 AT 10:15 AM, THE SURVEYOR MEASURED THE DISTANCE FROM THE MIDDLE OF RESIDENT #103'S BED TO BATHROOM DOOR TO BE APPROXIMATELY 7 FEET IN DISTANCE. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) (EMPLOYEE #2) ON 02/28/13 AT 10:45 AM, THE DON SAID SHE DID NOT KNOW WHY RESIDENT #103'S BED ALARM DID NOT TRIGGER WHEN RESIDENT #103 CHANGED SURFACES FROM BED TO FLOOR. THE DON SAID RESIDENT #103'S BED ALARM WAS DESIGNED TO TRIGGER WHEN THE RESIDENT STOOD UP. THE DON SAID CNA #6 WAS NOT AVAILABLE FOR INTERVIEW. DURING THE INVESTIGATION, MULTIPLE ATTEMPTS WERE MADE TO CONTACT CNA #6. PHONE MESSAGES LEFT BY THE SURVEYOR WERE UNRETURNED. REVIEW OF THE ALARM MANUFACTURER'S OWNER'S MANUAL (UNDATED) PROVIDED BY THE FACILITY REVEALED THAT "ALARMS/ALERTS ARE BATTERY-POWERED MONITORS THAT ALERT YOU WITH AN ALARM WHEN A RESIDENT ATTEMPTS TO LEAVE THEIR BED, CHAIR OR WHEELCHAIR." THIS MANUAL ALSO INDICATED "PRESSURE PAD ALARMS/ALERTS USE A PRESSURE SENSOR TO ALERT YOU WHEN A RESIDENT'S WEIGHT IS LIFTED FROM THE BED OR CHAIR PAD."

THIS CITATION PERTAINS TO INTAKE # MI 089. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS FOR 3 (#102, #103 AND #104) OF 4 SAMPLED RESIDENTS, ALL REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 4, RESULTING IN FALLS WITH INJURY. FINDINGS INCLUDE: RESIDENT #102: ACCORDING TO THE FACE SHEET DATED 3/15/2011, RESIDENT #102 WAS admitted to the facility on [DATE]. RESIDENT #102 HAD SEVERAL DIAGNOSES, WHICH INCLUDED HEART FAILURE, HIGH BLOOD PRESSURE AND A PERSISTENT MENTAL DISORDER. ACCORDING TO THE CARE PLAN DATED 3/13/2012, RESIDENT #102 WAS TO AMBULATE WITH CONTACT GUARD ASSISTANCE AS TOLERATED, AND SHOWED EVIDENCE OF MUSCLE WEAKNESS, AN UNSTEADY GAIT, BALANCE DEFICIT AND DECREASED RANGE OF MOTION. ACCORDING TO THE MONTHLY SUMMARY COMPLETED BY THE NURSING STAFF, DATED 6/7/2012, RESIDENT #102 REQUIRED LIGHT ASSISTANCE AND WAS A "1 PERSON ASSIST" FOR BED MOBILITY, TRANSFERS, AND AMBULATION. ACCORDING TO THE REHABILITATION SCREEN DATED 6/13/2012, RESIDENT #102 WAS REFERRED FOR A NEW ASSESSMENT BECAUSE OF A FUNCTIONAL DECLINE IN HER ACTIVITIES OF DAILY LIVING, AND SPECIFICALLY A DECLINE IN HER ABILITY TO SELF-TOILET. REVIEW OF A REHABILITATION SCREEN DATED 6/14/2012 REVEALED THAT RESIDENT #102 WAS SCREENED BY THE THERAPY DEPARTMENT AND IT WAS DETERMINED THAT RESIDENT #102 REQUIRED MINIMAL TO MODERATE ASSISTANCE WITH TOILETING AND TRANSFERS, CONTACT GUARD ASSISTANCE AND A ROLLING WALKER TO ENSURE HER GAIT WAS SAFE FOR AMBULATING. ACCORDING TO "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPIST ASSISTANTS," BY OLGA DREEBEN, PUBLISHED BY JONES & BARTLETT, 2006, MIN (MINIMAL) ASSISTANCE REQUIRES THE STAFF TO "CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 25 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM ACCIDENTS THAT ARE PROBABLE." MOD (MODERATE) ASSISTANCE REQUIRES THE STAFF TO "CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 50 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM ACCIDENTS THAT ARE PROBABLE." CONTACT GUARD ASSISTANCE REQUIRES THE STAFF TO CONTINUOUSLY GUIDE THE RESIDENT'S ACTIONS AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. DURING AN INTERVIEW ON 6/27/2012 AT 11:30 A.M., THE MANAGER OF THE FACILITY'S THERAPY DEPARTMENT (TM #1) SAID THAT RESIDENT #102 REQUIRED STAFF SUPERVISION AND ASSISTANCE TO BE SAFE. TM #1 SAID THAT RESIDENT #102 WAS NOT SAFE TO AMBULATE, TRANSFER OR TOILET INDEPENDENTLY. ACCORDING TO THE NURSE'S NOTES DATED 6/19/2012 AT 1:40 P.M., RESIDENT #102 WAS HEARD "...CALLING OUT FOR 'HELP'..." AND FACILITY STAFF FOUND HER "...SITTING ON BUTTOCKS AT SIDE OF TOILET (ON FLOOR) WITH BACK AGAINST BATHROOM WALL...LEGS STRETCHED OUTWARD WITH EXTERNAL ROTATION TO LLE (LEFT LOWER EXTREMITY)..." RESIDENT #102 COMPLAINED OF LEFT LEG PAIN AND WAS NOTED TO BE HAVING "...DRY HEAVES..." ACCORDING TO THE NURSE'S NOTES, THE "...LLE INNER ANKLE ASPECT OF BONE