Every finding on record at Medilodge of Southfield

This citation pertains to Intake Number(s): 2974196 and 2794550.Based on observation, interview and record review, the facility failed to protect the residents right to be free from physical abuse by staff and residents for four (R801, R805, R809, and R810) out of six reviewed for abuse resulting in R808 punching R801 in the jaw causing fear, pain and discoloration, attempting to choke R809, and hitting R810 in the face; and a staff member pushing R805 causing a fall.Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed the following allegation: Physical contact made from (R808) to (R801) . On 5/20/26 at 2:20 PM, an interview was conducted with R801. When queried about any physical altercations with other residents, R801 reported she was hit in the face by another resident a couple months ago. R801 reported she was walking around on the unit when a guy who was seated in a wheelchair, stood up and came behind her and hit her in the jaw. R801 closed her fist and made a punching motion to demonstrate how she was hit by the other resident. R801 stated, It hurt so much! It was sore for a while! R801 further reported she cried because it hurt and yelled for help and the other male residents in the area were yelling to call the cops to get that man out of here. R801 said she was very scared, did not understand why the other resident hit her, and that she was glad he was not in the facility any longer. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] with diagnoses that included: metabolic encephalopathy and dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] and 3/30/26 revealed R801 had severely impaired cognition and no behaviors. A review of a Nurses' Notes for R801 revealed, At about 7:50AM writer was notified that Resident received physical contact on her face by (R808). Witnessed by Housekeeper .Resident assessed, was crying in pain, holding her left jaw, site noted with discoloration . A review of an Investigation Summary submitted to the SA by the facility revealed the following: On 2/12/26, a housekeeping staff person witnessed .(R808), make physical contact with his closed hand to the left lower jaw of .(R801) .(R801) had some discoloration to the left jaw and complaints of pain at the time of the incident .(R801) was interviewed. She stated she was just saying hello or good morning and the other resident hit her .(R808) was petitioned out for a psychiatric evaluation .(R808) is assigned a 1:1 caregiver for supervision. The resident is being monitored for behaviors related to agitation and hitting others . A review of R808's clinical record revealed R808 was admitted into the facility on 5/23/24 and discharged on 3/15/26 with diagnoses that included: seizures and dementia. A review of a MDS assessment dated [DATE] and 3/1/26 revealed R808 had severely impaired cognition. A review of a Nurses' Notes for R808 dated 2/12/26 revealed, Resident was reported to have been physically aggressive by making contact with (R801) face .Resident was petitioned to (hospital) at about 10:am via two police officers . Further review of R808's progress notes revealed the following: On 1/23/26, the following was documented in a Nurses' Notes, Was reported to writer that Resident made contact with the palm of his hand on (R810) face by his doorway . On 2/4/26, the following was documented, Resident spent most of his day sitting guarding his doorway, to prevent other Residents from wandering into his room and sometimes roommates . On 2/8/26, the following was documented, Resident continue to guard his doorway compulsively. Gets up immediately to stop any peer attempting to go in. Only gets away from doorway for bathroom, meals, and some times wheels towards the dining room and returns right away to the door . On 3/2/26, it was documented that Resident charged toward CNA (Certified Nursing Assistant) threaten to beat his behind, called him derogatory, inappropriate names. CNA was moved off of the current assignment (1 on 1) with resident, new CNA assigned . On 3/6/26, it was documented that Resident agitated, attempted to be physical with assigned 1:1 CNA. Told CNA to stay away from him. CNA sitter was switched, staff educated to keep a safe reasonable distance while redirecting resident . On 3/12/26, it was documented that Writer was notified by 1:1 monitor that she was sitting on the right side of resident in hallway. Another Resident walked into this resident's room. Both the resident (R808) and the aide stood up. While she was standing next to the resident, she attempted to redirect the other resident to leave this resident's room. As the other resident was walking out of the room, this resident made contact with the other residents neck with both of his hands .Administrator was notified . On 3/15/26, it was documented that Writer received phone call while at home, that the resident slapped his Nurse in the face causing injury .Writer observed the Nurse with red welts and scratches to the right side of her face. The Nurse complained of a headache and being dizzy. Due to pain and bleeding to the nose and face, the Nurse was sent to the hospital for treatment . It was documented in a progress note that R808 was transferred to the hospital on 3/15/26 and then to another facility when discharged from the hospital. On 5/20/26 at 1:14 PM, an interview was conducted with Acting Administrator 'M', Regional Director 'N', and Regional Nurse 'O' in regard to the above physical altercations by R808 toward R801, R809, and R810. Regional Director 'N' reported that she did not think the physical contact made by R808 was abuse because it had to be willful. When queried about whether R808 making contact with R809's neck with both hands, making contact with the palm of his hand to R810's face as a reaction to the other resident's entering or attempting to enter his room and whether that was considered willful, a response was not offered. A review of a Petition for Mental Health Treatment dated 2/12/26, revealed R808 was petitioned to the hospital as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or unintentionally seriously physically injury self or others, and has engaged in an act or acts or made significant threats that are substantially supportive of this expectation. It was documented that R808 punched female resident in the face after she told him 'Good Morning' . On 5/20/26 at 3:30 PM, an interview was conducted with CNA 'K' (the staff member that witnessed the physical altercation between R808 and R809 on 3/12/26). When queried about what happened, CNA 'K' reported they were assigned to provide 1:1 supervision to R808 that day. CNA 'K' reported she was unaware why R808 was on 1:1 supervision and later found out there was a binder that they were supposed to document in, and it contained information about the resident. CNA 'K' explained while seated with R808 outside of his room, R809 wandered into R808's room. CNA 'K' stood up to redirect R809 from R808's room and R808 also stood up and put his (R808) hands around his (R809) neck and attempted to choke him. CNA 'K' reported R808 did not like other residents going into his room or near it. On 5/20/26 at 3:43 PM, an interview was conducted with Licensed Practical Nurse (LPN) 'L' (the staff member that witnessed the physical altercation between R808 and R810 on 1/23/26). When queried about what happened, LPN 'L' reported it happened quickly and R810 was wandering the unit as she typically did and out of nowhere R808 walked up to her and hit her in the face. LPN 'L' said it was unprovoked and said R808 used the palm of his hand to hit R810 on the side of the face. LPN 'L' reported it was not with major force but was an act of aggression. A review of an incident report for R808 dated 1/23/26 revealed LPN 'L' reported R810 was attempting to enter another resident's room (R808) and the resident assigned to that room (R808) made contact with palm of his hand to the resident. R805 A FRI (Facility Reported Incident) was reported to the State Agency (SA) detailing a physical incident that occurred between R805 and Certified Nursing Assistant (CNA) G on 3/10/26. A review of R805's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: bipolar disorder, schizophrenia, Parkinson's disease and dementia. The resident had a Brief Interview for Mental Status (BIMS) score of 4/15 (severely cognitively impaired), had been deemed incompetent and had a court appointed Legal Guardian for both medical and financial needs. The resident's Care Plan noted, in part, the following: Focus: Resident has behaviors related to dementia, bipolar disease, schizophrenia.as evidenced by verbal aggression towards staff.she has periods of manic behavior and can be impulsive(initiated 10/24/23).Interventions:.approach resident in a calm manner to avoid frustration and behavior escalation: if resident becomes agitated and show signs of escalation, re-approach later (10/24/23). A review of the facility's Incident/Accident (IA) report and accompanying documents noted the following: Alleged Abuse: Date 3/10/2026 5:00 PM.Resident: R805.Location: Activity Room .Person Preparing Report: Nurse J.Incident Description: Writer (Nurse J) had heard Staff and Resident behind her. Staff tell the resident stand back, stop. Writer was faced forward, when writer turned around Resident was on the floor behind me, writer initially assumed, Resident.slipped to the floor. Writer was educated that the staff and resident had contact, that's how resident landed on the floor.Resident unable to give Description. .Summary of Events: On Tuesday, March 10, 2026, at 3:55 PM, nurse (herein after Nurse J) notified the Administrator of a suspected incident. The nurse reported that she had her back turned to (R805) and the CNA (G), when (R805) fell but that from her peripheral vision she thought the CNA put her arm out and touched the resident, causing the fall.The CNA was called to the Administrator's office. (CNA G) reported that she was re-directing the resident, (R805) away from the double doors that exit the unit. She states the resident was aggressive, striking the CNA in the face. The CNA states she attempted to walk away from the resident and was at the sink outside of the dining room washing her hands. The resident was behind the CNA, hitting her and yelling out. The CNA reported that she turned around with her left arm out in attempt to stop the resident from hitting her, she made physical contact at the shoulder area of the resident and the resident fell down.two staff members who were working on 2-North and witnessed the event came to the Administrator's office to report what they witnessed.CNA (H) was assigned to room [ROOM NUMBER] and was outside of the door. The door to room [ROOM NUMBER] is in the small hall outside of the dining room and near the sink where (CNA G) was washing her hands. (CNA H) stated she heard (CNA G) state, She hit me in my face followed by something that sounded like If she hits me again, I'm going to slap her.CNA H observed (R805), hitting (CNA G). CNA H observed CNA G turn around and make <sic> physical contact with one hand to the resident, (R805) fell down.The Activity Aide (Staff I), was coming out of the bathroom, across the hall from the area of the sink and entrance to the dining room. She observed (CNA G) holding he resident (R805) by the hands.(CNA G) let go of (R805's) hands and went to the sink .(Staff I) states she heard (CNA G) say something that sounds like I'm going to hit her back. R805 was hitting (CNA G) from behind while (CNA G) was washing her hands. (Staff I )observed (R805) turn around and put one hand on (R805), pushing her away and she fell and got back up.The facility suspended (CNA 'G) immediately pending investigation .Based on the investigation and statements provided.the facility believes that the allegation of physical abuse is inconclusive. However, the CNA will be terminated as an outcome of five-day investigation for failing to adhere to our standard of care in the manner in which she handled the situation with the resident. A Performance Improvement form was included in the IA packet and read, in part: .Employee name: [CNA G].Today's Date: 3/10/26.Reason for Counseling/Corrective Action: Staff reported that (CNA G) pushed a resident.[CNA G] was suspended pending investigation.Corrective Action Plan: BLANK.Time Frame for Improvement: BLANK.Employee Comments: BLANK. On 5/20/26 at approximately 11:28 AM, an interview was conducted with CNA H. CNA H reported that they had been employed by the facility for approximately seven years, first as an activity assistant and then a CNA. CNA H reported that they generally work the day shift on the memory care locked unit on 2 North where R805 resides. CNA H was asked about the incident involving R805 and CNA G on 3/10/26. CNA H reported that they were very familiar with R805 and noted at times she can be combative but easily redirected. With respect to the incident on 3/10/26 they were assigned to provide 1:1 care for another resident and observed R805, trying to push on the locked doors and observed R805 hitting CNA G. CNA G then moved to the sink located on the side of the activity room, not far from the locked doors as R805 hit her on her nose and she had a nose ring. As CNA G was washing herself at the sink, R805 was behind her and she heard CNA G saying that if she hits her again, she was going to hit/slap her back. CNA H noted that R805 did push on CNA G and then CNA G then turned around and using both hands on her shoulders and shoved her and R805 fell to the floor. CNA H said was a terrible event and was very upset that CNA G shoved the resident and they reported the incident to the Administrator. CNA H further reported that while the resident at times can be aggressive, they can be redirected and there was no need to treat the resident like that. On 5/20/26 at approximately 11:57 AM, an interview was conducted with Staff I. Staff I reported that they had been employed by the facility for over a year as an activity aide and generally worked with residents on the locked memory unit. When asked about the 3/10/26 incident involving R805 and CNA G, Staff I reported that they were exiting out of the bathroom near the double doors and CNA G had her hands on the resident's arms. CNA G then let go of the resident's hands and let R805 go. CNA G then moved to the sink area and was trying to wipe off her nose and said if the resident tried to hit her again, she was going to knock her out. R805 then hit CNA G from behind as she was at the shower and CNA G turned around and pushed her away and the resident fell to the floor. On 5/20/26 at approximately 1:05 PM, a phone interview was conducted with CNA G. CNA G reported that they were suspended and then terminated from the facility following the incident with R805 and did not provide the termination details. On 5/20/26 at approximately 1:46 PM, an interview was conducted with the Acting Administrator. When asked about the incident and the determination that the incident was inconclusive even though CNA G was terminated, the Acting Administrator noted they were not familiar with the incident. On 5/20/26 at approximately 1:50 PM, an interview was conducted with Risk Manager B regarding the inconclusive finding and if so, why was CNA G terminated. Risk Manager B reported the facility determined CNA G did not provide R805 with needed standard of care but did not consider it abuse as the resident was not physically injured. A review of CNA G's personnel record did not contain documentation pertaining to their termination. The facility was asked to provide any documentation pertaining to the termination of CNA G. No documents were provided by the end of the Survey. On 5/20/26 at approximately 3:15 PM, an interview with Nurse J was conducted on the Memory Care -2nd floor unit. Nurse J was asked about the incident between CNA G and R805. Nurse J noted that she did not observe any of the incident and demonstrated that she was standing at her medication cart with their back facing the sink. They then heard a noise, turned around and saw R805 on the ground. Nurse J noted that they reported the incident to the Administrator. The facility policy titled, Abuse, Neglect and Exploitation (revised 1/10/24) was reviewed and read as follows: .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 .Definitions: Abuse means willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include staff to resident abuse and certain resident to resident altercations .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .physical abuse includes but is not limited to hitting, slapping, punching, biting and kicking .

This citation pertains to Intake Number 2794550.Based on interview and record review, the facility failed to report witnessed resident to resident physical abuse to the State Agency for two (R809 and R810) of six resident reviewed for abuse who were physically abused by R808. Findings include:A review of R808's clinical record revealed R808 was admitted into the facility on 5/23/24 and discharged on 3/15/26 with diagnoses that included: seizures and dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] and 3/1/26 revealed R808 had severely impaired cognition.A review of R808's progress notes revealed the following:On 1/23/26, the following was documented in a Nurses' Notes, Was reported to writer that Resident made contact with the palm of his hand on (R810) face by his doorway .On 2/4/26, the following was documented, Resident spent most of his day sitting guarding his doorway, to prevent other Residents from wandering into his room and sometimes roommates .On 2/8/26, the following was documented, Resident continue to guard his doorway compulsively. Gets up immediately to stop any peer attempting to go in. Only gets away from doorway for bathroom, meals, and some times wheels towards the dining room and returns right away to the door .On 3/2/26, it was documented that Resident charged toward CNA (Certified Nursing Assistant) threaten to beat his behind, called him derogatory, inappropriate names. CNA was moved off of the current assignment (1 on 1) with resident, new CNA assigned .On 3/6/26, it was documented that Resident agitated, attempted to be physical with assigned 1:1 CNA. Told CNA to stay away from him. CNA sitter was switched, staff educated to keep a safe reasonable distance while redirecting resident .On 3/12/26, it was documented that Writer was notified by 1:1 monitor that she was sitting on the right side of resident in hallway. Another Resident walked into this resident's room. Both the resident (R808) and the aide stood up. While she was standing next to the resident, she attempted to redirect the other resident to leave this resident's room. As the other resident was walking out of the room, this resident made contact with the other residents neck with both of his hands .Administrator was notified .On 3/15/26, it was documented that Writer received phone call while at home, that the resident slapped his Nurse in the face causing injury .Writer observed the Nurse with red welts and scratches to the right side of her face. The Nurse complained of a headache and being dizzy. Due to pain and bleeding to the nose and face, the Nurse was sent to the hospital for treatment .It was documented in a progress note that R808 was transferred to the hospital on 3/15/26 and then to another facility when discharged from the hospital.On 5/20/26 at 11:03 AM, Acting Administrator 'M' was asked to provide any incident reports and investigations for R808 since January 2026. A review of an incident report for R808 dated 1/23/26 revealed, Per wound nurse, Resident made contact with his palm on (R810) face. It was documented the Administrator (Abuse Coordinator) was notified. A review of an incident report for R810 dated 1/23/26 revealed, Wound care nurse reported while walking over to 2 North. Resident (R810) was attempting to enter another resident (R808) room and Resident assigned to the room made contact with palm of his hand to the resident. It was documented the Administrator was notified.A review of an incident report for R808 dated 3/12/26 revealed, Writer was notified by 1:1 monitor that she was sitting on the right side of resident put in hallway. Another Resident (R809) walked into the resident's room. Both the resident and the aide stood up. While she was standing next to the resident, she attempted to redirect the other resident to leave the resident's room. As the other resident was walking out of the room, the resident made contact with the other residents neck with both of his hands. It was documented the Administrator was notified. On 5/20/26 at approximately 12:40 PM, an interview was conducted with Acting Administrator 'M'. Acting Administrator 'M' was asked about the facility protocol for reporting witnessed resident to resident abuse and reported the Administrator (who was not available during the survey) was the Abuse Coordinator and Risk Management Coordinator 'B' would be able to answer any abuse reporting and investigation questions. On 5/20/26 at approximately 12:45 PM, an interview was conducted with Risk Management Coordinator 'B'. When queried about her role, Risk Management Coordinator 'B' explained when there was an allegation of abuse, she was responsible to do the reporting and investigating at the directive of the Administrator. The Administrator was the person who made the decision whether an allegation was reportable to the State Agency or not. Risk Management Coordinator 'B' reported that if an allegation of abuse was not made by the resident (victim) and there was no injury, then it would not be reported to the State Agency, but an investigation would be done. Risk Management Coordinator 'B remembered the physical altercations by R808 toward R809 and R810 and said they were not reported to the State Agency.On 5/20/26 at 1:14 PM, an interview was conducted with Acting Administrator 'M', Regional Director 'N', and Regional Nurse 'O' in regard to the above physical altercations by R808 toward R809, and R810. When queried about why the incident of R808 hitting R810 in the face and putting his hands on R809's neck were not reported to the State Agency, Regional Director 'N' reported that she did not think the physical contact made by R808 was abuse because it had to be willful, that no allegation of abuse was made, and there was no injury. When queried about whether R808 making contact with R809's neck with both hands, making contact with the palm of his hand to R810's face as a reaction to the other resident's entering or attempting to enter his room and whether that was considered willful, a response was not offered. When queried about whether a reasonable person would experience emotional or psychosocial distress after being hit or choked, Regional Nurse 'N' reported that would be subjective. When queried about why an allegation of abuse had to be made if the incidents were witnessed by staff, Regional Nurse 'N' stated, Being witnessed does not mean it is abuse. At that time, the facility's investigation was reviewed and those present were queried about what the specific contact was that R808 made with R809's neck and R810's face and how it could have been determined that it was not abuse without gathering additional information about the contact. There was no evidence provided that specific information about the physical contact was investigated by the facility.On 5/20/26 at 3:30 PM, an interview was conducted with CNA 'K' (the staff member that witnessed the physical altercation between R808 and R809 on 3/12/26). When queried about what happened, CNA 'K' reported they were assigned to provide 1:1 supervision to R808 that day. CNA 'K' reported she was unaware why R808 was on 1:1 supervision and later found out there was a binder that they were supposed to document in, and it contained information about the resident. CNA 'K' explained while seated with R808 outside of his room, R809 wandered into R808's room. CNA 'K' stood up to redirect R809 from R808's room and R808 also stood up and put his (R808) hands around his (R809) neck and attempted to choke him. CNA 'K' reported R808 did not like other residents going into his room or near it. On 5/20/26 at 3:43 PM, an interview was conducted with Licensed Practical Nurse (LPN) 'L' (the staff member that witnessed the physical altercation between R808 and R810 on 1/23/26). When queried about what happened, LPN 'L' reported it happened quickly and R810 was wandering the unit as she typically did and out of nowhere R808 walked up to her and hit her in the face. LPN 'L' said it was unprovoked and said R808 used the palm of his hand to hit R810 on the side of the face. LPN 'L' reported it was not with major force but was an act of aggression. A review of R809's clinical record revealed R809 was admitted into the facility on 7/17/25 with diagnoses that included: Alzheimer's Disease and bipolar disorder. A review of a MDS assessment dated [DATE] revealed R809 had severely impaired cognition.A review of R810's clinical record revealed R810 was admitted into the facility on 6/27/17 with diagnoses that included: Alzheimer's Disease and schizoaffective disorder. A review of a MDS assessment dated [DATE] revealed R810 had severely impaired cognition and behaviors that included wandering. A review of a facility policy titled, Abuse, Neglect and Exploitation, revised 1/10/24, revealed, in part, the following: .The facility will have written procedures that include .Reporting of alleged violations to the Administrator, state agency .and to all other required agencies .within specified timeframes and required by state and federal regulations .immediately, but not later than 2 hours after the allegation is made, if the vents that cause the allegation involve abuse or result in serious bodily injury .

Based on observation, interview and record reviews the facility failed to adequately assess/monitor residents experiencing identified changes of condition, notify the Physicians of their continued decline and transfer the residents to higher levels of care in a timely manner, for four residents (R7, R97, R168 and R175) of four residents reviewed for changes in condition, resulting in R7 not being transferred to a higher level of care and expiring, R97 having a critically low hemoglobin level and expiring, R168 having to be transferred to the hospital and subsequently intubated and R175 contracting sepsis resulting in shock. These deficient practices resulted in the increased likelihood of serious harm, serious injury and/or death to occur. Findings include:The Immediate Jeopardy (IJ) began on [DATE] when the facility staff failed to implement Physician ordered interventions for R7 who had an identified change of condition including tachycardia and timely notify the Physician of the continued decline.The IJ was identified on [DATE] and the Administrator was notified of the Immediate Jeopardy on [DATE] at approximately 2:11 PM. A plan of removal was requested at that time to remove the immediacy.The surveyor team confirmed by Observation, Interview and Record review that the Immediate Jeopardy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal. The noncompliance remains at an isolated event with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA).R168 On [DATE] the medical record for R168 was reviewed and revealed the following: R168 was initially admitted to the facility on [DATE] and had diagnoses including Paroxysmal atrial fibrillation, Cardiac arrest and Hypertension. A review of R168's MDS (minimum data set) with an ARD (assessment reference date) of [DATE] revealed R168 was dependent on staff for most of their activities of daily living. R168's BIMS score (brief interview for mental status) was zero indicating severely impaired cognition. A Physican progress note dated [DATE] revealed the following: . pt (patient) seen for routine f/u (follow-up) after recent admission to this facility for long term care and possible rehab. Per chart review, pt had recent prolonged hospitalization at [name of local hospital] after suffering a cardiac arrest on [DATE] due to a large pulmonary embolism. He underwent 4 cycles of CPR (Cardiopulmonary resuscitation) .underwent mechanical thrombectomy for PE (Pulmonary embolism) .CVS (cardiovascular system): s1/s2 audible, tachycardia .4. A-fib/sinus tachycardia. -continue Xarelto and BBs (beta blockers). Add Cardizem for better BP (blood pressure) and rate control. -recent Echo 6/2025 preserved EF (ejection fraction) 60-65% .-d/w (discussed with) RD (Registered Dietician) and LPN (Licensed Practical Nurse) to increase FWF (free water flushes) to 250 q (every) 6 hrs (hours) in addition to TF (tube feeding). 5. HTN(Hypertension) /elevated BP. -continue Metoprolol, add Cardizem. 6. Dysphagia 2/2 #1 s/p (status/post) peg (percutaneous endoscopic gastrostomy) tube. -continue TF (tube feeding) per RD, increase FWF (free water fluids) to 250 q (every) 6 hrs (hours).POC (plan of care) d/w LPN, check routine labs, add CCBs (calcium channel blockers). A review of R168's Physican orders revealed R168's Cardizem was never administered to them and the increase of FWF to 250 Q 6 hours was never transcribed to the electronic Physican orders. A review of R168's Beats per minute (BPM's) revealed the following abnormal pulse vitals. [DATE] at 01:36 (139 PBM), [DATE] at 14:15 (138 BPM), [DATE] at 13:00 (138 BPM), [DATE] at 12:52 (138 BPM), [DATE] at 06:16 (138 BPM), [DATE] at 16:58 (126 BPM), [DATE] at 14:04 (132 BPM), [DATE] at 10:48 (144 BPM), [DATE] at 05:54 (130 BPM, [DATE] at 17:53 (138 BPM), [DATE] at 14:11 (137 BPM), [DATE] at 05:11 (136 BPM). A review of R168's progress notes revealed the following: [DATE] at 12:57-Note Text: Cardizem LA Tablet Extended Release 24 Hour 240 MG Give 1 tablet by mouth one time a day for HTN/Afib/tachycardia-not available [DATE]-Note Text: Writer checked resident’s vitals BP 122/87, HR (heart rate) 139 BPM, Temp: 97.5 F, SPo2 (oxygen saturation) 85%, Resp 39 breaths/min, BS (blood sugar) 196. Placed resident on 4L (liters)of oxygen via NC (nasal cannula). Did not do breathing treatment as HR was 139. Attempted to call MD (Medical Doctor), no answer. EMS (Emergency Medical System) called. Resident transferred to gurney by 3 paramedics and transported to [local hospital) by ambulance . [DATE]-Note Text: chief complaints/ History of present illness Call received from the nearest recording patience and becoming very short of breath and hypoxic and tachycardic with heart rates going up to 139 and pulse ox amateur and down to 85%And the time did not appear to be febrile Review of systems Patient not able to consistently answer/able to tell symptoms .Physical exam as listed above patient was . tachycardic otherwise unchanged from the past Assessment and planAcute hypoxia and tachycardia with shortness of breath /respiratory distress -patient was transferred to [local hospital] by EMS With help of the nurse on duty . [DATE]-Note Text: Addendum Pt (patient) in [local hospital] .-still appearing very short of breath and hypoxic /tachycardic with temperature of 102°F -requiring intubation/ventilation . On [DATE] at approximately 1:48 p.m., Physician QQ was interviewed pertaining to R168 being sent out to the hospital on [DATE]. Physican QQ indicated that on [DATE] they had ordered the cardizem and increase of FWF to 250 to try to bring down R168's heart rate and that they had thought that the orders had been entered into the electronic record. On [DATE] at approximately 4:49 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the Cardizem and FWF and reported that the orders should have been entered by the doctor or the Nurse that they had spoken with. The DON was queried regarding the cardizem not being available on [DATE] and they indicated that it is available in the back up and should have been administered. The DON was queried regarding R168's abnormal BPM's for the four days leading up to them being sent out to the hospital and they indicated that there should have been follow-up from the Nurses with the Physican to address it. Complaint # 2587232 Resident 97 On [DATE] a review of the record revealed that R97 was re-admitted to the facility on [DATE] with the diagnosis of End stage renal disease, anemia, renal dialysis with a brief interview for mental status score (BIMs) of 15 which indicated no cognitive impairment. A further review of the record revealed that R97 had a critically low hemoglobin of 5.7 on [DATE] and was sent to the hospital on [DATE]. R97 had a history of low hemoglobin as well as a history of being sent out to the hospital for the low levels. On [DATE] at 11:23 AM, a telephone interview was conducted with Family member “KK”, they were asked if they had any additional information, they would like to add to the complaint that was submitted to the state agency (SA). Family member “KK” reported that their sibling had expired in the hospital at 11:33 PM on [DATE] with a hemoglobin level of 3.2. Family member “KK” reported that the facility was aware of the low blood levels and would check them weekly. The facility was also good at sending R97 to the hospital when the hemoglobin level was about 5. Being Jehovah’s Witness, R97 would have refused a blood transfusion (per religious belief) but the hospital usually would give them iron and do other bloodless options to bring the hemoglobin to a stable level. Family member “KK” reported, that R97's hemoglobin had been a constant problem and when their hemoglobin was at 5 or lower, they would start to get confused and tired. Family member “KK” was asked, would R97, have wanted to be transferred to the hospital? Family member “KK” replied, Yes, she always went out. On [DATE] at 2:20 PM, an interview with Nurse “G”, was conducted and asked how did R97 present to them during their shift. Nurse “G” reported that R97 did not look well during their shift, but they continued to monitor the resident because the medical providers were aware of the critically low Hemoglobin of 5.7 and gave no new orders. R97 was alert and oriented and seemed to be at their baseline, just more tired since resident was dialyzed the day prior, so it was normal for them. R97, remained stable for the duration of their shift reported Nurse “G”. On [DATE] at 2:25 PM, an interview with the Director of Nursing (DON) was conducted. They were asked what the facility process was on change in conditions. The DON reported that they write a progress note and start a significant change. The significant change would be followed up with a meeting every Tuesday, Wednesday, and Thursday until the residents either get better or sent to a higher level of medical help. The DON was then asked about the process of reporting critically low lab levels. The DON reported that they notify the provider immediately to see if they wanted to add or change any orders or want the resident sent to the hospital, we also would put a progress notes in and start an SBAR(situation, background, assessment, and recommendation) tool. The DON was then asked, was staff expected to use current vital signs and documentation for the SBAR tool, the DON replied, yes. A review of the record revealed that on [DATE] at 7:22 PM a progress note was created and stated, “Resident labs came back, and hemoglobin is 5.72 and hematocritis [sic]19.6. HCP (healthcare provider) notified, no new orders.” On [DATE] at 6:40 PM a SBAR Commnication form and progress note was completed for the transfer to hospital. On [DATE] at 12:27 PM, an interview with Nurse Practitioner (NP) “II” was conducted. They were asked if they were notified for R97's critical hemoglobin level, the NP replied, No. NPII reported that they worked closely with NP “JJ” with R97's plan of care. NP “II” reported that R97 had a history of low hemoglobin levels and was a Jehovah’s Witnesses, refused blood transfusions and would get sent right back to the facility after being evaluated by the hospital. NP “II” was asked, why R97 was not sent to the hospital for the critical lab levels. NP “II” reported that they were unsure and if they were aware of the lab value they would have sent R97. NP “II” stated that they sent everyone to the hospital with critical lab values regardless of their religion, unless they refused to go. On [DATE] at 3:00PM, an interview with NP “JJ” was conducted, they were asked were they notified of the critical lab value for R97? NP “JJ” reported that they were notified of the critical lab value and since R97 was Jehovah’s witnesses and usually refused blood transfusions, they were not sent to hospital. NP “JJ” reported that they called the dialysis unit in an attempt to collaborate with the provider to see if they would order iron infusion on the day of their dialysis. NP “JJ” was asked did they physically assess R97, NP “JJ” reported they had not but they did ask the nurse if R97 was on their menstrual cycle or had any bleeding from anywhere and had them follow up if anything changes. The next day I called NP “II” but they informed them that R97 had been transferred to the hospital. NP “JJ” was asked why did they not send R97 to the hospital. NP “JJ” reported that, R97 did not accept blood products and at the time of being notified R97 was asymptomatic and if R97 experienced symptoms they would have sent them to hospital. On [DATE] at 9:35 AM, an interview with the DON was conducted, they were asked to provide documentation for the SBAR, the change in condition, documentation/care plan that stated they refused to go to the hospital for critically low hemoglobin. The DON reported that they would look into it. No additional information was provided by exit of survey. R7 Clinical record review revealed R7 was admitted to the facility on [DATE] for rehabilitation and Nursing care. R7 had an impaired genitourinary (urinary organs) status related to ESRD (End-Stage Renal Disease) and received in house dialysis on Tuesday, Thursday and Saturday. R7 required a tracheostomy (surgical opening in the windpipe to assist with breathing), and had impaired cardiovascular status related to hypertension. R7 was alert, oriented and capable of making their needs known. A Brief Interview of Mental Status (BIMS) scored 15/15, signifying R7 was cognitively intact. A record review of a Nursing Progress note dated [DATE] at 5:55 AM, authored by Licensed Practical Nurse (LPN) “X” documented R7 expressed they wanted to be sent to the hospital due to feeling short of breath, and their breathing “…just felt off…” and had a Blood Pressure (BP) reading of 146/110. On [DATE] at 4:40 PM, a telephone interview was conducted with LPN “X” who recalled the incident and remarked they were a newer Nurse and not familiar with tracheostomies and relied on R7 who explained to them they felt like they had a “plug” deep down and performed suctioning with little to no secretions. LPN “X” contacted the on-call Provider on [DATE] around 6:30-7:00 AM, (was not sure of the name) told them R7 was requesting to go to the hospital and commented R7 always wants to go to the hospital. LPN “X” remarked the comment was posed as if R7 liked to “cry wolf”. LPN “X” took orders to give a one-time dose of Clonidine (medication to treat high blood pressure), a breathing treatment and Tylenol and have day shift reassess. Record review of the Medication Administration revealed the Clonidine documented within the progress note, was not documented as an order and not documented as given. Per Regional Clinical Director “BB”, an override report from Pharmacy Liaison “CC” was pulled from [DATE] to [DATE] and confirmed the verbal order for R7 to be administered Clonidine on [DATE] was not pulled as an override. On [DATE] at 12:20 PM, the Medical Director explained when on call Providers are contacted on off hours they are triaged, and a daily report is generated for the entire Provider team. The Medical Director explained the On Call Triage Provider was Nurse Practitioner (NP)“HH”. Per the Medical Director, there was no follow up with R7 on [DATE] and on Thursday [DATE]. NP “Z” who typically sees residents at this facility had a last-minute emergency and Attending Physician “AA” was on call but did not see Residents that day, therefore R7 did not have a Provider assess them in person. Nursing documented R7 still did not feel well, so much so they did not want to go to Dialysis. And no documentation reflected a Provider was contacted that R7 was still not feeling well and refused to attend dialysis. The Medical Director remarked if they had seen them, they would have been more concerned about them refusing dialysis due to risk of volume overload and would have either convinced them to have dialysis in-house or send them out l as they were requesting and receive dialysis at the hospital. On [DATE] at 1:16 PM, a telephone interview with Regional Dialysis Manager “W” provided documentation that R7’s scheduled dialysis for Thursday [DATE] was rescheduled due to R7 was not feeling well. Record review of the Progress notes dated [DATE] and [DATE] revealed no documentation or thorough follow up from a Provider or Nursing what R7’s change of condition entailed and why they were not feeling well. On [DATE] at 10:38 AM, a telephone interview with Certified Nurse Assistant (CNA) “Y” confirmed they were familiar with R7 and remarked they were so nice and called them their “buddy”. R7 could tell you what they wanted and recalled that they wanted to go to the hospital. Per CNA “Y” they went into R7’s room on [DATE] around 3:00 AM observed them up, they requested water and was watching television. Per CNA “Y” they went in around 6:30 AM and R7 was observed unresponsive and a Code Blue (a code for a life-threatening medical emergency) was called, and CPR (Cardiopulmonary Resuscitation) was initiated. Record review of the State of Michigan Certificate of Death documented R7 was pronounced dead at the facility on [DATE] at 7:07 AM due to End Stage Renal Disease. R175 On [DATE] at 10:50 AM, R175 was observed lying in her bed with a low air loss mattress receiving oxygen through a tracheostomy (surgical hole in the windpipe). Two poles were observed in the room, one with tube feed infusion equipment and the other with intravenous (IV) infusion equipment. R175 did not respond to questions asked. Review of the clinical record revealed R175 was originally admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: diabetes, tracheostomy status and toxic encephalopathy. According to the BIMS staff assessment dated [DATE], R175 had severely impaired cognition. Review of R175’s progress notes revealed: An admission note dated [DATE] at 6:56 PM read in part, “…resident was admitted to (local Long Term Acute Care -LTAC- hospital) for metabolic encephalopathy underlying sepsis…” A nursing note dated [DATE] at 11:33 PM by RN “Q” read in part, “Resident vitals were 126/68 HR (heart rate) 135 spO2 [sic] (percent of oxygen in the blood). Writer notified physician about resident HR. Physician gave an order to writer to do a STAT CXR (chest x-ray) and metoprolol (beta-blocker medication) 12.5 BID (two times a day)… A nursing note dated [DATE] at 6:31 AM by RN “Q” read in part, “Resident spO2 [sic] decreased to 88%. Writer suctioned the resident trach (tracheostomy). Resident secretion has become thick. Resident spO2 is still remaining 88%. Writer informed Physician about the resident spO2. Writer was given an order ‘Duoneb (inhalation medication) q4 (every 4 hours) PRN (as needed)’… A nursing note dated [DATE] at 7:34 AM read in part, “Resident was unresponsive to verbal/physical/pain response. BS (blood sugar) was unreadable by glucometer, tachycardia (high heart rate), tachypneic (high respiratory rate) and diaphoretic (sweating). Physician was contacted but was unable to answer phone. Writer contacted DON who agreed an emergency transfer should be ordered. BP (blood pressure) 80/49 HR 131 RR (respiratory rate) 38 T (temperature 97.4 Spo2 86%” It should be noted, there were no progress notes found from any Medical Provider, from R175’s first admission or from the second admission on [DATE]. Review of R175’s vitals tab in the clinical record revealed documentation on [DATE] at 6:54 PM, when R175 was admitted , then no documentation until [DATE] at 7:45 AM when R175 was sent to the hospital. Review of R175’s discharge paperwork from the hospital dated [DATE] revealed R175’s admitting diagnosis was septic shock (the last and most severe stage of sepsis – immune system has an extreme reaction to an infection). On [DATE] at 12:07 PM, Nurse Practitioner (NP) “O” was interviewed and asked if she had seen R175. NP “O” explained she had at the hospital and at the facility. When asked about the lack of progress notes, NP “O” explained she was behind in writing notes. On [DATE] at 3:08 PM, the DON was interviewed and asked how often vitals should be done for a new admission. The DON explained they should be taken on admission and every shift. When informed of the lack of vitals for R175, the DON acknowledged the concern. The DON was asked how long had R175’s HR been elevated prior to the progress note on [DATE] at 11:33 PM, and if the HR had decreased or stayed the same until R175 was sent to the hospital on [DATE]. The DON asked to see if there was a SBAR Communication Form completed. Review of a SBAR document dated [DATE] at 8:28 AM revealed the only boxes with information were the boxes the electronic medical record system auto-populated by the system, including the vitals that were taken on [DATE] at 6:45 PM, three days prior. The DON explained without R175’s vitals documented, the lack of progress notes and an empty SBAR, it was hard to see what the story was. On [DATE] at 9:36 AM, Dr. “P”, R175’s attending physician, was interviewed by phone and asked about the lack of Medical Provider progress notes. Dr. “P” explained sometimes he was late in documenting. Dr. “P” was asked if he followed up after being call about R175 having a HR of 135 and he gave orders for a chest x-ray and Metoprolol. Dr. “P” explained he usually looked to see what was documented in the chart. When informed there were no vitals documented for R175, Dr. “P” had no answer. Dr. “P” explained residents were “sicker” when admitted now than they used to be in the past. Dr. “P” was asked if residents were sicker now, did not that require more monitoring. Dr. “P” had no answer. On [DATE] at 10:02 AM, RN “Q” was interviewed by phone and asked about R175 during her first admission. RN “Q” explained she worked the midnight shift on weekends and had R175 when she was first admitted on Friday [DATE], then when she came back on Saturday [DATE], R175 was different, her BS was elevated and her HR was high… called the doctor, who ordered an x-ray… was surprised it was negative for pneumonia, knew something was not right, then on Sunday [DATE] her breathing got worse. RN “Q” was asked if she took vitals as none were documented. RN “Q” explained she did, must not have put them in the computer. On [DATE] at 10:10 AM, LPN “R”, who was R175’s day shift nurse on [DATE] and [DATE], was interviewed by phone and asked if he had taken R175’s vitals. LPN “R” explained he “always” took vitals before giving medications. When informed there were no vitals documented for R175, LPN “R” had no answer. LPN “R” was asked if R175’s HR had been elevated. LPN “R” explained he thought her HR at baseline was a little elevated, like 90 to 100. When informed R175 had been sent to the hospital with Septic Shock, LPN “R” explained he never saw any symptom of Septic Shock, she had been stable. LPN “R” was asked if any Medical Provider had seen R175 on her first admission. LPN “R” explained usually there are no Medical Provider’s that come to the facility on the weekends. Review of a facility policy titled, “Notification of Changes” revised [DATE] read in part, “…Circumstances requiring notification include: 1. Accidents… 2. Significant change in the resident’s physical, mental, or psychosocial conditions such as deterioration in health, mental or psychosocial status… 3. Circumstances that require a need to alter treatment… 4. A transfer or discharge of the resident from the facility…” The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the immediacy. The facility assessed current residents for a change in condition by reviewing labs and vital signs. Education was provided to nursing staff on assessment, notifying the physician and implementing orders and documentation.

This citation pertains to intake #1194668.Based on record review and interview, the facility failed to purchase a surety bond in an amount equal to the current balance of personal funds held in the resident trust fund. This deficient practice has the potential to affect 82 resident's that have funds managed by the facility. Findings include:On [DATE] at 2:24 PM, the facility was requested to provide a list of residents that have personal funds managed by the facility (resident trust fund), and the facility's surety bond (an agreement between the principal [the facility], the surety [the insurance company], and the oblige [either the resident or the State acting on behalf of the resident], wherein the facility and the insurance company agree to compensate the resident (or the State on behalf of the resident) for any loss of residents' funds that the facility holds, safeguards, manages, and accounts for).Review of the documentation provided revealed the provided list of residents that had current balances as of [DATE] included Total Accounts: 82 .Current balance $63,240.36 .The facility's surety bond which was dated [DATE] - [DATE] documented it was only for $45,000.00.On [DATE] at 8:32 AM, an interview was conducted with the Business Office Manager (Staff ‘H‘) who reported they had been in their role for about a year. When asked about the residents included on the documentation that had money in the facility's resident trust fund, Staff ‘H' confirmed there was at least one resident that had expired [DATE] but was still showing as having funds. They reported they were not sure why that happened and would follow-up. When asked about the surety bond amount which was much lower than the current balance for [DATE], Staff ‘H' reported they would follow-up.On [DATE] at 10:40 AM, Staff ‘H' provided additional documentation and reported the trust fund balances from previous months were lower than $45,000 and further reported they had not processed the patient pay amounts for the month of August yet, so it would be lower amount that what it was showing. Staff ‘H' was asked if there was a specific date the resident's patient pay amounts were removed for payment and they indicated there was not, and it varied. They were informed the current surety bond provided did not cover the current balance and remained a concern.On [DATE] at 1:15 PM, Staff ‘H' reported the facility's trust fund balance documentation of previous months were under $45,000 and they were still waiting to process patient pay amounts for the month. When asked if that usually occurs on a specific date, Staff ‘H' stated the dates varied for multiple residents. Staff ‘H' was informed the concern remained since the current balance of the resident trust fund was significantly higher than the amount of the surety bond.On [DATE] at 9:44 AM, the facility was requested to provide a policy regarding the surety bond. At 9:59 AM, the Administrator reported they did not have a policy regarding surety bond.