APPEARED RAISED...WITH EDEMA (SWELLING)..." AND A "...BROWN DISCOLORATION..." WAS NOTED AT HER ANKLE. ACCORDING TO THE NURSE'S NOTES, RESIDENT #102'S PHYSICIAN AND FAMILY WERE NOTIFIED AND RESIDENT #102 WAS TRANSFERRED BY EMERGENCY MEDICAL SERVICES TO A LOCAL AREA HOSPITAL AT 2:05 P.M. ACCORDING TO THE INCIDENT REPORT INVESTIGATION DATED 6/19/2012, RESIDENT #102 WAS NOT PROVIDED THE REQUIRED SUPERVISION AND ASSISTANCE WITH AMBULATION, TRANSFERS AND TOILETING AND WHILE ATTEMPTING TO RESPOND TO HER OWN TOILETING NEEDS, RESIDENT #102 fell TO THE FLOOR. ACCORDING TO THE HOSPITAL RECORDS SENT TO THE FACILITY WHEN RESIDENT #102 WAS readmitted , RESIDENT #102 SUSTAINED A "...BIMALLEOLAR FRACTURE (OF THE) LEFT ANKLE..." (BROKEN ANKLE) AND UNDERWENT AN "...OPEN REDUCTION AND INTERNAL FIXATION OF HER LEFT ANKLE..." (A METHOD OF SURGICALLY REPAIRING A BROKEN BONE) ON 6/20/2012. DURING AN INTERVIEW ON 6/27/2012 AT 11:49 A.M., THE FACILITY ADMINISTRATOR (ADM #1) REVIEWED RESIDENT #102'S CLINICAL RECORD AND SAID THE CARE PLAN DID NOT REFLECT THE RECOMMENDATIONS OF THE THERAPY DEPARTMENT. IN AN INTERVIEW ON 6/27/2012 AT 12:20 P.M., THE RESTORATIVE NURSE (REST #1) SAID THAT ACCORDING TO THE NURSING AND THERAPY ASSESSMENTS, RESIDENT #102 REQUIRED ASSISTANCE. REST #1 SAID THAT THE STAFF MEMBERS RESPONSIBLE FOR THE DIRECT CARE OF RESIDENT #102 ARE TO REFER TO THE "...ABC CARE PLAN..." POSTED IN THE RESIDENT'S ROOM FOR GUIDANCE IN CARING FOR HER. REST #1 REVIEWED RESIDENT #102'S CARE PLAN AND THE "...ABC CARE PLAN..." AND SAID THAT RESIDENT #102 WAS NOT RECEIVING ASSISTANCE WITH TOILETING, TRANSFERS OR AMBULATION BECAUSE THE CARE PLAN WAS NOT UPDATED WITH THE CORRECT INFORMATION. REST #1 SAID SHE DID NOT UPDATE THE CARE PLAN BECAUSE SHE DIDN'T KNOW ABOUT THE NURSING SUMMARY OR THERAPY'S RECOMMENDATIONS. DURING AN INTERVIEW ON 2/27/2012 AT 12:25 P.M., TM #1 SAID THAT WHEN THE THERAPY DEPARTMENT SCREENS A RESIDENT AND FIND A PROBLEM, RECOMMENDATIONS ARE MADE THAT SHOULD BE IMPLEMENTED TO ENSURE THE SAFETY OF THE RESIDENTS. TM #1 SAID, "...A BREAKDOWN IN COMMUNICATION OCCURRED..." USUALLY, THE RESTORATIVE NURSE WOULD BE COMMUNICATED WITH (DIRECTLY) AND THE CARE PLAN WOULD BE UPDATED. ON 2/27/2012 AT 12:33 P.M., ADM #1 SAID THE FACILITY'S "...PROCESS IS NOT WORKING..." AND THAT RESIDENT #102 "...DID NOT RECEIVE THE SUPERVISION NEEDED..." TO ENSURE HER SAFETY. ( ) RESIDENT #103: ACCORDING TO THE FACE SHEET DATED 3/13/2012, RESIDENT #103 WAS admitted to the facility on [DATE]. RESIDENT #103 HAD SEVERAL DIAGNOSES, WHICH INCLUDED HIGH BLOOD PRESSURE AND A DEMENTIA WITH BEHAVIORAL DISTURBANCES. ACCORDING TO THE CLINICAL RECORD, RESIDENT #103 WAS ASSESSED FOR HER INDIVIDUAL FALLS RISK AT THE TIME OF HER ADMISSION. RESIDENT #103'S UNDATED CARE PLAN IMPLEMENTED INTERVENTIONS TO REDUCE THE RISK OF FALLS INCLUDING A BED ALARM. ACCORDING TO THE NURSE'S NOTES DATED 5/20/2012 AT 6:26 A.M., RESIDENT #103 WAS FOUND "...SITTING ON (THE) FLOOR" IN HER ROOM WITH A 2.0 CM CUT ON THE BRIDGE OF HER NOSE AND A SMALL RED MARK ON HER LEFT MID BACK. ACCORDING TO THE NURSE'S NOTES, RESIDENT #103'S "...ALARM WAS UNHOOKED..." ACCORDING TO THE INCIDENT REPORT INVESTIGATION DATED 5/20/2012, WHEN RESIDENT #103 fell , HER BED ALARM WAS CHECKED AND WAS FOUND TO BE FUNCTIONAL, HOWEVER THE "...ALARM WAS UNHOOKED..." AND COULD NOT SERVE TO PROTECT RESIDENT #103. DURING AN INTERVIEW ON 6/28/2012, THE INFECTION CONTROL NURSE (RN #1) SAID THE FACILITY FAILED TO ENSURE RESIDENT #103'S SAFETY BY IMPLEMENTING SAFETY DEVICES PROPERLY. RN #1 SAID RESIDENT #103'S ALARM "...WAS ORDERED AND IT DIDN'T WORK...THAT'S OUR FAULT ..." ( ) RESIDENT #104: ACCORDING TO THE FACE SHEET DATED 6/21/2012, RESIDENT #104 WAS admitted to the facility on [DATE]. THE RESIDENT #104 HAD SEVERAL DIAGNOSES, WHICH INCLUDED URINARY TRACT INFECTION, MALAISE (A VAGUE FEELING OF DISCOMFORT) AND FATIGUE. ACCORDING TO THE MINIMUM (MDS) data set [DATE] RESIDENT #104 WAS ASSESSED AND WAS "...NOT STEADY, ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE..." RESIDENT #104 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS, AND WAS COMPLETELY DEPENDENT ON STAFF FOR LOCOMOTION AND TOILETING. ACCORDING TO THE CARE PLAN DATED 5/23/2012, RESIDENT #104 WAS TO TRANSFER WITH THE ASSISTANCE OF TWO STAFF MEMBERS. REVIEW OF A PHYSICAL THERAPY EVALUATION DATED 5/23/2012, REVEALED THAT RESIDENT #104 WAS EVALUATED BY THE THERAPY DEPARTMENT. THE THERAPY DEPARTMENT DETERMINED THAT RESIDENT #104 HAD POOR STANDING BALANCE AND REQUIRED MAXIMUM ASSISTANCE OF TWO STAFF MEMBERS WITH TOILETING AND TRANSFERS, AND REQUIRED MAXIMUM ASSISTANCE OF TWO STAFF MEMBERS TO ENSURE HER GAIT WAS SAFE FOR AMBULATING. ACCORDING TO THE PHYSICIAN'S NOTES DATED 5/25/2012 RESIDENT #104 WAS DISORIENTED AND "...AT HIGH RISK OF COMPLICATIONS INCLUDING...FALLS ..." ACCORDING TO THE ADMISSION assessment dated [DATE], RESIDENT #104 REQUIRED THE USE OF AN ALARM ON HIS WHEELCHAIR, AND HIS BED WAS TO REMAIN IN THE LOWEST POSITION. ACCORDING TO THE NURSE'S NOTES DATED 5/25/2012 AT 3:50 P.M., RESIDENT #104 STOOD UP ABRUPTLY AND fell TO THE FLOOR STRIKING HIS HEAD ON THE FLOOR. RESIDENT #104 WAS SENT TO THE LOCAL AREA HOSPITAL FOR EVALUATION AND RETURNED LATER THE SAME DAY WITH NO DEFINITIVE INJURIES. ACCORDING TO THE INCIDENT REPORT DATED 5/25/2012, THE ROOT CAUSE FOR RESIDENT #104'S FALL WAS DETERMINED TO BE THAT RESIDENT #104 WAS "...IMPULSIVE ... " AND "...CONFUSED..." ACCORDING TO THE INCIDENT REPORT, "...CORRECTIVE MEASURES FOR PREVENTION OF SIMILAR INCIDENT..." INCLUDED "...CLOSE SUPERVISION BY STAFF..." IN AN INTERVIEW ON 2/28/2012 AT 11:12 A.M., THE FACILITY ADMINISTRATOR (ADM #1) SAID CLOSE SUPERVISION MEANS THE RESIDENT SHOULD BE WITH STAFF AT ALL TIMES, EITHER AT A NURSING STATION, OR IN A SUPERVISED ACTIVITY OR IN A SUPERVISED THERAPY SESSION. ADM #1 SAID THAT WHEN THE RESIDENT WAS NOT DIRECTLY SUPERVISED, THE RESIDENT SHOULD BE IN BED WITH ALL CARE PLANNED SAFETY DEVICES IN PLACE. ACCORDING TO THE NURSE'S NOTES DATED 5/26/2012 AT 10:30 A.M., RESIDENT #104 WAS SITTING AT THE NURSE'S STATION WHEN HE "...UNCLIPPED (HIS) SAFETY ALARM..." STOOD UP, AND fell TO THE FLOOR. ON 6/28/2012 AT 12:02 P.M., ADM #1 REVIEWED RESIDENT #104'S CLINICAL RECORD AND WAS UNABLE TO PROVIDE EVIDENCE THAT RESIDENT #104 WAS BEING PROVIDED WITH CLOSE SUPERVISION BY FACILITY STAFF WHEN HE fell . ADM #1 WAS UNABLE TO EXPLAIN HOW RESIDENT #104 fell IF HE WAS UNDER CLOSE SUPERVISION OF STAFF ON 5/26/2012 AND SAID, "...I DON'T KNOW IF HE (#104) WAS (BEING) SUPERVISED..." ACCORDING TO THE NURSE'S NOTED DATED 6/3/2012 AT 11:00 A.M., RESIDENT #104 WAS "...CONSTANTLY REMOVING (HIS) LAP BUDDY AND ATTEMPTING TO AMBULATE WITHOUT ASSISTANCE..." ACCORDING TO THE NURSE'S NOTES DATED 6/3/2012, AT 12:15 P.M., RESIDENT #104 WAS IN THE DINING ROOM FOR LUNCH WHEN HE STOOD UP, BECAME UNBALANCED, STUMBLED BACKWARDS, LOST HIS BALANCE AND fell , BUT WAS CAUGHT BY A VISITOR. ON 6/28/2012 AT 12:02 P.M., ADM #1 REVIEWED RESIDENT #104 ' S CLINICAL RECORD AND WAS UNABLE TO PROVIDE EVIDENCE THAT RESIDENT #104 WAS BEING PROVIDED WITH CLOSE SUPERVISION BY FACILITY STAFF WHEN HE fell on [DATE]. ADM #1 SAID THAT ONCE IT IS DETERMINED THAT A RESIDENT REQUIRES CLOSE SUPERVISION, IT IS TO BE CONTINUED INDEFINITELY, BUT IN RESIDENT #104'S CASE, THERE WAS NO EVIDENCE THAT IT WAS IMPLEMENTED CORRECTLY OR CONTINUED. ADM #1 SAID THERE SHOULD HAVE BEEN SEVEN TO EIGHT STAFF MEMBERS PRESENT IN DINING ROOM AT 12:15 P.M. AND RESIDENT #104 REQUIRED PHYSICAL ASSISTANCE WITH EATING. ADM #1 SAID, "...STAFF WERE PROBABLY ASSISTING OTHER RESIDENTS..." BUT THERE WAS NO EVIDENCE STAFF WERE SUPERVISING RESIDENT #104. ADM #1 SAID THAT IF STAFF MEMBERS WERE PRESENT AND SUPERVISING AS THEY SHOULD HAVE BEEN, A VISITOR TO THE FACILITY WOULD NOT HAVE INTERVENED INSTEAD OF STAFF. ( ).

THIS CITATION PERTAINS TO INTAKE NUMBER MI 274 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ASSISTANCE AND SUPERVISION AND FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT FALLS FOR ONE (#501) RESIDENT, OF THREE RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL OF FOUR SAMPLED RESIDENTS, RESULTING IN RESIDENT #501 SUSTAINING A FALL WITH A HEAD INJURY. FINDINGS INCLUDE: RESIDENT #501 expired on [DATE] DUE TO ISSUES UNRELATED TO THIS CITATION. ACCORDING TO THE FACILITY'S "ADMISSION RECORD," RESIDENT #501 WAS A [AGE] year OLD FEMALE WHO WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #501'S "physician's orders [REDACTED].#501 HAD [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT #501 REQUIRED SUPERVISION, "OVERSIGHT, ENCOURAGEMENT OR CUEING" WITH BED MOBILITY, TRANSFERS, WALKING IN ROOM AND PERSONAL HYGIENE. THE MDS INDICATED THAT RESIDENT #501 NEEDED LIMITED TO EXTENSIVE ASSISTANCE WITH DRESSING, TOILETING AND BATHING. A REVIEW OF THE FACILITY'S "INCIDENT REPORT" REVEALED, "...DATE OF INCIDENT, [DATE] AT 10:30 P.M., PT (PATIENT) OBSERVED LAYING ON HER LEFT SIDE WITH LARGE AMOUNT OF BLOOD ON FLOOR WITH LACERATION TO TOP OF HER HEAD. CORRECTIVE MEASURES FOR PREVENTION OF SIMILAR INCIDENT/EDUCATION: CLIP ALARM/PRESSURE PAD REINSTATED..." A REVIEW OF THE FACILITY'S "QUALITY ASSURANCE INVESTIGATION" DOCUMENT REVEALED, "...FALL DURING AMBULATION, UNASSISTED. IMMEDIATE ACTION TAKEN: ICE TO HEAD WOUND, GAUZE TO WOUND, VITALS ATTEMPTED. TYPE OF INJURY: LACERATION, UNABLE TO FULLY ASSESS, HEAD LACERATION DEEP PROFUSE BLEEDING...RESIDENT (#501) WAS OBSERVED ON FLOOR, LEFT SIDE, UNABLE TO DESCRIBE, LOSS OF CONSCIOUSNESS, NOT SPEAKING MUCH, BUT MOANING...UNASSISTED TRANSFER, DID NOT USE CALL LIGHT, SLIPPERY FOOTWEAR ON." ACCORDING TO THE DOCUMENT, HISTORY OF FALLS WAS CHECKED "YES" ON ,[DATE]; DOES RESIDENT HAVE UNSTEADY GAIT WAS CHECKED "YES" INITIALLY, THEN CHANGED TO "NO." ACCORDING TO THE DOCUMENT, WAS A SAFETY DEVICE ORDERED WAS CHECKED, "NO. DISCONTINUED DUE TO RESIDENT OBJECTION [DATE]," SAFETY DEVICE IN PLACE WAS CHECKED "NO"; RESIDENT'S CONDITION PRIOR TO EVENT WAS DESCRIBED AS "ALERT, CONFUSED, BEHAVIORAL ISSUES, VISUAL CHANGES." RESIDENT [DIAGNOSES REDACTED]." CURRENT MEDICATIONS WERE NOTED AS "ANTIDEPRESSANTS, NARCOTICS, PSYCHOTROPICS..." A REVIEW OF THE HOSPITAL "TRAUMA ASSESSMENT" DATED [DATE] REVEALED "..XXX[AGE] year OLD FEMALE WITH A HEARD UNWITNESSED FALL AT NURSING HOME WHO HAS A PAST medical history of [REDACTED]. ACCORDING TO RADIOLOGIST, THE CT (COMPUTED TOMOGRAPHY) SCAN SHOWS AN ACUTE HEMORRHAGE ON LEFT GLOBE OF EYE. PATIENT ALSO EXPERIENCE A SCALP LACERATION UPON FALL WHICH WAS SUTURED IN THE ER (emergency room ). CT SCAN OF HEAD/NECK NEGATIVE. PATIENT DEMENTED AND EXAM LIMITED..." UPON REVIEW OF THE CLOSED CLINICAL RECORD, IT WAS REVEALED THAT RESIDENT #501 HAD A FALL ON [DATE] AND WAS "...CONFUSED WITH POOR SAFETY AWARENESS AND REFUSED ASSISTANCE AND WAS IMPULSIVE..." A REVIEW OF RESIDENT #501'S "FALL RISK ASSESSMENT" FOR [DATE] REVEALED A FALLS RISK SCORE OF "10". "...TOTAL SCORE OF 10 OR ABOVE REPRESENTS HIGH RISK..." RESIDENT #501'S "BED SAFETY ASSESSMENT" DATED [DATE], REVEALED THAT RESIDENT #501 had a history of [REDACTED]. ACCORDING TO THE ASSESSMENT DOCUMENT, "RESIDENT IS AMBULATORY WITH ASSIST, CAN GET OUT OF BED WITHOUT ASSISTANCE, COGNITIVE LEVEL: ALERT WITH CONFUSION..." THE BED SAFETY ASSESSMENT FURTHER INDICATED THAT RESIDENT #501'S "...FUNCTIONAL LEVEL OF RESIDENT: SBA (STAND BY ASSISTANCE) FOR SAFETY, BED MOBILITY: SBA FOR SAFETY. IS THE RESIDENT (#501) ABLE TO VOICE THEIR CHOICE ABOUT BED SAFETY INTERVENTIONS, "NO. IMPULSIVE." BED SAFETY RECOMMENDATIONS: SENSOR PAD ALARM, NON SKID MAT NEXT TO BED, ASSIST BAR X (TIMES) 2..." ON [DATE], DURING THE FACILITY'S QUARTERLY REVIEW, THE BED SAFETY ASSESSMENT NOTED, "...DISCONTINUE SENSOR PAD ALARM DUE TO REMOVES IT FREQUENTLY AND THROWS IT AWAY..." A physician's