Based on observation, interview, and record review facility failed to maintain food service equipment based on professional standards for food service safety resulting in the potential to result in food borne illness among all residents who consume food/drinks from the kitchen. Findings include:An initial kitchen tour was completed on 8/12/25 at approximately 8:50 AM with the Dietary Manager (DM) LL. The ice machine filter cover in the kitchen appeared brown in color. The ice machine filter did not have any date labels on the filter. DM LL was questioned about their process for ice machine cleaning and maintenance. They reported that the facility utilized an outside vendor for cleaning and the unit was cleaned two weeks ago. When queried about the color and further documentation, DM LL reported that the records were maintained by the facility's maintenance department. They were requested to provide the cleaning/maintenance records after their last annual/re-certification survey to the current date. They were not sure why the ice machine filter had no service dates. The ice machine had a service sticker with handwritten service data with the following information:The sticker read Ice Machine Maintenance Log and had the following dates: 5/13/24; 8/22/24; 7/30/24; 1/26/24 and 3/3/23.A request for ice machine service/filter change documentation was requested to the facility administrator. The facility provided additional documentation revealed ice machine service/filter change records dated 5/22/24 and 1/26/24 (approximately over 15 months ago). There were no other records for any routine inspection, cleaning and filter change between these two periods.A review of the latest correspondence sent to the facility administration in December-2024 by the County's Environmental Health Epidemiologist recommended to follow the control measures as part of the facility's Water Management Plan (WMP) and to ensure that facility's water management team is implementing the facility's WMP. Review of facility's WMP book revealed the section titled Operation, Maintenance, and Control Limits. The sub-section for routine maintenance, monitoring, and cleaning for ice machine revealed a plan that included:Daily - Visual monitoringMonthly - Cleaning/De-scaling; Filter inspectionDuring a follow up interview with DM LL on 8/14/25 at approximately 9:50 AM, they were notified of the concern with the routine maintenance and cleaning of the ice machine. They reported that they understood the concern. When queried about the process and their expectations, UM LL reported that they expected to clean and change filters at least every 3-6 months and they were unsure of the facility policy. They added that the facility maintenance director was completing the checks and scheduling filter changes.An interview with Maintenance Director MM was completed on 8/14/25 at approximately 12:20 PM. They reported that they had been at this since September-2024 and added that they were not sure how often the facility was doing the monitoring and filter changes prior. Maintenance Director MM was notified of the concern, and they reported that they understood and added that were going to start doing the monitoring quarterly.An interview with the facility administrator was completed on 8/14/25 at approximately 4:15 PM. During this interview Regional Director of Operations (RDO) DD was present in the office. They were notified of the concerns with routine monitoring and maintenance of ice machines. The administrator reported that they understood the concern and did not have any further explanation.A facility provided document titled Ice Storage with a revision date 7/1/25 did not reveal any specific monitoring and maintenance protocols. It read Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions and maintains a copy of these guidelines. No additional guidelines for maintenance were provided prior to the survey exit.According to the 2022 FDA Food Code Section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and(B) Maintained in good repair. According to Food Code Section 4-602.13 Nonfood-Contact Surfaces. Nonfood-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on interview and record review, the facility failed to identify area of deficiency and maintain an effective quality assurance and performance improvement program (QAPI) for respiratory care, catheter care and residents experiencing changes in condition. This practice has the potential to affect all residents that reside in the facility. Findings include:On 8/15/25 at approximately 11:12 a.m., a review of the facility's QAPI program was conducted with the facility Administrator. The Administrator reported they have only been the Administrator for a few weeks but was aware there were some areas of concern regarding the QA program. The Administrator was queried what action plans the facility had been working on to maintain sustained compliance and reported that a few areas of concern that they had identified were respiratory and catheter care. The Administrator was queried what interventions they had in place to maintain compliance for catheter care and they indicated they were doing audits and reviewing Physican orders. The Administrator was queried what was being done to address respiratory care and they reported they had been working on ensuring tracheostomy care was being done correctly. At that time, the Administrator was queried regarding the concerns the survey team had identified during the survey including catheter care and respiratory care and they indicated that they would have to review their process. The Administrator was queried regarding the survey teams concerns regarding identifying compliance issues potentially related to resident deaths and hospitalizations and they reported they did not identify concerns with those areas as the Director of Nursing and been reviewing deaths and hospitalizations. The Administrator indicated that they were working to immediately correct the survey teams identified deficiencies in those areas. Cross-Reference tags F684, F690 and F695. On 8/15/25 a facility document titled QAPI plan was reviewed and revealed the following: Purpose: It is the policy of this facility to systematically collect data as part of the QAPI program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice. In addition, the purpose of this document is to serve as a plan to assist the facility in development, implementation, and maintenance of an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The goal is to create a process that ensures care and services delivered meet accepted standards of quality. The QAPI plan is supported by multiple, specific policies and procedures to support the facility in the above stated purpose. Key components of this plan may include but are not limited to 1. Tracking and measuring performance. 2. Establishing goals and thresholds for performance improvements. 3 Identifying and prioritizing quality deficiencies 4. Systematically analyzing underlying causes of systemic quality deficiencies.5. Developing and implementing corrective action or performance improvement activities. 6. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Prioritization of program activities that focus on high-risk, high-volume, or problem- prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves. Explanation and Compliance Guidelines: 1. Data will be collected from all departments, residents, and family members. a. Sources of data include, but are not limited to varying for situational awareness: i. The facility assessment ii . Paper and electronic medical records iii. Stand up meeting data collection/ stand down meeting follow up iv. Grievance logs v. Medical record audits and drug regimen reviews vi. Skilled care claims vii. Clinical logs such as for falls, pressure injuries, and weights (including SOC meetings) viii. Staffing trends ix. Incident and accident reports, including reports of adverse events or abuse, neglect, or exploitation (Risk Management, FRI/SRI (Reportable events) Log) x. Minimum Data Set (MDS) (Carewatch data sets) xi. Quality measures (QM report)/ 5 Star Reports xii. Survey outcomes/ Plan of Correction Support Calls/ QCR results xiii. Staff, resident, and family satisfaction surveys (Resident Voice 72, 7 day and Discharge survey as well as the entire caring partners program. Caring partners data in the Power BI System) xiv. Suggestions from staff, residents and families- given formally or informally in care conferences, at staff meetings or shift to shift huddles. xv. Trigger calls man xvi. DON Weekly Report xvii. Facility Dashboard Review xviii. Return to Hospital Report/Review xix. Infection control binder basics audits xx. Dietary Quick Rounds/ Monthly Sanitation Audits xxi. Resident Council Minutes xxii. Family Council Minutes xxiii, Safety Committee Meeting/ Outcomes xxiv. Compliance Line Calls xxv. Business Development Workbook xxvi. Health Care Source reports (Recruitment/Retention/ Applicant flow reports) xxvii. New Hire/Turnover reports xxviii. DSO (Days Sale Outstanding)/Cash Report/ Medicaid Pending/LOCD Logs XXIX. Pharmacy Scorecard/ Pharmacist review xxx. TELs compliance report (Preventative maintenance/ work orders) xxxi. Triple Check Weekly/Month1y tool xxxii. QAPI QAD Audits b. Facility staff are responsible for following departmental procedures for data collection, whether by policy or forms instructions related to the data collection. c. Sample data collection forms vaty depending on the source. 2, Data collection methodology is to be consistent, reproducible and accurate to produce valid and reliable data, and support all departments and the facility assessment.3. The facility will determine the frequency of data collection based on the issue identified and facility QAA committee. 4. Performance indicators will be established based on data and will be monitored/evaluated in the QAA Committee meetings. a. A combination of process, outcome, and use measures will be utilized to monitor progress towards goals. The type of measure used will be appropriate to the type of data being collected. b. Goals will be modified as necessary. 5. Facility QAA Committee shall be interdisciplinary and shall: a. Consist at a minimum of:i. The Director of Nursing Services ii. The Medical Director of his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the administrator, owner, a board member or other individual in a leadership role; and iv. The Infection Preventionist v. A member of direct care staff b. Meet at least quarterly, but generally monthly, and as needed (adhoc QAPI meetings) to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary c. Develop and implement appropriate plans of action to correct identified qualify deficiencies. d. Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. e. The QAA committee must sign to verify approval of all plans of correction written. Program Development Guidelines: l . Program Design and Scope. The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. b. At a minimum, the QAPI program will: i. Address all systems of care and management practices. ii. Include clinical care, quality of life, and resident choice. iii. Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a Skilled Nursing Facility (SNF) or Nursing Facility (NF)

Based on observation, interview and record reviews the facility failed to ensure meals were maintained and served at a palatable temperature affecting multiple residents, including multiple residents from the confidential group interview, resulting in dissatisfaction with meals and the potential for nutritional decline. Findings include: On 8/13/25 at approximately 2:30 PM, a Resident Council meeting was held with seven residents who asked to remain anonymous. Residents were asked about the food provided at the facility. One resident noted that they reside on the second floor and often food is served late and thus their food is cold. They noted that when they choose to eat in their room, they are always served last. Another resident reported that at times food is also cold when eating in the dining room. They noted that the facility may help residents get to the first-floor dining room at around 5:00 PM, but often they must wait until staff come and sometimes, they wait till almost 6:30 PM, resulting in cold food. Past Resident Council Minutes were reviewed and revealed the following: Date of Meeting: 4/7/25… New Business…Residents report that their breakfast is usually cold…”. Date of Meeting: 4/21/25…New Business…Residents report floor staff are stating they are not able to reheat food…When eating in the dining room residents report ice cream is served melted…”. “Date of Meeting: 6/2/25 .New Business…Meal served on 6/1/25 reported no steam coming from the steamtable…The BBQ Cheeseburger and fries were served cold in in the dining room on the 1st floor. Residents reported the meal was cold for room trays as well…”. “Date of Meeting: 7/7/25…New Business…Residents state lunch and dinner are served cold…”. On 8/13/25 at approximately 3:01 PM, an interview was conducted with Activity Director (AD) “EE” along with Corporate Activity Director (CAD) “FF”. AD “EE” reported they have been with the facility for about six weeks. CAD FF noted they started to fill in as the Activity Director in April 2025. When asked about the residents who reported concerns regarding cold food, they reported they were aware that residents had concerns regarding cold food. They noted that food was cooked to a correct temperature however, when staff did not serve food timely it resulted in cold food. On 8/14/2025 at approximately 12:50 PM an interview with the Administrator was conducted. When asked if they were aware of resident's concerns pertaining to cold food, they reported that they were new to the facility and were aware of the resident council notes pertaining to cold food. They noted that perhaps the minutes referred to old concerns but as they were new to the facility they could not confirm one way or another. A temperature test for food palatability was completed with the Dietary Manager (DM) “LL” on 8/14/25. Lunch cart for 2-North unit arrived on the floor at approximately 1:05 PM. Nursing staff started passing the trays to residents’ rooms. DM “LL” arrived on the unit at approximately 1:20 PM, while staff were still passing the lunch trays. Temperature of the check on the test tray completed by DM “LL” revealed the following: The tray had regular meals that was served for lunch: Milk, Coffee, Juice/Fruit Punch, Pork, Cabbage, potatoes, and desert/pie. The food temperatures were as follows: Milk - 52.4 degrees Coffee – 121 degrees Juice – 61.8 degrees Dessert/Cream pie - 54 – icing on the pie appeared melty and was soft/mushy Cabbage - 121 Pork – 102.3 degrees Potatoes – 102.1 degrees An interview was completed with DM “LL” after the temperature test and queried why the food temperatures were not meeting the requirements and resident concern about cold food from multiple residents. DM “LL” reported they were using plate warmers, and they were unsure why they food temperatures were not meeting their requirements, and they would look into their process. [NAME] also added that sometimes the staff were busy, and the trays were not served timely. They were notified that for the staff started serving approximately 5 minutes after the cart arrived today. They reported that they understood the concern.

This citation pertains to intake #'s 1194664 and 1194670.Based on observation, interview and record review the facility failed to ensure residents received assistance with oral hygiene, incontinence care, bathing, and nail care for three (R8, R138, and R152) of seven residents reviewed for Activities of Daily Living (ADL). Findings include:R152 On 8/12/25 at 10:19 AM, R152 was observed lying in his bed with his hands on his chest. R152 was asked if he was able to move both arms. Upon R152 moving his left hand, that had been covering his right hand, it was observed the fingernails on R152’s right hand were approximately ½ to ¾ inches long. R152’s fingernails on his left hand were approximately ¼ to ¾ inches long. R152 was asked if he wanted his fingernails long. R152 explained he wanted them short, but no one at the facility had ever cut them. Review of the clinical record revealed R152 was admitted into the facility on 7/2/25 with diagnoses that included: dysphagia following cerebral infarction (difficulty swallowing after a stroke), hypertension and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R152 had severely impaired cognition. Review of R152’s ADL care plan revised 7/11/25, revealed R152 required assistance of staff for all ADL’s. On 8/13/25 at 9:49 AM, R152 was observed lying in bed. When asked about his fingernails, R152 showed both hands and the fingernails appeared to look the same. R152 was asked how often he received showers or bed baths. R152 explained he did not know. When asked what days he was supposed to get showers, R152 explained he did not know. Review of Certified Nursing Assistant (CNA) documentation for R152 revealed a task titled, “Bath on designated days” that only documented two bed baths, on 7/27/25 and 7/28/25. On 8/14/25 at 9:49 AM, CNA “S” was interviewed and asked where showers or bed baths were documented. CNA “S” explained it was documented in the computer. When asked who at the facility cut fingernails, CNA “S” explained the CNA’s cut fingernails. On 8/14/25 at 10:23 AM, CNA “T” and CNA “U” were interviewed and asked who cut fingernails. CNA “T” explained the CNA’s cut them. When asked how often fingernails were cut, CNA “U” explained fingernails were cut when they were getting long, or the resident requested them to be cut. On 8/14/25 at 10:25 AM, the Unit Manager (UM) for R52’s Unit, UM “V”, was interviewed and asked how often residents received a shower or bed bath. UM “V” explained residents received showers twice a week on set days, but could have them more often if they wanted. UM “V” was asked how often fingernails were cut. UM “V” explained some residents preferred them long, but all other residents’ nails should be cut when they were getting long. UM “V” was informed in the six weeks R152 had been at the facility, he had only received two bed baths. UM “V” explained she would look into that. Upon observation of R152’s fingernails with UM “V”, UM “V” asked R152 if he would let her cut his fingernails. R152 nodded his head to indicate agreement and explained he wanted them short. On 8/14/25 at 12:32 PM, R152 was observed with short fingernails. R152 explained he was happy they were cut, and he felt better. No additional documentation for R152’s showers or bed baths was provided prior to the end of the survey. R8 On 8/12/2025 at 10:19 AM, R8 was observed walking independently throughout the hallways, wearing a red bike helmet. When approached, R8 did not respond verbally, but smiled. On 8/12/25 at 12:20 PM, a phone interview was conducted with R8’s Legal Guardian (LG). When asked about whether they had any concerns with the resident’s care since they recently admitted into the facility, the LG reported they had concerns about the staff not brushing his teeth. They further expressed concern that prior to admission, the resident came from a horrible situation of neglect in an adult-living facility in which neglect was substantiated including neglect of oral care. The LG reported “I’m concerned about his teeth…His breath smelled really bad. I shouldn’t have to come and ask them to brush, that should be part of the routine.” When asked if anyone had reached out to them to discuss his refusals, or attempt to have them intervene if refusals continued, the LG reported they did not. Review of the clinical record revealed R8 was admitted into the facility on 7/14/25 with diagnoses that included: other disorders of psychological development, cerebral palsy, type 2 diabetes mellitus without complications, congenital cataract, abnormal weight loss, adult failure to thrive, and microcephaly. According to the Minimum Data Set (MDS) assessment dated [DATE], R8 had severe cognitive impairment, had no behavior concerns such as refusing care, has functional limitation in range of motion to one side of both upper and lower extremities, does not use a mobility device, and requires partial/moderate assistance with oral hygiene. Review of the section of the electronic medical record (EMR) for documentation of oral care over the past 30 days revealed oral care was done only once a day, or not at all. Documentation included: On 8/12/25 done at 22:59; On 8/11/25 at 09:03 (check marked as Resident Refused with no further follow-up); On 8/10/25 done at 22:59; On 8/9/25 at 14:59 (check marked as “NO” for the question was oral care provided) and done at 22:45; On 8/8/25 at 8:56 (check marked as Resident Refused with no further follow-up) and done at 16:57; On 8/7/25 at 09:12 (check marked as Resident Refused with no further follow-up) and done at 17:30; There was no oral care documented for 8/5/25; On 8/3/25 at 09:37 (check marked as “NO” for the question was oral care provided) and done at 21:19; On 8/2/25 at 10:08 (check marked as Resident Refused with no further follow-up) and 17:16 (check marked as “NO” for the question was oral care provided); On 8/1/25 at 20:33 (check marked as “NO” with no further follow-up); There was no oral care documented for 7/31/25; On 7/30/25 at 09:37 (check marked as “NO” with no further follow-up) and done at 22:59; On 7/29/25 at 08:55 (check marked as Resident Refused with no further follow-up). The entries marked as NO and Resident Refused from 7/29/25 - 8/12/25 were all signed off by Certified Nursing Assistant (CNA ‘E’). R138 On 8/12/2025 at 10:36 AM, R138 was observed lying in bed with oxygen via nasal cannula. When asked about whether they had any concerns with receiving assistance with care, R138 reported concerns with incontinence care and stated “You only get changed once in an eight hour shift…Most of the time when I get changed, it’s just before they (Nursing Assistants) go home, maybe 2:30 PM. They say I’m heavy and difficult to change and can’t do without help…They’re also giving me water pills so you know I need to be changed more than once.” Review of the clinical record revealed R138 was admitted into the facility on [DATE], discharged on 3/6/25 and readmitted on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia, morbid obesity due to excess calories, and contracture of muscles in right and left lower leg. According to the MDS assessment dated [DATE], R138 had intact cognition, had no behavior concerns (such as refusal of care), was always incontinent of bowel and bladder, and was not on a bowel toileting program. According to the profile section, R138 was identified as their own responsible party for both clinical and financial decisions. Review of the task section of the EMR which documented if shower/baths were given included: “ADL-I prefer shower/Sponge bath Wednesdays and Saturdays. The documentation for the past 30 days included only two entries on 7/16/25 and 8/13/25. The sections for 8/2, 8/6 and 8/9 were left blank. Further review of the documentation for R138’s “Bladder Elimination” section of the EMR prompted direct care staff to document Qshift (Day 7:00 AM - 3:00 PM, Evening 3:00 PM - 11:00 PM, and Night 11:00 PM - 7:00 AM). However upon review of the documentation, there were multiple blank (incomplete) entries that coincided with the concerns reported by R138 which included: On 8/2 day and evening shift (blank); On 8/3 day and night shift (blank); On 8/4 evening shift (blank); On 8/5 day shift (blank); On 8/6 day shift (blank); On 8/9 day and evening shift (blank); On 8/10 day shift (blank); On 8/11 day and evening shift (blank). On 8/14/25 at 11:30 AM, an interview was conducted with the Director of Nursing (DON). When asked about the facility's expectations for documenting resident care provided, the DON reported it should be put in as “real time” (when care was actually provided). When asked if the EMR system alerted the facility if there were missed opportunities for ADL documentation and they reported in the morning they get a report that shows a percentage per unit and the expectation is to have better than 85% and should flag if for example no shower was given or if it was refused. The DON then pulled up the task sections of the EMRs for both R8 and R138 and reported they saw the same limited documentation for bathing, incontinence care and oral care. When asked what should happen if a resident refused care such as bathing, incontinence care, or oral care and the DON stated anyone who refuses should immediately let the nurse know and then follow up later. The DON further stated “We usually ask three times.” The DON reviewed R8's oral care documentation of refusals and when asked why it was marked as No for if oral care was provided but not noted as refused, and also about all the refusals or “No” responses were from the same CNA (CNA ‘E’) the DON reported they had no idea and would have to follow-up with that CNA. On 8/14/25 at 1:17 PM, a phone interview was conducted with CNA ‘E’. When asked about their documentation of “No” oral care and refusals, CNA 'E' reported the resident did not allow them to brush their teeth and always refused for them. When asked what they did when the resident refused oral care, i.e., did they notify anyone, CNA 'E' reported they no, they just documented refused and “No” in the electronic medical record. According to the facility's policy titled, Activities of Daily Living (ADLs) dated 12/28/2023: .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 properly store and secure medications and biologicals in one of eight medication carts and one of four medication rooms observed for medication storage. Findings include:On 8/14/25 at 12:32 PM, the Back Hall medication cart on the 1 North Unit was observed with LPN “L”. Upon opening the top left drawer, LPN “L” picked up a medicine cup of pills that was sitting in the drawer. The cup was not covered or labeled with a resident name. LPN “L” was asked what the medicine cup of pills was. LPN “L” explained she had prepared the medications for a resident, but they were not in their room, so she put it in the drawer to give them when they came back to the room. When asked who the resident was, LPN “L” explained she did not remember their name as she did not usually work that unit. A review of the stock medicine in the top left drawer revealed a bottle of Aspirin 81 milligrams (mg) that had a manufacturer expiration date of 1/2025. On 8/14/25 at 1:35 PM, the 1 North medication room was observed with LPN “M”. There were two small refrigerators one on top of the other. LPN “M” explained the top refrigerator was for the applesauce used for medication administration and protein supplements. In the door of the refrigerator was a clear plastic cup and straw that appeared to be iced coffee that still contained ice. When asked if the iced coffee was a residents’ or staff, LPN “M” explained she believed it was staff. In the bottom refrigerator medications were kept. A multidose vial of Aplisol (Tuberculin Purified Protein Derivative) had an open date of 5/28/25. When asked how long a multidose vial was good after opening, LPN “M” explained she did not know. On 8/14/25 at 2:05 PM, the Director of Nursing (DON) was interviewed and informed of the expired medications and the staff food in the medication room refrigerator. The DON explained there should never be any staff food in the medication room. Review of the manufacturer’s package insert for Aplisol dated 11/2013 read in part, “…Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency…” According to the facility's policy titled, Medication Storage dated 1/30/2024: .All drugs and biologicals will stored in locked compartments (i.e., medication carts, cabinets, drawers .Only authorized personnel will have access to the keys to locked compartments .Narcotics and Controlled Substances .Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key . On 8/12/2025 at 10:15 AM, during an observation of the facility’s secured memory care unit which had many residents ambulating and/or self-propelling in the hallway, the medication cart assigned to Nurse ‘F’ was observed unlocked. There was no nurse observed within the area that had direct supervision of the unsecured medication cart. A short time later, Nurse ‘F’ returned to the cart and stated, “Oh no, dang it, I thought I had locked the cart. On 8/13/2025 at 8:06 AM, during an observation of the breakfast meal on the facility’s secured memory care unit, a medication cart was observed stored in the areas just outside of the dining room and was unlocked. The nurse assigned to that medication cart was Nurse ‘G’ and they were not observed to have direct supervision of the cart, they were administering medication to a resident who was eating breakfast in the dining room. A short time later, a Corporate staff was observed to walk by the cart and engage the locking mechanism. On 8/13/2025 at 8:09 AM, Nurse ‘G’ returned to the cart, unlocked it to obtain additional medication, then left the cart unlocked and proceeded to leave the area again. At that time, upon opening the top drawer of the unlocked medication cart, there was a small container of applesauce dated 8/12/25 and a gold watch stored in with the lancets used to obtain blood for blood sugar monitoring. On 8/13/25 at 8:11 AM, Nurse ‘G’ returned to the medication cart and was asked to complete a further observation of the contents of the cart. When asked about why the cart was left unlocked, Nurse ‘G’ reported “Oh, I forgot to lock it?”. They were informed of both observations and offered no further response. When asked about whether the applesauce should be stored in the top drawer of the medication cart, Nurse ‘G’ reported that was because this was a dementia unit and residents took stuff off the top of the cart. When asked the gold watch stored in and touching the lancets, Nurse ‘G’ removed the watch and placed in another area of the top drawer. When asked if any resident belongings should be stored in the medication cart, Nurse ‘G’ reported sometimes there was and sometimes things might also be kept in the narcotic box. Upon observation of the narcotic box, Nurse ‘G’ retrieved a black cell phone. When asked if they could identify who’s phone that was or who put it there, Nurse ‘G’ reported they were not sure. On 8/13/2025 at 8:15 AM, an interview was conducted with the Director of Nursing (DON). When asked if there should be any resident belongings stored in the medication carts, the DON stated, unless they have money they might store in lock box until able to give to administration. When asked if applesauce should be stored in the medication cart, they reported it should be a cooler with ice that's usually on top of the med cart. When asked if the medication carts should be locked when unsupervised, the DON reported they should always be locked when the Nure is not at the cart. The DON was informed of the multiple observations and reported they would have to follow-up.

Based on observation, interview and record review the facility failed to ensure timely interventions were implemented to prevent the development of two facility acquired pressure ulcers for one (R21) out of three residents reviewed for pressure sores/wounds. Findings include: On 8/12/25 at approximately 10:37 AM, R21 was observed lying in bed. Next to their bed was a pair of heel boot protectors. When asked why their boots were on the wheelchair, R21 reported that they are used for their heels that had sores and was waiting for staff to put them on as they no longer were able to do it on their own. They noted that they had been at the facility for several years and never had a problem with their heels, but a few months ago they started. R21 further noted that they believe they got the pressure ulcer because their heels were rubbing on the bed sheet.A review of R21's clinical record was conducted and revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Type II diabetes, generalized anxiety disorder and depression. A review of R21's Minimum Data Set (MDS) with a target date of 6/9/25 noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition) and was marked No for the questions Resident has a pressure ulcer/injury, a scar over bony prominence. In addition, it was marked No as to the resident at risk of developing the pressure ulcer and No as to whether the resident had one or more unhealed pressure ulcers.Continued review of R21's clinical record documented, the following:3/26/25: Physician Progress Note: .Has been having some intermittent L (left) heel pain on/off . *It should be noted that no interventions/orders for the left heel were put in following the physician visit.4/10/25: Order: Voltaren (arthritis pain relief- with a side effect noting may cause blisters) apply to left heel topically every shift for pain. *It should be noted that this order for pain relief was placed approximately 15 days after R21 complained of pain. 4/14/25: Skin Assessment: R21.Are there any new abnormal skin areas.Site: Left heel. Comments.DTI (deep tissue injury).soft, red and boggy, tender to touch.refer to wound care.4/17/25: Psychiatry Follow-up: .Patient seen in his room today with no signs of depression.anxiety. He has been having issues with his foot, as he appears he may have developed a blister.that may be a diabetic wound.The patient states he will see a wound care doctor on Monday but has not yet seen them.4/21/25: Skin and Wound Evaluation: [R21].Type: Blister.Location: Left heel.Acquired: In-house.Area: 4.3 cm (centimeter).Length 3.1 cm.Width 1.9.Notes: Resident prefers not to wear heel lift boots. *It should be noted that there was no documentation that indicated R21's heel boots were either ordered or refused.Care Plan: Focus: Resident has impaired skin integrity as evidenced by: Diabetes to Right heel, Blister to left heel.related to wearing shoes without socks.Date initiated 4/23/25.Revision on 8/5/25.Interventions: Administer medications as ordered (4/23/25).Encourage resident to reposition self if able.Pressure redistribution device in chair (4/23/25).Heel Protectors while in bed (8/12/25). *It should be noted that there was no orders for the Heel Protectors noted in R21's electronic medical record as of 8/13/25.4/19/25: Order: Wound care to eval and tx R/t ulcer of left heel.4/19/25: Order Administration: .Voltaren External Gel.Apply to L heel. Resident refused stating that the wound care nurse told him not to have it apply anymore.4/20/25: Charting: .L heel xray results reveals no fracture or osteomyelitis.:.5/12/25: Physician Progress Note: .initially admitted to the facility in November of 2021.EHR (electronic health record) notes patient is having left foot pain.with.a left foot decubitus ulcer.An X-ray has been done which did not show any fracture of osteomyelitis.6/19/25: NP/PA (nurse practitioner/physician assistant) Progress Note: .Per.patient is having left foot pain with left foot plantar fasciitis and a left foot decubitus ulcer.Patient seen in hallway.He states his wound is 'worse' because he was not offloading his heel properly in bed. He has pain when he tries to put pressure on his heel. 7/14/25: Alert Note: Skin and Wound- new wound identified via S & W (skin/wound) eval.Care plan up to date.7/21/25: Physician Progress Note: .Seen for eval (evaluation) heel ulcers now has changes over both heels.7/28/25: Skin Issues: .Location: left heel.type: Blister.Wound acquired in-house.painful.(.92cm(centimeters)-length).(1.09 cm- width).(.2 cm-depth).#002: skin issue has been evaluated.Right heel.Diabetic foot ulcer.Length-2.53 (cm).Width 1.88(cm).2 area.3.74 undermining.slough 20%. Eschar 80% .8/9/25: Pertinent Charting: .Site of infection: Right Heel.Reason for antibiotics.new signs and symptoms.On 8/14/25 at approximately 1:05 PM, an interview was conducted with Wound Care Nurse (WCN) NN. WCN NN reported they are a LPN (licensed practical nurse) and started as the wound care nurse at the facility in August 2024. WCN NN was asked as to the facility's protocol to prevent facility acquired pressure ulcers. WCN reported that new admits are assessed as to their potential for wounds. Skin assessments are then done weekly by nursing staff. If staff notice any change in skin conditions, they are to notify WCN NN. WCN NN noted that there have been no wound physicians in the facility for several months . WCN NN was then queried about the two pressure ulcers recently acquired by R21 and what interventions, if any, were put in place to prevent their development. WCN NN reported that they were made aware of R21 left heel in April 2025 and started treatments for the wound and initially believed it may have been caused by him not wearing socks with shoes. When asked if they were aware that the physician noted some concerns in March 2025. They noted that they were not made aware at that time. WCN NN was then asked as to interventions to prevent the development of the pressure ulcer on the right heel. They reported the resident might be having some vascular issues and is scheduled to see an outside physician in the future.On 8/14/25 at approximately 1:28 PM, R21's heel wounds were observed. The left heel appeared to be healing. The right heel appeared to be one inch in diameter with black eschar (nonviable dead tissue) obscuring the wound bed. The eschar appeared to be slightly raised and not completely attached.A review of the facility document titled Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol (last reviewed/revised on 3/20/24) was reviewed and revealed the following: Policy.Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing 9. Change of condition/New Skin alteration: A. Complete head to toe skin assessment, document in the medical record; .B. Notify Physician; .C. Obtain new orders as needed; .D. Notify the resident and resident's representative of all new and/or non/healing worsening PU/PI's; (Pressure Ulcers/Pressure Injuries) E. Complete new Norton's Plus scale; .F. Refer to Registered Dietician as needed; .G. Update plan of care to reflect any new risk, goals, and interventions; .H. Initiate significant change MDS as indicated.

Based on observation, interview and record review the facility failed to ensure residents were treated with dignity during nursing care for one resident (R59) out of two residents reviewed for dignity/respect. Findings include:Based on observation, interview and record review the facility failed to ensure residents were treated with dignity during nursing care for one resident (R59) out of two residents reviewed for dignity/respect. Findings include:On 8/12/25 at approximately 9:16 AM, Certified Nursing Assistance (CNA) T was observed changing R59. There was no privacy curtain wrapped around the resident's bed. R59 shared a room with two other residents. One resident was ambulating around the room and was able to observe the resident being changed. The Surveyor was interviewing another resident and had the potential to view R59 during care. CNA T left the room and R59 was sitting on the side of the bed. Their call light was on the floor.Following the observation, Nurse K was asked about the call light on the floor and the failure of CNA T to ensure R59's privacy curtain was used. Nurse K lifted the call light off the floor and noted that while the privacy curtain should have been used, they believed it was not working and when they tried to pull it around the resident it was not working. Nurse K reported that they would ensure it was fixed. Nurse K was asked if they knew how long it was not in working correctly but was not able to provide a date.On 8/14/25 at approximately 12:05 PM, R59 was observed sitting in their room. They were asked if their privacy curtain had been fixed. R59 noted they believed so, but was not certain and noted that they were legally blind. When asked about the incident that occurred on 8/12/25, R59 reported that they were not happy that they were exposed during care.On 8/14/25 at approximately 12:50 PM, the Administrator was asked about the facility's protocol for ensuring privacy during care. The Administrator reported that nursing staff should ensure residents privacy during care and noted that they were not aware of the situation that occurred on 8/12/25 and would ensure the privacy curtain was working correctly and discuss the concern with staff.The facility policy titled, Promoting/Maintaining Resident Dignity (10/26/23) was reviewed and documented, in part: 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.All staff members are involved in providing care to residents to promote and maintain resident dignity.maintain resident privacy.

Based on observation, interview, and record review facility failed to provide appropriate equipment (in a timely manner) for two residents (R176 & R177) of two residents reviewed for reasonable accommodation of needs. This deficient practice has the potential for accidents and improper care with feelings of frustration and dissatisfaction. Findings include:R176Record review revealed R176 was admitted to the facility on [DATE] for skilled rehabilitation and nursing needs after hospitalization. R176's admitting diagnoses included acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), morbid obesity, diabetes and pulmonary embolism (blood clot in lungs). Based on Brief Interview for Mental Status assessment (BIMS) dated 8/11/25 revealed a score of 15/15, indicative of intact cognition.An initial observation was completed on 8/12/25 at approximately 9:20 AM. R176 was observed laying on their bed. A few minutes later they were observed from the hallway outside of their room. They were observed sitting on the edge of the bed. When the surveyor walked into room R176 was observed sitting on the bed frame on the left side of the bed and the mattress was pushed over to the right. They had a 4 wheeled walker in the front. R176 reported that they came over to the facility last Thursday from the hospital. The room had two regular chairs and a regular wheelchair folded up. R176 was queried if they were comfortable and why they were sitting on the bed frame. They reported they needed something to sit on, and they were unable to sit on the mattress as their feet wouldn't touch the ground with the mattress. They were asked if they were comfortable sitting on the edge of the bed and if they could sit on a chair. R176 reported that they needed an extra wide chair and wheelchair the facility did not have any. They added that they were not comfortable sitting for an extended period of time on the edge of the bed without any back support and they had to sit on the edge of bed to watch television on the left side of the bed. R176 reported that they had a wide recliner chair in the hospital and stated that I hope I get a chair soon. R176 was queried about if they had spoken with any staff and they reported the staff members were aware and were unsure why they did not have an appropriate chair/wheelchair to sit on. During the conversation R176 was leaning back and forth to get themselves comfortable.During a follow-up observation on 8/12/25 at approximately 11:25 AM (from the hallway), R176 was observed sitting on the edge of their bed. They were rocking back and forth a few times; then they leaned forward on to their 4 wheeled walker and stood up to stretch their back and sat back down. They appeared uncomfortable.Later in the afternoon another follow-up observation and interview were completed at approximately 1:10 PM. R176 was in their room in bed. During this interview R176 confirmed again their concern about not having an appropriate chair to sit on and no one had spoken with them or provided any updates.Review of hospital discharge summary and the internal admission notification revealed the R176's height, weight and their need for bariatric equipment prior to admission to the facility on 8/7/25.During an interview with the unit manager (UM) V on 8/13/25 at approximately 9:15 AM they were queried why R176 did not have an appropriate chair or wheelchair to sit in the room and observations of R176 sitting on the bed frame trying to get themselves comfortable; UM V reported that they were going to order R176 a bariatric bed that goes lower and a wider chair/wheelchair. When queried further why did R176 not have the appropriate equipment since they were admitted (7 days) they did not provide any further explanation. R177Record review revealed R177 was admitted to facility on 8/7/25 after hospitalization for skilled nursing care and rehabilitation services. R177's admitting diagnoses included exacerbation of Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, Obstructive Sleep Apnea, morbid obesity, and hyperventilation syndrome. Based on Brief Interview for Mental Status Assessment (BIMS) dated 8/11/25, R177 had score of 15/15, indicative of intact cognition.An initial observation was completed on 8/12/25 at approximately 10:15 AM. R177 was observed in their bed. R177 was so close to the edge of the bed on the left side of the bed and there was approximately 3-4 inches of space on the right side of the bed. The bed did not have enough room to safely roll to the side. An initial interview was completed during this observation. They reported that they came over to the facility last Thursday. When queried about their bed to see if they were comfortable, R177 reported that the bed was too small and there was no room to turn; they had been lying flat on their back. They added that they were told that they were getting a wider bed on the day they were admitted to the facility, and they did not know why they still did not have one. They added that the bed did not have any bars to hold on and it was very tricky to turn in bed. They did not have a bariatric wheelchair or chair in their room. R177 had a roommate, and the room did not appear to have enough space to accommodate all the bariatric equipment.A follow-up interview was completed with the resident later that day at approximately 2:45 PM. During the interview R177 confirmed they had concerns about longer waiting times and over the weekend they had to wait several hours for help. They also confirmed that they had spoken with the staff and voiced their care concerns and their bed being too small.A follow-up observation was completed on 8/13/25 at approximately 9:25 AM. R177 was observed laying on their back in the same bed. They confirmed that no one from the facility had provided them with any updates about a wider bed.Review of R177's Electronic Medical record revealed a care plan dated 8/7/25. R177 needed two-person assistance with mobility in bed and toileting. Review of R177's discharge documents from the hospital revealed R177's height, weight and the need for bariatric set up prior to admission to the facility. R177's care plan dated 8/8/25 revealed that R177 needed a bariatric Hoyer lift for transfers.During an interview completed with UM V on 8/13/25 at approximately 9:15 AM they were queried about R177's bed and room set up. UM V reported they were ordering a wider bed for R177. They were queried why R177 did not have an appropriate since admission to the facility until the concern was brought to the attention of facility by the surveyor, UM V did not provide any further explanation.An e-mail was sent to the facility administrator on 8/13/24 at 9:23 AM requesting the grievances and facility follow-ups for R177 since their admission to the facility. The facility did not provide any grievance reports.An e-mail was sent to the facility administrator on 8/13/25 at 4:59 PM requesting proof of the order for R176 and R177's equipment. The facility provided the delivery document that beds were delivered on 8/13/25 later in the afternoon. The proof of delivery did not have any details on when the order was placed.On 8/13/25 at approximately 10:15 AM an initial interview was completed with the facility administrator. During this interview the Regional Director of Operations (RDO) DD was present in the room. They were notified of observations for R176 and R177 and concerns about not having the appropriate bariatric equipment. The administrator reported that the bed was ordered yesterday (8/12/25). They were queried about why they were not ordered when they were admitted to the facility, and they have been at the facility since 8/7/25 they did not provide any further explanation.An interview with Rehab Manager (RM) OO was completed on 8/13/25 at approximately 2:30 PM. They were queried of the wheelchair for R176, and they reported that physical therapy was trying some of their equipment from the facility but were also ordering a new wheelchair through a vendor. They were also asked why R177 could not have any enabler bars on the bed, and they stated they would follow up. They were notified of concerns about not having the right equipment since admission and they reported that they understood the rationale of the concern.An interview with customer service representative for the facility's rental equipment vendor PP was completed via phone 8/14/25 at approximately 9:20 AM. They were provided with the order number and queried when the order was placed. The representative PP reported that they would deliver all their equipment the same day. They checked the records and reported that they took the order from the facility on 8/13/25 before noon and the equipment was delivered on 8/13/25 in the afternoon.An interview with the Director of Nursing (DON) was completed on 8/13/25 at approximately 4:30 PM. They were notified of the equipment concerns for R176 and R177 and queried about their process. The DON reported that R176 and R177 were admitted through central admissions, and they did not have enough time to get the appropriate equipment before they were admitted . When queried further why they were not ordered for several days after the admission and until the concern was brought to the attention of the facility by the surveyor, they did not provide any further explanation. They reported that they understood the rationale for the concern.Review of facility provided document titled Accommodation of Needs with a revision date of 12/28/23 read in part, Policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered.Policy Explanation and Compliance Guidelines: 1. The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility.2. The facility will ensure that common areas frequented by residents are accommodating physical limitations and enhance their abilities to maintain independence.3. Facility staff shall make efforts to reasonably accommodate the needs and preferences of the residents as they make use of their physical environment.4. Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible.