orders [REDACTED]. THERE WERE NO ADDITIONAL INTERVENTIONS ADDED AND NO ORDERS FOR ADDITIONAL MONITORING TO ENSURE SAFETY. UPON FURTHER RECORD REVIEW, THERE WERE NO SAFETY INTERVENTIONS IMPLEMENTED AFTER RESIDENT #501'S SENSOR PAD ALARMS WERE REMOVED, EVEN THOUGH RESIDENT #501 REMAINED AT HIGH RISK FOR FALLS. A REVIEW OF RESIDENT #501'S "ROUTINE MEDICATION" SHEET REVEALED THAT RESIDENT #501 HAD RECEIVED THE FOLLOWING MEDICATIONS ON [DATE], THE EVENING OF HER FALL: "...HYDROCODONE/APAP 7XXX,[DATE] ONE TABLET EVERY 4 HOURS AS NEEDED. (VICODIN, NARCOTIC PAIN MEDICATION, CAUSES IMPAIRED COGNITION, DROWSINESS) GIVEN AT 4:00 P.M..." "...HYDROCODONE/APAP 7XXX,[DATE] ONE TABLET BY MOUTH AT BEDTIME GIVEN AT 9:00 P.M...." "...ALPRAZOLAM (XANAX) 0.5 MG (FOR INSOMNIA AND ANXIETY. SEDATIVE, CAUSES DROWSINESS) ONE TABLET BY MOUTH AT BEDTIME GIVEN AT 9:00 P.M...." "...MIRTAZEPINE (REMERON) 15 MG ONE TAB BY MOUTH AT BEDTIME (FOR DEPRESSION, CAUSES IMPAIRED COGNITION, MOOD CHANGES)..." ON [DATE] AT 10:05 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) WAS ASKED WHAT INTERVENTIONS WERE IN PLACE PRIOR TO RESIDENT #501'S FALL ON [DATE], THE DON SAID, "...JUST REMINDERS..." WHEN ASKED IF RESIDENT #501 WAS IDENTIFIED AS A FALLS RISK, THE DON SAID, "YES, BUT THERE WERE NO OTHER INTERVENTIONS IN PLACE. SHE (#501) WAS STILL A "FALLS" RISK AFTER THE ALARMS WERE REMOVED AND SHE had a history of [REDACTED]. WHEN ASKED IF RESIDENT #501 HAD FALL MATS, THE DON SAID, "..SHE HAD NON SKID MATS.." WHEN ASKED IF THE FACILITY INITIATED EVERY 15 MINUTES CHECKS OR ANY OTHER INTERVENTIONS AFTER THE SENSOR ALARMS WERE DISCONTINUED IN ORDER TO ENSURE RESIDENT #501'S SAFETY, THE DON SAID, "...NO. BUT THAT'S A GOOD IDEA..." ON [DATE] AT 10:17 A.M., DURING AN INTERVIEW, CNA #3 (CERTIFIED NURSING ASSISTANT) REPORTED, "...SHE (#501) WASN'T REAL FRIENDLY. SHE ALWAYS WANTED ME TO LEAVE HER ALONE. SHE COULD GO FROM HER CHAIR TO THE TOILET. SHE COULD WALK WITH HR WALKER AND SHE WAS INDEPENDENT. SHE DIDN'T HAVE ANY ALARMS AND I DON'T RECALL HER HAVING ANY FLOOR MATS..." WHEN ASKED TO RECALL THE EVENTS OF RESIDENT #501'S FALL ON [DATE], CNA #3 REPORTED, "...I MADE MY ROUNDS AND THEN WAS SITTING AT THE DESK. IT WAS QUIET AND I HEARD "HELP! HELP!" I WALKED DOWN THE HALL AND WENT INTO HER (#501) ROOM AND SAW HER ON THE FLOOR. SHE HAD BLOOD FROM HER HEAD. I WENT AND GOT THE NURSE. HER (#501) HEAD WAS FACING THE FOOT OF THE BED..." WHEN ASKED TO REVIEW RESIDENT #501'S CNA CARE GUIDE IN ORDER TO DETERMINE IF SHE WAS TO BE AMBULATING INDEPENDENTLY AND WITHOUT STAFF ASSISTANCE, THE DON, WHO WAS PRESENT DURING THE INTERVIEW WITH CNA #3 REPORTED, "...THE CARE GUIDE SAYS STAND BY ASSIST..." ON [DATE] AT 11:35 A.M., THE RESTORATIVE NURSE, LPN #1 REPORTED, "...SHE (#501) WAS TO HAVE STAND BY ASSISTANCE AND HER ROLLING WALKER BECAUSE SHE HAD AN OCCASIONAL LOSS OF BALANCE. SHE HAD THE SAME STATUS BEFORE HER FALL AND SHOULD NOT HAVE BEEN AMBULATING ALONE..." WHEN ASKED WHO MADE THE DECISION TO DISCONTINUE RESIDENT #501'S ALARMS, LPN #1 SAID, "...I DID, BECAUSE I FELT THE ALARMS CAUSED HER MORE ANXIETY AND SHE WAS AT GREATER RISK FOR FALLS..." WHEN ASKED IF RESIDENT #501 REMAINED A FALL RISK, LPN #1 SAID, "YES." WHEN ASKED WHAT OTHER INTERVENTIONS OR MONITORING MEASURES WERE IMPLEMENTED TO ENSURE RESIDENT #501'S SAFETY, LPN #1 SAID, "NONE." THE FACILITY ADMINISTRATIVE STAFF WAS UNABLE TO EXPLAIN WHY RESIDENT #501 WAS ALLOWED TO AMBULATE INDEPENDENTLY WITHOUT STAFF ASSISTANCE. FURTHER, THE FACILITY STAFF COULD NOT EXPLAIN WHY NO OTHER INTERVENTIONS OR MONITORING TOOLS WERE IMPLEMENTED TO PREVENT FALLS AND ENSURE RESIDENT #501'S SAFETY. A REVIEW OF THE FACILITY'S "FALLS MANAGEMENT" POLICY REVISED [DATE] REVEALED: "...PURPOSE: TO IDENTIFY EACH RESIDENT AT RISK FOR ACCIDENTS AND/OR FALLS. TO IMPLEMENT CARE PLANS TO PREVENT INCIDENTS. TO EDUCATE STAFF IN WAYS TO PREVENT FALLS. TO ASSURE EFFECTIVE MONITORING OF FALLS INTERVENTIONS..."

THIS CITATION PERTAINS TO INTAKE # MI 664 BASED ON INTERVIEWS AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THAT 1 OF 4 SAMPLED RESIDENTS (#104) REVIEWED FOR PRESSURE ULCER TREATMENT FROM A TOTAL SAMPLE OF 8, RECEIVED PRESSURE ULCER DRESSING CHANGES AS PRESCRIBED BY THE PHYSICIAN, RESULTING IN INFECTION AND THE WORSENING OF THE WOUND. FINDINGS: RESIDENT #104 ACCORDING TO THE FACE SHEET DATED 6/24/2011, RESIDENT #104 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 5/7/2011. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #104 HAD SEVERELY IMPAIRED DECISION MAKING SKILLS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. RESIDENT #104 DID NOT WALK AND REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE EXTENSIVE ASSISTANCE WITH BED MOBILITY, TRANSFERS, DRESSING, TOILETING AND BATHING. STAFF ASSESSED RESIDENT #104 TO BE AT RISK FOR PRESSURE ULCERS AND DOCUMENTED THAT AN UNRESOLVED STAGE 3 (FULL THICKNESS TISSUE LOSS) PRESSURE ULCER WAS PRESENT. THE FACILITY DOCUMENTED RESIDENT #104 REQUIRED ULCER TREATMENTS THAT INCLUDED MEDICATION AND NONSURGICAL DRESSINGS. ACCORDING TO THE ADMISSION NURSING ASSESSMENT COMPLETED ON 5/07/2011, RESIDENT #104 HAD A STAGE TWO PRESSURE ULCER ON HER UPPER BACK AT THE TIME OF HER ADMISSION. THE BRADEN SCALE ASSESSMENT COMPLETED ON 5/7/2011 IDENTIFIED RESIDENT #104 AT RISK FOR PRESSURE ULCERS. A CARE PLAN DATED 5/07/2011 IDENTIFIED RESIDENT #104 AT RISK FOR SKIN BREAKDOWN DUE TO IMMOBILITY, POOR APPETITE, HISTORY OF PRESSURE ULCERS, HISTORY OF SKIN TEARS, HISTORY OF BRUISING AND HISTORY OF RECENT HIP SURGERY. A CARE PLAN DATED 5/09/2011 IDENTIFIED THAT RESIDENT #104 HAD A STAGE THREE PRESSURE ULCER ON HER LEFT UPPER BACK. THE FACILITY STAFF WERE REQUIRED BY EACH OF THESE CARE PLANS TO COMPLETE PHYSICIAN ORDERED TREATMENTS TO PREVENT INFECTIONS AND/OR ANY ADDITIONAL TISSUE BREAKDOWN. PHYSICIAN ORDERS [REDACTED].#104 HAD ON HER LEFT UPPER BACK WITH NORMAL SALINE AND APPLY ALLERYN EVERY FIVE DAYS. STAFF COULD DO THIS DRESSING CHANGE MORE OFTEN IF NEEDED. ACCORDING TO THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. FOR THE NEXT 7 DAYS, 5/17/11 THROUGH 5/22/11, STAFF FAILED TO COMPLETE THE ORDERED DRESSING CHANGE NECESSARY TO TREAT THIS PRESSURE ULCER. ON 5/23/2011, STAFF DID COMPLETE THE DRESSING CHANGE AS ORDERED. STAFF THEN FAILED FOR THE NEXT SIX DAYS TO COMPLETE THE ORDERED DRESSING CHANGE NECESSARY FOR THIS PRESSURE ULCER. THE NURSE PRACTITIONER ' S PROGRESS NOTES DATED 6/02/2011 IDENTIFIED RESIDENT #104 WAS ASSESSED AND HAD "A DECUBITUS ULCER APPROXIMATELY TWO INCHES ACROSS WITH DRAINAGE, WHICH WAS SLIGHTLY FOUL SMELLING, PURULENT WITH POSITIVE ESCHAR..." A WOUND CONSULT WAS ORDERED. NURSING NOTES DATED 6/03/2011 REVEALED RESIDENT #104 HAD A MODERATE AMOUNT OF PURULENT DRAINAGE "SEEPING THRU (HER) DRESSING ON (HER) BACK." NURSING NOTES DOCUMENTED THAT THE "WOUND CENTER (WAS) YELLOW SLOUGH WITH REDNESS SURROUNDING (THE) WOUND AREA..." ON 6/03/2011 A PHYSICIAN ORDERED STAFF TO OBTAIN A LABORATORY CULTURE FROM THE WOUND RESIDENT #104 HAD ON HER BACK. THE WOUND CULTURE OBTAINED FROM THE PRESSURE ULCER ON RESIDENT #104'S BACK WAS SENT TO A LABORATORY ON 6/03/2011 FOR TESTING. ON 6/10/2011 AT 4:16 P.M., THE LABORATORY INFORMED THE FACILITY OF THE CULTURE RESULTS FOR RESIDENT #104 VIA FACSIMILE. THE CULTURE REPORT DOCUMENTED THE "RECOVERY OF ABUNDANT AMOUNTS OF STAPHYLOCOCCUS AUREUS" WITH A LIST OF ANTIBIOTICS USEFUL IN THE treatment of [REDACTED]. ON 11/03/2011 AT 11:00 A.M., THE WOUND CARE LICENSED PRACTICAL NURSE (WCN#1) SAID BETWEEN 5/16/2011 AND 5/31/2011 SHE ONLY CHANGED RESIDENT #104'S DRESSING THREE