Based on observation, interview, and record review the facility failed to ensure that catheter orders and monitoring were in place for one resident (R174) of one resident reviewed for catheter care resulting in the potential for infection and other complications. Findings include:On 8/12/25 at 9:43 AM, R174 was observed, lying in bed with foley Cather on ground and with no privacy bag. An attempt to interview R174 was made R174 was not verbal or able to understand questions.A review of the record revealed that R174 was readmitted to the facility on [DATE] with the medical diagnosis of Cognitive communication deficit, Alzheimer disease and dementia with a brief interview for mental status score (BIMs) that was skipped due to it not being conducted. A further review of the medical record indicated that there were no orders in place for a foley Cather nether was a care plan put into place. On 8/13/25 at 1:30 PM an interview was conducted with the Director of Nursing (DON), and asked what the protocol was with someone with a foley catheter. The DON reported that the resident should have a diagnosis, orders, privacy bag, stat lock (anchoring device), care plan and continuous monitoring. The DON was invited to observe R174. R174 was observed lying in bed with the foley catheter directly resting on the ground with no privacy bad. The DON then educated the nurse who was caring for R174 on the observed findings. The DON was asked did R174 have a diagnosis for a foley catheter, the DON reported they would have to check back.

Based on interview and record review facility failed to follow up timely about the grievances expressed by the resident and follow their grievance process for one (R177) of one resident reviewed for grievances. This deficient practice has the potential for dissatisfaction and frustration with the care/services received during their stay at the facility. Findings include: R177Record review revealed R177 was admitted to facility on 8/7/25 after hospitalization for skilled nursing care and rehabilitation services. R177's admitting diagnoses included exacerbation of Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, Obstructive Sleep Apnea, morbid obesity, and hyperventilation syndrome. Based on Brief Interview for Status Assessment (BIMS) dated 8/11/25 R177 had score of 15/15, indicative of intact cognition.An initial observation was completed on 8/12/25 at approximately 10:15 AM. R177 was observed in their bed. R177 was so close to the edge of the bed on the left side of the bed and there was approximately 3-4 inches of space on the right side of the bed. An initial interview was completed during this observation. They reported that they came over to the facility last Thursday. When queried about the services and care, R177 reported that the facility staff were not very responsive when they needed help, especially at night and weekends. When they were queried further they added that they had to wait several hours for assistance over the weekend when they had called for help and they were very concerned. When queried if they had spoken with any facility staff member about their concern; R177 reported that they spoke with the nurses and they did not remember their names. When queried about their bed if they were comfortable, R177 reported that it was too small and there was no room to turn. They added that they were told that they were getting a wider bed on the day they were admitted to the facility and they did not know why they still did not have one. They added the bed did not have any bars to hold on and it was very tricky to turn in bed, even with staff assistance.A follow-up interview was completed with the resident later that day at approximately 2:45 PM. During the interview R177 confirmed they had concerns about longer waiting times and the over the weekend when they had to wait several hours for help. They had also confirmed that they had spoken with the staff and voiced their care concerns and their bed being too small.Review of R177, the Electronic Medical Record revealed a care plan dated 8/7/25. R177 needed two-person assistance with mobility in bed and toileting.An e-mail was sent to the facility administrator on 8/13/24 at 9:23 AM requesting the grievances and facility follow-ups for R177 since their admission to the facility. The facility did not provide any grievance reports.Review of R177's Speech Language Pathology evaluation dated 8/9/25 revealed that R177's executive function, memory, and problem-solving skills were within functional limits.An initial interview with Unit Manager (UM) V was completed on 8/13/25 at approximately 9:15 AM. UM V was queried if they were of aware of any concerns regarding R177. UM V stated Yes and they heard about it yesterday. When queried further they initially reported they heard about care concern from a Certified Nursing Assistant (CNA) that R177 waited a long time for staff assistance. UM V then stated that they heard the concern from a nurse, who worked on the unit, but they were not a regular nurse for the unit. When queried further they reported they went and spoke with R177 with their Regional Director of Operations (RDO). UM V also added that they interviewed the staff who had worked on the unit.A follow-up observation was completed on 8/13/25 at approximately 9:25 AM. R177 was observed in the same bed laying on their back. They were queried if anyone from the management team had spoken with him about the concerns they had and followed up. R177 reported several staff members have been coming in and out; they did not know who they were and no one had asked them about their concerns.A follow-up interview with the Unit Manager (UM) V was completed on 8/13/25 at approximately 1 PM when they had approached the surveyor. UM V reported that they had spoken with R177 and they did not have any concerns. UM V also added that R177 reported that they were getting the care but not thorough care that staff were not wiping the resident clean. When queried further about their follow up when they had the concern they reported that they should have initiated the grievance process and followed up.During an interview with R177's family member (who were listed as the 1st emergency contact) on 8/14/25 at approximately 8:20 AM, they reported that their father had expressed concern about long waiting time to get staff assistance and they had waited over 4 hours to get staff assistance on one occasion. R177's family member also added that their father informed them that facility staff members were aware of their care concerns. An interview with the facility administrator was completed on 8/13/25 at approximately 10:15 AM. During this interview the Regional Director of Operations (RDO) DD was present in the room. The administrator was queried if they were aware of R177's care concerns and they reported that they went and spoke with R177 earlier that day and they did not have any concerns. They were notified of the interviews with the resident and the interview with UM V who were aware of the concerns that were reported by a staff member and queried about the expectations for their staff. The Administrator reported that staff and UM V should have followed their facility's grievance process. They were notified of the concern with follow up on R177's concern and both the administrator and RDO DD reported that they understood the rationale for the concern and staff should have followed the facility grievance process.An interview with Director of Nursing (DON) was completed on 8/13/25 at approximately 4:35 PM. They were notified of the R177's concern and interview with UM V and their response. They were queried about the expectations for their staff. The DON reported that the staff were expected to notify them of the concerns and should have initiated the grievance investigation/follow-up process. They were notified of the concern and they reported that they understood the concern.Review of facility provided document titled Quality Assistance Procedure with a revision date of 10/30/23 read in part, Policy: Residents, their representatives (sponsors), other interested family members, or resident advocates may file a Quality Assistance Form. The facility will provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. The facility will consider the views of a resident or family group and act upon the assistance request and recommendations of such groups concerning issues of resident care and life in the facility.Policy Explanation and Compliance Guidelines:1. Any resident, his or her representative (sponsor), family member, or resident advocate may file a Quality Assistance Form concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form.2. Upon admission, residents are provided with written information on how to file a Quality Assistance Form.3. Quality Assistance forms will be placed in areas of the facility for easy access by those wishing to issue a concern4. Quality Assistance request may be submitted orally or in writing. The administrator may delegate the responsibility of Quality Assistance investigation to appropriate department manager5. Upon receipt of a written Quality Assistance Form/request, the department manager will investigate the allegations and submit a written report of such findings to the administrator 6. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken.

This citation pertains to intake #2572077Based on interview and record review the facility failed to thoroughly complete a discharge summary for two residents (R172 and R173) of five residents reviewed for discharges. Findings include: R172 On 8/12/25 a concern submitted to the State Agency was reviewed which alleged R172 and R173 were inappropriately discharged from the facility. On 8/13/25 the medical record for R172 was reviewed and revealed the following: R172 was initially admitted to the facility on [DATE], had diagnoses including Edema and Cellulitis and was discharged on 9/7/24. A review of R172's MDS (minimum data set) with an ARD (assessment reference date) of 6/30/24 revealed R172 needed assistance from facility staff with most of their activities of daily living. R172's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A review of R172's Discharge to Home/Community/AL(assisted living)/Equal Care Setting assessment (a documented provided to the resident upon discharge that has a summary of their care) revealed the following areas that were left blank on the form: B. Nutrition and Allergies-1.Diet ordered by physician at time of discharge: [Blank]. 2. Calorie Information and Special Instructions: [Blank] .4.Dietary Recap: [Blank]. 5. Name of Dietary Services person completing section: [Blank] .D. Activities. 1. Activities Recap: [Blank] 2. 2.Name of Activities person completing section: [Blank] .E. Nursing Summary: Skin/Wounds: [Blank] .Assistance with Care and Activities of Daily Living: 2. Dressing [Blank]. 3. Bathing [Blank]. 4. Eating [Blank] 5. Toileting [Blank] .Devices:7. Assistive Devices (check all that apply) [Blank]. Recap: 8. Nursing Recap [Blank]. 9. Name of Nursing person completing section [Blank]. F. Medications: .2.At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? [Blank]. 3. At the time of discharge to another provider, did the facility provide the resident's current reconciled medication list to the subsequent provider? [Blank] .J. Discharge Services and Equipment: 1. Home Care Agency-[Blank] .3. Meal Agency-[Blank]. 4. State Ombudsman (include contact number)-[Blank] .Equipment-[Blank] R173 On 8/13/25 the medical record for R173 was reviewed and revealed the following: R173 was initially admitted to the facility on [DATE], had diagnoses including Presence of Pacemaker and [NAME] insufficiency and was discharged on 9/7/24. A review of R173' MDS (minimum data set) with an ARD (assessment reference date) of 9/5/24 revealed R173 required set-up assistance or supervision from facility staff with their activities of daily living. R173's BIMS score (brief interview of [NAME] status) was 15 indicating intact cognition. A review of R173's Discharge to Home/Community/AL/Equal Care Setting assessment (a documented provided to the resident upon discharge that has a summary of their care) revealed the following areas that were left blank on the form: B. Nutrition and Allergies-1.Diet ordered by physician at time of discharge: [Blank]. 2. Calorie Information and Special Instructions: [Blank] .4.Dietary Recap: [Blank]. 5. Name of Dietary Services person completing section: [Blank] E. Nursing Summary: Skin/Wounds: [Blank] .Assistance with Care and Activities of Daily Living: 2. Dressing [Blank]. 3. Bathing [Blank]. 4. Eating [Blank] 5. Toileting [Blank] .Devices:7. Assistive Devices (check all that apply) [Blank]. Recap: 8. Nursing Recap: n.a 9. Name of Nursing person completing section: n.a F. Medications: .2.At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? [Blank]. 3. At the time of discharge to another provider, did the facility provide the resident's current reconciled medication list to the subsequent provider? [Blank] .J. Discharge Services and Equipment: 1. Home Care Agency-[Blank] .3. Meal Agency-[Blank]. 4. State Ombudsman (include contact number)-[Blank] .Equipment-[Blank] On 8/13/25 at approximately 3:16 p.m., during a conversation with Social Work Director C (SWD C), SWD C was queried regarding the mostly blank discharge forms for both R172 and R173 and the lack of clinical information that was provided up on discharge and they indicated that they did identify the same issue around that time with facility staff failing to complete the discharge form, SWD C reported that each discipline in the facility should have filled out their sections completely. On 8/13/25 a facility document titled Discharge Planning Process was reviewed and revealed the following: Policy: It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions 1. Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary will be provided to the receiving care provider. The Discharge Summary should include a. An overview of the resident's stay that includes but not limited to: diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results' b. A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. c. Reconciliation of all pre-discharge medications with the resident's post discharge medication to include prescription and over the counter medications

This citation pertains to intake #1194668.Based on observation, interview, and record review, the facility failed to provide medically related social services related to discharge planning for one (R138) of one resident reviewed for social services. Findings include:Review of a complaint filed with the State Agency included allegations that R138 has expressed their desire to move to a different facility, but staff won't assist them with completing the transfer.On 8/12/2025 at 10:36 AM, R138 was observed lying in bed with oxygen via nasal cannula. When asked to review their concerns, R138 reported they have been wanting to go to another nursing home and have been asking social work staff for months, but nothing is being done. They further reported they were supposed to transfer to another nursing home and wanted to be back in the Detroit area and had a facility set up in March 2025, but they ended up being hospitalized around the time of transfer and instead of going to the new nursing home, they returned to the current facility. When asked what they have been told by the facility's social service staff, R138 stated they tell me they have spoken to different social service staff and are told they are looking into it but have had no follow-up.Review of the clinical record revealed R138 was admitted into the facility on [DATE], discharged on 3/6/25 and readmitted on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia, morbid obesity due to excess calories, other pulmonary embolism without acute cor pulmonale, fracture of unspecified part of neck of right femur (3/13/25), contracture of muscle in right and left lower legs, unilateral primary osteoarthritis right knee, and repeated falls.According to the Minimum Data Set (MDS) assessment dated [DATE], R138 had intact cognition, had no behavior concerns, and did not have an active discharge plan to return to the community.According to the profile section of the electronic medical record (EMR), R138 was identified as their own responsible party for both financial and clinical needs.Review of the care plans included:Resident plans to discharge to Another SNF (Skilled Nursing Facility/Nursing Home) Clinic. This was initiated on 4/28/25. There were only two interventions which read, Coordinate care/discharge with new facility upon discharge (initiated 4/28/25), and Encourage resident/family/responsible party to participate in the discharge planning process. (initiated 4/28/25).Review of the social service progress notes revealed no documentation of what attempts had been completed to transfer R138 to another nursing home.Review of the social service assessments since March 2025 included:Social Service Progress Review - V 10 dated 6/9/25, locked 6/11/25 documented, .Things that make you become anxious/agitated: Being here .Has accepted placement .2. No .Describe .wants to transfer .Describe and indicate any interventions being used to address placement acceptance .Looking for relocation .Review of Discharge Plan .Looking to transferring to another SNF Clinic .Referral Status .none . Social Service Progress Review - V 10 dated 7/28/25 - locked 7/30/25 documented, .Things that make you become anxious/agitated .Being here in a facility .Has accepted placement .2. No .Describe .Wants to transfer .Review of Discharge Plan .LTC (long term care) until able to transfer .Referral Status .(blank) .On 8/13/25 at 11:45 AM, an interview was conducted with the Social Service Director (SSD ‘C') who reported they had been in their role since July 2024. SSD ‘C' further reported there have been several changes since the last recertification survey in the social service staff and they were currently the only licensed social worker. SSD ‘C' reported Social Service Assistant (Staff ‘D') had only been working at the facility for a short time.When asked if they were aware of R138's desire to transfer to another facility, SSD ‘C' reported they were. When asked what had been done to assist with this process, SSD ‘C' reported R138 was set up to transfer to the facility they wanted but it didn't work out. SSD ‘C' reported they attempted to transfer to other facilities but further reported the resident wanted a specific lift (this was not identified in the resident's clinical record - in progress notes, care plans, or social service assessments). SSD ‘C' reviewed the documentation available for R138 and confirmed there was no other details included as to what facilities had been attempted, or any other specifics details. SSD ‘C' reported they would follow-up with Staff ‘D', however there was no further follow-up or documentation provided by the end of the survey.According to the facility's policy titled, Discharge Planning Process dated 10/20/2023: .The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge .The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community .The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities .The facility will assist residents and their resident representatives in choosing an appropriate post-acute care provider (i.e. another SNF .that will meet the resident's needs, goals and preferences .The Social Services Director, or designee, shall compile available data as needed on other post-acute care options to present to the resident, including, but not limited to .Data on providers within the resident's desired geographic areas, where available .

Based on observation, interview and record review, the facility failed to ensure routine dental services were provided for one resident (R18) of one resident reviewed for ancillary services. Findings include:On 8/12/2025 at approximately 11:50 a.m., R18 was observed in their room, up in their wheelchair. R18 was observed to not have any teeth with their gum lines showing. R18 was queried if they have ever seen a dentist at the facility to examine their gums or to get dentures and they indicated they have not but would like dentures to be able to eat harder foods. On 8/13/25 at approximately 8:45 a.m., R18 was observed in their room, eating breakfast. R18 was queried regarding their ability to eat their soft breakfast, and they reported that they cannot eat anything hard because they have no teeth. On 8/13/25 the medical record for R18 was reviewed and revealed the following: R18 was initially admitted to the facility on [DATE] and had diagnoses including Dysphagia and Heart Failure. A review of R18's MDS (minimum data set) with an ARD (assessment reference date) of 5/20/25 revealed R18 needed supervision from facility staff with most of their activities of daily living. R18's BIMS score (brief interview of mental status) was 10 indicating moderately impaired cognition. A dietary note dated 4/8/25 revealed the following: Resident being seen for weight loss. Weight trend: 5.6%/8.6# x1 month and -10.4%/16.8# x6 months. Weight previously stable x5months. CBW (current body weight) 144.6# with BMI (body mass index) 29.2. Reviewed CBW/wt trend with resident- reports she has been consuming roughly two meals a day and that she does not wish to lose more weight. States she has been eating her chips and sodas. Observed chip stash and a bag of eaten chips at bedside.Resident had c/o (complaints of) pain on L (left) arm and did have x-ray 2/27/25 that revealed humeral fracture. Hospital records for evaluation showed dx (diagnosis) of bone contusion. Follow up x-ray on L arm was negative for fractures. Current diet order: Regular diet, Level 3 texture, Regular fluid, thin consistency- resident states she consumed pizza from outside the facility for lunch today. Referred to SLP (speech and language pathologist) for potential diet upgrade. Resident states she would also like to see if she can get dentures r/t (related to) she is edentulous (without teeth). Collaborated with social work. A Psychiatry evaluation dated 4/9/25 revealed the following: Abnormal weight loss *: Patient has experienced a 6 pound weight loss over 1 month (5% loss) and a 16 pound weight loss over 6 months (10% loss). Patient reports she is only accustomed to eating 2 meals a day instead of 3 but states she will try to increase to 3 meals daily after being notified of weight loss. Dietitian reports patient needs new dentures which is making eating difficult. Will monitor weight closely, consider dental evaluation for new dentures, and consider nutritional supplements if weight loss continues . A review of R18's routine dental consultations did not reveal any dental examinations/consults in their record since 3/5/22. On 8/13/25 at approximately 3:04 p.m., the facility Social Work Director C (SWD C) was queried regarding the lack of dental consults for R18 and R18's indications of wanting dentures in April 2025 due to their weight loss. They indicated they were unaware of the need of R18 to see the dentist would make sure they were seen on the next scheduled examination date. SWD C indicated they previously had some issues with dental services but did not know about R18's need for a referral to be seen for dentures.

Based on observation, interview and record review the facility failed to ensure proper infection control protocols and practices for implementation of enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two (R5 and R10) of three residents reviewed for infection control. This deficient practice has the likelihood to result in cross-contamination and the spread of infection and disease. Findings include:R10 Record review revealed R10 was admitted to the facility on [DATE] for skilled nursing and rehabilitation services after hospitalization. R10’s admitting diagnoses included sepsis, Urinary Tract Infection (UTI) complicated, with Extended Spectrum Beta-Lactamase resistance (ESBL) (ESBLs are enzymes that specifically target and degrade certain antibiotics, rendering them ineffective), history of viral hepatitis, reduced mobility and weakness. An initial observation was completed on 8/12/25 at approximately 10:20 AM. R10 was observed in their bed. R10’s door had a signage that read “Enhanced Barrier Precautions” and the door had a holder with Personal Protective Equipment (PPE – gown, mask, and gloves). Based on definition from Centers for Disease Control and Prevention (CDC) EBPs are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). Review of R10’s Electronic Medical Record (EMR) revealed dated 7/23/25 that read, “Use enhanced barriers while performing high-contact activity with the resident related to ESBL (extended sprctrum betalactamase) every shift”. Further review revealed that R10 was still receiving antibiotics for their infection diagnosed during the hospital stay. An order dated 7/23/25 read “Fosfomycin Tromethamine Oral Packet 3 GM (gram) (Fosfomycin Tromethamine) Give 1 packet by mouth one time a day every Fri for ESBL for 30 Days”. Review of discharge orders from hospital in the hospital transfer form dated 7/23/25 read in part, “Place patient in contact isolation for E. coli ESBL positive in urine…”. Based on definition from CDC contact isolation/precautions are described as specific measures taken to prevent the transmission of infectious agents that are spread by direct or indirect contact with the resident or their environment. Contact precautions require healthcare personnel to wear gowns and gloves every time they enter a resident's room. Contact precautions are implemented for residents with known infections that can be transmitted through contact. Review of facility’s internal admission communication memo included with the hospital referral had resident admission details (diagnosis, admission date/time, room number, physician etc.) and had “contact isolation: ESBL in urine”. During the follow up observation completed on 8/13/25 at approximately 8:35 AM, R10 was observed in their bed. Room door had the same signed that read “Enhanced Barrier Precautions”. An interview with Registered Nurse (RN) “I” was completed on 8/13/25 at approximately 8:45 AM. They were queried about the signage on the door and why. RN “I” reported that R10 had UTI (urinary tract infection), and it was colonized (Colonization means bacteria are present and growing on or inside a person/animal without causing any noticeable illness or harm) and that is why R10 was on EBP. When RN “I” was queried about the current antibiotics that R10 was on and the discharge orders from the hospital, RN “I” reported that R10 should have been contact precautions not EBP and they got this resident confused with another resident. They added they would let the Infection Preventionist know. An interview with the facility’s infection preventionist (IPC) “GG” was completed on 8/13/25 at approximately 11:35 AM. They reported that they recently accepted the Infection Preventionist role on an interim basis. They were queried about R10 and the current orders for antibiotics and discharge orders from the hospital and why this resident was on EBP and not on contact precautions. IPC “GG” reviewed the EMR and reported that R10 should have been on contact precautions, not EBP. IPC “GG” was notified of the concern and agreed and reported that they would update the orders, care plan, and change the signage on the R10’s room door. At approximately 12:45 PM, the signage on R10’s room door read “CONTACT PRECAUTIONS”. Two staff members from the therapy department were observed entering into R10’s room with no PPE and the door was closed. A few minutes later they were observed when the door was opened, and they exited the room, which was brought to the attention of the unit manager (UM) “V” who were in the hallway outside R10’s room. UM “V” was notified of the concern, and they reported that all staff should be following the precautions as ordered. An interview with the Director of Nursing (DON) was completed on 8/13/25 at approximately 4:25 PM. They were notified of the concerns. DON reported that their team would review the discharge records from hospital and would make a decision for appropriate precautions. They added that IPC “GG” was covering in the current role on an interim basis and might have received guidance from other team members. When queried about staff expectations for PPE use, the DON reported that they were notified by the nursing team about staff members not using appropriate PPE and they understood the concerns. On 8/14/25 at approximately 4:25 PM, the facility administrator and Regional Director of Operations (RDO) “GG” were notified of the concerns. The administrator reported that they were aware of the concerns and they did not have any questions. A facility provided document titled “Infection Prevention and Control Program” with a revision date of 12/27/23 read in part, “Policy: this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Definitions: “Staff” includes facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facilities nursing aid training programs or from affiliated academic institutions. Policy Explanation and Guidelines: 1. The designated infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. Staff are responsible for following policies and procedures related to the program. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating and controlling infections and communicable diseases for residents, staff, volunteers, visitors and other individuals providing services under a contractual agreement based upon a facility assessment and accepted national standards. b. The infection preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and report surveillance findings to the facilities quality assessment performance improvement. c. Licensed nurses participate in surveillance through assessment/evaluation of residents and reporting changes in condition to the resident’s physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. 4. Standard Precautions: a. Staff shall assume that all residents are potentially infected or colonized with an Organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facilities established hand hygiene procedures. c. Staff shall use personal protective equipment (PPE) according to established facility policy. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. e. Environmental cleaning and disinfection shall be performed according to facility policy. Staff have responsibilities related to the cleanliness of the facility and should report problems outside of their scope to the appropriate department. 5. Isolation Protocol: (Transmission Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by the current CDC guidelines. b. And residents on transmission based precautions should be placed into a private or single room if available/appropriate, are cohorted with other residents with the same pathogen, or share a room with the roommate with limited risk factors, in accordance with national standards next bullet C residents should be placed on the least restrictive transmission based precaution one of the shocked us to duration possible under the circumstances. c. When a resident on transmission-based precautions must leave the residents’ care or unit in nurse will, that unit shall communicate to all involved departments the nature of isolation and shall prepare the resident for transport in accordance with the current transmission-based precaution guidelines d. When a resident on transmission-based precautions must lead the resident care unit in nurse on that unit dash area shall communicate to all involved departments nature of isolation and shall prepare the resident for transport in accordance with the transmission-based precaution guidelines….”. R5 On 8/12/2025 at 9:36 AM, R5 was observed lying in bed, asleep and did not awaken upon entry to the room. There was no signage posted on the door, but there was an over the door PPE (Personal Protective Equipment) caddy that contained disposable gowns, surgical masks, and gloves. On 8/12/2025 at 9:38 AM, a Certified Nursing Assistant (CNA) approached the room and started to grab PPE that was hung from the door, but then was redirected by staff and left to go down the hallway. On 8/12/2025 at 9:40 AM, Nurse ‘F’ was asked about the PPE on R5’s door and they reported they weren’t their nurse but would find out. A quick review of the electronic medical record (EMR) revealed R5 had current orders for EBP that were in effect since 2/13/25 for due to a wound. On 8/12/25 at 9:42 AM, Nurse ‘F’ returned and reported it was because the bed to the right of R5 has a dialysis port. On 8/12/25 at 9:43 AM, a CNA returned to the room with another CNA and began talking to R5 about getting them cleaned up and dressed for the day and closed the door. None of the nursing staff were observed to don/doff any PPE upon entry, or upon exit from the room. There were no disposable gowns observed in the trash can in the room. On 8/12/25 at 10:13 AM, R5 was now observed dressed and seated in a wheelchair. Their entire right foot was observed to be wrapped in white bandages with a piece of tape dated 8/12/25. Continued observations of R5 on 8/13/25 revealed there was no signage placed that indicated what, if any precautions were in place. Review of the clinical record revealed R5 was admitted into the facility on 8/21/24 and readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus with other specified complication, Alzheimer's disease with late onset, paranoid schizophrenia, other encephalopathy, and arterial ulcer. According to the MDS assessment dated [DATE], R8 had BIMS 9/15, had no venous or pressure ulcers but is at risk. Further review of the progress notes included: An entry on 8/11/25 at 6:53 AM read: “Skin Issues: Skin Issue: #001: Skin issue has been evaluated. Location: Right Dorsum 2nd Digit (Second toe). Issue type: Arterial. Progress: Stable: previously deteriorating wound characteristics plateaued. Wound acquired in-house. It is unknown how long the wound has been present….Staged by: In-house nursing. Length (cm) (Centimeter): 0.54 Width (cm): 0.73 Depth (cm): 0.2 Area (cm2) (cubic centimeter): 0.31 Undermining: No. Tunneling: No. Epithelial: 20%. Granulation: 80%. Slough: 0%. Eschar: 0%. Exudate amount: Moderate. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Other: pink or red. Periwound: Attached. Surrounding tissue: Maceration. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Moderate 26-75%. Cleansing solution: Generic wound cleanser. Primary dressing: Calcium alginate. Secondary dressing: Dry. Modalities: None. Additional care: Incontinence management. Additional care: Turning / repositioning program. Additional care: Moisture barrier. Additional care: Mattress with pump.Skin Issues Note: Wound is stable. Treatment is Calcium Alginate, Dry Dressing.Skin issue education: Turn every 2 hours. Skin issue education: Change / shift positions frequently. Skin issue education: Moisture barrier. Skin issue notification: Guardian. Skin issue notification: Provider.” Review of the current physician orders included: Cleanse with wound cleanser. Pat dry. Apply Calcium Alginate as directed to Right Dorsum 2 nd Digit (Toe). Cover with Dry Dressing every day shift for wound care AND as needed for wound care. This order started on 8/12/25. (There were previous wound care orders in place prior to this order.) Use enhanced barriers while performing high-contact activity with the resident. For wound every shift. This order started on 2/13/25. On 8/13/25 at 11:25 AM, an interview was conducted with the current Infection Preventionist (IP ‘A’). They reported they were in their role as Interim IP since about 6/20/25. When asked to explain how the facility implemented EBP and determined who was on and what should be done, IP ‘A’ reported they usually discussed that in team meetings and coordinated with the wound care nurse to identify which resident has wounds and reported anyone with wounds would require EBP. When asked about R5's wounds, they reported they received information from the wound care nurse it was resolved and they thought it was the end of last week. When informed of the concerns that R5 was observed with wound care treatment since 8/12, has current orders for EBP and wound care notes with measurements of current wounds, IP ‘A’ reported if the resident no longer had wounds, the wound care nurse would change the order to discontinue EBP. When asked what would be implemented for a resident that was on EBP, IP ‘A’ stated there would be signage on the door, an orange dot by their name, gowns, gloves and hand sanitizer that’s to be used on the walls and all nursing carts. IP ‘A’ was informed of the observations of lack of EBP use and knowledge from staff of R5 being on EBP and they reported they would have to follow-up. There was no additional information provided by the end of the survey. On 8/14/25 at 11:56 AM, further review of the physician orders included: Use enhanced barriers while performing high-contact activity with the resident r/t (related to) wound. every shift. Active start date 8/13/25. According to the facility's policy titled, Enhanced Barrier Precautions (EBP) dated 3/26/2024: .Initiation of Enhanced Barrier Precautions .an order for enhanced barrier precautions will be obtained for residents with any of the following .wounds (e.g., chronic wounds such as pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers .Indwelling medical devices .Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply .Implementation of Enhanced Barrier Precautions may include but is not limited to .Make gowns and gloves readily available near or outside of the resident's room .Position a trash can for discarding PPE after removal, prior to exiting the room or before providing care to another resident in the same room .High-contact resident care activities to consider include .Dressing .Providing personal hygiene .Changing briefs or assisting with toileting .

Based on observation, interview, and record review, the facility failed to obtain physician orders for two residents (R176 & R95) of three residents reviewed for respiratory care resulting in the potential for respiratory difficulties related to no orders for R176's Bi-level Positive Airway Pressure (BiPAP - a breathing aid/machine that helps people with breathing difficulties) and no orders for R95's tracheostomy care/speaking valve (a surgical procedure that creates an opening in the trachea/windpipe to allow for breathing and/or to remove secretions). Findings include: On 8/12/25 at 9:51 AM, R95 was observed in their room with their eyes closed, lying in bed with a tracheostomy(trach) which had a purple speaking valve to assist the resident with communication and speech. R95 was on room air (breathing on their own without supplemental oxygen), with suction and trach supplies set up near the bed. A review of the record revealed R95 was admitted to the facility on [DATE] with the medical diagnosis of Trach Status, Muscle weakness and cough with a Brief interview for mental status (BIMs) of 15 completed on 6/12/25 indicating no cognitive impairments. A further review of the record reveal that R95 did not have any orders to monitor, clean, or check the speaking valve. On 8/12/25 at 12:07PM, an interview with the Director of Nursing (DON) was conducted The DON was asked for the protocol with residents with a speaking valve, should there be monitoring order, cleaning orders and/or periods of rest noted? The DON explained that they would reach out to the corporate Respiratory therapist to clarify speaking valve orders/protocol. No additional information, was provided by the exit of survey. R176 Record review revealed R176 was admitted to the facility on [DATE] for skilled rehabilitation and nursing needs after hospitalization. R176’s admitting diagnoses included acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), morbid obesity, diabetes and pulmonary embolism (blood clot in lungs). Based on the Brief Interview for Mental Status assessment (BIMS) dated 8/11/25, R176 had intact cognition. An initial observation was completed on 8/12/25 at approximately 9:25 AM. R176 was observed laying on their bed. They reported that they came over to the facility last Thursday from the hospital. They reported that they had been using a BiPAP machine at home for years and they also had one while they were at the hospital. They pointed to a machine that was on the nightstand on the left side of their bed and reported that the facility provided a CPAP ((Continuous Positive Airway Pressure machine that delivers the same pressure during both inhalation and exhalation) and they were unsure why they did not have the right machine (BIPAP). R176 also added that they were using the unit the facility had provided them with as they needed something to sleep. A follow up observation and interview was completed later that day at approximately 1:10 PM. During this interview R176 confirmed again their concern about not having the right breathing aid. They reported that they can feel the difference but they needed to use something so they could sleep. R176 also confirmed that they had not received any information from the nursing staff on the rationale. Review of R176’s hospital discharge summary revealed that R176 was admitted to the hospital with diagnosis of acute on chronic respiratory failure with hypoxia and hypercapnia, Obstructive Sleep Apnea (sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage in airway) and was on BiPAP. Review of hospital discharge orders revealed a BiPAP order that read: BiPAP Set Rate-12 Breaths/min; IPAP (Inspiratory Positive Airway Pressure-18 CmH2O; EPAP/Expiratory Positive Airway Pressure)-5 CmH2O; Minute Ventilation:13.3 L/min. Review of facility admission orders did not reveal any orders for BiPAP and the admission care plans that did not reveal any care plan that R176 was receiving any BiPAP. Review of R176’s nursing admission progress notes from 8/7/25 did not reveal any documentation on BiPAP. A nursing progress note dated 8/13/25 at 2:13, read, “Resident CPAP (Continuous Positive Airway Pressure) is on….”. It must be noted that CPAP is a different breathing aid than BiPAP with no physician order. An interview with Registered Nurse (RN) “I” who was assigned to care for R176 was completed on 8/13/25 at approximately 8:35 AM. RN “I” was queried about the equipment that R176 had at their bed side. RN “I” confirmed that it was a CPAP (not BiPAP that was ordered at discharge) that R176 used at nighttime and they confirmed that there were no physician orders. They added the admitting nurse verified that residents had the right equipment and had placed those orders in the chart. They added that they would call the attending physician and obtain orders and would ensure that they had the right equipment and set-up. An interview with Unit Manager “V” was completed on 8/13/25 at approximately 8:55 AM. They were questioned about the process for obtaining physician orders for appropriate equipment that was ordered upon discharge from the hospital and how did they ensure that they had the appropriate set up as ordered by the physician. UM “V” added that the equipment was ordered through their vendor; the admitting nurses ensured the accuracy of the settings and unit manager would follow up after. They were queried about R176’s equipment and concerns with residents not having the right equipment and no physician order for the equipment they had at bedside. UM “V” reviewed the medical record and confirmed that R176 should have orders for BiPAP upon admission there were no orders and they were unsure of the equipment that R176 was currently using. They added they would call the attending physician and obtain an order and would add them to their care plan. UM “V” also confirmed that they did not have any respiratory therapist to ensure that R176 had the right equipment and set up. UM “V” was notified of the concerns and they reported that they understood the rationale for concern and they would follow up. An interview with the Director of Nursing (DON) was completed on 8/13/25 at approximately 4:15 PM. The DON was questioned about the process for obtaining physician orders for the equipment that was ordered and to ensure the accuracy of the settings. The DON reported that the equipment was ordered by their admissions coordinator based on the discharge orders from the hospital and the admitting nurse ensured the orders were in place as well as the accuracy of the equipment settings. They were notified of the concerns for R176 and they reported that they understood the concerns. An interview with the facility administrator was completed on 8/13/25 at approximately 10:15 AM. During this interview the Regional Director of Operations (RDO) “DD” was present in the room. They were notified of the concerns of R176 not having the physician orders for BiPAP that was ordered upon discharge and nursing staff not following up to ensure the R176 had the right equipment with the right settings as ordered. Review of the facility provided document titled “Positive Airway Pressure (PAP) Therapy” with a revision date of 6/23/25 read in part, “Purpose: Positive Airway Pressure therapies have a wide range of applications in nursing home facilities. Health benefits of appropriately administered PAP therapy depend substantially on selection of the appropriate delivery device, input of accurate pressure level settings, correct application of delivery interface and equipment, and compliance from the user. It is imperative that knowledgeable and competent healthcare personnel are present in the setup, initiation, and monitoring of PAP therapies. Definitions: Continuous Positive Airway Pressure (CPAP) - One continuous pressure delivered and maintained throughout the respiratory cycle. Bi-level Positive Airway Pressure (BiPAP) - One level of positive pressure is delivered for inspiration, followed by a decrease to a second set pressure to allow for expiration. Average Volume Assured Pressure Support (AVAPs) - Provides a targeted tidal volume by automatically adjusting the inspiratory pressure support within a set range. Auto-adjusting Positive Airway Pressure (APAP) - Continuous delivery of pressure, with the delivered pressure fluctuating to meet the users ventilatory needs based on previous breaths taken. Procedure Explanation: Any method of PAP therapy administration must have an order in the residents EMR by a licensed provider to include the mode, pressure settings, liter flow of oxygen if applicable, and frequency of use. The respiratory therapist provides assistance to the residents in initiating therapy, ensuring the interface mask or pillows fit appropriately and comfortably and provide documentation in the residents EMR (electronic medical record). If a respiratory therapist is not assigned to the unit, therapy is only to be applied by knowledgeable and competent personnel…”.

This citation pertains to Intake Number(s): MI00152656 Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property and the facility's investigation into the allegation to the State Agency within the required time frame for one (R802) of three residents reviewed for misappropriation of property. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 4/11/25 at 11:48 AM revealed an allegation that the facility did not prevent misappropriation of R802's property (a pink wallet). On 5/28/25, on unannounced, onsite investigation was conducted. A review of R802's clinical record revealed R802 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on 4/9/25 with diagnoses that included: systemic lupus erythematosus. A review of R802's Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had moderately impaired cognition and no behaviors. A review of a Nurse's Note progress note dated 4/5/25 revealed, Resident alert and able to make own needs known. Reported to this writer at around 0230 (2:30 AM) that she was missing 2 wallets from her purse. She stated that the 2 wallets are pink in color and one of them had her state ID (identification) and her Social Security card. The administrator called and was notified. A review of an investigation conducted by the facility revealed the following: A Quality Assistance Form dated 4/6/25 that documented staff communicated to the Administrator R802 reported they were missing a pink wallet. It was assigned to Housekeeping Supervisor (HS) 'A' to review and the documented findings noted, Will search laundry for 2 days and follow up with (R802). The section for Plan/Actions was left blank. The following was documented in the resolution section, Search for 2 days. Nothing was found. The form was signed by HS 'A' on 4/9/25 and the rest of the form was blank and did not indicate R802 was followed up with. A typed document (investigation) revealed the following: .(Facility Name) - Misappropriation .Date of Incident: 4/11/2025 (It should be noted that according to the progress note and Quality Assistance Form mentioned above, R802 reported a missing wallet on 4/5/25) .BIMS (Brief Interview for Mental Status): 15 (A score of 15 indicated R802 had intact cognition) .Documentation of Notifications .State Survey Agency: 4/11/2025 (six days after R802 initially reported the missing wallet according to the progress note in the clinical record) .On 4/5/2025, (Certified Nursing Assistant - CNA 'F') called Admin (Administrator) around 2:30am and stated (R802) said she is missing her wallet. (CNA 'F') stated she searched the entire room and found 2 wallets. At that time (R802) said those are not the wallets she was looking for, it was a pink wallet. The wallets that were found were both black. (R802) insisted she had a pink wallet. Admin reported the missing wallet to (HS 'A') and instructed her to search laundry to see if the wallet was send <sic> down in the resident's sheets by mistake. (R802) does not usually get out of the bed and keeps her personal item in the bed with her. (R802) stated she was not accusing anyone of stealing the wallet but she needs to locate it because he <sic> identification and social security card is in the wallet . .(HS 'A' ) stated she search laundry for 2 days 4/6 and 4/7 to see if the wallet would be in laundry. She reported being unable to locate a wallet . .(R802's roommate) reported that she knows (R802) has a purse that she keeps her personal items in and she knows she has a wallet .unable to identify what color the wallet is due to (R802) having several items .(R802) rarely leaves the room and she always keeps her purse in bed with her . .On 4/8 (three days after R802 reported the missing wallet) (R802) was experiencing a change of condition and was unable to speak due to having a sore throat. She was unable to give further input about the missing wallet . .On 4/9 (R802) was sent to the hospital due to change of condition . .On 4/11 (R802's sister) came to the facility and stated some <sic> had stolen (R802's) wallet out her purse before she was sent to the hospital and she called the police to come and search her room. She reported her state ID card and her social security card was in the wallet . .(R802) remains hospitalized as of 4/16 . .Determination .In conclusion, the facility COULD NOT substantiate misappropriation. (R802) nor her sister were able to identify anyone who may have stolen the resident's wallet. The resident remains hospitalized and unable to assist with further investigation efforts . A Statement of Witness form indicated CNA 'F' was interviewed via telephone by the Administrator on 4/16/25. It was documented on the form that the date of the incident was 4/5/25. The Statement of Witness noted, Admin received a phone called that (R802) said her wallet was missing. When she and nurse .searched the room they found 2 wallets but (R802) said those were not the ones and she had a 3rd one that is pink that she cannot find. It has her ID and SS (Social Security) care in it. A second Statement of Witness form indicated R802's sister was interviewed via the telephone by the Administrator on 4/16/25. The following was documented as the statement, Admin called (R802's sister) over the phone to get more info on the missing wallet. (R802's sister) stated it was a missing purse. Admin stated (R802) had told her it was pink wallet. (R802's sister) was still there in the hospital with (R802) and she asked her what was missing. (R802) confirmed it was her wallet with SS card and state ID. The third and final Statement of Witness form indicated R802's roommate was interviewed on 4/16/25 and documented what was included in the summary mentioned above. There was no indication in the investigation summary or the Statement of Witness forms that any other residents were interviewed to determine if anyone else was missing personal items. There was no evidence that R802 was interviewed outside of the initial allegation being made on 4/5/25. There was no evidence that any other staff members were interviewed other than CNA 'F' who R802 reported the allegation to. On 5/28/25 at 12:33 PM, an interview was conducted with the Administrator, who was the Abuse Coordinator for the facility. When queried about what was done to investigate R802's allegation of a missing wallet that contained her ID card and SS card, the Administrator reported she completed a concern form and asked Housekeeping Supervisor (HS) 'A' to check in the laundry but nothing was found. When queried about what was done to investigate further when no wallet was found in the laundry, the Administrator reported when the staff called her on 4/5/25 and said R802 had multiple wallets I assumed that was one of them. When asked if R802 was interviewed to obtain more information about the missing wallet, the Administrator said she did not interview her. The Administrator explained that she reported the missing wallet to the SA on 4/11/25 after R802's family called and said R802's wallet was stolen prior to her going to the hospital. The Administrator reported R802 had a lot of stuff in her room and never said it was stolen just missing and further explained that she would not assume any missing item was stolen and would just try to find the item so when R802 told the staff her wallet was missing on 4/5/25, the Administrator said if the resident told her it was stolen she would have investigated it as stolen. However, the Administrator did not talk to the resident at that time and stated, I don't have to talk to her to see if it was missing or stolen. When queried about what was done to investigate the missing wallet after R802's sister reported it as stolen, the Administrator reported R802's roommate was interviewed. The Administrator reported she did not interview any other residents to determine if anyone else in the facility had missing items and stated, Nobody reported anything missing. The Administrator reported by the time R802 was in the hospital she was unable to be interviewed. The Administrator reported no additional staff were interviewed about the wallet. .A review of the facility's policy titled, Abuse, Neglect and Exploitation reviewed/revised on 1/10/24 revealed, in part, the following, .An immediate investigation is warranted when suspicion of abuse, neglect, and exploitation, or reports of abuse, neglect or exploitation occur .Written procedures for investigations include .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations .Providing complete and thorough documentation of the investigation .

This citation pertains to Intake(s): MI00144759 & MI00144593. Based on observations, interviews, and record reviews the facility failed to implement measures/restrictions implemented by the County's health department after the identification of a facility resident diagnosed with presumptive healthcare associated Legionella (a type of bacteria that causes pneumonia), failed to timely and accurately conduct surveillance of the facility's infections, and failed to ensure water management meetings were being conducted as documented in the facility's policy for three residents (R705, R706 and R708) of six reviewed for infection control. This had the ability to also affect 140 of 140 residents that resided in the facility at the time of the survey, resulting in non-compliance with the local Health Department/County's Epidemiologist restrictions and the risk of growth and spread of Legionella. The facility failed to maintain an effective infection surveillance program and failed to conduct water management meetings as indicated in the facility policy, which resulted in an Immediate Jeopardy (IJ). The IJ was identified on 6/13/24 at 1:00 PM. The IJ began on 5/21/24. The Assistant Administrator (AA) B who was the acting Administrator in the absence of the facility's Administrator during the survey was notified of the IJ on 6/13/24 at 4:10 PM, and a plan of removal was requested to remove the immediacy. The IJ was removed and verified on 6/13/24 based on the provider's implementation of removal. Although the immediacy was removed the facility's deficient practice was not corrected and remained widespread with the potential for harm that is not immediate jeopardy. Findings include: Review of an email sent from the County's Epidemiologist (CE) A dated 5/15/24 at 12:10 PM, documented in part .Thank you for meeting with us today. As mentioned on the call, this case is what CDC (Centers for Disease Control and Prevention) considers a presumptive healthcare associated case in that the case spent the 10 days prior to symptom onset at the facility. The (county name) County Health Division will be completing an environment investigation at your facility (date and time) .While the investigation and environmental sampling are pending, the Health Division is making the following restrictions .Continue or immediately begin surveillance - order urinary antigen tests and a respiratory sputum panel with Legionella cultures for any resident with clinical presentation consistent with pneumonia. Ideally, the specimen collection for culture and urinary antigen tests should be done simultaneously, and if possible, before initiation of antibiotic therapy. Reporting a number of patients with those symptoms in the last six months and testing for those with symptoms in the last month will suffice. Please report any results back to me .Identify the water/plumbing system that serves the case's room. Begin bottled water and ice restrictions for all patient rooms/areas on the water system. Water and ice received through a filter of 0.2 microns can be used instead .It is imperative to order and install the filters as soon as possible in order to use the water system. Filters are recommended to be maintained and replaced according to manufacturer recommendations .Remove aerators from all sink faucets. Avoid using sinks in resident rooms until 0.2 micron filters can be installed on faucets . This email was addressed to the facility's Administrator and Corporate personnel. The survey team entered the facility on 6/12/24 for an unannounced survey and was escorted to a room with an attached bathroom. The bathroom sink did not have a filter on the faucet and there was no signage hung alerting the surveyors to not use the sink/water. The facility staff failed to inform the surveyors of the current Legionella restrictions implemented by the Health Department. There was no hand sanitizer or hand wipes provided. An initial facility observation was completed on 6/12/24 at approximately 11:00 AM. During this observation on the 2nd floor (North unit) locked unit that housed residents with cognitive impairments, multiple residents were observed ambulating with/without assistive devices and in their wheelchairs on the unit. Residents were observed walking in and out of their rooms and in the hallways. The faucet in the hallway to the dining room area was dripping and it did not have a filter installed on the faucet. There were no signs alerting residents/staff not to use the sink. The faucets were observed in the bathrooms of the following resident rooms: 204, 205, and 206. The faucets did not have any point of use filters and had running cold water. There were no signs near the faucets/in the bathrooms alerting residents/visitors not to use the water. During this observation an interview with CNA E (who was assigned to the unit) was conducted at approximately 11:15 AM. During the interview CNA E was queried if they were aware of any concerns related to the facility's water. They reported that they were aware of the water issues related to Legionella and they were using the water from jugs that were kept at the nursing stations. They pointed to a cart that had 5-gallon water jugs and a cooler with ice. They reported they were using the jug water to provide to the residents for hydration. They also reported that the facility had installed a filter on the shower, and they were giving showers to the residents. CNA E was queried how they were washing their hands (before, after and/or during the shower if need be). They reported that they were asked to use hand sanitizers and hand wipes. When queried what did they do if their hands were visibly soiled or had to wash after care, showers etc. and they had reported that they were using sanitizer and wipes. CNA 'E' confirmed that the shower room faucet did not have an appropriate filter and they were not able to wash their hands. CNA 'E' was questioned about the residents' rooms. They confirmed that the faucets in resident bathrooms were working and did not have any filters. They added that residents were not supposed to use the sinks and they did not understand why water supply to sinks were not shut down. When queried about the residents who needed close supervision due to their cognitive abilities who were ambulatory and how they were monitoring these residents to make sure they were safe and not using the water from the sinks, they reported that was a concern and they were doing their best to monitor. CNA 'E' reported that there were seven residents who were able to ambulate/move around in their wheelchair between rooms [ROOM NUMBERS]. There were also other ambulatory residents in the back of the hall. A follow up observation was conducted on the 1st floor shower room on the South hallway across from room [ROOM NUMBER] at approximately 1:00 PM on 6/12/24. The faucet on the hand wash sink did not have a filter. An unopened 5-gallon water container was observed on the floor near the sink. The shower room did not have hand sanitizer and/or hand wipes. There were no signs posted in the shower room alerting not to use the water from the sink. An interview with the Licensed Practical Nurse (LPN) D who was assigned to the 1-south hallway was conducted at approximately 1:05 PM. The surveyor accompanied the LPN to the shower room on the 1st floor on South Hall. LPN D was queried about how they were handling the water situation and providing care for the Residents. They reported that there was a filter in the shower, they were getting ice from outside, and they were using hand sanitizers. LPN D was queried on how staff were washing hands after a shower, they reported that they were using the sink and hand sanitizer. When queried further they reported that staff used bottled water to wash hands. When queried about the unopened 5-gallon bottle on the floor and how staff were able to lift the container, get water and wash their hands, LPN D did not provide any further explanation. LPN D was queried about how staff provided bed baths for their residents. They reported that staff were getting water from the showers into a wash basin and carried to the resident rooms. It must be noted that throughout these observations completed on 6/12/24 and 6/13/24, no staff members were observed taking water from the shower rooms to resident rooms for any bed baths/ADL (Activity of Daily Living) care. An interview with Registered Nurse (RN) F was conducted on 6/12/24, at approximately 1:15 PM. They were assigned to the 1-south hall. RN F was queried about how they were handing the water situation. RN F reported that there were filters in the shower rooms; they were using hand sanitizer and wipes to clean their hands. RN F was queried about the running water in the resident bathroom sinks and they reported that the hot water to the sinks were turned off and cold water was still on. RN F stated the residents knew they were not supposed to use the bathroom sinks, and they were provided with hand wipes. When queried further on how they were monitoring all the residents to ensure they were not using the sinks including residents who had cognitive impairment, RN F reported that most of their residents were alert and did not provide any further explanation. Follow up room observations were completed on 6/12/24, at approximately 4 PM on the same loop where the R708 (first resident identified with presumptive Legionella at the facility) resided to check the bathrooms sinks for filters. R708 resided in room [ROOM NUMBER], that had a shared bathroom with room [ROOM NUMBER]. The shared bathroom between rooms [ROOM NUMBERS] had a filter installed on the water line under the sink. There was water dripping from the filter. A pink wash basin was placed under the filter and there was puddle of water on the floor around the basin. There were no filters installed in any other resident rooms in the south hallway and the sinks had running cold water. There were no signs in the bathrooms alerting residents, staff, and visitors to not use the sinks. Several bathrooms did not have any hand sanitizers. During these observations residents were queried. Two residents reported they were using their bathroom sinks to wash their hands. One resident reported that they did not have hot water, but they were able to use cold water to wash their hands. One other resident reported, We can't even brush our teeth, it has been a while. An observation of a shared bathroom between room [ROOM NUMBER] and 128 had a large puddle of unknown white fluid under the sink. Observations made on 6/12/24 starting at 4:09 PM, of multiple rooms were conducted- 101 & 102 shared bathroom, 103, 104 & 105 shared bathroom, 106 & 108 shared bathroom, 107 shower/sink, 110 & 112 shared bathroom, 111 & 113 shared bathroom, 114 & 116 shared bathroom, 115, 118, 201, 202 & 203 shared bathroom, 204, 205 water visualized running, 206, 207, 208, 209 constant drip, sink visualized half full with water & 211 shared bathroom, 210 & 212 shared bathroom, 213 & 215 shared bathroom, 214 & 216 shared bathroom, 217, and 218 a constant drip from the bathroom sink was observed. None of the rooms contained filters on the sinks or shower. There were no hand wipes or source of water observed in any of the resident rooms to ensure good hand hygiene was maintained. An observation was completed on the 2nd floor south hallway on 6/12/24 at approximately 4:30 PM. There was one filter installed on the shower. There were no filters installed on the hand wash sink in the shower room. There was no bottled water and there was no hand sanitizer in the shower room. During a follow-up room observation in the same hall on 6/13/24, at approximately 9:30 AM, a water cup filled with water was placed over the bathroom sink in room [ROOM NUMBER] that read 6/13 - 223-1. There were no filters in any of the resident room bathrooms sinks on the unit. Most of the bathrooms on the unit did not have any hand sanitizers. An interview was completed with the Assistant Administrator (AA B) on 6/12/24 at approximately 12:40 PM. AA B was queried if they had any Legionella concerns at the facility and they had reported that they did. They added that one Resident (R708) was transferred to hospital from the facility and the facility was notified by the County Health Department that R708 tested positive for Legionnaires' disease at the hospital. AA B also added that the County Health Department team was onsite at the facility, and they gave recommendations. They also added that they were doing precautionary testing and following the recommendations from the County Health Department. The surveyor requested the recommendations they had received from the local County Health Department. AA B reported that they received it via e-mail, and they would share. Later AA B provided a copy of the letter from the County Epidemiologist (CE A). The letter was not dated and when queried AA B they reported that they had copied the information from the e-mail. The surveyor had requested AA B to share the email communication between the facility and local County Health Department. Facility did not provide the information; however, the information was received from the CE A via e-mail. A follow up interview was completed with AA B on 6/12/24 at approximately 12:50 PM, and they were queried about the current measures they had in place. They reported the shower rooms had filters and residents were able to take showers and there was a filter installed on the hand wash sink in the kitchen. They were using bottled water for cooking needs and for drinking since 5/15/24 and they had been in touch with the County Health department. AA B also added that Residents and families were communicated with via mail, and they were notified in person. AA B was queried if they had any water consultants assisting with the implementation of preventative/control measures and they reported that they had their internal team and did not have any third-party consultants and they were meeting monthly. They also reported that they believed the hand wash sinks in shower rooms were functional i.e. had appropriate filters in place. Later during rounds, it was observed that shower room sinks did not have any filters. They were queried if the residents/families were sent any follow up communication since the initial communication, and they reported that they had not sent any further communication. An interview with the CE A was completed via phone on 6/12/24, at approximately 1:45 PM. CE A were queried on presumptive Legionella case and their recommendations/follow up with the facility. CE A had reported that R708 who tested positive for Legionnaire's was a resident of the facility. R708 had remained in the facility for the entire incubation period (the time it takes for an infection to develop after an individual was exposed to disease causing organism such as Legionella bacteria) and had tested positive at the hospital. The facility was initially notified on 5/15/24 and an onsite environmental investigation and sampling was completed on 5/17/24. CE A stated their reports were pending, waiting for the test results. CE A had shared that the facility was provided with the measures they needed to implement immediately. They were queried if the facility's water was safe to use without the 0.2-micron filters on resident bathroom sinks, hand wash stations in the shower rooms etc. CE A confirmed that it was not safe to use the water without the filters and the facility was notified of the recommendation about three weeks ago. They had also followed up with a maintenance staff member (Senior Maintenance Director) SMD G from the organization on having the appropriate filters in place. They were unaware that the 0.2-micron filters were not in place in all locations as per their recommendations and reported that they would follow up with their facility contact, SMD G. After the telephone interview, CE A provided the surveyor the e-mail communications that was initially provided to the facility after the health department visit at the facility 5/17/24. A request was sent via e-mail to AA B to provide the receipts for the 0.2-micron filters that were currently installed in shower rooms, ice machine etc. Review of the facility provided document revealed that SMD G had placed the order for filters on 5/22/24; 7 days after the initial directive was received was received from the County health department. Further review of the receipt revealed the order was shipped via ground shipping. It was unclear on when the facility had received and installed the filters based on the information provided during the survey. An interview with the facility Director of Maintenance (DM H) was completed on 6/12/24, at approximately 2:10 PM. DM H was queried about the current process with the presumptive Legionella concern at the facility. They reported that the facility currently had 0.2- micron filters at the following locations, four in the shower rooms (one in each shower room x 4), two were in ice machines, one in the kitchen, one in the shared bathroom for rooms 120 & 121, and one in their dialysis unit. They added that they were using bottled water for drinking, cooking etc. When queried why they did not have any filters in Resident bathroom sinks and hand wash sinks in the shower rooms etc., DM H reported that they were just following the instructions from the management, and they understood the concern. They were queried further about the running water in the sinks and reported the hot water was turned off based on the information they had received that Legionella bacteria did not grow in cold water. They had confirmed that the facility management and the SMD G were involved and aware of the current facility process. They also added that first test recommended by the County health department was completed on 6/3/24 (16 days after the initial e-mail was sent to complete water sampling at 14 different locations at the facility) and the results were currently pending. A follow-up interview was completed via phone with CE A later that day (6/12/24), at approximately 3:35 PM. CE A was notified of the observations on running cold water in the resident room bathroom sinks, shower rooms etc. and queried if that was acceptable. CE A confirmed that was not safe and that was not their guidance provided to the facility. CE A also stated the facility should have signage posted on areas where the water was not safe to use, and they also stated the facility was highly recommended to use water management consultants who specialize in this area. An interview with RN I was completed on 6/12/24 at approximately 4:35 PM. RN I was assigned on the 2-south hall. RN I was queried on their process with the water situation and when providing care for their residents. They reported that they were using hand sanitizer and wipes. When queried further about handwashing/infection control, they reported that there was no place for staff to wash their hands and they had to use hand sanitizers and wipes. They added the process was not ideal and they were doing the best they can. An interview was completed with the Director of Nursing (DON) on 6/13/24 at approximately 9 AM. During part of this interview, the Regional Nurse Consultant (RNC J) was present. The DON was queried on how they had been handling resident care by following the infection control measures and recommendations from the County Health Department. They reported on the nursing end, staff were providing bottled water to the residents for drinking. The water from the shower rooms with filters were used for showers. The DON was queried about how nursing staff were doing bed baths, and they reported the staff were supposed to use water from the filtered showers. The DON was informed of the observations made by the surveyor on 1st and 2nd floor that staff were not getting water from the shower rooms as reported. During the interview, RNC J reported the local County Health Department guidance were recommendations based on presumptive case (R708) who tested positive at the hospital. RNC J stated (R708) was using a BiPAP machine (a device that helps with breathing) which could have been the potential source. When queried further that R708 had never left the facility prior to the hospital transfer (where they were diagnosed with Legionella) and why the facility had not implemented the County health department guidance/restrictions, they reported that they understood the concerns. RNC J was queried if they had a water management consultant assisting with their processes, RNC J reported that was just a recommendation and they had an internal team handling the situation. RNC J was queried further on who was their internal water management expert and they reported that they would find out and report back. No additional information was received by the end of the survey. On 6/13/24 at 12:39 PM, AA B and the DON were interviewed and asked why the sinks in the resident rooms did not have the 0.2 micron filters installed as directed by the County's Health Department and Epidemiologist. AA B stated the shower rooms on each floor had a filter attached to one shower head and they felt that was sufficient for each floor. At 3 PM, AA B and the DON were interviewed a second time and queried on where and how staff performed their hand hygiene. They reported that staff were supposed to use wipes and hand sanitizer. The DON confirmed that there was no handwashing sink for the nursing staff. They were queried on how they were monitoring the residents to ensure that they were not using the water from the bathroom as there was still running cold water. DON replied that staff were supposed to round and monitor. When queried further if it was practical and effective to monitor every movement of every resident in the facility with the staff, DON reported that they understood the concern. The DON was queried why the bathrooms in the resident rooms and common areas did not have any signage alerting not to use the water and the interview/observations were shared that residents were still using the sinks. The DON reported they should have signs and they would follow up. During an interview on 6/13/24 at 12:53 PM, SMD G was queried on why filters were not installed at each water source, as recommended by the Local Health Department, and SMD G stated it was being discussed at the upper management level. When inquired about protecting the residents from using water, SMD G stated the staff were supposedly going to monitor water usage on the resident halls. No additional explanation or documentation was provided by the end of the survey. INFECTION CONTROL SURVEILLANCE On 6/12/24 at 9:12 AM, upon entrance into the facility, AA B was asked to provide the facility's Infection Control Surveillance program for the last six months. A second request was made at 10:56 AM. A third request was made at 11:43 AM. At 11:53 AM, the DON provided January to April 2024 surveillance and stated they were currently working on May and June 2024. When asked how they were currently working on May 2024 considering the current date of 6/12/24, the DON stated the Infection Control Nurse (ICN) was not in the facility today. When asked if the Infection Control documents were maintained in the facility, the DON confirmed they were. The DON was then asked to provide both the May and June 2024 surveillance in its current state. Review of multiple medical records identified R's 705 and 706, to have been symptomatic and diagnosed with Pneumonia in May 2024. R705 A complaint received by the State Agency revealed that facility was not following infection prevention measures even after the facility water system was tested for Legionella. A document attached with the complaint revealed a letter sent from the facility dated 5/20/24 addressed to the residents, families and staff that read in part, .this letter is to provide information about a presumptive case of Legionnaires' disease at (Name of the facility omitted) and measures we are taking to protect the health of our residents, staff and visitors (Name of the facility omitted) is working closely with (name of county omitted) Health Department to investigate the source of this infection and take actions to prevent other people from becoming ill .we are taking a number of proactive measures in cooperation with (name of county omitted) Health Department . Record review revealed that R705 was a long-term resident of the facility. R705 was originally admitted to the facility on [DATE]. R705's diagnoses included dementia, mood disorder, depression, and history of falls. Based on the Minimum Data Set (MDS) assessment dated [DATE], R705 had Brief Interview for Mental Status (BIMS) score of 7/15, indicative of severe cognitive deficits. An observation was completed on 6/13/24, at approximately 10 AM. R705 was observed in their bed with their eyes closed. There was an oxygen concentrator sitting next to the bed and a Geri chair (recliner chair) was parked on the right side of the bed. Review of the Electronic Medical Record (EMR) revealed that R705 had a public guardian. Review of R705's progress notes revealed the following documentation: On 5/18/24 at 10:54 a nurses note read in part, Patient was having shortness of breath on arrival. I checked her O2, and it was 84%. I called the on-call doctor. They gave me new orders. They were put in for oxygen nasal canula 2 liters .Mucinex for 3 days every 12 hours chest x-ray 2 views . On 5/20/24 at 23:17 chest x-ray done at 4:45 PM. On 5/20/24 at 20:38 a note read in part, .called x-ray co .results patchy modest bilateral airspace disease, pneumonia should be considered in appropriate clinical setting. Recommended follow up .New orders to start doxycycline (antibiotic) 100 mg. BID (2 times/day) x 7 days . On 5/21/24 at 12:22 a note read in part., writer call and spoke with pharmacy regarding doxycycline not available in back up. Pharmacy stated med is coming out this afternoon . On 5/21/24 at 21:38 a note read in part, Resident is on ABT (antibiotic) for respiratory infection . On 5/22/24 a practitioner note read in part, Reason for visit: E&M (Evaluation and Management) of PNA (pneumonia), .and multiple other medical conditions requiring monitoring . Nursing progress notes from 5/23/24, 5/24/24, 5/25/24, 5/26/24, and 5/27/24 revealed that R705 continued to receive antibiotics for pneumonia. Review of the physician orders and progress note did not reveal that R705 was ordered any respiratory sputum panels with Legionella cultures and urinary antigen tests as directed by the County health department due to recent positive case of Legionnaire's disease. An interview was completed with R705's Guardian on 6/13/24 at approximately 10:55 AM. The Guardian was asked if they had received any notification from the facility regarding Legionella. The Guardian had checked with the case worker for R705 and reported that they did not receive any notification from the facility. An interview was completed with the DON on 6/13/24, at approximately 9 AM. The DON was queried about the current testing process for any residents with respiratory symptoms. The DON reported they were using the swabs and urinary antigen testing based on the recommendations from the County health department. The DON was queried about tests that were completed for R705 who was diagnosed with pneumonia on 5/20/24 and had received antibiotics. The DON reviewed the EMR for R705 and confirmed that they did not complete a swab or urinary antigen test for the resident, and they were not sure how it was missed. They also added that facility infection preventionist (ICN C) was ordering the tests and following up on any resident with pneumonia symptoms. R706 A review of R706's medical record revealed R706 was admitted to the facility on [DATE], with diagnoses that included: Dementia, Alzheimer's disease and chronic obstructive pulmonary disease and required staff assistance for all ADLs. Review of the progress notes revealed the following: On 5/15/24 at 3:06 AM, a Physician Progress Note documented in part . Seen for persistent cough . On 5/17/24 at 3:13 AM, a Physician Progress Note documented in part . Patient has been coughing lately and appears to be slightly lethargic below his baseline alertness . On 5/20/24 at 3:19 AM, a Physician Progress Note documented in part . Followed up for continued lethargy . Will repeat X-ray to make sure there is no acute process . On 5/21/24 at 2:55 PM, a Nurses' Note documented in part . Advised NP (Nurse Practitioner) of recent new onset of generalized weakness, unable to transfer himself without assistance from staff, and continued on going cough . On 5/21/24 at 3:45 PM, a NP/PA (Physician Assistant) Progress Note documented in part . Patient seen and examined following complaint of wheezing, cough, weakness, and AMS (Altered Mental Status), will order CXR (chest x-ray) . ordered 1 gm (gram) rocephine (antibiotic) and prednisone taper (steroid medication) . On 5/22/24 at 10:37 PM, a Pertinent Charting-Infections/Signs Symptoms note documented in part . Site of infection: lungs . Patient had a positive CXR result for pneumonia, wheezing and coughing . Patient was placed on oral ABT (antibiotics) x 10 days . Patient is on droplet precautions . Patient started on oral ABT for pneumonia . On 6/12/24 at 1:04 PM, the ICN C provided the May 2024 Surveillance. ICN C was asked why May 2024's Infection Surveillance was not completed before today and ICN C explained they wait until the month was over to gather and put together the surveillance data and information. ICN C then stated they were currently working on June 2024 data to provide. Review of the May 2024 Infection Control Surveillance documents noted the following in part: INFECTION CONTROL SUMMARY May 2024 . We had a resident test positive for Legionella in the hospital which we have negative results for the facility quarterly water testing. We tested two residents that showed signs of respiratory symptoms, and all received back negative results for Legionella in urine and sputum . R's 705 and 706 were not identified as having signs/symptoms of Legionella. The line listing documented R705 to have treatment of doxycycline 100 mg (milligram- antibiotic), however the line listing did not document a diagnosis or symptoms. Further review of the line listing documented R706 to have pneumonia and to have the treatment of levofloxacin 750 mg (antibiotic). Further review of May's 2024 Infection Control documents revealed no urinary or sputum testing for Legionella for R's 705 & 706. The documents did contain three resident's sputum tests for Legionella, however no urinary testing was completed for the three tested residents as documented in the May 2024 summary. ICN C failed to identify all residents with signs/symptoms of Legionella and test as directed by the Health Department using urinary and sputum testing and failed to document and report findings to the Health Department Epidemiologist as directed. Review of a facility policy titled Infection Surveillance revised 10/26/23, documented in part . A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections, monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . Infection surveillance refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data . The facility will collect data to properly identify possible communicable disease or infections before they spread by identifying . Data to be collected, including how often and the type of data to be documented, including . The infection site, pathogen (if available), signs and symptoms, and resident location, including summary and analysis of[TRUNCATED]

This citation pertains to intake #MI00142805. Based on interview and record review, the facility failed to ensure ongoing assessment and monitoring for one resident (R701) with a tracheostomy and a diagnoses of diabetes, of three residents reviewed for assessment and monitoring, resulting in the delay of identification of a change of condition including respiratory distress, decreased blood oxygen saturation levels, elevated blood pressure, and hyperglycemia requiring a transfer to the emergency room and placement in the intensive care unit. Findings include: A complaint received by the State Agency from a hospital employee alleged R701 was not monitored or provided care by the licensed nurse on the night of 2/12/24-2/13/24 resulting in the day shift nurse having to call 911, EMS responding to the resident in respiratory distress with a blood oxygen saturation of 71% (normal value is 95% or greater) and elevated blood glucose levels. On 3/6/24 at 11:18 AM, a review of R701's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and discharged to the hospital on 2/13/24. R701's diagnoses included: acute respiratory failure with hypoxia, presence of a tracheostomy, diabetes, intracerebral hemorrhage, and presence of a feeding tube. A review of a progress note entered into the record by Nurse 'B' at 7:56 AM on 2/13/24 was reviewed and read, .Note Text: writer upon morning rounds observed resident to have labored breaths using accessory muscles to breath <sic>. writer <sic> continued assessment on resident vitals signs 155/61, hr 119, (normal value 60-110) temp 99, pulse ox (blood oxygen saturation) 71 (%). writer <sic> gave resident treatment along with increased oxygen VIA 10 liters trach (tracheostomy mask) and with 72/73% return. writer <sic> then call <sic> 911 and resident was sent to (Hospital Name) Via Ambulance <sic> MD aware, family aware . It was noted R701's blood sugar was not obtained at that time. A review of R701's Medication Administration Records (MAR's) was conducted and revealed the following: A physician's order for monitoring continuous oxygen delivery via a trach at 5 liters per minute to be documented every shift, left blank for the midnight shift on the night of 2/12/24 thru 2/13/24. A physician's order for tracheostomy care to be performed every shift and as needed, left blank for the midnight shift on the night of 2/12/24 thru 2/13/23. A physician's order to obtain vital signs (blood pressure, temperature, pulse, respiratory rate, oxygen saturation, and pain level) to be performed every shift, left blank for the midnight shift on the night of 2/12/24 thru 2/13/24. A physician's order to obtain blood sugar and administer insulin per sliding scale at 6 AM, left blank on 2/13/24. On 3/6/21 at approximately 12:35 PM, a review of the schedule and assignment for the midnight shift on the night of 2/12/24 thru 2/13/24 was reviewed and was blank for the nurse, but revealed Certified Nurse Aide (CNA) 'C' had been assigned to R701's care, and CNA 'D' had also been assigned to the unit. On 3/6/21 at 2:08 PM, an attempt to contact Nurse 'B', who transferred the resident to the emergency roiagnom on [DATE] and took over for the midnight nurse was made, however; their voicemail box was full, a message could not be left, and the call was not returned. On 3/6/21 at 2:17 PM, a phone interview was conducted with CNA 'C' (assigned to R701 on the midnight shift from 2/12/24 thru 2/13/24). They were asked who the nurse was that was assigned to R701's care and said it was Nurse 'E'. They were asked if they observed Nurse 'E' provide any care to R701 during their shift that night and said they saw Nurse 'E' go into their room one time for approximately two or three minutes. CNA 'C' volunteered their belief Nurse 'E' had been terminated from the facility and they thought Nurse 'E', Wasn't very professional. On 3/6/21 at approximately 2:22 PM, an interview was conducted with CNA 'D' and they also confirmed the nurse assigned on that unit was nurse 'E' on 2/12/24 thru 2/13/24. On 3/6/24 at approximately 2:30 PM, an attempt to contact Nurse 'E' (assigned to R701's care on the night of 2/12/24 thru 2/13/24) was conducted, however; the automated message revealed the phone number was no longer in service. On 3/6/24 at 2:55 PM, an interview was conducted with the facility's Director of Nursing and Assistant Administrator. They were asked about Nurse 'E' and said the facility was in the process of terminating their employment. When asked about the grounds for termination, they said they were looking into an incident involving Nurse 'E', but Nurse 'E' stopped showing up for their scheduled shifts and would not answer their phone. They were asked what type of incident was being investigated and said a resident had a change of condition and had to be transferred to the the emergency room and it was discovered Nurse 'E' had been assigned to their care immediately prior to their transfer. They were asked if the investigation documents could be reviewed, they agreed and provided an investigation folder. On 3/6/24 at approximately 3:10 PM, a review of the provided documents reviewed revealed the following: A typed investigation summary indicated the facility had not been able to reach Nurse 'E'. The summary further included a surveillance camera timeline. The timeline revealed Nurse 'E' entered R701's room only once during their shift on 2/12/24 thru 2/13/24 at 2:49 AM. On 3/6/24 at 3:30 PM, a follow-up interview was conducted with the facility's Director of Nursing and Assistant Administrator regarding the missing assessment and monitoring of R701 and they acknowledge the concern. A review of a facility provided documents was conducted and revealed the following: A policy titled, Tracheostomy Care revised 10/2023 read, Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice . A policy titled Medication Administration revised 1/2023, read, Policy: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by a physician and in accordance with professional standards of practice . A job description for the Licensed Practical/Vocational Nurse read, .Coordinates and provides nursing care for residents .Documents the resident's condition and nursing needs .Administers medications and performs treatments for assigned residents, and documents that treatment .

This citation pertains to Intake(s): MI00138981 and MI00138993 Based on observation, interview and record review, the facility failed to initiate and thoroughly investigate allegations of inappropriate sexual contact reported by R701 and R702 and failed to prevent further inappropriate sexual contact from occurring for R703 and protect other residents who resided in the facility. This deficient practice resulted in immediate jeopardy (IJ) when R701 and R702 reported that they no longer wanted Certified Nursing Assistant (CNA) A to provide care due to inappropriate contact and the facility continued to schedule CNA A who then worked with R703 who also alleged and reported CNA A touched them inappropriately during incontinence care. The IJ was identified on 8/25/23 at approximately 4:04 PM The IJ began on 8/18/23. The Administrator was notified on 8/25/23 at 4:48 PM and a plan of removal was requested to remove the immediacy. The IJ was removed on 8/29/23 based on the provider's implementation of removal and verified onsite on 8/29/23. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with the potential for harm that is not immediate jeopardy. Findings include: An anonymous complaint was filed with the State Agency (SA) that alleged R701, R702 and R703 complained that Certified Nursing Assistant (CNA) A touched them inappropriately while doing care. According to the complainant, R701 and R702 reported that CNA A fondled their testicles while providing care. R703 complained that CNA A stuck their finger inside while providing care. The complainant reported that the facility Director of Nursing (DON) was aware of the incidents and continued to allow CNA A to work on various units at the facility including the locked dementia unit. A Facility Reported Incident (FRI) was also filed with the SA. The FRI reported that R703 alleged CNA A inappropriately rubbed her legs and vaginal area. *It should be noted that the FRI reported did not provide any information that pertained to other residents, including R701 and R702. At the start of the Survey on 8/25/23 no other FRIs had been reported to the SA that dealt with allegations made by R701 and R702. The facility policy titled, Abuse, Neglect and Exploitation (revised 10/24/22) was reviewed and documented, in part, the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies that prohibit and prevent abuse .Abuse means the willful infliction of injury .It includes .sexual abuse, physical abuse and mental abuse .Sexual Abuse is non-consensual sexual contact of any type with a resident .Prevention of Abuse .Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship .Investigation of Alleged Abuse A. an immediate investigation is warranted when suspicion of a crime of abuse .or reports of abuse .occur. B. Written procedures for investigations include: .Investigating different type of alleged violations .Identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse .has occurred, the extent, and cause .Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation .Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator .Reporting .A. The facility will have written procedures that include .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other agencies .Taking all necessary actions as a result of the investigation, which may include .a. Analyzing the occurrence(s) to determine why abuse .of a resident occurred .b. Defining how care provisions will be changed and/or improved to protect residents .d. Identification of staff responsible for implementation of corrective actions .Coordination with QAPI (Quality Assurance and Performance Improvement). The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse 1. Cases of physical or sexual abuse, for example by facility staff .will be reviewed for and receive corrective action .this coordinated effort results in the QAA committee determining a. if a thorough investigation is conducted. b. Whether the resident is protected. c. Whether an analysis was conducted as to why the situation occurred. d. Risk factors that contributed to the abuse .Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about .v. Tracking patterns of similar occurrences . R703 On 8/25/23 at approximately 9:18 AM, R703 was observed lying in bed. The resident was alert and able to answer questions asked. R703 was asked if they had ever been touched inappropriately by staff. They stated Yes and reported that CNA A entered the room to do a check and change. While the resident could not provide an exact date of the incident, they noted that it was prior to the weekend of 8/18/23. They named CNA A as the perpetrator and indicated that he had only been assigned to her a few times. They further reported that CNA A applied cream to their buttocks and then applied cream to their vaginal area and kept rubbing the cream for an extended period of time. R703 reported that they had been a resident at the facility for three years and never had had any issues with staff until this incident. R703 stated that they felt violated and continued to ask the Surveyor why me. When asked if they reported what had happened, R703 noted that they told another CNA a few days after the incident and then a nurse came in to talk to them. R703 reported that the police also came to the facility, and they discussed the concern with the officer. R703 stated that they did not want CNA A to ever be assigned to them and did not want to continue talking about the incident. A review of R703's clinical record was reviewed and revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: fractured femur, muscle weakness, schizophrenia and thyroid cancer. A review of the resident's Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition) and was incontinent of both bladder and bowel. Continued review of R703's clinical record documented, in part, the following: 8/18/23 : IDT (interdisciplinary team) note: .Writer informed by CNA that resident would like to have a discussion. Writer entered resident's room and asked resident what she wanted to talk about. Resident stated to writer that I feel as though a male CNA touched me inappropriately. Writer asked resident to explain the situation and she stated, He put the cream on my vagina for too long. Writer asked resident how long it took for the CNA to apply the cream, and she stated, Longer than what I'm used to . (Authored by Nurse B) 8/21/23: Social Services: .met in resident's room to discuss reported incident. Resident stated that a male CNA put cream on her during brief change, resident reported that care took longer than usual . On 8/25/23 at approximately 12:40 PM an interview was conducted with Nurse B. Nurse B was asked about the allegation made by R703 and they noted that CNA C reported to them that R703 wanted to talk with them. Nurse B noted that when they went to speak with R703, they told her that CNA 'A put cream on her vagina, continued to rub the cream and felt that it was going on for a long time. After R703 made the statement, Nurse B reported the alleged incident to the Administrator and DON. They stated they never heard anything else as to what happened. When asked if rubbing cream on a woman's vagina was a normal task for a CNA, Nurse B responded it was not. On 8/25/23 at approximately 12:51 PM, an interview was conducted with CNA C regarding the allegation made by R703. CNA C reported that after getting R703 out of the shower she told her that one of the aides touched her inappropriately. Before she even finished the story, CNA C stated that she went to get Nurse B. While they were both in the room, R703 reported that CNA A massaged her vagina with cream. CNA C reported that they were frequently assigned to work with R703, and they did not put cream on the resident's vagina. CNA C stated that they had never worked with CNA A as he usually worked the afternoon/evening shifts. They stated following reporting the incident they never were interviewed by facility staff or local police. R702 On 8/25/23 at approximately 9:45 AM, a phone interview was conducted with R702. R702 reported that they were in the hospital but anticipated they would be returning to the facility. R702 was asked if they ever felt abused by staff at the facility. R702 stated that two to three months ago, a male CNA fondled their bottom and genital area. R702 was able to identify the CNA as CNA A. R702 noted that they reported their concern about the incident to another female staff member. R702 was not able to provide the name of the person they reported the incident to but told them they did not want CNA A working with them. R702 did not recall being interviewed by any staff members including the Administer/Abuse Coordinator. A review of R702's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Type I diabetes, chronic kidney disease and Paraplegia. A review of their MDS indicated a BIMS score of 15/15 and noted the resident was incontinent of bladder and bowel. Continued review of R702's clinical record documented, in part, the following: 6/28/23: Nurses Note: Resident spoke with resident <sic>expressing concern, yesterday on afternoon shift resident stated he had a bowel movement his CNA cleaned him up he noticed CNA had put cream on his bottom and his buttocks was sore and he wanted to know why his buttocks was hurting him . (Authored by the DON). *It should be noted that CNA A was assigned to the unit R702 resided on 6/27/23 and 6/28/23. An order dated 6/28/23 read, Cleanse area with normal saline. Pat dry. Apply Dermseptin (an ointment used to provide a skin barrier) every shift and prn to Groin until healed. *This order did not go into effect until after R702 made a concern that a CNA put cream on his bottom. R701 On 8/25/23 at approximately 10:13 AM, a phone interview was conducted with R701. R701 reported that they were at the facility for rehabilitation following a stroke. They noted that they discharged a few weeks ago. When asked as to whether they had experienced staff abuse, including inappropriate touching, R701 stated that a male CNA (noted as CNA A) fondled their testicles on the afternoon/evening shift. When asked when the incident occurred, they noted they felt he did it more than one time. R701 stated that he knew what he felt as CNA A was changing him, and he knew it was wrong. They stated that they reported the incident to the Director of Nursing (DON) before they were discharged from the facility. A review of R701's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Chronic Respiratory Failure, Type II diabetes and heart failure. A review of R701's MDS noted the resident had a BIMS score of 15/15. A request was made for any incident/accident (IA) reports and/or grievances pertaining to R701, R702 and/or R703. The only IA provided that indicated alleged sexual abuse pertained to R703. A review of the IA regarding R703 revealed, in part, the following: .On 8/18/23, R703 stated that she felt a male CNA took too long to put cream on her vagina .on 8/18/23, R703 reported that she was uncomfortable with a male CNA taking too long to put cream on her on 8/15/23 .an interview with R703 who stated, Two nights ago a male CNA came in to my room for check and change for me and my roommate. When he did his check and change on me, he started using a cream on my behind, then he went to the front of my body and rubbed between my legs and touched my vagina like he was rubbing my behind .The employee was identified as CNA A .Employee was suspended pending the investigation. Per his interview he stated, I was putting barrier cream on R703. The resident asked me why I was putting cream on her, and I said to her that it was to prevent chaffing .Residents were interviewed that were on CNA As assignment .Conclusion: The facility is unable to substantiate that abuse has occurred . Continued review of the IA noted a Performance Improvement Form dated 8/18/23 that documented, in part: Name (CNA A) .Date of Hire (5/9/23) .Reason for Counseling/Corrective Action: Suspension pending investigation .Corrective Action Plan (This area was left blank) . The document was signed and dated by the DON on 8/18/23 and signed by CNA A and dated on 8/22/23. *It should be noted that CNA A returned to work on 8/21/23 and according to the punch card and facility schedule was assigned to the 2 South Hall on 8/21/23, 2 North (a locked memory unit) on 8/22/23 and 1 South on 8/23/23. An attempt to contact CNA A via phone was made on 8/25/23 at approximately 1:00 PM. A voice message was left. No return call was made by the end of the Survey. A review of CNA A personnel file was conducted. There were no documents in the residents file that pertained to allegations of abuse. Further there was no indication of any additional training on how to provide proper care during a check and change. On 8/25/23 at approximately 1:26 PM, an interview was conducted with Social Worker (SW) E. SW E was asked if they were aware that R703 reported that they had been sexual abused by CNA 'A. SW E noted they were aware that R703 reported that during incontinence care, CNA A took a very long time trying to clean her up and she had never experienced any other staff touching her for so long. SW E indicated that R703 did not want CNA A to work with her again. SW E was asked if R703 had ever voiced any concerns about other staff and/or exhibited any behavior concerns. SW E reported that R703 did not. When asked if they had worked with other residents who expressed a concern about CNA A, SW E stated that R701 reported that they felt uncomfortable when CNA 'A provided care and did not want him to be assigned to him anymore. When asked if they knew what made them feel uncomfortable, SW E reported that she was not aware of the details but noted that the DON went and talked with him. On 8/25/23 at approximately 1:47 PM a phone interview was conducted with the DON. The DON was asked about the alleged complaint pertaining to R703. The DON stated that Unit Manager (UM) B reported that CNA C told her that R703 reported that CNA A had touched her private area. The DON stated that when she went to talk with R703 they stated that CNA A put cream on her, and she thought it was just for her bottom but then the CNA started to rub the cream in her vaginal area and kept rubbing it. The DON stated that it made the resident feel uncomfortable, however they did not consider it to be sexual in nature. The DON was asked if any other residents reported CNA A made them feel uncomfortable and/or reported inappropriate sexual contact. The DON reported R702 told her that following care from CNA A their buttocks hurt and wanted to know why it hurt. The DON stated they never considered the statement to be an allegation of sexual abuse as there was no penetration. The DON stated following the statement made by R702 they completed a skin assessment and noted excoriation on the buttocks. She then asked him to be seen by wound care. The DON was asked if there were any other residents that reported any concerns with CNA A. They stated that R701 had reported that when CNA A was changing his brief, he touched his scrotum and R701 did not want the CNA to take care of him again. The DON was asked if any of the concerns/allegations pertaining to R701 and R702 were reported to the Administrator/Abuse Coordinator. The DON reported that they believed they brought up the concerns with the Administrator. The DON could not specify a certain date but noted that it may have been sometime in July 2023. The DON also reported that they had completed some one-to-one education with CNA A. *It should be noted that no documentation pertaining to concerns alleged by R701 and R702 was provided by the end of the Survey. In addition, there was no documentation provided by the facility that indicated CNA A received any one-to-one training regarding providing proper incontinence care. On 8/29/23 at approximately 3:10 PM, the Surveyor reported to the Administrator/Abuse Coordinator that R701 and R702 had made allegations that CNA A had touched them inappropriately during care. The Administrator reported that they had not been informed by any staff of the allegations and would start an investigation. When asked if their concerns as mentioned by SW E and the DON should have been reported to them, the Administrator responded that they should have. When asked if they had been aware of the allegation made by R701 and R702 would they have not permitted CNA A to continue working, the Administrator noted that currently the CNA is suspended. The facility submitted a removal plan on 8/29/23, revealing the following: -Residents 701 and 702 no longer reside in the facility. -The Certified Nursing Assistant (CNA A) has been suspended pending investigation. -Current residents in the facility with a BIMS of Nine (9) or Current residents residing in the facility with a BIMs of 9 or below have had a skin assessment, to ensure there are no signs of abuse by the Nurse Managers on 8/25/2023 -Residents in the facility with BIMs 10 or above have been interviewed, if they feel safe here and been treated with respect and dignity by Social Service Director/Designee On 8/25/23. -The same residents were asked on 8/29/23 if they feel like they have been touched inappropriately or sexually abused while at this facility. -Administrator will audit Caring Partners, Grievances and for the past 30 days to ensure all concerns or issues have been investigated and reported per policy. 8/25/23 -Any issues or concerns will be addressed per policy. -Facility staff have been educated by the Assistant Nursing Home Administrator/Designee on the Abuse and reporting Policy on 8/25/23. Any staff not educated then will be educated at the start of their next shift. -DON/Designee will audit 24 report to ensure all concerns or issues have been investigated and reported per policy. Any issues will be investigated and reported immediately. -Compliance 8/25/23