TIMES. SHE SAID SHE COMPLETED DRESSING CHANGES ON 5/16/2011, THEN SEVEN DAYS LATER ON 5/23/2011 AND EIGHT DAYS LATER ON 5/31/2011. ON 11/02/2011 AT 1:30 P.M., THE DIRECTOR OF NURSING REVIEWED RESIDENT #104'S MEDICAL RECORD AND SAID THE CIRCLED STAFF INITIALS ON 5/19/2011, 5/24/2011 AND 5/20/2011 IN THE TREATMENT ADMINISTRATION RECORD, MEANT STAFF DID NOT COMPLETE THE ORDERED DRESSING CHANGES ON THOSE DAYS. SHE REVIEWED THE MEDICAL RECORD FOR DOCUMENTED EVIDENCE THAT STAFF COMPLETED THE DRESSING CHANGES AS ORDERED, EVERY FIVE DAYS, BETWEEN 9/15/2011 AND 9/31/2011. SHE THEN SAID BETWEEN 5/16/2011 AND 5/23/2011 STAFF PERMITTED SEVEN DAYS TO ELAPSE BEFORE THE DRESSING WAS DRESSING WAS CHANGED AND BETWEEN 5/23/2011 AND 5/31/2011 STAFF PERMITTED EIGHT DAYS TO ELAPSE BEFORE THE DRESSING WAS CHANGED. THE DIRECTOR OF NURSING FAILED TO EXPLAIN HOW THESE ACTIONS TAKEN BY THE FACILITY ENSURED RESIDENT #104 RECEIVED THE NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING AND PREVENT INFECTION FOR THE PRESSURE ULCER ON HER BACK. THE DIRECTOR OF NURSING WAS THEN INFORMED OF THE DOCUMENTED INFECTIOUS SYMPTOMS AND THE POSITIVE WOUND CULTURE RESULTS FOR RESIDENT #104 AND SAID, "OH GREAT."

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, MONITOR AND PROVIDE PAIN MEDICATIONS FOR TWO ( #'S 501 AND 505) OF SEVEN RESIDENTS FROM A TOTAL OF 24 SAMPLED RESIDENTS, RESULTING IN RESIDENT COMPLAINTS OF PAIN IGNORED DURING SKIN TEAR TREATMENT AND PERSONAL CARE. FINDINGS INCLUDE: ON 9/08/11 AT 10:30 A.M., A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED FOR RESIDENT #501, WITH TREATMENT/WOUND CARE NURSE (A). AT THE BEGINNING OF THE SKIN TEAR TREATMENT, RESIDENT #501 ASKED TREATMENT NURSE (A) TO, "...PLEASE BE CAREFUL..." TREATMENT NURSE (A) REMOVED THE (LOOSE) KERLIX DRESSING FROM AROUND THE LEFT UPPER ARM AND GRABBED THE SANTYL DRESSING BY THE UPPER LEFT CORNER AND BEGAN TO RIP OFF THE DRESSING. IT WAS OBSERVED THAT THE DRESSING HAD ADHERED/ATTACHED TO RESIDENT #501'S UPPER ARM TISSUE. THE SKIN WAS PULLED AS THE TREATMENT NURSE RIPPED AT THE DRESSING. RESIDENT #501 BEGAN CRYING, "... THAT HURTS... PLEASE BE CAREFUL... IT'S (THE DRESSING) STUCK TO MY SKIN...YOU'RE PULLING MY SKIN...OH, PLEASE BE CAREFUL... PLEASE GO SLOW... OH, PLEASE SOAK IT... (THE DRESSING) WITH WATER... IT WILL COME OFF EASY IF YOU JUST SOAK IT...THAT'S WHAT THEY (THE OTHER NURSES) DO... PLEASE STOP..! THE TREATMENT NURSE DISREGARDED RESIDENT #501'S CRIES AND PLEAS TO STOP RIPPING OFF THE DRESSING AND TO SOAK IT WITH WATER SO THAT THE DRESSING COULD BE RELEASED FROM RESIDENT #501'S TISSUE AND EASILY REMOVED. THE TREATMENT NURSE CONTINUED TO PULL OFF THE DRESSING. NEW GRANULATION TISSUE WAS OBSERVED ATTACHED TO THE DRESSING AS IT WAS REMOVED. TREATMENT NURSE (A) WAS ASKED "WHY" SHE IGNORED AND DISREGARDED RESIDENT #501'S PLEAS AND CRIES TO "STOP"-- RESIDENT #501 WAS VISIBLY IN PAIN. TREATMENT NURSE (A) STOPPED REMOVING THE DRESSING AND REPLIED, "THE DRESSING WAS NOT SUPPOSE TO STICK TO THE SKIN". A LARGE SKIN TEAR WAS OBSERVED ON RESIDENT #501'S UPPER ARM THAT MEASURED APPROXIMATELY 4 CENTIMETER (CM) BY 5 CM. THE DERMIS WAS ABSENT, LEAVING TISSUE VISIBLY EXPOSED, REDDENED AND INFLAMED. ACCORDING TO THE CURRENT CLINICAL RECORD AND ADMISSION FACE SHEET RECORD, RESIDENT #501 WAS admitted TO THE FACILITY FROM A LOCAL hospital on [DATE] FOR REHABILITATION. RESIDENT #501 HAD [DIAGNOSES REDACTED]. THE HOSPITAL RECORD REVEALED THE RESIDENT WAS BROUGHT TO THE EMERGENCY DEPARTMENT SECONDARY TO GENERALIZED WEAKNESS AND RECENT FALL. THE HOSPITAL RECORD INDICATED RESIDENT #501 PRESENTED TO THE HOSPITAL WITH A