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from sexual abuse for one resident (R703) of three reviewed for abuse resulting in R703 being inappropriately touched by a Certified Nursing Assistant (CNA A) during incontinence care causing feelings of helplessness, anxiety and mental anguish. Findings include: An anonymous complaint was filed with the State Agency (SA) that alleged R703 complained that CNAA touched them inappropriately while doing care. A Facility Reported Incident (FRI) was also filed with the SA. The FRI reported that R703 alleged CNA A inappropriately rubbed her legs and vaginal area. The facility policy titled, Abuse, Neglect and Exploitation (revised 10/24/22) was reviewed and documented, in part, the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies that prohibit and prevent abuse .Abuse means the willful infliction of injury .It includes .sexual abuse, physical abuse and mental abuse .Sexual Abuse is non-consensual sexual contact of any type with a resident .Prevention of Abuse .Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship .Investigation of Alleged Abuse A. an immediate investigation is warranted when suspicion of a crime of abuse .or reports of abuse .occur. B. Written procedures for investigations include: .Investigating different type of alleged violations .Identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse .has occurred, the extent, and cause .Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation .Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator .Reporting .A. The facility will have written procedures that include .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other agencies .Taking all necessary actions as a result of the investigation, which may include .a. Analyzing the occurrence(s) to determine why abuse .of a resident occurred .b. Defining how care provisions will be changed and/or improved to protect residents .d. Identification of staff responsible for implementation of corrective actions .Coordination with QAPI (Quality Assurance and Performance Improvement). The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse 1. Cases of physical or sexual abuse, for example by facility staff .will be reviewed for and receive corrective action .this coordinated effort results in the QAA committee determining a. if a thorough investigation is conducted. b. Whether the resident is protected. c. Whether an analysis was conducted as to why the situation occurred. d. Risk factors that contributed to the abuse .Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about .v. Tracking patterns of similar occurrences . On 8/25/23 at approximately 9:18 AM, R703 was observed lying in bed. The resident was alert and able to answer questions asked. R703 was asked if they had ever been touched inappropriately by staff. They stated Yes and reported that CNA A entered the room to do a check and change. While the resident could not provide an exact date of the incident, they noted that it was prior to the weekend of 8/18/23. They named CNA A as the perpetrator and indicated that he had only been assigned to her a few times. They further reported that CNA A applied cream to their buttocks and then applied cream to their vaginal area and kept rubbing the cream for an extended period of time. R703 reported that they had been a resident at the facility for three years and never had had any issues with staff until this incident. R703 stated that they felt violated and continued to ask the Surveyor why me. When asked if they reported what had happened, R703 noted that they told another CNA a few days after the incident and then a nurse came in to talk to them. R703 reported that the police also came to the facility, and they discussed the concern with the officer. R703 stated that they did not want CNA A to ever be assigned to them and did not want to continue talking about the incident. A review of R703's clinical record was reviewed and revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: fractured femur, muscle weakness, schizophrenia and thyroid cancer. A review of the resident's Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition) and was incontinent of both bladder and bowel. Continued review of R703's clinical record documented, in part, the following: 8/18/23 : IDT (interdisciplinary team) note: .Writer informed by CNA that resident would like to have a discussion. Writer entered resident's room and asked resident what she wanted to talk about. Resident stated to writer that I feel as though a male CNA touched me inappropriately. Writer asked resident to explain the situation and she stated, He put the cream on my vagina for too long. Writer asked resident how long it took for the CNA to apply the cream, and she stated, Longer than what I'm used to . (Authored by Nurse B) 8/21/23: Social Services: .met in resident's room to discuss reported incident. Resident stated that a male CNA put cream on her during brief change, resident reported that care took longer than usual . On 8/25/23 at approximately 12:40 PM an interview was conducted with Nurse B. Nurse B was asked about the allegation made by R703 and they noted that CNA C reported to them that R703 wanted to talk with them. Nurse B noted that when they went to speak with R703, they told her that CNA 'A put cream on her vagina, continued to rub the cream and felt that it was going on for a long time. After R703 made the statement, Nurse B reported the alleged incident to the Administrator and DON. They stated they never heard anything else as to what happened. When asked if rubbing cream on a woman's vagina was a normal task for a CNA, Nurse B responded it was not. On 8/25/23 at approximately 12:51 PM, an interview was conducted with CNA C regarding the allegation made by R703. CNA C reported that after getting R703 out of the shower she told her that one of the aides touched her inappropriately. Before she even finished the story, CNA C stated that she went to get Nurse B. While they were both in the room, R703 reported that CNA A massaged her vagina with cream. CNA C reported that they were frequently assigned to work with R703, and they did not put cream on the resident's vagina. CNA C stated that they had never worked with CNA A as he usually worked the afternoon/evening shifts. They stated following reporting the incident they never were interviewed by facility staff or local police. A request was made for any incident/accident (IA) reports and/or grievances pertaining to R703. A review of the IA regarding R703 revealed, in part, the following: .On 8/18/23, R703 stated that she felt a male CNA took too long to put cream on her vagina .on 8/18/23, R703 reported that she was uncomfortable with a male CNA taking too long to put cream on her on 8/15/23 .an interview with R703 who stated, Two nights ago a male CNA came in to my room for check and change for me and my roommate. When he did his check and change on me, he started using a cream on my behind, then he went to the front of my body and rubbed between my legs and touched my vagina like he was rubbing my behind .The employee was identified as CNA A .Employee was suspended pending the investigation. Per his interview he stated, I was putting barrier cream on R703. The resident asked me why I was putting cream on her, and I said to her that it was to prevent chaffing .Residents were interviewed that were on CNA As assignment .Conclusion: The facility is unable to substantiate that abuse has occurred . Continued review of the IA noted a Performance Improvement Form dated 8/18/23 that documented, in part: Name (CNA A) .Date of Hire (5/9/23) .Reason for Counseling/Corrective Action: Suspension pending investigation .Corrective Action Plan (This area was left blank) . The document was signed and dated by the DON on 8/18/23 and signed by CNA A and dated on 8/22/23. An attempt to contact CNA A via phone was made on 8/25/23 at approximately 1:00 PM. A voice message was left. No return call was made by the end of the Survey. A review of CNA A personnel file was conducted. There were no documents in the residents file that pertained to allegations of abuse. Further there was no indication of any additional training on how to provide proper care during a check and change. On 8/25/23 at approximately 1:26 PM, an interview was conducted with Social Worker (SW) E. SW E was asked if they were aware that R703 reported that they had been sexual abused by CNA 'A. SW E noted they were aware that R703 reported that during incontinence care, CNA A took a very long time trying to clean her up and she had never experienced any other staff touching her for so long. SW E indicated that R703 did not want CNA A to work with her again. SW E was asked if R703 had ever voiced any concerns about other staff and/or exhibited any behavior concerns. SW E reported that R703 did not. On 8/25/23 at approximately 1:47 PM a phone interview was conducted with the DON. The DON was asked about the alleged complaint pertaining to R703. The DON stated that Unit Manager (UM) B reported that CNA C told her that R703 reported that CNA A had touched her private area. The DON stated that when she went to talk with R703 they stated that CNA A put cream on her, and she thought it was just for her bottom but then the CNA started to rub the cream in her vaginal area and kept rubbing it. The DON stated that it made the resident feel uncomfortable, however they did not consider it to be sexual in nature.

This citation pertains to Intakes MI00135989, MI00136742, MI00136994, MI00137746, MI00136638. This citation has citation has four deficient practices. Deficient Practice #1 Based on interview and record review the facility failed to prevent the elopement of one resident (R294) of three residents reviewed for elopement, resulting in immediate jeopardy (IJ) when R#294 who was previously identified as an elopement risk and had severe cognitive impairment, exited the building and left the facility premises without staff supervision, increasing the likelihood of serious injury, serious harm, serious impairment, or death. Findings include: The immediate jeopardy (IJ)began on [DATE], it was identified by the survey team on [DATE] and the facility was notified of the IJ on [DATE], and a removal plan was requested. On [DATE], the State Agency completed onsite verification that the Immediate Jeopardy was removed on [DATE], however the facility remained out of compliance at a scope of isolated and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On [DATE] a concern submitted to the State Agency was reviewed which alleged multiple residents had eloped from the facility premises without staff knowledge. On [DATE] the medical record for R294 was reviewed and revealed the following: R294 was initially admitted to the facility on [DATE] and had diagnoses including Schizophrenia, Chronic obstructive pulmonary disease and Chronic Respiratory failure with hypoxia. A Nursing admission evaluation dated [DATE] revealed the following: .C. Summary of review-Resident is at risk for elopement/wandering at this time[Yes] Elopement/Wandering risk as evidenced by: patient getting on elevator and attempting to go outside and smoke . A review of R294's care plan revealed the following: Focus-Resident has impaired cognitive function related to BIMS (Brief Interview for Mental Status) score, disorganized thinking dx (diagnosis) of schizophrenia .Further review of R294's care plan revealed a second focused area that included the following: [R294] is at risk for elopement r/t (related to) newly admitted to facility, impaired cognition, decreased safety awareness, history of elopement dx of schizophrenia .Date Initiated: [DATE] . A review of R294's progress notes revealed the following: [DATE]-Patient needs to be monitored as an elopement risk. Patient has tried to get on elevator several times during the shift. Patient also is a smoker and asked writer several times for a cigarette. Will endorse to oncoming nurse. Will continue to monitor. [DATE] at 8:28 a.m.,- resident was not in his bed. [DATE] at 8:37 a.m.,- At the beginning of shift, 11pm, when writer came in resident was not in his bed. Writer asked the outgoing nurse about resident but she said she did not see him at the beginning of her shift. Writer tried to contact the nurse before to confirm if she saw resident. At 5am, writer went outside to search for resident. Writer saw another resident who confirmed that resident was standing around the facility. Writer looked around but did not see resident. CNA (Certified Nursing Assistant) for resident she saw resident At 7am, writer searched for resident but still could not find him. DON (Director of Nursing) contacted. [DATE] at 8:44 a.m.,- At 6am, writer asked resident's roommate if he saw resident. The roommate stated that he was here when I went to sleep, but when I woke up I did not see him. [DATE] at 1:13 p.m.,- Resident was queried regarding leaving facility, He stated, He went outside to smoke but then decided he wanted to visit friend that stays on 8 mile and evergreen, resident didn't appear to be in any distress, answer questions appropriately. Writer spoke with [representative of guardianship] at Guardian company and updated her on residents arrival and spoke about smoking policy/agreement and she requested information via email to her to look over, but at this time she denies for resident to smoke. She was also updated on plan of care that resident will move to secured unit temporarily, [guardianship representative] agreed to plan of care. Resident did agree to a smoking patch for the time being until re evaluation. [Physician] updated on residents arrival and plan of care no concern at this time. [DATE] at 4:34 p.m.,- Resident escorted back to facility by [Local Police Department]. Resident fully clothed and has on footwear. Resident was offered lunch and consumed 100%. Attempted skin assessment however resident denied . [DATE] at 5:41 p.m.,- Resident visited on [location of new room] Resident was standing at his bedside. Bims attempted with a score of 6 received (severe cognitive impairment). Resident displaying some increased anxiety with pacing in bedroom. Nurse manager notified. Resident added to elopement precautions. Smoking assessment completed, resident deemed not safe to smoke at this time. Smoking assessment and smoking agreement sent to residents guardian per their request. Residents care plan updated. Resident to be seen by psych services at next scheduled visit. Social services to continue to observe and make recommendations prn (as needed). [DATE] at 1:46 p.m.,-Observed resident in his assigned room on unit. Resident was sitting on the side of his bed. He did not want to engage with writer and only responded to questions with, you'll be going soon. Resident did not appear in distress at this time. Staff interviewed and reported no concerns at this time regarding residents behavior or mood. Staff reports he is eating well and is taking his medication with no concerns. Writer spoke with residents guardian on this date, obtained consent to receive information for the initial social services history from his sister. Letters of guardianship requested. [facility psychiatric provider] consent and consent for psychotropic medications sent to guardian for signatures. Guardian reports a history of mental health treatment with [name of local community mental health agency] although his case was closed in December on 2022 related to non compliance with medication management and treatment. Guardian anticipates the need for long term care reporting the group home is no longer able to care for him related to his care needs. Sister [name of sister] reports a long history of wandering and walking away from homes or doctors appointments, often being missing for 3 to 4 days at a time. She reports this as his MO. Dx includes Schizophrenia, sister reports a long history of mental illness including multiple psychiatric hospitalization s since his late teen years . On [DATE] a facility investigation pertaining to R294's elopement from the facility on [DATE] was reviewed and revealed the following: On [DATE] at approximately 8:17am the Administrator received a call from [Name of Director of Nursing] (DON) informing the Administrator that resident [R294] was not in the facility. She stated the staff was unsuccessful in the search of the facility as well as the grounds and surrounding neighborhood. The Administrator arrived to the facility at 8:30am and joined the search for resident [R294],immediate corrective measures: Codes to exit doors were changed, as it was identified that another resident put the code in for [R294] . On [DATE] at appropriately 10:19 a.m., during a conversation with the Director of Social Services M (DSS M), DSS M was queried regarding the elopement incident for R294 on [DATE]. DSS M indicated they were not involved at the time of the incident on ,d+[DATE] but after they were informed of the incident, they updated the elopement risk information for R294. DSS M was queried if R294 had cognitive impairment and they indicated they did and that R294 was unsafe to be in the community without staff supervision. On [DATE] at approximately 10:44 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding elopement for R294 and reported that R294 eloped before receptionist got to the facility. The DON reported that other residents should not have the code to the door, but that some residents have the code for unknown reasons. The DON reported that they keep telling staff that residents cannot know to the code and to be vigilant when putting the code in to ensure other residents do not leave the facility without supervision/staff knowledge. On [DATE] at approximately 11:58 a.m., R294 was observed in their room, laying in their bed. R294 was queried regarding their elopement from the building on [DATE]. R294 was queried if they could remember what happened that day and they reported they did not. R294 was queried if they remembered where they were trying to go and they indicated they did not. R294 was queried if they could provide any other information on the day that the police officer brought them back to the facility and they reported they could not. On [DATE] a facility document titled Unsafe Wandering and Elopement Prevention was reviewed and revealed the following: Policy: Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Nursing personnel must report and investigate all reports of missing residents. Policy Explanation and Compliance Guidelines: l. 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 episodes. Staff will be informed at shift change of the modifications to the resident's care 3. Interventions for unsafe wandering and elopement attempts will be entered onto 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. 5. If a resident is discovered to be missing a search shall begin immediately. 6. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the licensed nurse in charge as soon as practical. 7. Should an employee observe a resident leaving the premises, he/she should: a. Attempt to prevent the departure; b. Obtain assistance from other staff members in the immediate vicinity, if necessary; c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises; and d. Be courteous in preventing the departure and in returning the resident to the facility. On [DATE] Removal of the immediacy was confirmed onsite when the facility took the following actions: 1. Residents will be assessed upon admission, if residents are deemed an elopement risk they will be placed on the secured unit. Residents identified as elopement risk will be placed in the elopement binder (which is kept at the reception desk and each nursing station) so they can be identified as being such. 2. Facility door code was changed. Staff was educated that no resident should have the code and receptionist will assist the residents in signing out when they are exiting the building. 3. Resident #294 has been re-assessed by the licensed nurse and remains in stable condition on [DATE], his room was moved to the secure unit on the second floor. 4. The DON/designee has re-educated staff on the safe wandering & elopement policy on [DATE]. 5. The DON/designee has re-assessed current residents for elopement risk , 16 residents have been deemed at risk for elopement. Elopement risk books have been updated, care plans have been updated. 39592 Deficient Practice #2 Based on interview and record review, the facility failed to ensure one (R444) of two residents reviewed for trachostomy care/accidents had appropriate supervision for a resident known to remove their trachostomy tube resulting in R444 removing the outer/inner cannula, flange, and trachostomy collar, was cyanotic (bluish in color due to inadequate oxygenation) and required emergent transportation to the hospital. Findings include: A complaint was filed with the State Agency on [DATE] that alleged in part, .(R444) had a sitter . removed their trach (trachostomy tube) . was without oxygen for a period of time . now in the hospital . Review of the closed record revealed R444 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease (COPD), tracheostomy status, dependence on supplemental oxygen and Down Syndrome. According to the Minimum Data Set (MDS) assessment, R444 had severely impaired cognition and required the supervision to extensive assist for activities of daily living (ADL's). Review of R444's progress notes revealed: A Nurse Note dated [DATE] at 5:54 PM read in part, .Upon skin assessment trach size 5 shiley cuffed with trach care complete upon admit . A Nurse Note dated [DATE] at 2:51 PM read in part, .writer explained trach care tasks at each encounter with trach tie changed and dated resident requires frequent rounding due to observed removing trach mask at times followed by re-direction each time . A Nurse Note dated [DATE] at 5:10 PM read in part, .was observed in fowlers position (semi-sitting position in bed) with head back with trach inner canula out and eye closed non-responsive to verbal/tactile stimuli . resident positioned for immediate return of inner cannula/cpr (cardiopulmonary resuscitation)/aed (automated external defibrillator) support with effective outcome . orderto [sic] . Hospital ER (emergency room ) . A Nurse Note dated [DATE] at 7:37 PM read in part, Resident arrived at the facility . Resident pulled his Trach out, Nurse assisted to push the trach back in . ordered the resident to go out and checked via 911. A Nurse Note dated [DATE] at 12:36 AM read in part, Resident came back from [Hospital] at 11:50PM . Educated resident on safety more emphasis on the trach. Instructed resident not to pull his trach, explained benefits vs (versus) risk . A Nurse Note dated [DATE] at 2:19 AM read in part, Resident readmitted on [DATE] at 7PM but was transferred back to hospital for pulling out his trach. Resident came back after few hours from hospital . Placed resident on 1:1 due to tendency of pulling out his trach . A Nurse Note dated [DATE] at 10:01 PM read in part, 9:15pm observed resident lying across his bed. Resident had pulled Outer/inner cannula, flange, trach collar, all the components were laying on his bedside table. Residents lips were cyanotic . Resident was transferred to hospital . A Nursing Evaluation Summary dated [DATE] at 3:26 AM read in part, readmission on [DATE]. Resident has a trach and required One-on-One. On [DATE] at 11:44 AM, Staffing Coordinator GG was interviewed and asked if R444 had a 1:1 sitter assigned to him when he had been at the facility. Staffing Coordinator GG explained R444 never had an assigned sitter. When asked how she would know to assign a sitter to a resident, Staffing Coordinator GG explained the Director of Nursing (DON) would tell her. On [DATE] at 3:56 PM, Registered Nurse (RN) HH, who was R444's assigned midnight nurse on [DATE]-[DATE], was interviewed by phone and asked about supervision for R444. RN HH explained R444 was on 1:1 supervision because he had pulled his trachostomy tube out several times. RN HH was asked who had put R444 on 1:1. RN HH explained she did not remember if she did or if he had it when she came on. When asked who could assign a 1:1 sitter for a resident, RN HH explained the nurse could do it, or the DON would decide someone needed one. On [DATE] at 1:15 PM, Licensed Practical Nurse (LPN) Z, who was R444's assigned day nurse on [DATE], was interviewed and asked about R444's 1:1 sitter. LPN Z explained she had pulled a Certified Nursing Assistant (CNA) from the floor to be a 1:1 sitter, and he had not pulled out his trachostomy tube on her shift. On [DATE] at 3:54 PM, RN II, R444's assigned afternoon nurse on [DATE], was interviewed and asked about supervision for R444. RN II explained R444 did not have a 1:1 sitter . it was not given in report that he needed one . checked on him frequently throughout her shift because he had just come back from the hospital for pulling out his trachostomy tube. On [DATE] at 9:45 AM, the DON was interviewed and asked who could put residents on 1:1 supervision. The DON explained the nurse can initiate a 1:1 if concerned for safety, then the Interdisciplinary Team (IDT) team would meet and decide if a resident needed 1:1 supervision. The DON was asked why R444 did not have 1:1 supervision after pulling his trachostomy tube out multiple times. The DON explained she would have to look into the matter. No further information was provided before the end of the survey. 47283 Deficient Practice #3 Based on observation, interview, and record review, the facility failed to complete accurate assessment and implement adequate supervision and interventions based on the assessed needs and/or per plan of care for five residents (R27, R75 and R121 for smoking; R60 for falls; and R109 for maintaining nothing by mouth (NPO) status, resulting in the increased potential for accidents and serious injury such as falls, burns and aspiration/choking episodes Findings include: R75 R75 was admitted to the facility on [DATE] after hospitalization . R75 was living in the community with their family prior to hospitalization . R75's admitting diagnoses included: chronic obstructive pulmonary disease (COPD), diabetes, seizures, schizophrenia, dementia, and depression. R75 had a Brief Interview of Mental Status (BIMS) score of ,d+[DATE], which indicated moderate cognitive impairment. Review of R75's Electronic Medical Record (EMR) revealed a Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE]. MDS assessment revealed that R75 needed supervision for ambulation in the room, on the unit, and off the unit. R75 did not use any assistive device based on the MDS assessment. A review of the discharge summary dated from the hospital revealed that R75 had a diagnosis of tobacco use and they were smoking every day, 0.25 packs/day. R75 currently resided within the facility's secured unit, located on the second floor. An initial observation was completed on [DATE], at approximately 12:45 PM. R75 was observed in their room. During the observation, an interview was completed. R75 was able to answer questions appropriately. R75 reported that they had been at the facility for a few weeks and that they were anxious, and they wanted to smoke a cigarette. R75 reported that facility staff did not allow or assist them, and they did not understand why. R75 reported that they were smoking prior to coming to the facility and the facility had their smoking supplies. The supplies were with the staff custody on the first floor. R75 was able to walk around in the room independently without any assistive device. Later that day, at approximately 5:30 PM, R75 was observed entering through facility main entrance with a few other residents. A second observation was completed on [DATE], at approximately, 9:15 AM. R75 was observed in their room and reported that no one had come to see them or help them. R75 also reported that they would like to go downstairs and needed at least one cigarette. R75 reported that they had spoken with staff members, unable to provide any specifics. R75 was observed walking back and forth down the hallways, multiple times later during the day. Further review of R75's EMR revealed a safe smoking evaluation dated [DATE]. The summary of the evaluation read, Resident does not wish to smoke at this time, if a change occurs the smoking evaluation will be updated. Further review of R75's EMR did not reveal that R75 was receiving any smoking cessation alternatives, who was an active smoker prior to admission to the facility. There was no care plan in place. A follow-up observation was completed on [DATE], at approximately, 10:05 AM. R75 was observed in their room sitting on a chair next to bed. Later that day another observation was completed at approximately, 12:30 PM. R75 was able to recall the previous meeting with the surveyor and had asked if the surveyor followed up with the facility staff on their smoking situation. R75 reported they were tired and upset about this smoking situation. R75 was queried about the safe smoking evaluation that reported that they did not wish to smoke. R75 reported that was incorrect. R75 reported that they need their cigarettes and they needed someone to help them. They were not sure why their wish was not recorded accurately on their records. A review of the list of Residents who smoked at the facility provided by the facility administration did not reveal R75's name on the list. The list had fifteen residents. The list also did not reveal if any of residents needed any assistance or supervision. Residents were observed smoking in the courtyard area in front of the facility on [DATE] and [DATE]. An interview was completed with the staff member UU on [DATE], at approximately 9:30 AM. Staff member UU was queried on their role with the facility's resident smoking protocol. Staff member UU reported that they received an updated list of residents who smoked at the facility from administration or social work. They maintained the list on the front desk for staff reference and provided the updated list. Staff member UUreported that they kept all the resident smoking supplies in a lock box. Staff member UU also reported that they were giving out the leave of absence form to the residents to sign out when residents went out to smoke. Staff member UU also reported that if residents needed supervision, staff members were staying with the residents. The updated list had twenty residents. There was a note that read Needs assistance next to the names of four residents. R75's name was on the updated list with needs assistance note next to their name. Staff member UU was queried if R75 had any smoking supplies in the lock box. Staff member UU checked the lock box and said YES. Staff member UU showed R75's cigarettes and supplies that were kept in in a bag. An interview was completed with staff member VV on [DATE] at approximately 9:50 AM. Staff member VV was queried about the safe smoking assessment for R75 that was completed by them. Staff member VV reported that they needed to speak with the Director for any questions related to smoking policies before they could answer. A follow up interview was completed with the staff member VV later that day, at approximately 12:20 PM. Staff member VV was queried about R75's wishes and their safe smoking evaluation that did not match with the resident's wishes, and R75 is on the facility's updated list of residents who smoked and R75 had their supplies since they had been admitted to the facility. Staff member VV reported that R75 was not listed as a smoker on the list, and they were not sure what happened, and they would check. Staff member VV agreed that an assessment should be completed with appropriate care plan interventions before resident names are added to the list. Staff member VV was queried why the assessment did not reflect R75's wishes since admission to the facility and no further explanation was provided. Staff member VV reported that they would follow up. An interview with unit manager (Staff member I) was completed on [DATE], at approximately 10:40 AM. Staff member I was queried on the safe smoking evaluation. Staff member I reported that social worker or social work representative completed the assessment. If a resident was deemed safe, they obtained a physician order and completed a care plan for the resident. Staff member I was queried on the protocol for active smokers who were deemed unsafe. Staff member I reported that they would follow up with the providers and obtain orders for nicotine cessation alternatives. Staff member I was queried on R75's wishes, current assessment, updated smoking list and the current plan they had in place. Staff member I reported that no one from their unit smoked and they were not aware that R75 was on the smoking list, and they would follow up. An interview was completed with the Administrator on [DATE], at approximately 12:45 PM. The Administrator was queried on their smoking policy and inconsistencies with the resident smoking assessment and care plan for R75. The Administrator reported that they were admitting active smokers and agreed that there were inconsistencies with their processes. The Administrator reported that the smoking list should be consistent with the resident's assessment and care plan, and if residents were not safe, staff should be following up with the providers to offer alternatives. The Administrator reported that they understood the concern and they would follow up with their team. A facility document titled Smoking Policy- Non-Smoking Campus - Residents with a revision date of [DATE] (prior to the date of admission for R75), read in part, It is the policy of the facility to establish and maintain safe resident smoking practice for a nonsmoking campus . Smoking Area: 1. Prior to, or upon admission, residents shall be informed that smoking is not permitted inside of the facility or any facility property Smoking Articles: Residents who were grandfathered in prior to facility becoming a non-smoking that have smoking privileges shall not be permitted to retain any types of smoking articles . R60 R60 was a long-term resident of the facility, originally admitted to the facility on [DATE]. R60's admitting diagnoses included Dementia, psychosis, osteoarthritis, and muscle weakness. R60 was residing on the secured unit in the floor of the facility. R60 had a Brief Interview for Mental Status (BIMS) from Minimum Data Set Assessment (MDS) dated [DATE] revealing significant cognitive impairment. R60 needed extensive assistance from staff for their mobility in bed, to get in and out of bed, and to assist with their Activities of Daily Living (ADL). An initial observation was completed on [DATE], at approximately 12:15 PM in the hallway with a staff member. R60 was sitting in their wheelchair and the staff member was assisting the resident. R60 had a raised area and cut on their forehead. The area on the forehead was exposed and there was no bandage or treatment during this observation. Later that day, at approximately 2:15 PM, R60 was observed sitting in a wheelchair in the dining room. An observation was completed on R60's room earlier that day at approximately, 12:45 PM. R60 was not in their room during this observation. R60 had a regular mattress in their bed. No other devices were observed in their room. On [DATE], follow up observations were completed, at approximately 9:30 AM and 11:20 AM. During both observations R60 was observed in their bed. R60's bed was in the low position. There were no fall mats next to bed during both observations. On [DATE], at approximately 10 AM, another observation was completed on R60's room. R60 was not in their room and there were no fall mats observed in the next to bed or folded and stored near the area. A review of R60 Electronic Medical Record (EMR) revealed that R60 was at risk for falls. R60's care plan revealed fall prevention interventions. One of the interventions included read, Fall mat to left side of the bed, initiated on [DATE]. A review of nursing progress notes dated [DATE], at 23:15 read, Resident was observed on the floor in her bedroom, resident was assessed, resident has a wound on her scalp, the guardian the DON and the doctor were all notified, the wound was cleaned and dressed, the resident was given pain meds, neuro-checks started . An interview and observation were completed with Unit Manager (staff member I) on [DATE], at approximately 10:50 AM. Staff member I was queried on R60's recent fall and fall interventions. Staff member I reported that R60 had a fall from their bed and reviewed the care plan the interventions that were in place for R60, that included fall mat on the left of the bed. Staff member I and this surveyor were in R60's room. R60 was not in their bed at that time. Staff member I was queried about the fall mat for the left side. Staff member I reported that staff would remove and store in the room when resident was in not in bed. Staff member I was asked to show the stored fall mat in the room. Staff member I attempted to locate the fall mat in R60's room and they were unable to find the fall mat. Staff was notified of the observations while R60 was in their bed and fall mat was not in place. Staff member I reported that they would follow up and obtain one. A review of facility document titled Accidents and Supervision with a revision date of ,d+[DATE], read in part, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazards(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary . 30675 R109 On [DATE] at 10:43 AM, R109 was observed asleep, laying in bed with a tube feeding pump that was next to the bed that was on and set to a rate of 76 Milliliters (ML) an hour. There was approximately 800 ML of the jevity tube feeding formula that remained in the container. Additionally, there was a suction machine stored on the bedside dresser. On [DATE] at 2:35 PM, R109 remained laying in bed in the same manner as observed earlier, with the same amount of tube feeding formula that remained in the container. The tube feeding pump was turned off. On [DATE] at 2:37 PM, R109's family (introduced as the resident's daughter, granddaughter and great-granddaughter) entered the room and woke the resident up. When asked about the resident's use of a tube feeding, the granddaughter reported R109 had some recent weight gain and further reported the resident was now on a pleasure tray. On [DATE] at 2:40 PM, R109's granddaughter was observed to ask Certified Nursing Assistant (CNA 'TT') for a cup of coffee for the resident. CNA 'TT' was observed to go down the hallway, retrieve a cup of coffee and provide to the family. On [DATE] at 2:43 PM, CNA 'TT' was asked to discuss the observation in which they provided R109's family with coffee. CNA 'TT' reported the granddaughter worked at the facility as a CNA and they had asked for the coffee and they gave it to them. When asked given the resident was on tube feeding, how did they know whether R109 was able to have liquids and whether they had checked before providing the coffee, CNA 'TT' reported they did not check and provided it because the granddaughter had asked for it. Review of R109's current physician orders included: An order that started on [DATE] read, NPO (Nothing By Mouth) diet, NPO texture. An order started on [DATE] read, Enteral Feed one time a day Jevity 1.5 @ 76 ml/hr x 16 hrs via pump via peg (Percutaneous Endoscopic Gastrostomy - a feeding tube surgically placed through the abdomen into the stomach) (1216 ml VTBD/Volume to be Delivered) Up at 1600 (4:00 PM), down when total volume delivered. May hold for ADL (Activities of Daily Living) care. An order that started on [DATE] read, Daughter [name redacted] and Granddaughter [name redacted] may provide with small amounts of pureed food or ice cream for pleasure. Must be [TRUNCATED]

Based on observation, interview and record review, the facility failed to identify and implement interventions to address changes in range in motion (ROM) for one (R42) of three residents reviewed for limited ROM, resulting in R42 developing contractures of the lower extremities. Findings include: On 8/8/23 at 9:51 AM, R42 was observed lying in bed on their right side with their knees bent and drawn upwards. R42 was asked if they could straighten out their legs. R42 explained they could not straighten out either leg. Both legs remained bent at the knees as R42 attempted to straighten them out. Review of the clinical record revealed R42 was admitted into the facility on [DATE] with diagnoses that included: dementia, rheumatoid arthritis and osteoarthritis. According to the Minimum Data Set (MDS) assessment dated [DATE], R42 had moderately impaired cognition and required the total dependence of staff for activities of daily living (ADL's). The MDS assessment also indicated R42 had no impairment of ROM to the lower extremities. Review of R42's musculoskeletal care plan revealed an intervention revised 2/8/23 that read, Encourage/supervise/assist) the resident with use of supportive devices splints, braces, canes, crutches etc.) as recommended. [sic] An additional intervention initiated 1/20/23 read, Monitor/document/report to Nurse/MD PRN (as needed) s/sx (signs and symptoms) or complications related to arthritis: Joint pain; Joint stiffness, usually worse on wakening; Swelling; Decline in mobility; Decline in self care ability; Contracture formation/joint shape changes; Crepitus (creaking or clicking with joint movement); pain after exercise or weight bearing. On 8/9/23 at 8:37 AM, R42 was observed lying in bed on their back with their knees bent so their legs appeared to form an inverted V. Review of R42's Certified Nursing Assistant (CNA) documentation revealed no orders for Restorative Nursing on R42's lower extremities. On 8/10/23 at 9:30 AM, Therapy Director V was interviewed and asked about R42's apparent lower extremity contractures. Therapy Director V explained she would review the Physical Therapy (PT) evaluations and look into the matter. Therapy Director V was asked for R42's PT evaluations. Review of R42's PT evaluations revealed: An initial PT Evaluation & Plan of Treatment dated 1/20/23 that read in part, .LE (lower extremity) ROM: R(right)LE = Impaired; L(left)LE ROM = WFL (within functional limits) . RLE ROM: Right Hip = WFL; Knee = Impaired; Ankle = Impaired . A(active)ROM - (R) Knee: Flexion = 110* (degrees); Extension = -30* . AROM - (R) Ankle: Dorsiflexion = -50*; Plantar Flexion = 0* . A PT Discharge Summary dated 2/24/23 read in part, .Discharge Recommendations and Status: .Restorative Program Established/Trained = Restorative Range of Motion Program . Range of Motion Program Established / Trained: Bilateral LE ROM of knee, ankle and hip with in pt's (patients) pain tolerance-3x 10 R (repetitions), 2sets [sic] to prevent further contracture . A PT evaluation dated 7/12/23 read in part, .LE ROM: RLE ROM = Impaired; LLE ROM = Impaired . LLE ROM: Left Hip = Impaired; Knee = Impaired; Ankle = Impaired . AROM (R) Hip: Flexion = NA (not able); Extension = NA . PROM - (R) Hip: Flexion = 40* . AROM - (R) Knee: Flexion = NA; Extension = NA . PROM- (R) Knee: Flexion 30* . AROM - (R) Ankle: Dorsiflexion = NA (75% lost PROM); Plantar Flexion = NA . AROM - (L) Hip: Flexion = NA; Extension = NA . AROM - (L) Knee: Flexion = NA; Extension = NA . AROM - (L) Ankle: Dorsiflexion = NA; Plantar Flexion = NA . It should be noted that when R42 was admitted on [DATE], there was an impairment to the RLE, however on 7/12/23, R42's right knee was fixed at 30* along with contractures to the right hip and ankle. Also, R42's LLE had no impairment upon admission, however on 7/12/23 the left hip, knee and ankle were contracted. On 8/10/23 at 11:39 AM, Therapy Director V was asked how Restorative Nursing recommendations were communicated to the Restorative CNA's. Therapy Director V explained they filled out a form and gave it to the Director of Nursing (DON). The DON put the recommendations into the resident's chart in the CNA tasks. Review of R42's PT OT (Occupational Therapy) Restorative Program form dated 2/19/23 had Level III written at the top right corner and read in part, .Splints: 2-3 hours R knee brace increase up to 8 hours daily . On 8/10/23 at 12:23 PM, the DON was interviewed and asked why R42's Level III Restorative recommendation were not implemented. The DON explained she would look into the matter. The DON was asked for any documentation that any of the recommendations were done. No documentation or information on the recommendation was provided by the end of the survey. On 8/10/23 at 1:30 PM, Restorative CNA FF was interviewed and asked about R42's lower extremities. CNA FF explained R42 had no specific directions for the legs, there were directions for the upper extremities so she would work with R42 on their arms. When asked if R42 had splints for their knees, CNA FF said yes. CNA FF was asked where the splints were. CNA FF first looked in R42's bedside three drawer table, then looked in the full length wardrobe. Down at the bottom of the wardrobe R42's splints were found. On 8/10/23 at 2:18 PM, Therapy Director V was asked about the difference in R42's PT evaluations from January 2023 to July 2023. Therapy Director V explained there had been a significant decline in R42's lower extremities. When informed the recommendation for splints to be applied daily had not been implemented, Therapy Director V explained if the splints had been used, there probably would not have been as much of a decline in function. Review of a facility policy titled, Restorative Nursing Programs revised 1/1/22 read in part, .The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility . Definition: .Level III Restorative Nursing - The resident's goal(s) or highest functional level has been achieved. The goal(s) now become prevention or minimization of functional decline or impact on activities of daily living . Anyone can make a referral to the restorative Nursing Program .

This citation pertains to intake: MI00132990. Based on interview and record review the facility failed to ensure multiple wound consultations were completed per the physician's order, ensure accurate documentation of wound assessments and ensure consistent identification of a wound decline for one (R802) of one resident reviewed for pressure ulcers, resulting in the resident to have developed four additional pressure wounds, a Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) wound to the left ankle with palpable bone, DTI (Deep Tissue Injury- Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the left and right hallux, and a DTI to the right ankle) within four weeks of admission into the facility. Findings include: Review of a complaint submitted to the State Agency (SA) documented a concern regarding the facility staff to have failed to provide adequate and appropriate care to prevent and treat pressure sores. Review of the medical record revealed R802 was admitted to the facility on [DATE], with diagnoses that included: acute and chronic respiratory failure with hypoxia, dysphagia, atrial fibrillation, diastolic heart failure, hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, dependence on supplemental oxygen and tracheostomy status. A Minimum Data Set (MDS) assessment dated [DATE], documented Severely impaired cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). Review of a Nursing Admission Evaluation skin assessment dated [DATE] at 3:47 AM, that documented in part . Does the resident have any identified skin conditions/wounds- Yes . Right heel- DTI (Deep Tissue Injury) - discoloration . Left heel- discoloration? DTI . The document was left blank for the length & width measurements of the discoloration identified. Review of an admission Braden Scale For Predicting Pressure Sore Risk dated 10/21/22, documented a score of 14 which indicated a Moderate Risk. Review of the physician orders documented two orders for a wound consult on 10/21/22. The first wound consult was ordered on 10/21/22 at 3:00 PM, that documented as needed for boggy/discoloration b/l (bilateral) heel. Further review of the physician orders revealed a second wound consult ordered the same day on 10/21/22. Review of the October 2022 Treatment Administration Record (TAR) revealed an order to Cleanse with wound cleanser. Pat dry. Apply skin prep q (every) shift and prn (as needed). Bilateral heel every shift implemented on 10/21/22. Review of the medical record revealed no documentation of the wound consultation to have ever been completed. Further review of the medical record revealed no documentation of the wound characteristics, no measurements and no documented detailed assessment of the heels. Review of a facility policy titled Pressure Injury Prevention and Management revised 1/1/22, documented in part . The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . Assessments of pressure injuries will be performed by a licensed nurse, and documented in the medical record . Review of a Nursing note dated 11/11/22 at 3:01 PM, documented in part . Resident seen for skin integrity on 11/10/22. Bilateral foot ulcer noted. Treatment initiated, wound care to follow up weekly. Resident daughter notified on 11/11/22 of resident current wound care needed <sic> . Daughter stated, she in <sic> house yesterday, notice resident is very fidgety, and boot may be kicked up. Writer inform <sic> daughter of current treatment and wound care team will follow up with residents wound care . Will follow up with wound care in 1 week . Review of the medical record revealed no documentation of the skin integrity . Bilateral foot ulcer . wound assessments, wound characteristics or wound measurements documented of the bilateral foot ulcers identified on 11/10/22. Review of the physician orders documented a third wound consult ordered on 11/10/22 by the facility's Wound Nurse (WN) H. Review of the medical record revealed no documentation of R802 to have had a wound consultation with the wound practitioner after the third wound consult was ordered. Review of the November 2022 TAR documented on 11/11/22 a new order for Povidone-Iodine Solution 10%, cleanse with wound cleanser, pat dry, apply betadine, let dry, cover with non-border/or ABD (abdominal) pad, Kerlix roll and tap to the left lateral ankle, left medial foot, left heel, right lateral ankle, right medial foot and right heel was implemented. Review of multiple Skin & Wound Evaluation dated 11/15/22 (completed by WN H) documented in part: At 12:32 PM, . Pressure . Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration . Right Lateral Malleolus . In-House Acquired . Area 1.7 cm2, Length 2.4 cm, Width 0.9 cm, Depth Not Applicable . % Eschar- 100% of wound filled . At 12:34 PM, . Pressure . Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration . Left Heel . Present on Admission . Area 13.6 cm2, Length 4.2 cm, Width 4.0 cm, Depth Not Applicable . % Eschar- 100% of wound filled . At 12:37 PM, a second assessment was documented for the Left Heel . Pressure . Unstageable: Obscured full-thickness skin and tissue loss . Slough and/or eschar . Left Heel . Present on Admission . Area 19.5 cm2, Length 5.8 cm, Width 4.5 cm, Depth Not Applicable . Eschar . % Eschar- 100% of wound filled . At 12:39 PM, . Pressure . Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration . Medial Left Foot . In-House Acquired . Area 0.9 cm2, Length 1.2 cm, Width 1.0 cm, Depth Not Applicable . % Eschar- 100% of wound filled . At 12:40 PM, . Pressure . Unstageable: Obscured full-thickness skin and tissue loss . Slough and/or eschar . Left Lateral Malleolus . In house Acquired . New . Area 11.1 cm2 (centimeters squared), Length 5.2 cm, Width 3.1 cm, Depth Not Applicable . % Granulation- 20% of wound filled . % Eschar- 80% of wound filled . Exudate- Light . Serosanguineous . On 11/10/22 WN H documented bilateral foot ulcers identified with no documentation of measurements or characteristics of the wound identified. Five days later WN H completed five Skin & Wound evaluation(s) that identified four different pressure wound ulcers (as two assessments identified the same area), which indicated the assessments were not accurate. The November 2022 TAR documented treatment being applied to six areas (1) the left lateral ankle, 2) left medial foot, 3) left heel, 4) right lateral ankle, 5) right medial foot and 6) right heel. There was no Skin & Wound evaluation(s) completed for the right heel and right medial foot. Review of a NP (Nurse Practitioner)/PA (Physician Assistant) note dated 11/19/22 at 11:38 AM, documented in part . Reports patient has been fidgety or anxious and patient is constantly moving legs removing the bilateral LE (Lower Extremity) heel lift boots. Discussed new/worsening wounds to LE 2/2 (secondary to) heel lift boots continuously being removed by non-purposeful movement from the patient. Reports that patient's daughter also reported anxious/restless behavior . Review of a Nursing note dated 11/20/22 at 2:30 PM, documented in part . Resident has recent change in skin integrity to bilateral feet . She continue <sic> to be fidgety and rubs boots off at time <sic>. Alternative intervention to float heel with pillows in place, turn and repositioning in place. Will follow up with wound care team . Review of a Nursing note dated 11/21/22 at 5:20 PM, documented in part . Family member request that resident be sent to the hospital . states it appear to her that there has been a decline since her admission to this facility . The resident was transferred to the hospital per the family member's request. Review of the medical record revealed at the time of R802's transfer to the hospital the resident had not been seen by the wound practitioner the entire inpatient stay at the facility. Further review of the medical record revealed no documentation of a physician to have assessed R802's wounds or followed up to ensure the effectiveness of the implemented treatment. Review of the hospital records revealed wound care consultations and photos of the resident wounds taken by the hospital staff. The initial wound care consultation documented in part, . #1 Location: Left Ankle stage 4 pressure injury . Wound base: moist, pink/yellow slough, palpable bone . Measurement: 4.0 cm (centimeters) x 4.5 cm x 0.4 cm . Drainage: moderate serous . Full thickness skin loss with exposed / palpable fascia, muscle, tendon, ligament, cartilage, or bone - is observed. Slough and/or eschar is present over a potion of the wound base . #2 location: Left hallux Deep Tissue Pressure Injury (DTPI) . Wound base: dark, intact, nonblanchable . Measurement: 1.0 cm x 1.0 cm x unable to determinable depth . #3 Location: Left Heel Deep Tissue Pressure Injury (DTPI) . Wound base: dark, intact, nonblanchable . Measurement: 4.2 cm x 4.0 unable to determinable depth . #4 Location: Right Heel Deep Tissue Pressure Injury (DTPI) . Wound base . dark, intact, nonblanchable . Measurement: 3.0 cm x 3.0 unable to determine depth . #5 Location: Right Hallux Deep Tissue Pressure Injury (DTPI) . Wound base: dark, intact, nonblanchable . Measurement: 1.5 cm x 2.0 unable to determine depth . #6 Location: Right Ankle Deep Tissue Pressure Injury (DTPI) . Wound base: dark, intact blister present . Measurement: 3.0 cm x 1.4 unable to determinable depth . This indicated a resident who entered the facility with DTI's to both heels, within a month developed four additional wounds: a Stage 4 wound to the left ankle with palpable bone, DTI to the left and right hallux, and a DTI to the right ankle. Review of the medical record revealed no documentation of the staff to have identified the worsening of the resident's left ankle wound. On 2/14/23 at 12:33 PM, WN H was interviewed and asked why a wound consultation was never completed for R802 although it was ordered three times by the physician and WN H stated they believe the resident went out to the hospital and that is the reason R802 was not seen. When confirmed that the resident was transferred to the hospital however was in the facility for a month and admitted with two DTI's to both heels, WN H was then asked why the resident was not seen within the month of inpatient care at the facility although having entered the facility with wounds and WN H stated if a resident entered in the facility with wounds they would have been seen by the wound physician. WN H stated they would look into and follow back up. At 2:09 PM, WN H returned and stated they completed a wound assessment after the admission nurse and didn't identify any areas of concern, however, implement the skin prep and float boots for the resident preventive measures. WN H then stated based off their skin assessment and no wound to have been found the resident was not added to the wound care practitioner list. WN H stated the list is generated by them which identifies a list of residents for the wound practitioner to consult with weekly. WN H then stated the resident was not seen following the implementation of the third physician order wound consult because the wound practitioner was on vacation and when they return the R802 was at the hospital. WN H was then asked how they were informed of the additional wounds identified on R802 on 11/10/22, as there was no documentation in the medical record of the wound nurse to have been informed of the new wounds and WN H stated they couldn't recall but believed an aide might have informed them of R802's wounds as they were leaving the facility on 11/10/22. This indicated the WN H stated when they completed a wound assessment on R802 after the admission assessment was completed by the admitting nurse, WN H did not identify any concerns or discoloration to R802 heels that warranted the resident to be seen by the wound practitioner however, WN H documented on the two Skin & Wound evaluation(s) dated 11/15/22 that both DTIs to the heels were identified On Admission.

This citation pertains to intake: MI00130772. Based on interview and record review the facility failed to implement adequate and effective fall interventions to prevent falls for one (R804) of three residents reviewed for falls, resulting in a displaced transcervical fracture of the right proximal femur which required a transfer to the hospital and surgical intervention. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part, . (R804) who was labeled a Fall Risk, rang for help from a nurse and with no response to get up from (R804) bed to go to the bathroom. On (R804) way back to (R804) bed (R804) fell and suffered a cracked femur bone on (R804) right side. (R804) laid there on the floor the remainder of the morning for approximately 5 hours until someone came in and found (R804) on the floor . Review of the medical record revealed R804 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses that included: dementia, emphysema, muscle weakness and a history of falling. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition and required staff assistance for all ADLs. Review of an admission Fall Risk Evaluation dated 5/12/21, documented a score of 18, which categorized R804 as a high fall risk. Review of a Nursing note dated 11/24/21 at 5:46 AM, documented in part . Resident observed sitting on the floor next to (R804) bed in (R804) room claimed she lost her balance and fell . This was around 4:30am . Around 7:30 am resident claimed that (R804) hit her head when she fell and now complaining of headache and bilateral hip pain Norco 5-325 1 tab given as per order resident placed in bed comfortably . Dr (doctor) . notified with order to transfer resident to (hospital name) for CT scan (CAT scan) . Review of the hospital discharge documented provided to the facility upon R804's readmitted d 11/29/21 at 9:29 AM, documented in part . Primary Diagnosis: Right Hip Fracture . presented to the ED (emergency department) after falling out of her wheelchair at (nursing home facility name) earlier this morning. The patient states that she was on the ground for a while before anyone helped her up . The patient admits to 10/10 pain to her right hip . history of dementia hypertension admitted after she sustained a fall at the nursing home she had negative CAT scan for any acute pathology unfortunately the patient had minimally displaced transcervical fracture of the right proximal femur patient was taken to the OR (Operating Room) with open reduction internal fixation she is confused pleasantly not in distress . Procedure . Open Reduction Internal Fixation Hip with Cannulated Screw with Fluoro (11/24/2021) . R804 was discharged from the hospital and transferred back to the facility on [DATE]. Review of a care plan titled The resident for falls related to: generalized weakness, Hx (history) of falls . Initiated: 5/13/2021, documented the following interventions: . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Bed in low position when not providing care . Encourage rest periods as needed to avoid overtiring . These interventions were not adequate or effective for a resident diagnosed with dementia, categorized as a high fall risk and had a documented diagnosis of a history of falls. On 2/15/23 at 12:04 PM, the Director of Nursing (DON) was interviewed and asked about the lack of adequate and effective fall interventions to have been implemented to prevent further falls for R804. The DON stated they were not employed with the facility at the time of R804's inpatient stay however would look into the record to see what they could find. No further explanation or documentation was provided by the end of survey.

This citation pertains to intake #MI 959 Based on interview and record review the facility failed to ensure an unsupervised exit did not occur for one resident (R#901) with previously identified elopement behaviors and severe cognitive impairment of three residents reviewed for elopement, resulting in immediate jeopardy (IJ) when R#901 exited the building and left the facility premises without staff knowledge or supervision increasing the likelihood of serious injury, serious harm, serious impairment, or death. Findings include: The IJ began on 9/17/21. The IJ was identified on 9/29/21. The facility was notified of the IJ on 9/29/21 at 1:21 p.m., A plan to remove the immediacy was requested. The immediacy was removed on 9/29/21 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 actual harm that is not immediate jeopardy. On 9/28/21 a concern submitted to the State Agency for review revealed an allegation that R901 had eloped from the facility without knowledge of facility staff. On 9/28/21 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Dementia with Behavioral Disturbance, Restlessness and Agitation and [CONDITION(S)] with Delusions. A review of R901's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/15/21 revealed R901 had delusions and a BIMS score (brief interview of mental status) of three indicating severely impaired cognition. A review of R901's initial care plan revealed the following: Focus-The resident is an elopement risk r/t (related to) the dx (diagnosis) of Dementia. Record states she attempted to leave the hospital. She self ambulates and required redirection and re assurance. Revision date-8/10/21 . A Nursing note dated 8/10/2021 revealed the following: some confusion noted continent of bowel and bladder one person supervising assist for toileting needs appetite good resident has been ambulating throughout the unit and was educated on safety resident is in common area adjusting well to the unit safety measures will remain in place. A behavior note dated 8/27/21 revealed the following: Behavior displayed: paranoia, refusing medications, wandering. History of behaviors: newly admitted to facility. Interventions attempted: redirect, provide reassurance and support .Comments: Resident admitted with dx (diagnosis) of dementia, metabolic [CONDITION(S)], psychotic d/o (disorder) with delusions, Alzheimer's disease . A Nursing note dated 9/18/21 at 2:22 a.m., revealed the following: Resident left the building somehow, she was found by the police, the police called the building, that was when we confirmed that she was our resident, this was around 9pm, the police brought her back and ask for the supervisors name and phone number. The resident say she was going to California to see her son .The last time I saw the resident was around 7:40 pm, during dinner, resident was trying to eat. The family, the DON and the doctor were all notified . A facility investigation pertaining to R901's elopement on 9/17/21 revealed the following: On September 17, 2021, approximately 9:45 pm, staff receptionist (activities aide F) received a call from the [local police department]. Police Department inquired if the facility had a resident by the name of [R901]. Resident was able to tell the Police officers her name and room number. Police Department gave the resident name to the receptionist. Receptionist went to the [R901's Nursing Unit] to speak with the Nurse (Nurse G). Nurse confirmed that the resident was not on the unit .Police [Names of police officers] returned the resident to the facility about 10:00 PM .Upon completion of investigation, the receptionist left the front desk to drop off a delivery without asking for coverage. Staff Receptionist and other receptionist were immediately reeducated on Attendance at all times while on Front desk and Receptionist duties . A police report dated 9/17/21 pertaining to R901's elopement was reviewed and revealed the following: 10:12 p.m.,-Caller states a [R901 demographics] wearing pink hat, robe is sitting on her porch .Husband asked if she needs any help but she said she is fine and is just sitting there, appears disoriented .10:29 p.m.,-Supposed to be at [name of facility] .10:29 p.m.,-Female on board headed to [name of facility] .10:44 p.m.,-TOT (turned over to) staff . On 9/29/21 at approximately 8:15 a.m., the facility Administrator was queried how R901 eloped from the building without staff knowledge. The Administrator indicated they believed R901 went behind someone after that person got off of the elevator and then went down to the first floor. The Administrator indicated the front receptionist was not at the front desk to prevent R901 from exiting thorough the automatic doors and the receptionist did not notify anyone to take their place while they were gone. The Administrator indicated they had to provide education to staff to ensure that no residents are behind them when getting off of the elevator and had to educate the receptionist on ensuring someone is providing coverage at the front desk if they have to leave it. On 9/29/21 at approximately 9:40 a.m., Social Worker I (SW I) was queried regarding R901's elopement from the facility on 9/17/21. SW I indicated that R901 had been previously identified as an elopement risk upon admission due to them trying to leave the hospital. SW I was queried if it was safe for R901 to be off the facility grounds unsupervised and they indicated that it was not due to R901's dementia. SW I was queried how R901 got out of the facility, and they indicated they did not know but R901 probably went down the elevator while someone was getting off. SW I indicated that once inside the elevator a code was not needed to go down to the first floor on the elevator. On 9/29/21 at approximately 10:08 a.m., Nurse G was queried regarding R901's elopement. Nurse G indicated that they had last seen R901 during dinner at around 7:00-7:30 p.m., and it was the last time they saw them until the police returned R901 to the facility at around 10:30 p.m., Nurse G was queried if R901 had been an elopement risk and they indicated they had and that they had to redirect R901 and other residents on the unit multiple times due to their behaviors. On 9/29/21 at approximately 10:25 a.m., Activities aide F (AA F) was queried regarding R901's elopement from the facility on 9/17/21. AA F indicated they were the front desk receptionist at the time R901 eloped from the facility. AA F indicated that the exit doors automatically lock at 8:00 p.m., and they had left the front desk unattended for approximately 15 minutes between 7:15 p.m., and 8:00 p.m. AA F reported they did not get anyone to cover for them when they left. AA F indicated they thought R901 went on the elevator, came down and left the facility when they had left the front desk unattended. AA F was queried if they were supposed to get coverage when they left the front and they indicated they should have but they didn't at that time. AA F indicated the police brought R901 back to the facility around 10:30 p.m. On 9/29/21 a facility document titled Unsafe Wandering & Elopement Prevention was reviewed and revealed the following: Policy: Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Nursing personnel must report and investigate all reports of missing residents . Removal of the immediacy was confirmed onsite when the facilty took the following actions: - The Front entrance door was checked to ensure it was locked, same day as occurrence. - Nursing Supervisor initiated a Head count for all current residents, all residents accounted for., same day as occurrence. - Maintenance Director checked all doors, doors on units and stairwells. All doors were locking and functioning properly, same day as occurrence. - The front door will no longer automatically open at any time, going forward an entering and exiting code will need to be entered to allow the door to automatically open. The staff have been reeducated on the changes. - The Elevator will have STOP signs to remind staff to ensure the Elevator closes before they walk away from the Elevator to ensure the door closes and no residents get on the Elevator. - Affected Resident Care Plan and Elopement assessment was reviewed on 9/17/21, same day as occurrence. - Current residents were assessed for Risk of Elopement on 9/20/21. - Current resident's care Plans were reviewed to ensure that residents at risk for Elopement were identified on 9/20/21. - Elopement Binders on each unit were reviewed and updated on 9/20/21. - Facility began immediately educating staff on Unsafe Wandering & Elopement Prevention on 9/17/21, same day as occurrence

This citation pertains to intake number: MI 036. Based on observation, interview and record review, the facility failed to accurately reconcile and transcribe a steroid medication ([MEDICATION(S)]) order for one (R906) of three residents reviewed for quality of care, resulting in an immediate jeopardy (IJ) when the facility failed to identify and implement the correct order of [MEDICATION(S)] 50 mg (milligram) once a day order for three days. The facility staff administered [MEDICATION(S)] 50 mg daily for seven weeks and three days. R906 was transferred to the hospital and admitted to the Intensive Care Unit (ICU) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The IJ begin on 7/27/21 and was identified by the team on 9/30/21. The facility was notified of the IJ on 9/30/31 at 12:51 PM and a plan to remove the immediacy was requested. The immediacy was removed on 10/1/21 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 actual harm that is not immediate jeopardy. A complaint submitted to the State Agency alleged the facility failed to administer ([MEDICATION(S)]) medication as ordered and the resident (R906) was overmedicated. On 9/28/21 at approximately 4:25 PM, an observation was made of R906 laying on their back in bed with a pink gown on. Multiple attempts of verbal stimuli was made, however unsuccessful. The resident did not open their eyes or respond. Multiple strands of R906's hair which had fallen out of the resident's head was observed all over the resident's pillowcase. A black cellphone, eyeglasses, and orange fat free sherbet was observed on the nightstand next to the resident's bed. A full glass of thickened water was observed on the residents over head table. There was no staff observed in the room. When asked, the resident's roommate stated in part, . She doesn't wake up often . R906 was admitted into the facility on [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 (indicating intact cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of a hospital Patient Medication Discharge List provided on admission to the facility contained a prescription dated 7/20/21 for the following, [MEDICATION(S)] 50 mg oral tablet, 1 tab(s) PO (oral) qdayACbkfst <sic> (every day before breakfast) for 3 days. Review of R906's July, August & September 2021 Medication Administration Records (MARS) revealed R906 was administered [MEDICATION(S)] 50 mg every day from 7/24/21 until 9/13/21 when the resident was transferred to the hospital for a change of condition. The physician ordered the [MEDICATION(S)] to be administered once daily for three days, however the facility staff administered the [MEDICATION(S)] once a day for seven weeks and three days. The discrepancy was never identified by the facility staff. The [MEDICATION(S)] order the facility implemented documented in part, . [MEDICATION(S)] tablet, 50 MG, Give 1 tablet by mouth one time a day for Pain- Mild . Review of a facility Provider - History & Physical dated 7/23/21 at 6:32 PM documented in part, . [CONDITION(S)] with joint pains. - s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Seen by Rheum (Rheumatologist) in hosp (hospital): much of her pain is due to prior damage and not due to active inflammation . Review of a facility policy titled Medication Reconciliation dated 1/1/2021 documented in part . This facility reconciles medication upon admission . Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Processes . Verify resident information received . Compare orders to hospital records, etc. Obtain clarification orders as needed . Follow procedures on the medication reconciliation form . Licensed staff from new unit to verify that all medications are accounted for, and that medications on hand match physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility did not accurately reconcile R906 [MEDICATION(S)] medication. Review of the hospital Transfer Form dated 7/23/21, provided to the facility upon R906's admission to the facility, documented instructions for R906 to follow up with the Rheumatologist within 1 to 2 weeks after being discharged from the hospital. Review of a facility Provider - History & Physical dated 7/23/21 at 6:32 PM documented in part, . - Follow-up with rheumatologist or with (doctor name redacted) . On 9/29/21 at 3:24 PM, the DON was interviewed and asked for the Rheumatologist consultation report to see if the Rheumatologist identified the [MEDICATION(S)] error. The DON returned shortly after and stated the Rheumatologist appointment was never scheduled. On 9/29/21 at 5:04 PM, Licensed Practical Nurse (LPN) J (the nurse who transcribed and reconciled R906's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharged medication list contained a prescription for [MEDICATION(S)] once daily for three days, not once daily for seven weeks and three days. On 9/30/21 at 8:07 AM, the Director of Nursing (DON) was interviewed and stated the facility policy is the admitting nurse would reconcile and transcribe the resident medications with the physician. The unit manager would then do a medication reconciliation as a double check to ensure that all medications are accurate. The facility medication reconciliation process was not accurately completed by LPN J or the unit manager for R906's admission medications. Review of a Pharmacy Medication Review dated 8/27/21, completed by the facility's contracted pharmacist failed to identify the error in the reconciliation and transcription of R906's [MEDICATION(S)] medication. On 9/30/21 at 8:55 AM, an interview was attempted via telephone with the pharmacist, and they did not answer the phone or return the phone call by the end of survey. On 9/29/21 at 4:07 PM, Physician K (R906 primary physician at the facility) was interviewed via telephone and asked if the resident was supposed to be on three days of [MEDICATION(S)] or seven weeks and three days and Physician K stated in part, . I have to take responsibility of that because they are all under my name, usually I would look at these. My history and physical said 5 days only . Physician K was asked was there additional monitoring and labs that should have been ordered for R906 while being administered [MEDICATION(S)] medication and Physician K stated in part, . Had I known that she was on it, normally I would have ordered labs if they are started on [MEDICATION(S)] . I think everything is patient care and patient safety, obviously I have to take responsibility. As a medical professional we made an error, that we fixed and have to move forward . Physician K stated that he was the attending physician for R906 in the hospital and had discussed the error with the family of R906 when they talked in the hospital. Physician K was then asked if they had informed the Administration staff or IDT (Interdisciplinary team) of the error so that additional education and training could be provided to the staff and Physician K admitted they had not notified the facility staff of the error. On 9/29/21 at 3:24 PM, the DON was interviewed and asked about the [MEDICATION(S)] error for R906 which resulted in the resident's hospitalization . The DON stated they were unaware of the [MEDICATION(S)] medication error. The facility admitting nurse LPN J, unit manager, contracted pharmacist and physician all failed to identify and correct R906's [MEDICATION(S)] medication error. Review of a Nursing 2019 Drug Handbook (Wolters Kluwer) documented in part, [MEDICATION(S)] . Adverse Reactions . [CONDITION(S)] . [CONDITION(S)] . Effects on lab test results- May increase glucose and cholesterol levels . Use cautiously in patients with . hypertension . Monitor patient's . potassium level . weigh patient daily; report sudden weight gain to prescriber . Review of the R906's weights revealed the following weights: 7/27/21 - 87 pounds 8/1/21 90.2 pounds 8/9/21- 95.2 pounds 8/18/21 - 95.5 pounds Further review of the medicale revealed no documentation that the physician was notified regarding the weight gain to rule out a possible side effect from the [MEDICATION(S)] medication. Review of the clinical record revealed no labs ordered to monitor for any adverse reactions of the [MEDICATION(S)] medication. Review of a Nurses' Notes dated 9/13/21 at 10:59 AM, documented in part . writer received message from resident guardian/daughter, regarding resident c/o (complaints of) pain She stated she had concerns that her mother had a stroke because she is confused and unable to talk coherently. Writer contacted (provider name redacted) and she had (doctor name redacted) call for Tele visit with resident. New orders to send resident to (hospital name redacted) . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient was seen by video conferencing-with help of the nurse on duty . complaining of abdominal pain intermittently . daughter also felt that her speech was not very clear today . need to rule out TIA/[CONDITION(S)] (Transient Ischemic attack/[CONDITION(S)]). Ordered immediate transfer to (hospital name redacted) for further evaluation . Review of a hospital Critical Care Consultation Note dated 9/13/21 at 3:03 PM, documented in part . presents for confusion and slurred, ICU consulted due to [CONDITION(S)] and elevated lipase . DKA Vs HHS 2/2 (secondary to) steroid use ([MEDICATION(S)]) . Severe dehydration secondary to above . Metabolic [CONDITION(S)] secondary above r/o (rule out) stroke . Blood sugar on admission - 914 .Elevated lipase r/o pancreatitis - Lipase- 1, 318 . Plan . Insulin drip . IV fluid hydration . glucose checks q1 (every hour) . presents due to confusion. Most history gathered via her daughter. Patient's daughter states 4 days ago she began to call her mom, but for the first 2 days there was no answer. On Saturday her mom answered, and her responses seemed confused, and she seemed hard to focus. On Sunday her roommate answered and said that the mother cannot come to the phone. The daughter went to (facility name redacted) this morning and was able to see her mom through the window. Her mom was confused and did not appear to be like herself. She was more lethargic and had slurred speech . Patient daughter states when she was at (facility name redacted) a worker name (worker name redacted) told her she was on [MEDICATION(S)]. Record review show [MEDICATION(S)] 50mg per day. Daughter states she . did not realize her mom was on [MEDICATION(S)] and does not know how long her mom has been taking it or how much she is taking. Patient states she has no history of diabetes previously . Review of a hospital History and Physical dated 9/13/21 at 3:43 PM, documented in part . Preliminary Report . [CONDITION(S)] with metabolic acidosis; no known diabetic history . [CONDITION(S)] may in part be prompted by recent high dose [MEDICATION(S)] use . Lab Results . WBC: 13.76 . High . Glucose Level: 914 . Critical . BUN: 59 . High . BUN/CREAT Ratio: 74 High . Sodium Level: 128 . Low . Potassium Level: 5.2 . High . Review of a Nurses' Notes dated 9/24/21 documented in part, . Resident admitted with Foley catheter same in place & patent draining clear urine. The resident was readmitted back to the facility after their hospitalization . On 9/30/21 at 9:23 AM, the Social Worker (SW) I was asked to complete a current BIMS assessment on R906. SW I returned shortly after and stated in part It will be a 99. The resident is unable to complete the interview. (R906) won't respond to anything verbal. At this time (R906) is severely cognitively impaired. R906 admitted into the facility on [DATE] with a BIMS of 13 (intact cognition). Removal of the immediacy was confirmed onsite when the facilty took the following actions: - The Unit Manager will be re-educated on the Drug Regime review. - The Pharmacist will be re-educated on the Pharmacy Drug Regime review process by the Medical Director. - The Medical Director will review pharmacy drug regimen reviews for the month of September. - The Medical Director will re-educate the Primary care Physician on medication orders and notify the facility of any errors noted. - All current residents have been reviewed by the DON and the Clinical team for Medication reconciliation on 9/30/21 - Current Licensed Nurses have been re-educated on the Medication Reconciliation Policy and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . - The facility will review the past 30 days of admissions/re-admissions to ensure medication reconciliation has been completed and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - The facility will review the past 30 days of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - The DON will review all new and re-admissions for medication reconciliation to ensure transcription is completed correctly per the Physician orders.