CATEGORY I (PAYNE MARTIN CLASSIFICATION SYSTEM) SKIN TEAR TO THE LEFT WRIST, AND A "U" SHAPED LINEAR SKIN TEAR THAT MEASURED 12 CM IN LENGTH WITH SMALL SEROSANGUINOUS DRAINAGE, AND SLIGHT PERI-WOUND [DIAGNOSES REDACTED]. ON THE LEFT ARM, THERE WAS A CATEGORY III SKIN TEAR (PAYNE MARTIN CLASSIFICATION SYSTEM), THAT MEASURED 7 CM X 12 CM, WITH PARTIAL THICKNESS WOUND WITH COMPLETE [MEDICATION NAME] FLAP LOSS, A RED BASE, AND SMALL SEROSANGUINOUS DRAINAGE, SLIGHT [DIAGNOSES REDACTED]. (CATEGORY I- SKIN TEAR WITHOUT TISSUE LOSS, CATEGORY III-SKIN TEAR WITH COMPLETE TISSUE LOSS). THE FACILITY'S NURSING ADMISSION ASSESSMENT AND PLANS OF CARE, DATED 9/06/11, INDICATED RESIDENT #501 WAS ALERT AND ORIENTED TO PERSON, PLACE AND TIME. THE NURSING ADMISSION ASSESSMENT INDICATED RESIDENT #501 HAD SKIN TEARS ON HER LEFT WRIST AND UPPER ARM, AND THAT RESIDENT #501 HAD VERY THIN SKIN ALL OVER HER BODY. THE PAIN assessment dated [DATE] INDICATED RESIDENT #501 EXPERIENCED PAIN WHEN TREATMENT WAS PROVIDED TO THE LEFT UPPER ARM AND LEFT WRIST. THE PAIN WAS CAUSED BY TACTILE STIMULATION. PHYSICIAN ORDERS [REDACTED]. (2). [MEDICATION NAME] 100 MG BY MOUTH EVERY FIVE HOURS AS NEEDED FOR PAIN AND TYLENOL 325 MG ONE TAB EVERY FOUR HOURS AS NEEDED FOR PAIN." PRIOR TO THE TREATMENT AND DRESSING CHANGE, TREATMENT NURSE (A) FAILED TO ASSESS RESIDENT #501 FOR PAIN AND OFFER PAIN MEDICATION PRIOR TO THE DRESSING CHANGE. ON 9/08/11 AT 10:40 A.M., AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING AND RESIDENT #501. RESIDENT #501 EXPLAINED HOW TREATMENT NURSE (A) HAD DISREGARDED HER PLEAS AND CRIES TO STOP THE DRESSING CHANGE; AND, AS A RESULT, INFLICTED UNNECESSARY PAIN TO RESIDENT' #501'S UPPER LEFT ARM WHEN THE DRESSING WAS RIPPED AND PULLED. RESIDENT #501 STATED: "IT WAS AWFUL...IT DIDN'T HAVE TO BE DONE THAT WAY... I AM ALMOST [AGE] years OLD...I DESERVE SOMETHING...I DON'T DESERVE TO BE TREATED THAT WAY... I ASKED HER (TREATMENT NURSE (A) TO PLEASE STOP AND SHE DIDN'T LISTEN..." THE DIRECTOR OF NURSING REPORTED TREATMENT NURSE (A) SHOULD HAVE STOPPED THE DRESSING CHANGE AND LISTENED TO RESIDENT#501. THE TREATMENT NURSE SHOULD HAVE ASSESSED FOR PAIN AND ALTERED HER TECHNIQUE OF REMOVING THE DRESSING. THE ALTERATION IN SKIN INTEGRITY PLAN OF CARE FOR RESIDENT #501, DATED 9/06/11, INTERVENTIONS INCLUDED, QUESTION RESIDENT ABOUT PAIN AT THE SITE. HOWEVER, THE PLAN OF CARE DID NOT PROVIDE ANY PAIN RELIEF INTERVENTIONS. REVIEW OF THE FACILITY'S PAIN MANAGEMENT POLICY AND PROCEDURE, DATED 3/01/07 DIRECTED STAFF TO "PROVIDE TIMELY PAIN MEDICATION ADMINISTRATION FOR ALL RESIDENTS EXPERIENCING ACUTE OR CHRONIC PAIN..." ( ) ACCORDING TO THE FACE SHEET, RESIDENT #505 WAS diagnosed with [REDACTED]. THE RESIDENT WAS RECEIVING HOSPICE CARE. ON 9/7/11 AT 11:00 A.M., RESIDENT #505 WAS OBSERVED RECEIVING A BED BATH BY STAFF MEMBERS (B) AND (C). RESIDENT #505 STATED SHE WAS IN PAIN. STAFF (B), STATED, "I WILL LET THE NURSE KNOW." ON 9/8/11 AT 10:00 A.M., THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. AND SCHEDULED [MEDICATION NAME] FOR PAIN AT 1:45 P.M. THERE WAS an order for [REDACTED]. THERE WAS NO EVIDENCE THE RESIDENT WAS ASSESSED FOR PAIN AND GIVEN MEDICATION, IF NEEDED, NEAR THE TIME SHE WAS RECEIVING A BED BATH AT 11:00 A.M. ON 9/8/11 AT 11:20 A.M., STAFF (B) WAS INTERVIEWED AND STATED SHE TOLD THE MEDICATION NURSE YESTERDAY, DURING RESIDENT #505'S BED BATH, THAT RESIDENT #505 VOICED SHE WAS IN PAIN. THE MEDICATION NURSE, STAFF (D), WAS INTERVIEWED ON 9/08/11 AT 11:30 A.M. AND REPORTED STAFF (B) DID NOT INFORM HER THAT RESIDENT #505 VERBALIZED PAIN DURING HER BED BATH ON 9/07/11. ( / )