Based on observation, interview and record review the facility failed to ensure residents received routine care for personal hygiene including nail care and hair removal for five residents (R#30, R#29 R#48, R#55, and R#19 ) out of seven reviewed for Activities of Daily Living (ADLs) resulting in R#30 sustaining an infected open wound to the right thigh and the potential for continued poor hygiene and embarrassment. Findings include: R#30 On 4/06/21 at approximately 11:02 AM, R#30 was observed lying in bed the resident's fingernails on both the left and right hand were long and extended approximately one quarter over the nail bed. Dark black debris was observed under the nails. The resident was alert and able to answer questions asked. When queried as to ADL care provided by the facility, R#30 reported that he had a large wound on the right thigh that was infected. When asked what happened, the resident indicated that he was very itchy and kept scratching his legs, he indicated it got worse and turned into a blister that popped and became infected. When asked whether his nails are trimmed/clipped by facility staff, R#30 reported that sometimes they do and sometimes they don't. When queried as to the last time his nails were clipped, cut, or filed, R#30 could not recall. On 4/7/21 at approximately 9:41 AM was observed lying in bed. The resident's nails were still long, and debris remained under the nails. A review of R#30's clinical record documented that the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 (moderately cognitively impaired) and required extensive assistance for most ADLs. A review of R#30's care plan documented, in part, the following: Focus: The resident is at risk for skin breakdown Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short (9/21/2018) .Focus: Resident has staphylococcus in right thigh (3/25/2021) .Interventions .Administer prescribed antibiotic .Focus: the resident needs activities of daily living .Personal Hygiene: The resident requires supervision assistance by (1) staff with personal hygiene . A review of the resident's skin and bathing sheets were provided. While the documents indicated the resident received showers there was no indications that his nails had been cut, trimmed, or filed. A transcribed NP/AP (nurse practitioner/physician assistant) progress note dated 3/25/21 documented, in part: .Skin infection right anterior thigh .patient has a recent history of scratching his right anterior thigh region causing open blisters and wound site. Last week wound care dressing changes were ordered .patient developed open ruptured blister sites with partial thickness breakdown to the right anterior thigh last week .today there is serosanguineous (blood and fluid) blister formation .Patient has a recent history of scratching this area .Wound treatment will be modified and performed daily .Patient will be started on [MEDICATION(S)] (antibiotic) 100 mg 1 tab . twice daily for 1 week for skin infection. He is encouraged to not scratch this area and keep his hand hygiene intake . A progress note (dated 3/28/2021) documented, .Resident present staph infection to right thigh anterior . A medication order for [MEDICATION(S)] [MEDICATION(S)] (100 mg) give 1 tablet by mouth two times a day for infection for 7 days .The order was continued on 4/1/21 for another 7 days [MEDICATION(S)] Ointment 2% apply to right thigh wound topically every day shift for skin infection right wound . A Wound Evaluation (dated 4/1/2021) documented, #1 Blister: Body Location: Right Thigh (front). Deteriorating- 1 month old. Acquired: In-House Acquired .Dimensions: Area 33.1 cm (centimeter), Length 5.82 (cm), Width 6.6 (cm) and Deepest Point 0.2 cm . Pain .6 (intermittent) . On 4/7/21 at approximately 9:51 AM was observed lying in bed. Again, the resident's nails were long and unkempt. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse LL indicated that the resident received pain medication prior to the treatment. The resident's wound on the right thigh was observed and found to be a large and oval shaped on the resident's upper right thigh. The wound appeared to have a large open area with swollen red area, pink skin and dark areas surrounding the open area. The resident complained of stinging during the wound treatment. Nurse LL was queried as to R#30's long and unkempt nails. Nurse LL indicated that they needed to be cut and cleaned. When asked about the infected wound, and the resident's history of scratching, Nurse LL responded that the long nails and resident's history of scratching could have been a possible cause of the wound and further infection. When asked who is responsible for caring for R#30's nails, Nurse LL reported that the Certified Nursing Assistants (CNAs) generally performed that task. On 4/8/21 at approximately 8:31 AM an interview was conducted with R#30's assigned CNA, CNA MM regarding ADL care, including nail care. CNA MM reported that resident shower sheets were completed following a shower. When asked if the sheets indicated that nail care, shaving and other personal hygiene was noted on the sheets, CNA MM reported that they could indicate those areas on the sheet or in the resident's electronic record. When queried if she was aware that R#30 had a care plan that indicated the resident's nails should be kept short, CNA MM responded she was not aware. On 4/8/21 at approximately 10:10 AM an interview and record review were conducted with the Director of Nursing (DON) regarding R#30's nail care and current blister infected wound. The DON was asked how staff can ensure R#30's nails are cared for per the resident's care plan. The DON indicated that on the electronic Kardex system there is an area the includes personal hygiene. When the personal hygiene task section on the Kardex for R#30 was reviewed there was nothing that specified that nail care was provided for the resident. The DON was queried as to how CNAs would be aware that R#30 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON responded that the resident's nails should have been cared for per the resident's care plan to prevent wounds and infection. R#29 On 04/06/21 at 10:32 AM, R#29 was observed in their room. The resident had a number of long hairs on the lower portion of her chin. The resident was alert and able to answer questions asked. R#29 was queried as to whether she received assistance with ADL care, that including bathing and personal hygiene particularly chin hairs. The resident responded that she did not care to take showers based on a traumatic history related to showers, but was able to bath most of her body, with the exception of her back on her own. With respect to her long chin hairs, R#29 responded that she had requested a tweezer to care for the chin hairs, but still had not received anything. R#29 indicated that she was embarrassed by the long chin hairs. A review of R#29's clinical record documented the resident was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's MDS indicated the resident had a BIMS score of 9/13 (moderately cognitively impaired) and required extensive one person assistance with personal hygiene. A review of the resident's shower sheets showed no documentation that indicated personal hygiene pertaining to facial hair removal was provided. On 4/8/21 at approximately 10:15 AM an interview was conducted with the DON. The DON was queried as to how residents, including R#29 received routine care for personal hygiene. The DON indicated that personal hygiene care, including removal of facial hairs should be provided by the CNAs. Resident #48: On 4/6/21 at 9:35 AM, 10:56 AM, 1:01 PM, 2:55 PM, and 4/7/21 at 8:13 AM, observations of R48 revealed the resident's nails were long in length with dark debris underneath the nail tips and the beginning of a full beard. R48 was unable to respond to questions asked due to significant cognitive limitations. On 4/6/21 at 2:56 PM, Certified Nursing Assistant (CNA 'M') was observed to enter in R48's room with a trash can liner and then immediately exited the room. At that time, CNA 'M' confirmed they were the CNA assigned to R48 for the day shift (7am-3pm) and was asked to observe R48. Upon observation, R48 was in the same position as the earlier observations and when queried about the resident's specific care needs, CNA 'M' reported they were not sure of the resident's specific needs as This is my first time working with him. I usually bounce around. When asked what care had been provided to R48 given the longer, dirty nails and facial hair, CNA 'M' reported I only changed his brief when I first came on about 8am. When asked about the reason for the lack of repositioning and further care throughout the shift, CNA 'M' declined to offer any further response. Review of the clinical record revealed R48 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R48 had severely impaired cognition, had no mood or behavior concerns, required extensive assistance of two + persons physical assist for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. Review of the care plans revealed a potential impairment to skin integrity initiated on 1/26/21, revised on 3/29/21 that included an intervention that started on 1/26/21 to Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. There was no documentation that identified R48 had declined any offer of ADL care. Review of the documentation provided by the direct care staff of what specific care was provided revealed there was no documentation for the day shift on 4/6/21. Resident #55: On 4/6/21 at 10:33 AM, R55 was observed lying in bed. The right hand appeared contracted without any assistive/protective device in which the middle, ring and pinky fingers were observed bent tightly towards the palm and the nails appeared long in length. The resident's facial hair was longer with a full beard approximately 1/4 long in length. On 4/7/21 at 8:03 AM, R55 was observed lying in bed, making grunting noises and grabbing towards their neck with the left hand. At that time, the nails were observed long in length with dark debris underneath the nail tips. Review of the clinical record revealed R55 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the annual/medicare-5day MDS assessment R55 had severely impaired cognition, had no mood concerns, had physical behavioral symptoms directed towards others which occurred 1 to 3 days, required total dependence of two+ persons physical assist for bed mobility, transfers, dressing, toilet use, personal hygiene, bathing, and had upper extremity impairment on one side, and lower extremity impairment on both sides. On 4/7/21 at 2:45 PM, an interview was conducted with the Director of Nursing (DON) to review lack of ADL care for R48 and R55. When informed of the concerns regarding observations and interview with staff the DON reported there was no reasonable explanation that should have occurred as there were plenty of staff. R#19: On 4/06/21 at 11:55 AM R#19 was observed in their room, and the resident's fingernails on their left hand were observed to be long in length. On 4/08/21 at 8:31 AM R#19 was observed in their room and was observed up and out of bed seated in a geri-chair. Restorative Staff 'V' was observed to be present in the resident's room at the time of the observation. At this time, R#19 was observed to have long fingernails on both hands. Restorative Staff 'V' was queried as to whether the resident's nails appeared a little long in length, confirmed they were, and said they could be cut. Review of the clinical record for R#19 revealed the resident was admitted to the facility 7/18/19 and was readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual MDS assessment dated [DATE] revealed the resident was rarely to never understood. The facility policy titled, Nail Care (implemented 1/1/2021) was reviewed and documented, in part, Policy: .The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .1. Assessments of a resident's nails will be conducted on admission and readmission 3. routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .4. Routine nail care, to include trimming and filing, will be provided on a regular basis and as the need arises .5.Principles of nail care: a. Nails should be kept smooth to avoid skin injury .Only licensed nurses shall trim or file fingernails of residents with diabetes .d. Each resident will have his/her own nail care equipment . A facility policy titled, ADLs (implemented 1/ ) was reviewed and documented, in part, Policy: The facility will ensure a resident's abilities in ADLs do not deteriorate .This includes the resident's ability to 1. Bathe, dress, and groom: . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on observation, interview and record review, the facility failed to assess, monitor, and ensure interventions were in place to prevent the development and/or worsening of pressure ulcers for five (R48, R55, R108, R82, and R99) of seven residents reviewed for pressure ulcers, which has the increased potential for development of infection, delayed identification and/or healing, and decline in overall health status. Findings include: According to the facility's policy Turning and Repositioning dated 10/30/20, .Turning and repositioning is a primary responsibility of nursing assistants .The facility has established routine turning and repositioning schedules consisting of every 2-4 hours .A routine turn schedule includes using both side-lying and back positions, alternating from the right, back, and left side .The frequency of turning and repositioning will be documented in the resident's plan of care . Resident #48: On 4/6/21 at 9:35 AM, 10:56 AM, 1:01 PM and 2:55 PM, observations of R48 revealed the resident was positioned in the same manner at each time (lying in bed on their left side, facing the wall with pillows on the bed behind their back). Although an air mattress and bilateral heel protectors were in place, the resident's position remained unchanged at each of these observations. Throughout these multiple observations, R48 was observed asleep and would awaken upon approach but was did not respond when conversation was attempted. On 4/6/21 at 2:56 PM, Certified Nursing Assistant (CNA 'M') was observed to enter in R48's room with a trash can liner and then immediately exited the room. At that time, CNA 'M' confirmed they were the CNA assigned to R48 for the day shift (7am-3pm) and was asked to observe R48. Upon observation, R48 was in the same position as the earlier observations and when queried about the resident's specific care needs, CNA 'M' reported they were not sure of the resident's specific needs as This is my first time working with him. I usually bounce around. When asked if they were aware of any concerns with any skin breakdown, CNA 'M' stated, Nuh uh. When asked what care had been provided to R48, CNA 'M' reported, I only changed his brief when I first came on about 8am. When asked about the reason for the lack of repositioning and further care throughout the shift, CNA 'M' declined to offer any further response. Review of the clinical record revealed R48 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R48 had severely impaired cognition, had no mood or behavior concerns, required extensive assistance of two + persons physical assist for bed mobility, dressing, eating, toilet use, personal hygiene and bathing, was totally dependent of two + persons physical assist for transfer, had an indwelling catheter, was always incontinent of bowel, did not have any healed or unhealed pressure ulcer/injuries, but was identified as at risk for developing pressure ulcers. Additional review of the MDS assessment dated [DATE] documented R48 had no unhealed pressure ulcer/injuries. Review of the care plans revealed there were no revised interventions since 1/26/21. The pressure ulcer care plan documented it was initiated 1/26/21 and revised 3/25/21 and read, The resident has pressure ulcer development to the left heels r/t boggy discolored heel, comorbidities, take 5 or more meds with the risk for pressure ulcer development to all dependent areas. Interventions included: Initiated 1/26/21, Administer treatments as ordered and evaluate for effectiveness. Initiated 1/26/21, Float heels. Initiated 1/26/21, Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length x width x depth), stage. Review of the nursing readmission assessment dated [DATE] included a section that addressed the resident's skin and was marked No for any identified skin conditions/wounds. Review of the weekly skin assessments since readmission on 3/10/21 revealed a skin assessment on 3/17/21 which did not identify any new or existing skin concerns. Review of the available wound/skin documentation for R48 included: Upon R48's readmission to the facility on [DATE], there were no identified wound/skin concerns until the skin assessment on 3/20/21 at 4:43 PM (noted by Licensed Practical Nurse/LPN 'EE' which documented, .Left buttock .cleanse open area on the left upper buttock with w/c (wound cleanser) & apply 4x4 border foam d (dressing) daily & prn (as needed) . There were no nursing progress notes documented on 3/20/21 (date the left buttock pressure ulcer was identified). There was a skilled daily assessment completed by LPN 'EE' that documented, .noted 2 open area on the left upper buttock during ADL (Activities of Daily Living) same was cleansed with w/c & 4x4 border foam applied no drainage was noted, no odor logged in for wound nurse. This treatment was not documented on the treatment administration record on 3/20/21 as noted but was documented as first being done on 3/23/21 on the night shift. A skin assessment on 3/23/21 identified another wound/skin concern which documented, Left heel. An entry on 3/23/21 at 5:04 PM documented, Caregiver informed the charged <sic> nurse of the wound (blackish escar <sic>) on the left heel same was examined no odor, no drainage noted wound nurse informed & treatment initiated logged in. On 4/9/21 at 12:18 PM, a phone interview was conducted with LPN 'EE'. When queried about the identification of the change in skin condition and what was done at that time, LPN 'EE' reported the resident had been on a different floor of the building and upon identification of the change in skin, had provided a treatment and logged for wound nurse to see. When asked if the Physician had been notified of the change, LPN 'EE' reported they would review the physician log as that would have been logged there as well. Upon LPN 'EE's' review of the physician binder (as they were currently working at the facility), they reported there was no entry for R48 on 3/20. When asked about the lack of documentation that any treatment had been provided until 3/23, LPN 'EE' was unable to offer any further explanation and directed this surveyor to follow up with the wound nurse. Further review of the progress notes revealed that although a Nurse Practitioner (NP 'JJ') evaluated the resident on 3/23/21 at 7:20 AM, there was no documentation that addressed the resident's new/change in skin condition to the sacrum or heel. An entry on 3/24/21 at 11:22 AM, by NP 'KK' documented, .Presenting Problem: Redness buttocks and ulcer left heel .Resident was evaluated for left heel ulcer which appears to be chronic and also only recently reported no history sacrum and coccyx area. Wound care was placed for consultation and will be monitored and offloading and monitoring for any signs of infection. We will also order dermaseptin barrier cream to apply sacral area to prevent further breakdown and for protection .Patient is unable to give any review of system due to dementia . R48 was first seen by the Wound Care Nurse Practitioner/NP 'K') on 3/25/21 and documented the wounds as: Stage 3 pressure ulcer (Full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present) to the sacrum which measured 6.7 centimeters (cm) in length (L) x 2.4 cm in width (W) x 0.2 cm depth (D). Unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured with slough or eschar) to left heel which measured 2.9 cm L x 3.5 cm W x depth Unable to Determine (UTD). Recommendations on 3/25/21 by Wound Care NP 'K' included: continue with turning and repositioning in bed, dietitian to assess nutritional goals and supplements. R48 was next seen by Wound Care NP 'K' on 4/1/21 and documented the wounds as: Stage III pressure ulcer to the sacrum showed a decline and was currently an unstageable (US) which measured 5 cm L x 1.9 cm W x UTD D. Unstageable pressure ulcer to left heel which measured 2.2 cm L x 1.7 cm W x depth UTD. Recommendations on 4/1/21 by Wound Care NP 'K' included: [MEDICATION(S)] to wound base and cover with calcium alginate and foam dressing, maintain low air loss mattress, overlay for gerichair to offload pressure when in reclining chair, and make sure soft boots are in place to offload pressure. R48 was seen by Wound Care NP 'K' on 4/8/21 which included only measurements as the assessment was incomplete as of this review on 4/9/21: Sacrum measured 3.8 cm L x 1.5 cm W x not applicable D. Left heel measured 3.4 cm W x 3.5 cm W x not applicable D. Review of R48's wound description and above measurements were incorrectly documented on the facility's Skin & Wound Evaluation V5.0 as present on admission for each assessment, even after being brought to the Director of Nursing (DON) and Wound Care Nurse (LPN 'J's) attention on 4/7/21. On 4/7/21 at 2:02 PM, an interview was conducted with the Registered Dietitian (RD 'I') to review R48's nutritional needs as identified in the recommendation on 3/25/21. At that time, RD 'I' reported they were unaware that R48 had a new skin breakdown/pressure ulcers. When asked what the facility's process was for communication regarding changes in residents' skin conditions and recommendations for nutritional follow up, RD 'I' reported nutrition concerns were discussed weekly with the interdisciplinary team which includes wound care , dietitians, nursing, and occasionally social work. When asked if there were any meetings that may not have occurred or been missed, RD 'I' reported no. When asked where the nutrition documentation was maintained in the clinical record, RD 'I' reported it would be documented under progress notes . When asked to review the assessments and documentation available, RD 'I' reported R48 had a readmission nutritional assessment completed on 3/15/21 and the only other notes RD 'I' could see were weight fluctuations (weight gain). RD 'I' further reported if there were changes in the resident's skin, that would be discussed in the IDT meetings and stated, Not sure what happened there. On 4/8/21 at 11:49 AM, RD 'I' provided a nutritional note dated 4/8/21. There was no documentation that nutrition had addressed the resident's nutritional needs prior to discussion during survey on 4/7/21. On 4/7/21 at 2:45 PM, an interview was conducted with the DON to review resident's care concerns. When queried about the facility's wound process for monitoring, identifying changes, and following up, the DON reported Wound LPN 'J' was the wound nurse and does rounds with Wound NP 'K' on Thursdays. The DON reported when there was a change in residents' skin conditions, there is an alert in the facility's electronic medical record system that would trigger and gets an alert on the dashboard. If an alert were triggered, the wound nurse or nurse manager would review and then clear. The DON was requested to provide any further information if the system had triggered an alert, but no further information was provided by the end of the survey. The DON was asked about the discrepancy of the wound assessments completed that identified these wounds were present on admission, when the documentation identified that was incorrect and was first identified on 3/20/21 and reported there might have been an error in the way it was worded. The DON was asked about the facility's process for discussing/monitoring wounds and reported they had weekly interdisciplinary meetings. The DON was informed there was no available documentation that this had occurred for R48, and also informed of the lack of nutrition follow up as identified as a recommendation on 3/25/21. The DON was also informed of the observations for R48 and concern regarding lack of repositioning as well as interview with the CNA and reported there was no reasonable explanation for why that had occurred and would follow up. On 4/7/21 at 4:30 PM, the DON was requested to coordinate observation for wound care for R48 with Wound NP 'K' and Wound LPN 'J' as she had reported the wound NP would begin rounding residents with wounds at 6:00 AM on 4/8/21. On 4/8/21 at 8:35 AM, R48 was observed to have Wound NP 'K' and Wound LPN 'J' finishing up wound care for the resident. Wound NP 'K' reported they were not notified of the request to observe the resident's wound care and thought it was a request to review the wound documentation. At that time, Wound NP 'K' reported, I first consulted R48 regarding pressure ulcers on 3/25. (Name of Wound LPN 'J') enters the measurements into the system (electronic clinical record). On 3/25 R48 had stage 3 on the sacrum and unstageable to left heel. He got a low air loss mattress and boots at that time. I saw last week (4/1), and the sacral wound declined to a UTD (unable to determine) and asked for gerichair overlay. It's not in his room but in the common area and not sure if he gets up but I don't see him up. He does have the low air loss mattress and boots when I see him. This week sacrum is a little better could be stage 3 could be stage 4, there is less necrotic tissue. Left heel is macerated today, and edges of eschar are separating. Treatment will be changed to calcium alginate and foam every other day. (Name of Wound LPN 'J') said she was notified on 3/24. On that day I first saw him, I wrote an unavoidable note and I base that on cognition, nutrition, mobility and other co-morbidities. Wound NP 'K' was informed of the observations regarding lack of repositioning and incontinence care as well as lack of nutritional oversight as recommended in their evaluation on 3/25 and reported the facility's policy was to change or reposition residents every two hours. Wound NP 'K' further reported the dietitian gets a list of anyone who has pressure ulcers and reported they were not able to offer any further information as to the lack of coordination of recommendations. Resident #55: On 4/6/21 at 3:03 PM, R55 was observed lying in bed on an air mattress. The footboard had an electrical unit (box) that contained the controls for the air mattress that hung from the baseboard of the bed and connected to an air mattress. This unit was observed which was observed with the letters Broki written in black marker on the front. The electrical box was observed plugged into the wall as well as the mattress, but the unit was turned off with no indicator lights lit up. On 4/6/21 at 3:07 PM, Nurse Manager 'H' was observed in the hallway and asked to observe the resident's bed with the air mattress unit. At that time, Nurse Manager 'H' turned the unit on and reported, It's saying low right now (an amber low pressure alert was lit up), but someone must've hit it (turned off). Further observation of the air mattress unit revealed a blinking light for low pressure and an audible beeping. At that time, Nurse Manager 'H' requested Restorative Aide 'O' to come to inspect the air mattress unit. Restorative Aide 'O' and Nurse Manager 'H' began to inspect the air mattress unit. Nurse Manager 'H' reported if the air mattress unit was not working, the mattress would be deflated, but Restorative Aide 'O' reported that particular mattress on R55's bed would not deflate to the frame and that the air mattress was not working properly. On 4/7/21 at 8:55 AM, R55 was observed lying in bed, asleep. The bed was observed to have the same air loss mattress unit as observed on 4/6/21, with the amber low pressure alert lit up. Also, the letters BROKi now had a line through it (scratched out). At approximately 9:00 AM, Housekeeping Manager 'G' and Assistant Administrator 'Q' were observed to enter the room with a different air mattress unit. When asked about how long the resident had the existing air mattress unit, Housekeeping Manager 'G' reported they were unsure but that the current one was broken, and they were replacing it with one that worked. When asked who was responsible for providing items such as the air mattress unit, Housekeeping Manager 'G' reported themselves or the maintenance department and was unable to explain how or when the broken air mattress unit was in use for R55. At that time, a request was made for the specific manufacturer's information regarding the air loss mattress unit. Review of the clinical record revealed R55 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the annual/medicare -5day MDS assessment R55 had severely impaired cognition, had two stage 3 and one unstageable pressure ulcers, was at risk for developing pressure ulcers and had a pressure reducing device for the chair and bed. Further review of the wound documentation revealed the resident's pressure ulcers were healed as of 3/11/21 and had interventions to maintain skin integrity which included the use of an air loss mattress as of 1/13/21. Review of the documentation provided by the facility of the manufacturer's information regarding the air loss mattress included two different air loss mattress units which documented, in part, .In normal operation, the green NORMAL PRESSURE indicator should be illuminated. If the amber LOW PRESSURE indicator illuminates, remove the patient from the surface until the problem is resolved. Resident #108 On 4/6/21 at 9:27 AM, R108 was observed lying in bed on their right side sleeping, both of R108's legs bent at the knees and had the appearance of bilateral leg contractures. Review of the clinical record revealed R108 was originally admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R108 scored 3 on the BIMS exam, indicating severely impaired cognition. The MDS assessment also indicated R108 was totally dependent on staff for all ADL's including bed mobility, had a facility acquired Stage 4 pressure ulcer and had other open [CONDITION(S)] (wounds). Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. Apply topical skin prep and bordered foam. Left lateral ankle, every night shift every Tue, Thu, Sat for PI (pressure injury) site for protection AND as needed for PI site dated 2/11/21. On 4/7/21 at approximately 8:10 AM, LPN W was interviewed and asked about observing R108's wounds. LPN W explained R108 did not have any wounds. When informed there were orders for dressing changes, LPN W explained she would do the dressing changes at 12:00 PM. On 4/7/21 at 12:05 PM, during an observation of R108's left lateral ankle, LPN W peeled back a white 4x4 inch bordered dressing to reveal an open wound with dark drainage, that appeared to be serosanguineous (fluid and blood), staining the dressing. Between the wound and dressing was matter that appeared to be slough. LPN W was asked how long R108's wound on the left lateral ankle had been open. LPN W explained that since the order was written for the dressing change to be done on the midnight shift, she had not been aware of the order or the wound as an old pressure ulcer on the ankle had healed a while ago. Review of progress notes for R108 revealed: A nursing note dated 3/5/21 that read, Resident wounds healed, continue with Turn and Reposition per Care Plan. Review of R108's care plan revealed: Interventions for ADL care included, BED MOBILITY: The resident requires extensive assistance by x1 staff to turn and reposition in bed daily and as necessary. revised 8/12/19. Interventions for Impaired Skin Integrity care included, keep off the bony point area as much as possible to relief pressure. revised 7/22/17. Interventions for Pressure Ulcer care included, Educate resident's family regarding the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. initiated 8/13/19. On 4/7/21 at 3:18 PM, the DON was interviewed and asked about R108's left lateral ankle wound. The DON explained she was unaware of the open wound. The DON was informed of the observation of the open wound. The DON explained she would look into it. Further review of progress notes revealed a timeline of R108's facility acquired left lateral ankle pressure ulcer: A NP/PA note, .new deep tissue injury to left lateral ankle . dated 4/16/20. A SOC (Standard of Care)-Skin note, Stage 4 left lateral ankle wound with slight decline . dated 10/15/20. A NP/PA note, .Left lateral ankle stage 4 PI (pressure injury) is healed today to small region of scar tissue, no drainage, no [CONDITION(S)] (redness), no [CONDITION(S)] . dated 2/11/21. It should be noted, the only intervention implemented after R108's Stage 4 pressure ulcer healed was for a border foam dressing to be applied to the left lateral ankle three times a week. On 4/8/21 at 10:00 AM, an observation of NP K' and LPN J providing wound care on R108's left later ankle revealed a small amount of serosanguineous drainage on the dressing and a wound that appeared to have been recently cleaned and had a pink base and measured 1.4 x 1.4 x 0.2 cm. NP K was asked what type of pressure ulcer it was. NP K explained it was a reopened Stage 4 pressure ulcer. NP K was asked how long the pressure ulcer appeared to have been opened. NP K explained it appeared to have been open for less than a week. On 4/8/21 at 11:20 AM, a phone call was made, and a voicemail message left for LPN Z, who was the midnight shift nurse that had documented the dressing change on R108's left lateral ankle when the observation of an open wound was made on 4/7/20. No call back was made before the end of the survey. On 4/8/21 at 12:54 PM, CNA Y was interviewed and asked how often R108 was turned from side to side. CNA Y explained R108 should be turned every two hours, but she had not turned R108 since she had changed R108's brief at the start of her shift. It should be noted the day shift starts at 7:00 AM. On 4/8/21 at 2:24 PM, the DON was interviewed and asked again when R108's left lateral ankle reopened. The DON explained there was no documentation of the ankle reopening, therefore, it was unknown when it had reopened. The DON was asked to reach out to LPN Z to facilitate an interview. LPN Z did not call back before the end of the survey. R#99 A review of R#99's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MDS (2/18/21) indicated the resident was severely cognitively impaired and required total two person assist for most ADLs, including turning and repositioning. Section M of the MDS indicated that the resident was at risk for the development of pressure ulcers, but at the time did not have any unhealed pressure ulcers. Further review of R#99's clinical record noted a Nursing Admission Evaluation (2/18/19) documented Section .Skin: Does the resident have any identified skin conditions/wounds: Yes .Site: Coccyx and Groin .*No staging or measurements were noted A Nurse's note dated 2/19/21 documented, Resident seen today related to skin integrity .on skin assessment she was noted with left side of neck contracted. MASD (moisture -associated skin damage) Left back fold with MASD. Tip of left great toe discoloration. Treatment order for MASD and excoriation in place. Will continue to monitor. A Nurse's note dated 2/26/21 documented, Shower given today and hair washed no new skin issues .Resident repositioned to relieve pressure and for comfort. Nurse note dated 2/27/2021 documented, Resident has slight excoriation to the groin and labia over scar tissue. Current treatment in place. Keep brief open to air until healed. A physician note dated 3/1/2021 documented, .History of Present illness .I am evaluating this patient today for an admission history .She has a history of cerebral palsy .On exam today, she is resting in bed and appears comfortable .PHYSICAL EXAM .Skin: warm, dry . A Braden Scale for Predicting Pressure Sore Risk (3/5/21) - with a lock date of 3/10/2021 documented, 1. Sensory Perception: Completely limited .Moisture Rarely Moist .3. Activity: Bedfast: confined to bed .4. Mobility: Completely Immobile 5. Nutrition: Adequate .6. Friction & Shear: Problem . Score 11- High Risk . A Skin and Wound Evaluation (3/11/2021): Describe: .15. Pressure .Stage 2. Partial-thickness skin loss .22. Location: Right Ischial Tuberosity .23. In-House Acquired How long has the wound been present .12. Unknown .Area 1.0 cm 2. Length 1.1cm 3. Width 1.1 cm .Depth .3 cm . A Nurse Practitioner Note dated 3/11/2021 documented, .Today is an initial wound consult requested by medical physician for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3/12/21(9:13 AM) Nurses' Notes: Resident was sent to (name redacted) Hospital at 9:15 am for change in mental status . R#99's Care Plan documented, Focus: The resident is at risk for pressure ulcer development to the following areas. Right ischial tuberosity with scan tissue over the Right ischial tuberosity, labia and all dependent areas (date initiated 2/28/2021) .Interventions: Administer treatments as ordered (3/12/2021) .Daily skin evaluations by licensed nurse if current pressure ulcer (see TAR (treatment administration record) .The resident requires air loss mattress (3/12/21) . On 04/08/21 at approximately 12:27 PM an interview and record review was conducted with Wound Nurse J. When queried as to what interventions were put in place to prevent a facility acquired wound (Stage III) as indicated in the resident's record, Wound Nurse J stated that she would have to review the resident's records to further discuss. When asked why the resident who was at risk for pressure ulcer did not receive indication of a low air loss mattress or further treatment until 3/12/21, the day the resident was discharged to the Hospital, again Wound Nurse J indicated she would look into the resident's record but believed there may have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #99) .Wound Site (Right Ischial) .Admit Wound: N (no). In house wound Y (yes) . Resident #82 On 4/06/21 at approximately 9:46 a.m., R#82 was observed in their room lying on their bed. R#82 was observed to be on supplemental oxygen with a tracheotomy. R#82 was observed to be lying on a standard mattress (non air mattress) on their back. On 4/6/21 the medical record for R#82 was reviewed and revealed the following: R#82 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#82's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/11/21 revealed R#82 was dependent on facility staff for their activities of daily living. In addition, Section M on the MDS indicated that R#82 was at risk of developing pressure ulcers. A Braden Scale assessment (a tool used to evaluate potential for skin breakdown) dated 3/4/21 revealed a score of 10 indicating R#82 was a high risk for pressure ulcer development. A nurse note dated 3/22/2021 revealed the following: Resident noted with excoriation to the left buttock, treatment initiated. Will follow up. R#82's careplan was reviewed and revealed the following: Focus-The resident has is at risk for pressure ulcer development to the following areas <sic> dependent areas and bony projections r/t (related to) .B&B (bowel and bladder) incontinence, limited mobility, limited activity tolerance, comorbidities, taking 5 or more medications .Interventions (initiated 3/15/21)-The resident requires air loss mattress (a mattress with air flowing though it to reduce pressure on the body) . On 4/08/21 at approximately 11:15 a.m., R#82 was observed again in their room lying in their bed on a standard mattress. R#82's mattress was observed with Licensed Practical Nurse EE (LPN EE) and they indicated that R#82 was not lying on an air loss mattress as indicated in R#82's careplan. LPN EE indicated that R#82 had a room change at some point and that the mattress was not moved. LPN EE was queried if R#82 was a high risk for breakdown and they indicated he was because he was dependent. LPN EE indicated they would have to speak with the wound care nurse to find out what happened. On 4/08/21 at approximately 11:59 p.m., R#82 was observed in their room lying in bed. R#82's mattress was observed with wound care nurse J (WCN J). WCN J was queried if R#82 was in an air loss mattress as indicated on their careplan they indicated they were not. WCN J was queried if R#82 was high risk for breakdown and indicated they were. WCN J was queried why R#82 was not provided an air mattress and indicated they thought R#82 had a room change at some point and that they would have to get R#82 an air mattress. Review of a facility policy titled, Pressure Injury Prevention and Management revise 10/30/20 read in part, .Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Finding will be documented in the medical record .After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .

This citation pertains to intake #'s MI 478. Based on observation, interview, and record review the facility failed to ensure adequate supervision to prevent falls and failed to perform bed mobility and resident transfer per required level of assistance for three (R#19, R#104, R#274) of five residents reviewed for accidents, resulting in R#19 rolling out of bed, R#104 sustaining multiple falls with injury including an eyebrow laceration, and on separate incident, a head laceration requiring five staples and subsequent transfer to the hospital, and potential for injury during transfer for R#274 . Findings include: R#19: On 4/08/21 at 8:31 AM R#19 was observed in their room and was observed up and out of bed seated in a geri-chair. Review of the clinical record for R#19 revealed the resident was admitted to the facility 7/18/19 and was readmitted [DATE] with diagnoses which included, in part, diabetes mellitus and cerebral infarction. Review of an annual MDS assessment dated [DATE] revealed the resident was rarely to never understood and required the total dependence of two plus person physical assist for bed mobility. Review of a MDS assessment dated quarterly dated 12/20/20 documented the resident required the extensive assistance of two plus persons for bed mobility. Review of an incident and accident report dated 3/9/21 for R#19 dated 3/9/21 at 10:30PM documented, in part, Resident lost his balance in bed and fell . Per the I/A report, this incident was witnessed. Review of the Fall RCA Investigation Tool attached to the incident report documented, in part, [R#19] was laying on his side as I prepared to change him. I seen him slipping and was able to get there in time to safely guide him to the ground befor <sic> alerting [Name Redacted] (the charge nurse). This statement had been documented by Certified Nursing Assistant (CNA) 'DD'. Review of a re-enactment of the fall documented, He started Slipping When I saw him, I ran to grab him because it was too late to pull him back onto the bed. Review of the results of the conclusion section of the falls team meeting notes documented, CNA was turning Pt (and sign) resident rolled off bed CNA caught resident and lowered him to the floor no injury. Staff reeducated on 2 person asst. Review of a plan of care dated 1/1/20 and revised on 4/5/21 for R#19 revealed, in part, The resident needs activities of daily living assistance related to impaired mobility d/t (due to) s/p (status post) CVA (cerebrovascular accident) and weakness. Per an intervention dated 7/30/19 and revised 8/29/19 it was documented, BED MOBILITY: Requires 2pp (2 people) extensive assist. On 4/08/21 at 9:18AM a telephone interview was attempted with CNA 'DD'. A voicemail message was not able to be left at this time. On 4/08/21 at 10:09 AM the facility's Director of Nursing (DON) was queried in regard to whether the resident required two persons for bed mobility, and the DON confirmed the resident required two person assist. R#104: The clinical record for R#104 was reviewed and revealed the resident was admitted to the facility 6/27/19 and was readmitted on [DATE] with diagnoses which included, in part, dementia with behavioral disturbance, undifferentiated [CONDITION(S)], and [CONDITION(S)]. Per review of the resident's quarterly MDS assessment dated [DATE] the resident scored 6 out of 15 on a brief interview for mental status exam, which indicated the resident was severely cognitively impaired. Review of a I/A report for R#104 dated 10/19/20 at 7:10AM documented the resident was observed on the floor in hallway, and this event was unwitnessed. The description of the incident documented, Unable to tell writer res. confused Observed res. sitting on the floor in hallway near 2North back exit door. Per the Fall RCA Investigation Tool conclusion section of the form it was documented, Resident Ambulate in hallway to exit door apparently loss balance trying open door, no injury observed. Staff to maintain 1:1, PT (physical therapy) screen, Medication review. Per a QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT the following results of investigation was documented: Resident Ambulate in hallway with assist went to the Exit door loss balance trying to open door and fell no injury observed. Staff reeducated on maintaining 1:1 . Review of a I/A report dated 11/10/20 at 9:50PM for R#104 documented the resident had an unobserved fall in the hallway. A description of the incident documented, Another resident observed [R#104] attempting to sit in chair and fell . Review of a Fall RCA Investigation Tool form present with the I/A documented the following per the Re-Creation of Last 3 Hours Before Fall: 1 on 1 Supervised. The initial root cause of the resident's fall documented, unattended. Review of a I/A report dated 11/28/20 at 9:00PM revealed the resident had an unobserved fall in the resident room. It was documented the resident sustained a laceration to the left side of the back of the head and was sent to the hospital emergency department. Per a QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT the following results of investigation was documented: Resident was self transferring and slid to the floor, because has poor safety awareness and needs to be monitored for any behaviors, because has a history of putting self on the floor. Review of a progress note dated 11/28/20 at 11:27PM documented, in part, .Writer called to pt. room observed on floor on back. Per writer pt. had got off of floor . The cna was next to pt.the <sic> back of head on Lt.side bloody laceration .Pressure dressing applied to stop bleeding .transferred <sic> to [Hospital Name Redacted] . Review of a I/A report dated 11/29/20 at 3:19AM documented the resident had a witnessed fall in the first floor lobby. A brief description of the incident documented the following: Resident was up in wheelchair tried to get up and rolled to the Floor on First Floor lobby (on his way to the hosp. to get suture on his laceration back of head sustained From Fall in the afternoon). Review of a Fall RCA Investigation Tool form present with the I/A documented the following initial interventions to prevent future falls: Continue to Monitor the Resident. Review of a progress note dated 11/29/2020 at 3:51AM documented, .Resident up in wheelchair alert with confusion not in acute distress no c/o pain with dressing on head intact able to contact [Name Redacted] ambulance to transport resident to the hospital, [Hospital emergency department] notified report given [Name Redacted] ambulance came at 3:19 AMresident <sic> up in wheelchair tried to get up and rolled to the floor no apparent injury noted helped by [Name Redacted] staff to the stretcher transported to [Hospital Name] hospital . Review of a progress note dated 11/30/20 at 4:58PM documented, .Resident has laceration wound to the back of the head related to a recent fall. Laceration noted with 5 staples, no drainage noted, no c/o (complaints of) pain . Review of an SOC (standard of care)-Falls note dated 12/2/2020 at 2:29PM documented, in part, New Fall/Follow-Up: Resident has had multiple falls on 11/28/20 and 11/29/20. Situation (where/when/what/who): On 11/28/20 resident was lying on floor on his back and 11/29/20 resident was self transferring in hallway out of wheelchair and fell to the floor. Injury/No injury: Injury to back of head, sent to hospital. Factors involved (acute condition/environment, etc.): Continue to display poor safety awareness . Analysis of interventions to implement: Continue with the current Interventions and 1:1 supervision. Review of a I/A report for R#104 dated 1/13/21 at 9:05AM documented the resident had an unwitnessed fall in the resident room. A description of the incident documented, Resident was found on the floor by writer not too long after instructing resident to .sit down. It was documented the resident had a laceration to the left eyebrow. Review of a Fall RCA Investigation Tool form present with the I/A documented the following conclusion: Resident attempted to self transfer from bed to chair loss <sic> balance fell resulting in a sm skin tear. Tx rendered. Resident had 1:1, RA re-educate on monitoring, and communication c (with) Nurse when taking breaks. Review of a plan of care for R#104 dated 6/28/19 and revised 12/15/20 documented, The resident is at risk for falls related to: Generalized Weakness, Gait, Dx Dementia, Lack of safety awareness. HX of falls- HX known to put self on the floor. Per an intervention dated 10/21/20 it was documented, Maintain 1:1. On 4/08/21 at 10:02 AM, the facility's Director of Nursing (DON) was queried in regard to the resident's one to one status, explained the resident was always on one to one around the clock, and explained this had been the case for a very long time. Per the DON, the resident had the one to one for behaviors, and explained a distance would have to be maintained because the resident would hit the staff. The DON explained most of falls were observed because the staff were not close enough to the resident. When queried as to how the resident was kept safe, the DON explained R#104 did have wandering behavior, does have dementia, and they tried to reiterate to stay in the wheelchair and make sure the wheelchair was available. The DON explained the resident did have poor balance and was kept on the secured unit. Per the DON they tried to do everything they could to maintain safety, and make sure the resident did not have serious injury. The DON explained multiple interventions had been tried and acknowledged between the resident's behaviors and balance issues it was difficult. Review of a facility policy titled, Turning and Repositioning dated 1/1/21 and reviewed/revised 10/30/20 documented, in part, 6. Use the appropriate number of staff to perform the tasks safely. Review of a facility policy titled, Accidents and Supervision implemented 1/1/21 with a review/revision date of 10/30/20 documented, .The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Resident #274 On 4/06/21 at approximately 1:44 p.m., R#274 was observed in their room, sitting in a Geri chair (a brand of padded chairs). Certified Nursing Assistant GG (CNA GG) was observed entering R#274's room by themselves with a hoyer lift (a mechanical lift used to transfer a resident). No other staff were observed to enter R#274's room to assist CNA GG with the transfer. Approximately 10 minutes later CNA GG was observed coming out of R#274's room with the hoyer lift and R#274 was observed lying in their bed. CNA GG was queried if they had used the hoyer lift to transfer R#274 and they reported they had not because the Nurse on the unit was busy. CNA GG was then asked how they transferred R#274 to their bed and CNA GG reported they transferred R#274 from the Geri chair to the bed by herself with a pivot transfer (a functional transfer involving a resident standing up and turning to another surface with assistance from staff). CNA GG was queried if a pivot transfer with one person was the appropriate way to transfer R#274 and they reported they weren't sure but the nurse was busy so they could not use the hoyer lift as it requires two staff present to use. On 4/6/21 the medical record for R#274 was reviewed and revealed the following: R#274 was initially admitted to the facility on [DATE] and had diagnoses including Cerebral ischemic attack and [CONDITION(S)] and collapse. A review of R#274's MS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/31/21 revealed R#274 needed extensive assistance with 2 person physical assistance with transfers. R#274's BIMS score (brief interview of mental status was 4 indicating severely impaired cognition. A review of R#274's careplan and Kardex (instructions for direct care staff on how to provide care for a resident) failed to reveal a transfer status for R#274, as the care plan template was not completed with individualized information. Furhter review of the care plan revealed the following: The resident needs activities of daily living assistance related to: left sided weakness and generalized weakness, Disease Process- TIA (transient ischemic attack), Limited Mobility, Limited ROM (range of motion) .Interventions-TRANSFER: The resident requires (SPECIFY dependent or what assistance) by (X) staff to move between surfaces (SPECIFY FREQ) and as necessary. On 4/7/21 at approximately 10:41 a.m., Licensed Practical Nurse HH (LPN HH) was queried regarding the transfer status of R#274. LPN HH was observed reviewing R#274's medical record and indicated they could not find the transfer status for the resident. LPN HH indicated that transfer status is unusually located in the computer, but it was not. LPN HH indicated that therapy puts it in when they do their evaluation. LPN HH indicated that they would have to call therapy but that R#274 was a two person assist without the hoyer lift. LPN HH was queried regarding the one person pivot transfer that CNA GG did with R#274 and they indicated they had informed CNA GG to wait for them to assist with the transfer, but they did not. LPN HH was queried if CNA GG should have transferred R#274 with a one person pivot transfer and they reported they should not have and that CNA GG should have waited for them to help with the transfer because R#274 requires two people to safely transfer. On 4/7/21 at approximately 11:35 a.m., R#274's plan of care (POC) was reviewed with CNA II. CNA II was observed looking up R#274's transfer status on their Kiosk and indicated they could not tell what the transfer status of R#274 was because it was not indicated on the Kardex. CNA II was queried how they are aware of R#274's transfer status and they indicated that since R#274 had a sling in their chair they were a hoyer transfer. CNA II was queried how other CNA's would be able to tell the transfer status of R#274 and they indicated it would be the same way looking at the kiosk, but it was not there. On 4/7/21 at approximately 11:40 a.m., CNA N was queried how they could identify the transfer status of R#274. CNA N indicated they would look at the kiosk. CNA N was then observed reviewing the kiosk for R#274's transfer status and they indicated that it didn't tell the transfer status. CNA N was queried how they transferred R#274 when they got them up in the morning and they indicated R#274 had a sling so they used the hoyer lift. CNA N was queried how any other CNA would be able to identify the transfer status of R#274 and they indicated that it would be through the kiosk, but it was not there. A Physical therapy note for R#274 dated 4/7/21 revealed the following: Comments: Continues to require a hoyer lift for transfers. On 4/07/21 at approximately 3:48 p.m., the Director of Nursing (DON) was queried regarding transfer status for residents and how the nursing staff are aware of how a resident transfers. The DON indicated resident transfer status should be available in the careplan and the in kardex. The DON was queried how soon the transfer status should be available for the staff and they indicated it would be shortly after the therapy department did their evaluations. A facility document titled Safe Transfers and Movement of Residents revealed the following: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of residents. Gait belts can be used to assist with safe transfer .

This citation pertains to Intake Number: MI 702. Based on observation, interview, and record review, the facility failed to identify a known risk and implement interventions to reduce the risk of accidents for one (R#705) of one residents reviewed for accidents, resulting in a resident with a known history of alcohol consumption and having toxic substances (antifreeze) in their possession, ingesting a toxic substance and being admitted into the intensive care unit (ICU) at the hospital for severe lactic acidosis (a form of metabolic acidosis, in which excessive acid accumulates due to a problem with the body's oxidative metabolism and is typically the result of an underlying acute or chronic medical condition, medication, or poisoning), and required emergency [MEDICAL TREATMENT]. Findings include: A complaint was submitted to the State Agency that alleged R#705 was at the hospital. The complaint further stated that while in the facility R#705 locked herself in the bathroom refusing to come out st <sic> staff called 9-1-1. (R#705) will be admitted in the ICU at the hospital as she is in critical condition . R#705 is allowed to drink alcohol and often abuses alcohol. Tests are in process to see if she may have ingested something at (facility name redacted) due to her condition . On 1/6/21 at 2:15 PM, R#705 was observed in their room. R#705 was interviewed about their recent hospital admission. When asked why they were in the hospital, R#705 stated, I drank something. When queried further about what R#705 drank, they stated, I don't know. It was ammonia or something. I thought it was something else. R#705 reported the unknown substance was in a cup on their dresser. R#705 further reported that they did not remember going to the hospital and woke up in the hospital. At approximately 2:30 PM, all incident and accident (I&A) reports and any associated investigations for R#705 for the past three months were requested from the Administrator. A review of R#705's clinical record was conducted and revealed the following: R#705 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#705 had intact cognition and no behaviors. A Nurse's Note completed by Licensed Practical Nurse (LPN) C on 12/21/20 at 12:04 AM documented, Resident appears to have a mental status change unaware of surrondings <sic> mental status changes MD notified 911 called sent to hospital will continue to monitor. There were no other progress notes documented for 12/20/20 or 12/21/20. There was no transfer form present in the electronic medical record. A Physician Note completed by Physician E on 12/26/20 upon R#705's return to the facility from the hospital documented, . HISTORY &PHYSICAL EXAMINATION .Patient was admitted to (hospital name redacted) severe lactic acidosis, AKI (acute kidney injury) and ethylene [MEDICATION NAME] (a clear, [MEDICATION NAME] liquid primarily used in industrial manufacturing applications, and also is an ingredient in products like automotive antifreeze and coolant) ingestion), pt had emergent HD ([MEDICAL TREATMENT] - a process of purifying the blood of a person whose kidneys are not working normally) .she was stabilized and transferred for rehab . On 1/6/21 at 3:51 PM, LPN C was interviewed via the telephone. When queried about what occurred with R#705 on the day they were transferred to the hospital (12/20/20 or 12/21/20), LPN C reported R#705 was a resident who spent their entire day moving around the facility, was their own responsible party, and exited and entered the facility frequently throughout the day to smoke cigarettes. LPN C reported that on 12/20/20 around dinner time which was explained to be approximately 7:00 or 7:30 PM, a Certified Nursing Assistant (CNA) reported R#705 had abnormal behaviors and was not responding like usual to dinner. LPN C reported they went to R#705's room to assess them and the resident said, 'Yeah, yeah, I'm fine. I just have to go to the bathroom. LPN C further reported at that time R#705 entered the bathroom and locked both doors and stayed in the bathroom for a significantly long period of time. LPN C explained R#705 was not answering them, so after 45 minutes, they got a quarter and unlocked the door and found the resident disoriented with the water running, not making sense, and their eyes were moving really fast. At that time, LPN C reported she attempted to get R#705 into bed and to get vital signs, but the resident kept moving around in the wheelchair and they could not redirect them. LPN C stated, After that I thought maybe (R#705) was under the influence of something so I called the DON (Director of Nursing) and she told me to call the doctor to see if he wanted me to hold (R#705's) medications. The resident got consistently worse and combative, so I called 911 due to the mental status change. When queried about what time 911 was called, LPN C stated, It was almost shift change, so close to 11:00 PM. When queried about why they thought R#705 was under the influence of something, LPN C reported they knew she had a history of [REDACTED]. On 1/6/21 at approximately 4:00 PM, the Administrator was asked a second time if there were any I&As for R#705. The Administrator reported the DON was getting them together. When queried about if she was aware of what occurred with R#705 on 12/20/20, if it was known if the resident was under the influence of anything, and if there was an investigation, the Administrator stated, There should be an investigation because I know they found something like antifreeze in (R#705's) room. Hospital records for R#705 were reviewed and revealed the following: Discharge Summary Documents documented, History of Present Illness .presented from (facility name redacted) for altered mental status. Per staff patient was noticed to be more obtunded and slurring her words and called EMS. They also reported she leave the facility frequent and returns intoxicated .Her pH was found to be 7.05 (which is critical. Normal range is between 7.35 and 7.45), PC02 (concentration of carbon [MEDICATION NAME] in the blood) 14 (Critical result. Normal range is between 35.0 and 45.0), lactic acid 9.9 .Patient was transferred to the ICU for further monitoring .Hospital Course .Anion gap metabolic acidosis with lactic acidosis 2/2 (secondary) [MEDICAL CONDITION] with [MEDICATION NAME] (a poisonous substance that can be absorbed through the eyes, skin, lungs, and digestive system) .s/p (status [REDACTED].[MEDICATION NAME] Level . A Transfer Form dated 12/26/20 (sent to the facility from the hospital for readmission) documented, .Metabolic Acidosis Lactic . A History and Physical dated 12/21/20 documented, .Assessment/Plan .Anion gap metabolic acidosis with lactic acidosis .ICU supportive care . On 1/6/21 at 4:15 PM, the DON provided three I&As for R#705. There were no I&As from 12/20/21 or 12/20/20. The following I&As were provided by the DON: An I&A dated 11/4/20 (no time documented) noted, Resident slipped from chair to the ground outside. Upon picking her up something bulky was observed in the back of her chair and found to be antifreeze. A Quality Assessment & Assurance Investigation Report was attached and was blank except on page 5 under This section for Other Items not Classified noted a description of the event as Resident propelled self in rapid motion in wheelchair, causing her to fall from wheelchair onto concrete in front of facility sliding doors. Antifreeze container in wheelchair . There was no documentation of an interview with the resident or what was done in response to the antifreeze being found in the resident's possession. An I&A dated 10/31/20 (no time documented) noted, Nurse in charge was informed by caregiver that resident was observed on R (right) side .Resident confused but stated, 'I was drunk' . A Fall RCA Investigation Tool documented, .What appears to be the initial root cause(s) of the fall? Resident was smelling like alcohol .Describe initial interventions to prevent future falls: Resident will abstain from drinking alcohol . A Quality Assessment & Assurance Investigation Report dated 10/31/20 documented the following: .Resident was educated about the risks vs. benefits of using alcohol and taking prescribed medications, moved to the isolation unit due to exposure of environmental risks .Educate staff to monitor the resident at all times, and to keep in visible areas, and to provide redirection to reduce the potential for falls . There was no documentation of any implementation of monitoring or supervision to ensure resident's safety with alcohol use. At that time, the DON was interviewed. When queried about what occurred on 12/20/20 with R#705, the DON reported a nurse contacted her because R#705 had an altered mental status and was lethargic. The DON reported she told LPN C to contact the physician to see if he wanted to hold medications and to search R#705's room because on 11/4/20 there was something in her room. When queried about what was meant by something, the DON reported the R#705 was found with antifreeze and alcohol. The DON further reported LPN C called her back to inform her R#705 was being transferred to the hospital. When queried about whether LPN C reported anything other than a mental status change to the DON on 12/20/20, the DON stated, It was the weekend. I was not in the building. She only has to report to me that there was a change in condition and she also told me she was sending the resident to the hospital. I told her to search the room and nothing was found. When queried about whether an investigation was done after the physician documented R#705 ingested ethylene [MEDICATION NAME], the DON reported nothing was found in the resident's room. When asked what was the cause of R#705's change of condition, the DON stated, I don't know. Read the hospital records. Any additional information pertaining to R#705's change in condition on 12/21/20 was requested at that time. On 1/6/21 at 5:00 PM, the DON and Administrator were further interviewed. The DON reviewed the hospital records and stated, It just says she was admitted for a mental status change. I don't know why the physician said she ingested anything. When queried about the hospital record documentation that noted R#705 ingested [MEDICATION NAME], the DON reported the resident had a history of [REDACTED]. When queried about what was put in place on 10/31/20 and 11/4/20 when R#705 reported being drunk and when they were found with a bottle of antifreeze in their possession, the DON reported R#705 was their own responsible party and was allowed to go on leaves of absence and was not sure if there was anything in the care plan. When queried about what was put into place after the most recent hospitalized from [DATE] to 12/26/20, the DON reported she was unaware of any consumption of alcohol or other substances. The Administrator responded, And the resident said she didn't drink anything. When queried about when the resident was interviewed, a response was not offered. When queried about when LPN C contacted the DON, the DON reported she did not know the time. The DON reported she did not know that R#705 presented any other way other than lethargic with a mental status change and therefore did not identify a reason to investigate R#705's change in condition. The DON reported she was unaware that the length of time between when 911 was called and when R#705 first presented with a change in condition was approximately four hours. On 1/7/21 at 10:19 AM, Physician E was contacted via the telephone for an interview. Physician E was not available for an interview prior to the end of the survey. R#705's clinical record was further reviewed and revealed there was no care plan that addressed R#705's history of drinking alcohol while in the facility or a history of having toxic substances such as antifreeze in their possession. A care plan for alcohol dependence was added on 1/6/21. A Social Services Progress Note dated 11/4/20 documented, Writer notified that resident was found with empty bottles of Vodka and a bottle of antifreeze in her possession. Writer spoke with resident with ADON (Assistant Director of Nursing) and notified resident that having those items in her possession are prohibited and are grounds for immediate discharge. Resident verbalized understanding and agrees with immediate discharge. Referrals to be sent to other SNF's (skilled nursing facility) per facility procedures . There were no additional social services notes that included any interventions to monitor R#705 for safety when leaving and returning to the facility or documentation regarding a transfer to another facility.

This citation has two deficient practice statements. Deficient Practice #1: This citation pertains to intake #s: MI 766, MI 994, and MI 246. Based on observation, interview and record review, the facility failed to provide timely incontinence care to one (R#802) of four residents reviewed for incontinence care, resulting in the resident sobbing and expressing feelings of degradation and embarrassment, strong, stale urine odors observed on the resident, and the increased potential for infection and skin breakdown. Findings include: A review of multiple complaints reported to the State Agency included allegations that staff were not providing timely incontinence care and residents were subjected to waiting prolonged periods of time while in wet/soiled briefs. On 7/13/20 - 7/15/20, an unannounced, onsite investigation was conducted. On 7/13/20 at 12:02 PM, and 1:20 PM, R#802 was observed seated upright in bed. There was a strong, stale urine odor present at each of these observations. At that time, R#802 agreed to participate in an interview and when asked about the provision of care, specifically incontinence care, R#802 began to cry. R#802 continued to sob uncontrollably, and reported, .Last week I had to wait 13 hours to get changed. 13 hours. Not enough staff to help .Last week it was only one aide on midnights .I care about my personal hygiene but cause I'm paralyzed from the waist down it falls through the cracks .I sit in wet, dirty briefs most of the time .no one is considering the toll it's taking or what I'm going through. I'm only (resident's age redacted) years old . The resident reported this had been discussed with Administration, as well as reported to (name of State Agency and local nursing home advocacy company). On 7/15/20 at 10:45 AM, during an second interview with R#802, there was no urine odor noted. At that time, when asked about the lack of urine odor, R#802 reported It'll be good for a few days since (State Agency name) is here, but then will go back. A review of the clinical record revealed R#802 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented R#802 was cognitively intact (scored 15/15 on Brief Interview for Mental Status Exam/BIMS), exhibited no behavior concerns, required extensive assistance of one person for toilet use, was always incontinent of bowel and bladder and not on a toileting program. A review of R#802's toileting documentation (which included bowel and bladder elimination details) from 6/16/20 to 7/14/20 revealed multiple dates when there was only one entry documented (7/3/20, 7/5/20, 7/10/20, 7/12/20, 7/13/20). On 7/12/20, the only documented entry was at 12:40 AM. The next documented entry was on 7/13/20 at 8:04 pm. A review of R#802's behavior documentation from 6/16/20 to 7/14/20 revealed there was no documentation of any rejection of care. A review of R#802's ADL care plan included interventions which read, TOILET USE: The resident requires assistance by 1 staff for toileting : bedpan. Checked Q2H (every two hours), changed as needed. This intervention had been initiated 1/7/19 and revised on 3/12/19. A review of R#802's OBRA (Omnibus Budget Reconciliation Act) Level II evaluation (an evaluation to determine mental health needs) dated 3/6/20 indicated R#802 had [MEDICAL CONDITION] disorder, currently in remission and met criteria to remain in the nursing home setting. Further review of this extensive evaluation documented, in part, .(name of R#802) is a good historian, cognition intact, with frustration at certain things pertaining to the nursing home, expressed appropriately. There was no evidence of thought pathology or memory deficits. She states .trying to get a staff member here is like trying to flag down a taxi. You'll wait. I sit in my own waste .They don't answer the call light .Per (R#802's guardian) .could do better giving showers and changing her brief more frequently, which he states has mentioned to staff . On 7/14/20 at 12:57 PM, an interview was conducted with the Administrator, Corporate Consultant and Assistant Administrator. When asked about administration being notified of any concerns regarding care issues for R#802, the Administrator reported R#802 had sent an email to (name of local nursing home advocacy agency) and that concern had been forwarded through (name of Corporate Consultant). At that time, the Corporate Consultant acknowledged receipt of the resident's concerns and reported she was unable to provide any specific documentation. The Administrator, Corporate Consultant and Assistant Administrator were informed of the observations of the strong, stale urine odor and concern regarding the lack of incontinence care for R#802. On 7/15/20 at 1:15 PM, during an interview with the Director of Nursing (DON), when asked about the facility's process to ensure resident's were not left in soiled/wet briefs, the DON reported the residents should be checked and changed routinely. On 7/15/20 at 2:30 PM, a review of the documentation provided by the facility regarding urinary incontinence did not address routine care needs to prevent residents being left in wet/soiled briefs. A policy for Activities of Daily Living was requested, and per Administrator, there was no policy. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to ensure urinary catheter care was performed for two residents (R#'s 816 and 825) of three residents reviewed for urinary catheters, resulting in a formal complaint to the State Agency, the potential for poor personal hygiene and the development of infections. Findings include: R#825 On 7/15/20 at 2:10 PM, R825 was observed in bed, asleep. A urinary catheter drainage bag was observed to be hanging on the side of the bed. A review of R825's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R825's most recent Minimum Data Set assessment dated [DATE] indicated R825 had moderately impaired cognition, required extensive assistance for activities of daily living, and had a suprapubic catheter (a device inserted directly into the bladder to drain urine). A review of R825's Certified Nursing Aide (CNA) Tasks in the electronic medical record was conducted and revealed a CNA task for catheter care. A review of a 30-day look-back of the task revealed the following: 6/16/20 Catheter care performed twice 6/17/20 and 6/19/20 Catheter care performed once 6/20/20 Catheter care performed twice 6/28/20 Catheter care performed once 6/29/20 and 7/2/20 Catheter care performed twice 7/3/20 Catheter care performed once 7/4/20, 7/5/20, 7/9/20, 7/11/20, and 7/13/20 Catheter care performed twice. On 7/14/20 at 12:00 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding catheter care. The DON indicated that CNA's were responsible for performing catheter care, the care should be provided at least every shift (three shifts per day), and completion of the task should be documented into their (Name of electronic medical record program). R#816 On 7/14/20 a review of R816's closed clinical record was conducted and revealed an admitted [DATE] and discharge date of [DATE]. R825's [DIAGNOSES REDACTED]. R825's Minimum Data Set assessment dated [DATE] was reviewed and indicated R825 had intact cognition, required extensive assistance for activities of daily living, had bilateral upper and lower extremity range of motion deficits and presence of an indwelling urinary catheter. Continued review of R816's clinical record revealed physician's orders [REDACTED]. A review of R816's CNA tasks that were active during their admission was conducted and did not reveal any tasks for catheter care. A review of the treatment administration records was conducted and did not indicate R816 had any type of catheter care performed. On 7/14/20 at 2:25 PM, a request for documented catheter care for R816 was made to the facility's Administrator. Evidence of catheter care being performed for R816 was not provided by the end of the survey. A review of a facility provided policy titled, Catheter Care, Urinary with a review/revision date of 3/23/2011 was conducted, however; the policy described the process of how to perform catheter care, and did not address how often it was to be performed. The facility was asked if they had any additional information to provide regarding the concern; none was provided by the end of the survey.

Based on observation, interview, and record review the facility failed to: follow Centers for Disease Control and Prevention (CDC) guidelines for infection control for COVID-19 (Coronavirus Disease 2019), ensure adequate monitoring of residents, changing of isolation gowns and/or lab coats between caring for those residents positive for COVID-19 on the 1 South unit and then caring for residents without COVID-19 on the same unit, consistent donning of eye protection, gloves, and/or a gown when caring for residents with COVID-19, ensuring personal protective equipment (PPE) was changed following care for residents positive for COVID-19 prior to entering other areas of the building, and ensure signage was utilized to indicate transmission based precautions for residents positive for COVID-19. This deficient practice affected twenty-nine residents (R#701, R#702, R#703, R#704, R#705, R#706, R#707, R#708, R#710, R#711, R#712, R#713, R#714, R#715, R#716, R#717, R#718, R#719, R#720, R#721, R#722, R#723, R#724, R#725, R#726, R#727, R#728, R#729, R#730) of twenty nine residents reviewed for infection control on the 1 South unit and two of two residents(R#731 and R#732) reviewed for infection control on the 2 North unit, resulting in an immediate jeopardy to the health and safety of all residents residing at the facility due to the facility's infection control practices placing all residents at risk for serious harm and/or death due to the increased likelihood of transmission of COVID-19. Findings include: The Immediate Jeopardy (IJ) started on 4/27/20. The Immediate Jeopardy was identified on 4/27/20 at 12:30PM. The Administrator was identified of the Immediate Jeopardy via telephone and electronically on 4/29/20 at 12:30PM. The immediacy was removed on 5/1/20. Although the immediacy was removed, the facility remained out of compliance at the scope of widespread and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. An onsite survey was conducted on 4/27/20-5/4/20. On 4/27/20 at approximately 9:50AM, the facility's Administrator indicated the 1 South unit was being utilized as the COVID unit. 2 North Unit: On 4/27/20 at 10:22 AM, R#731 was observed in a wheelchair out of the door of their room on a non-COVID designated unit. The resident was not observed to be wearing a facemask. At 10:26 AM, the resident was observed out in the hallway not wearing a mask. Shortly after, the resident was observed using their wheelchair and moving down the hallway on the unit the resident resided. Review of the clinical record for R#731 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of documented temperatures per the resident's electronic medical record for the month of April 2020 revealed the following: 4/22/20: 98.0 F (Fahrenheit), 4/15/20: 97.8F, and 4/1/20: 98.0F. No additional documentation of the resident's temperatures was observed per the electronic vital sign recording of temperature for the month of April 2020. On 4/27/20 at approximately 10:41 a.m., R#732 was observed sitting in their wheelchair on the two North unit in a common area without any type of personal protective equipment covering their face. R#732 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#732's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/13/20 revealed R#732 needed assistance from facility staff with their activities of daily living. A review of R#732's recorded temperatures revealed only one documented temperature on 4/21/20 for April 2020 and only one documented temperature on 3/25/20 for March 2020. A review of R#732's oxygen saturation rates revealed the last documented saturation rate was on 12/10/19. Review of the CDC's, Preparing for COVID-19, Long-term Care Facilities, Nursing Homes revealed, in part, Encourage residents to remain in their room. If there are cases in the facility, restrict residents (to the extent possible) to their rooms except for medically necessary purposes. If they leave their room they should wear a cloth face covering or facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing . 1 South Unit: On 4/27/20 at approximately 10:56 a.m., PTA (Physical Therapy Assistant) G was observed coming out of R#729's room (Covid-19 designated room) without any isolation gown on. PTA G was observed to be wearing gloves in the hallway and seen walking down the designated COVID-19 unit, leaving the unit and entering the facility therapy gym. PTA G was queried if they had worn any personal protective equipment while treating R#729 in their room and they indicated they wore their lab coat, gloves and mask. PTA G was queried if they had worn an isolation gown while treating R#729 and they indicated they hadn't. On 4/27/20 at 11:16 AM, the set of double doors to the 1 South unit was observed, and one side of the double door was open. Upon entry to the unit, there was no visible notification (signage on resident room doors near entry to unit to indicate precautions) for those entering the unit to indicate a division in which rooms were being used to care for residents positive for COVID-19 versus which rooms were being utilized for residents without a [DIAGNOSES REDACTED]. Per the facility the following residents were positive for COVID-19, and were also residing on the 1 South unit: R#708, R#710, R#711, R#712, R#713, R#714, R#715, R#716, R#717, R#718, R#719, R#720, R#721, R#722, R#723, R#724, R#725, R#726, R#727, R#728, R#729, and R#730. Resident room doors were observed to be open for the rooms where R#713, R#714, R#715, R#719, R#720, R#721, R#722, R#723, R#724, R#725, R#726, R#727, R#728, R#729, and R#730 resided. It was noted during the onsite survey that residents who were not positive for COVID-19 also resided on the 1 South unit. These residents included the following (as of the morning of 4/27/20): R#701, R#702, R#704, R#705, R#706, and R#707. R#703, who was admitted the evening of 4/27/20, also was not identified as having COVID-19. Review of the clinical record for R#701, R#702, R#703, R#704, R#705, R#706 and R#707 revealed, in part, the following: R#701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#702 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per a note in the resident's clinical record dated 4/27/20 the resident had been .COVID19 negative x2. R#703 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. R#704 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per a note dated 4/23/20 it was documented the resident had been negative for COVID-19 in the hospital. R#705 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per a progress note dated 4/20/20 it was documented the resident displayed, no evidence of COVID-19 infection . R#706 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#707 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per physician orders [REDACTED]. On 4/27/20 at 11:20 AM, Licensed Practical Nurse (LPN) 'B' was queried as to what area of the unit was being used for residents positive for COVID, and explained it was the room where R#717 and R#718 resided, then down the hallway (which would include where residents R#717 through R#730 resided, which was different than the list of residents positive for COVID-19 provided by the facility). Per LPN 'B' people who were already clear (without COVID) were on the other part of the hallway. LPN 'B' was queried as to CNA staffing, and explained there were two CNAs (Certified Nursing Assistants) who were working as a team, and LPN 'B' acknowledged the CNAs had the full hallway. Observations of the resident room door for R#727, R#728, and R#729's room revealed a sign present to see the nurse before entering. On the room door for R#730's room was a sign indicating droplet precautions. Signs were not observed on the doors of the rooms where R#717, R#718, R#719, R#720, R#721, R#722, R#723, R#724, R#725, or R#726 resided to indicate if precautions were being utilized for the resident rooms. Review of a staff assignment sheet for CNAs for 4/27/20 for the 7:00 AM to 3:30 PM revealed the following: CNA 'F' was assigned to care for R#701, R#702, R#704, R#705, R#706, R#707 (residents who did not have COVID-19), and also R#708, R#710, R#711, R#712, R#713, R#714, R#715, and R#716 (who were positive for COVID-19) on the 1 South unit. Per the staff assignment sheet, CNA 'E' was assigned R#717, R#718, R#719, R#720, R#721, R#722, R#723, R#724, R#725, R#726, R#727, R#728, R#729, and R#730, all of whom were identified by the facility as positive for COVID-19. On 4/27/20 at approximately 11:30AM, Housekeeper 'C' was observed to enter the room where R#715 and R#716 resided. Housekeeper 'C' was observed to be wearing goggles on their forehead while in the resident's room. It was noted R#715 and R#716 were identified as positive for COVID-19 per the facility. Housekeeper 'C' was queried about use of a face shield (eye protection) and said that they knew the COVID wing was farther back (different rooms than where R#715 and R#716 resided). On 4/27/20 at approximately 11:34 a.m., CNA E was observed walking from the back end of the designated COVID-19 unit wearing a yellow isolation gown and was seen entering the Non COVID-19 section of the hallway and enter R#704 and 705's room (a non-COVID-19 room). On 4/27/20 at approximately 11:38 a.m., CNA E was observed coming out of R#710 and R#711's room (a designated COVID-19 room) wearing the same yellow isolation gown and was seen walking down the COVID-19 unit hallway to the clean linen cart (located on the hallway of the COVID-19 unit). CNA E was observed to reach their hand into the linen cart and retrieve new linen and subsequently enter R#713 and R#714's room (COVID-19 designated room). On 4/27/20 at approximately 11:52 a.m., CNA E was queried regarding which residents they were providing care for that day. CNA E indicated there were only two aides including them, so they didn't have room numbers assigned. CNA E reported they and CNA F were taking care of the whole hallway. CNA E was queried if they were keeping the same isolation gown on all day and they reported they were. CNA E was queried if they used the same isolation gown to provide care for the residents on the COVID-19 unit that they did for the residents at the end of the hall who didn't have COVID-19 and they reported that they did. CNA E reported the facility only provided one gown a day and they had to wear it for all the residents on the hall. On 4/27/20 at approximately 11:56 a.m., CNA F was observed wearing a white lab coat in the hallway. CNA F was queried regarding what residents they were assigned to provide care for. CNAF indicated they were working with CNA E and caring for all the residents on the hallway. CNA F was queried if they were wearing any disposable gowns when caring for the residents with COVID-19 and they reported they didn't. CNA F reported they were provided a white lab coat as their gown and were expected to wear the same lab coat all shift. CNA F was queried if they wore the same lab coat while caring for residents without COVID-19 that they did for residents with COVID-19 and they indicated that they did. On 4/27/20 at approximately 12:00 p.m., R#728 (positive for COVID-19) was observed in the hallway without a mask concealing their mouth or nose. On 4/27/20 at approximately 12:09 p.m., PTA G was observed in R#723, R#724 and R#725's room (COVID-19 designated room) wearing a lab coat (with no isolation gown over top) and gloves. PTA G was observed leaving the room, walking down the COVID-19 designated hallway, leaving the COVID-19 unit and returning to therapy gym wearing the same lab coat they had on in the room. On 4/27/20 at approximately 12:15 PM, Unit Secretary 'D' was observed to be wearing a lab coat and mask and entered the room where R#707 resided and asked the resident about their coffee or tea request. It was later noted per record review that R#707 was in isolation related to [MEDICAL CONDITION]. On 4/27/20 at approximately 12:15 p.m., CNA E was observed coming out of R#715 and R#716's room (COVID-19 designated room) wearing the same yellow isolation gown and was observed walking down the COVID-19 hallway into the shower room with the same isolation gown on. On 4/27/20 at approximately 12:19 p.m., CNA F was observed to enter R#723, R#724 and R#725's room (COVID-19 designated room) with a white lab coat (no isolation gown) and shortly thereafter was observed coming out of the room, went into the hallway with gloves still on, reached into the clean linen cart (located in the middle of the COVID-19 designated hallway) and pulled out clean linen with their gloved hand and was observed to reenter the room. On 4/27/20 at approximately 12:24 p.m., CNA F was observed coming out of R#723, R#724 and R#725's room with same white lab coat on, going down the hallway and entered R#704 and 705's room (designated non-COVID-19 room). On 4/27/20 at 12:24 PM, Unit Secretary 'D' was observed to enter the room where R#715 and R#716 resided (designated COVID-19 room). Unit Secretary 'D' was not observed to wear gloves and moved the curtain in the resident's room. On 4/27/20 at 12:33 PM, Unit Secretary 'D' was observed in the hallway in a lab coat and mask. Unit Secretary 'D' was not observed to have on a face shield, eye protection, or gloves and was observed to enter the room where R#726 resided. It was noted that R#726 was identified by the facility as being positive for COVID-19. On 4/27/20 at 12:40PM, Unit Secretary 'D' was observed to enter the room where R#717 and R#718 resided and was not observed to don gloves. It was noted that both residents were identified by the facility as positive for COVID-19. On 4/27/20 at approximately 12:46 p.m., Staff Member/Unit Secretary D was queried regarding wearing their lab coat and not utilizing any isolation gowns when they entered rooms on the COVID-19 unit. Staff member D indicated they brought their lab coat from home, used it all shift and then took it off when they got to their car when they left for the day. Staff member D was queried if they had used any other isolation gowns when entering the COVID-19 rooms or when they entered the non-COVID-19 rooms and they reported that they did not. On 4/27/20 at approximately 1:05 p.m., Nurse N (who also was working the 1 South unit) was queried if they had changed their isolation gown that they had been wearing that day and they indicated they had not. Nurse N was queried if they had worn the same isolation gown into COVID-19 positive rooms and non-COVID-19 rooms and they indicated they had. Nurse N reported the facility only gave them one gown a day. On 4/27/20 at approximately 2:12 p.m., CNA E was observed leaving the COVID-19 unit wearing the same yellow isolation gown they had used all day to care for the COVID-19 residents. CNA E was observed walking into the 1 north unit (designated non-COVID-19) with the isolation gown still on. CNA E was then observed walking back from the 1 north unit back into the designated COVID-19 unit (1 south). On 4/27/20 at 3:58 PM, the facility's Administrator and Clinical Liaison 'M' were queried regarding PPE at the facility. When queried, the Administrator explained that the facility had everything. Per the Administrator they had 400 gowns, 100 N-95 masks, and 75 goggles. It was explained during the interview that the county had been sending equipment as well. When queried about the use of a lab coat, it was explained that the company supplied the lab coat, and the lab coat would be washed and hung on hangers outside the laundry. Staff would punch in (clock in) and get the lab coat, then would get their temperature obtained. When queried as to gown use, it was explained that a gown would be provided if lab coat was not a suitable size for a staff member. Per Clinical Liaison 'M', staff were to apply a gown over the lab coat if a resident was in isolation. On 4/28/20 at approximately 9:00AM, it was noted that the room doors where R#708, R#710, R#711, R#712, R#713, R#714, R#715, R#716, R#717, R#718, R#719, R#720, R#721, R#722, R#723, R#724, R#725, and R#726 resided (all of whom were identified by the facility as positive for COVID-19) did not have a sign present on the room door to indicate that transmission-based precautions were being utilized. On 4/28/20 at approximately 9:08 a.m., restorative aide (RA) K was observed coming out of R#707's room (positive for [MEDICAL CONDITION]-[MEDICAL CONDITION]) with a blue disposable isolation gown on. RA K was then observed walking into hallway without taking off their isolation gown. On 4/28/20 at 9:12 a.m., RA K was observed to enter R#712's room (COVID-19 designated room) to attempt to weigh R#712 wearing the same blue isolation gown they had on when they were in R#707's room. On 4/28/20 at approximately 9:20 a.m., RA L was observed entering R#706's room (designated non-COVID-19 room) to weigh them wearing the same blue isolation gown they had on when they were observed walking from the COVID-19 designated unit. On 4/28/20 at approximately 9:25 AM, PTA 'G' was observed to enter the room where R#712 resided. It was noted that R#712 had been identified by the facility as positive for COVID-19. PTA 'G' was observed to wear a lab coat, mask, and goggles. The staff member was not observed to wear a disposable gown. On 4/28/20 at approximately 9:25 a.m., CNA F was observed dragging an open garbage bag of disposable dishware (used by COVID-19 positive residents to eat their meals) down the COVID-19 hallway on the floor past the designated COVID-19 unit and into the soiled utility room. CNA F was observed to be wearing a blue plastic isolation gown and face shield. On 4/28/20 at approximately 9:28 a.m., CNA F was observed to enter R#704 and R#705's room (designated non-COVID-19) wearing the same blue plastic isolation gown they had been wearing when they were observed in the COVID-19 designated unit. Immediately after leaving the room and returning a meal tray to the meal try cart, CNA F was observed entering R#703's room (another designated non COVID-19 room) wearing the same blue plastic isolation gown. On 4/28/20 at approximately 9:36 a.m., RA K was observed entering R#701 and R#702's room (designated non-COVID-19) with the same blue plastic isolation gown they were wearing when they were in R#707 (resident treated for [REDACTED].#712's rooms (positive for COVID-19). On 4/28/20 at 9:38 AM, PTA 'H' was observed to exit the room where R#721 and R#722 (designated positive COVID-19 room) resided. The staff member was observed in a lab coat. PTA 'H' was observed to enter the room where R#710 and R#711 (positive for COVID-19) resided and was observed to wear a lab coat without a disposable gown. The staff member was then observed to exit the unit in the lab coat. On 4/28/20 at approximately 9:39 a.m., RA K was observed entering R#703's room (designated non-COVID-19) with the same blue plastic isolation gown they were wearing when they were in R#707 and R#712's rooms. On 4/28/20 at approximately 9:40AM, PTA 'G' was again observed to wear a lab coat with no gown and enter the room where R#712 resided. On 4/28/20 at 9:45 AM, Unit Secretary 'D' was observed to enter the room where R#708 (COVID-19 positive) resided. Unit Secretary 'D' was not observed to have worn a gown. On 4/28/20 at 9:47 AM, PTA 'G' was again observed to enter the room where R#712 resided. PTA 'G' wore a lab coat with no gown. On 4/28/20 at 9:51 AM, a linen cart was observed on the 1 South hallway in the area of the unit where residents positive for COVID-19 resided. The front of the linen cart was not observed to be covered, and linens were visible on the shelves of the cart. On 4/28/20 at approximately 9:46 a.m., RA L and RA K were queried regarding wearing their PPE (personal protective equipment). RA L was queried if they had completed weights for residents residing in the designated COVID-19 unit and they indicated that they had. RA L was then queried if they had changed their isolation gown before getting the weights from the Non-COVID-19 residents and they indicated they had not. RA L indicated that they were told they had to wear the same isolation gown all day. On 4/28/20 at approximately 9:49 a.m., during a conversation with CNA I, CNA I was queried regarding their use of PPE while caring for residents on the one south hallway. CNA I indicated that prior to 4/28/20 they were not provided a face shield when caring for residents that had COVID-19. CNA I indicated that residents would cough all over them and the staff were getting sick. CNA I also indicated that they had to use the same isolation gown for all the residents on the hallway including the residents without COVID-19. CNAI was queried if they had any set residents for the day and they reported it was just them and another aide, so they were working the whole hall. CNAI was queried if they had provided care for residents with COVID-19 and residents without COVID-19 with the same isolation gown and they indicated that they had. CNA I reported the facility only gave them one gown that day and they had to care for everyone with it. CNA I reported that before 4/28/20 they weren't provided any isolation gowns and they had to provide care for all residents on the hallway just wearing lab coats. CNA I was queried how they knew what residents had COVID-19 and which residents did not, and they indicated that the only way they knew the difference was that residents who got standard meal trays didn't have the infection and residents that received paper dishware did. Review of a staff assignment sheet for CNAs for 4/28/20 for the 7:00AM to 3:30PM shift revealed the following: CNA 'I' was assigned to care for a set of rooms where R#701, R#702, R#703, R#704, R#705, R#706, R#707, R#708, R#710, R#711, and R#712 resided. It was noted that this assignment included residents who were identified as positive for COVID-19 and included care for residents without a [DIAGNOSES REDACTED]. CNA 'F', the second CNA on the unit, had been assigned to care for R#713, R#714, R#715, R#716, R#717, R#718, R#719, R#720, R#721, R#722, R#722, R#723, R#724, R#725, R#726, R#727, R#727, R#728, R#729, and R#730. All the residents included in the assignment for CNA 'F' had been identified by the facility as positive for COVID-19. On 4/28/20 at 9:52AM, PTA 'G' was observed to exit R#712's room in a lab coat and gloves. On 4/28/20 at approximately 9:56 a.m., Housekeeper J (HK J) was queried regarding what isolation gown they used when cleaning the rooms of the one south hallway. HK J indicated he used one isolation gown for the whole hallway. HK J was queried if they used any different isolation gowns for cleaning the non-COVID-19 rooms vs the COVID-19 rooms and they reported they didn't and that once they were finished with the whole hallway they would change their gown and go onto another unit. Review of the clinical record for R#708 to R#730 revealed the following: R#708 was admitted to the facility 4/21/20 with [DIAGNOSES REDACTED]. The resident had an order dated 4/22/20 for .transmission-based precautions related to positive or suspected COVID-19 status. R#710 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per a physician order [REDACTED]. R#711 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had transmission-based precautions ordered 4/23/20. R#712 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per a physician order [REDACTED]. R#713 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per a physician order [REDACTED]. R#714 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per a physician order [REDACTED]. R#715 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per a physician order [REDACTED]. R#716 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per a Physician Assistant/Nurse Practitioner note dated 4/16/20 it was documented to continue isolation precautions for the resident. R#717 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#717's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/16/20 revealed R#717 needed extensive assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#718 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#718's MDS with an ARD of 4/17/20 revealed R#718 needed extensive assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#719 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#719's MDS with an ARD of 1/31/20 revealed R#719 needed extensive assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#720 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#720's MDS with an ARD of 2/6/20 revealed R#720 needed assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#721 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#721's MDS with an ARD of 2/1/20 revealed R#721 needed assistance from facility staff with their activities of daily living. A nursing note dated 4/16/20 revealed the following: Patient arrived at 4:42pm via stretcher by two ambulance personnel. Patient is a (age redacted) female patient that is A&Ox1-2 and had a primary [DIAGNOSES REDACTED]. R#722 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#723 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#723's MDS with an ARD of 4/16/20 revealed R#723 needed assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#724 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#724's MDS with an ARD of 4/5/20 revealed R#724 needed assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#725 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#725's MDS with an ARD of 4/19/20 revealed R#725 needed assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#726 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#726's MDS with an ARD of 4/19/20 revealed R#726 needed assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#727 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#728 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#728's MDS with an ARD of 1/30/20 revealed R#728 needed assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. R#729 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#730 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#730's MDS with an ARD of 3/29/20 revealed R#730 needed assistance from facility staff with their activities of daily living. An active physician's orders [REDACTED]. On 4/28/20 at 12:00 PM the facility's Assistant Director of Nursing (ADON), who was covering the

This citation pertains to intake: MI 644 Based on interview and record review the facility failed to prevent a fall for one (R#702) of three residents reviewed for accidents, resulting in R#702 sustaining a [MEDICAL CONDITION] left femur, increased pain and an admission for hospitalization . Findings include: On 9/27/19 a complaint was submitted to the state agency, which documented in part . My mom was laying in her bed in obvious pain and scared. I pulled the covers back to see my Mom's left hip and thigh area severely swollen and reddish in color. I asked my mom was she in pain and she nodded yes. I pulled the covers back over her and pulled the call cord. After 10 plus minutes of no response, I stepped into the hall to get the nurse . The nurse advised me that she had called the x-ray tech several times and was expecting their arrival by 4 am and if the tech did not show by then she would continue to call for them. She was apologetic and assured me that she would closely monitor my Moms pain . the nurse called again with x-ray results stating that my Moms hip was fractured and that she was being transported to (hospital name redacted) for care . I arrived at (hospital name redacted) . A nurse entered the triage and when I said the facility said my Mom had a fracture, she corrected me and said No, your Mom hip is broken completely across. My mom was admitted and surgery was scheduled for the next morning . My mom was nonverbal, without her ability to walk or swallow/eat and suffered from paralysis of her right side because of complications of her . stroke . On 10/8/19 at 10:47 AM, a telephone interview was conducted with the complainant and they stated in part, My mom was completing rehab. She was 2 weeks away from being discharged when this happened . She was wheelchair bound and she would scoot herself with the wheelchair . The facility said she had a fracture, the hospital stated it was broke. She had surgery and needed two pins in her hip . She was in the hospital for one month then released home . She was continent before the fall now she is incontinent of fecal and urine . She doesn't speak but she understands and can nod yes or no . I tried to make a report with the facility and was told that I couldn't make a report and it will be dealt with internally . On 10/8/19 and 10/9/19 an onsite investigation into the complainant's allegations were conducted. A review of R#702's clinical record revealed the following: R#702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented R#702 required a one-person physical assistance for transfers, dressing, eating, hygiene and toilet use and was total dependence for bathing. Further review of the MDS revealed Moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) documented as Not steady only able to stabilize with staff assistance. The Function limitation in Range of Motion documented Impairment on one side for R#702 for the upper and lower extremities. A Mobile device section documented a Yes for R#702 as utilizing a wheelchair. A facility admission Fall Risk Evaluation dated 2/14/19 at 18:44 (6:44 PM), documented Interventions Required. A review of R#702's admission care plans revealed no care plan or interventions implemented to monitor R#702 as a fall risk. A care plan titled The resident needs activities of daily living assistance related to: Debility (Initiated 2/15/19) revealed two different Transfer interventions documented for R#702. The care plan documented in part, . Interventions: Toilet use: The resident requires (Extensive assistance) by (1) staff for toileting (Initiated and Revision on 3/25/19) . Transfer: the resident is able to transfer self without assistance (Initiated 2/15/19). Transfer: The resident requires Mechanical lift with 2 or more staff assist for transfer (Initiated 2/15/19 and revision on 2/21/19). A care plan titled (Resident's name redacted) have a communication deficit r/t (related to) Dx (diagnosis) [MEDICAL CONDITION]([MEDICAL CONDITION]; Stroke) (Initiated and revised on 2/27/19) documented in part, Interventions . Anticipate and meet needs (Initiated 2/15/19). A care plan titled (Resident's name redacted) has a bladder and bowel incontinence r/t (related to) [MEDICAL CONDITION], right sided weakness and impaired mobility (Initiated 2/15/19 and Revision on 2/27/19) documented in part, . Interventions . Brief use: The resident uses disposable briefs. Check q (every) 2 hours and change PRN (as needed) (Initiated 2/15/19 and revision 2/27/19). Incontinent: Check every shift and as required for incontinence. Wash, rinse and dry perineum (Initiated 2/15/19 and revision on 2/27/19). Provide peri-area with each incontinence episode (Initiated 2/15/19). On 2/27/19 A care plan titled (Resident name redacted) is at risk for falls related to: Balance deficits and Incontinence was Initiated. The care plan documented, . The resident will not sustain serious injury through the review date initiated 2/27/19, revision 2/28/19 and Target date 6/3/19 . Interventions . Anticipate and meet the resident's needs based on nursing assessments (Initiated 2/27/19). Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Initiated 3/5/19). Provide activities per the activity care plan to minimize potential for falls (Initiated 2/27/19). Provide for activities of daily living such as incontinence care, transfers, ambulation as written in the activities of daily living plan of care (Initiated 2/27/19). Remind the resident to do the following lock wheelchair when getting in and out of wheelchair (Initiated and revision on 3/5/19). A review of R#702's progress notes revealed on 2/28/19 at 21:50 (9:50 PM), a Nurses Note documented in part, . Note Text: resident was observed sitting on the floor next to the wheelchair around 8pm, she was trying to self-transfer to the bed from the wheelchair and she didn't lock the wheels or call for assistance, she has no apparent injury at this time, no c/o (complaints of) or grimace of pain, acute distress or discomfort . she is her own responsible party, Dr. (doctor) was notified, safety maintained will continue to monitor . A facility's' Incident and Accident report dated 2/28/19 at 8:00 PM, documented in part . Resident was observed sitting on the floor next to the wheelchair No (incident witnessed), no apparent injury, (Action taken) care plan update and resident education). The Incident and Accident report was not signed by the Medical Director or Administrator. A Fall Investigation Report provided by the facility for the fall on 2/28/19 revealed an incomplete investigation. The Investigation report contained no documentation noted for the following areas: Name, signature, date and time (by Nurse), Summary of meeting: Systemic or operation conditions that may contribute to falls, any patterns or trends to the resident falls, conclusion, additional care plan/Nurse Aide assignment updates, signatures with date and time, Fall Huddle, Medications given in last 8 hours prior to fall, did fall occur and a picture of area and position resident was found. A Quality Assessment & Assurance Investigation Report provided by the facility for R#702's fall on 2/28/19 revealed an incomplete report. The Investigation report contained no documentation noted for the following areas: last care provided by who, residents explanation of incident, level of assistance resident requires, list staff/witnesses that were present at time of incident, Immediate interventions implemented, comment section, were there other notifications i.e. family, police, state agencies, identify related secondary sources of information reviewed and date of person preparing report. The incident report did have a check mark noted for No for the documented question Was resident incontinent when incident occurred, despite the facility's' care plan for R#702 indicating that they are incontinent. A Physical Therapy Discharge Summary for R#702 dated 3/6/19 at 4:14 PM, documented in part . Discharge Recommendations: Rec (Recommend) 24/7 care/supervision, pt (patient) currently requiring Min (Minimum) PA (physical assistance) for most functional mobility and transfers . A Nurses Notes dated 4/4/19 at 23:49 (11:49 PM), documented in part Note Text: resident was observed sitting on the floor in the bathroom next to the toilet, she stated she tried to self-transfer to the wheelchair from the toilet, she said she forget to pull the call light to ask for assistance, x-ray was ordered r/t (related to) c/o (complaints of) pain on the left hip at a level 7, PRN (as needed) was given . dr (doctor) and family was notified, will continue to monitor. Review of R#702's clinical record revealed no documented body assessment completed by Nursing staff status [REDACTED]. A Transfer/Discharge Report dated 4/5/19 (no time documented) documented in part, . post fall c/o (complaints of) pain left hip/thigh. Increased swelling area located left thigh. Stat x-ray possible fracture. Final result is not get <sic> yet. On [MEDICATION NAME] last INR/PT 2.6. 911 called . and No was documented in the relevant information ambulation section. A Nurses Notes dated 4/5/19 at 7:21 AM documented in part, Note Text: Receiving the resident was lying in the bed 11:15pm, pm shift nurse reported that the resident had a fall on pm shift. STAT x- ray for hip and leg ordered . resident was not verbalize <sic>, but when asked the resident, does she has pain, she point her LE - thigh area, and nodded the head, pm nurse reported pain medication Tylenol given, no open area, no bruise noted at this time. the resident's daughter came to the building around 2:30am to see the resident, she still present some pain, located on left LE (lower extremity) and hip area . x- ray called again to make sure STAT (immediately) carried out . the resident had slept until x- ray technician came, technician told that staff that possible fracture, but no final result yet, after that the resident increase her pain, could not sleep, discussed with MN (midnight) supervisor, and (doctor name redacted) notified to sent <sic> the resident to . hospital ER (emergency room ), 911 call, arrived 05:00am, the resident left the building 05:10am, (hospital ER name redacted) called to notify the resident will arrive soon, and give reported <sic> to ER staff. the family member - the daughter notified through phone call, DON (Director of Nursing) and Administrator notified. An Incident and Accident Report for R#702 dated 4/4/19 at 11:00 PM, documented in part . Resident self-transfer herself from the toilet to wheelchair and fell on the floor . Bathroom, Fall, Unobserved, X-ray ordered, Assessment and Neurocheck . The report does not contain documentation in the following areas: Impairment status, Injury Type or Other specify, Medication given in in last 12 hours and Action taken. The form was not signed by the Medical Director or Administrator. A Fall Investigation Report provided by the facility for the fall on 4/4/19 at 11 PM revealed an incomplete investigation. The Investigation report contained no documentation noted for the following areas: Medications given in last 8 hours prior to fall, signature of nurse completing the form with date and time, Summary of meeting: Systemic or operational conditions that may contribute to falls? Any patterns or trends to the residents' falls, Conclusion, Additional Care Plan/Nurse Aide Assignment Updates, Signatures with date and time, Staff/Witness present at/or finding resident after fall, picture of area and position in which resident found, Identify related secondary sources of information reviewed and date of the person preparing report. A Quality Assessment & Assurance Investigation Report provided by the facility for R#702's fall on 4/4/19 at 11 PM, revealed an incomplete report. The Investigation report contained no documentation for the following areas: place of occurrence, staff involved, physician notification, state reportable, comment section, when was resident last seen, what were they doing, time of last meal/snack, last care provided/by who, was resident incontinent when incident occurred, residents explanation of incident and immediate interventions implemented. A review of the Certified Nursing Assistant (CNA) task documentation revealed blanks for the evening shift of 4/4/19 for bed mobility, dressing, personal hygiene, toilet use, transferring, bladder/bowel elimination, oral care and turn/positioning (Indicating these tasks were not completed by staff). An interview was attempted with Licensed Practical Nurse (LPN) G, the nurse on duty when R#702 fell on [DATE], however on 10/9/19 at 3:48 PM, the DON stated the nurse called in for the day. An interview with LPN G was attempted with the Administrator by phone and a message was left with phone number to return the call. A return call had not been received by the end of survey. On 10/09/19 at 4:48 PM, CNA F who was assigned to R#702 on the evening of 4/4/19 was queried regarding the fall on that evening and stated, I wasn't the one that found her. There were two other CNA's working that evening but they don't work here anymore. I did help get her up and back into bed. When she got in the bed, she was the most distraught. When asked if R#702 could tell them what happened, CNA F stated, No, she wasn't able to talk. On 10/9/19 at 5:40 PM, the Administrator was queried on the lack of documentation noted in the investigation for both of R#702's falls, asked how the facility concluded the investigation for the 4/4/19 fall by consistently documenting that R#702 stated she tried to self-transfer to the wheelchair from the toilet, she said she forget to pull the call light to ask for assistance when R#702 is not verbal. The Administrator was also queried on why R#702 was not checked on for toilet/brief change per their care plan on the evening of 4/4/19 per the CNA's toilet use and transfer task documentation and the Administrator stated, I can't comment on that. I wasn't the Administrator for the facility at that time. We are all new, the assistant administrator and Director of Nursing. None of us were here at that time. I could only read the documents that others wrote that you already have. A facility policy titled, Falls- Clinical Protocol (Reviewed/Revised (MONTH) (YEAR)) documented in part, As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling . Based on the assessment an initial plan of care will be developed and implemented to address identified risk. This will be revised as necessary . Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include; Resident's abilities and deficits, Balance (sitting/standing), Adaptive equipment needs, Proper use of mechanical lifts and transfer devices, shower beds, shower chairs, bathroom safety . For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke, Often, multiple factors in varying degrees contribute to a falling problem, Once a fall occurs it is important to gather as much information as possible; Observe for evident trauma, Observe to determine what the resident was attempting to do if possible, Observe for environmental hazards which may have contributed, If the resident is able, what does he/she state happened, Staff present and responders, what did they see/her, Provide emergency care and assessments/s as indicated . all un-witnessed falls regardless of the resident's cognitive states should have neurochecks per MD (medical doctor) orders or protocol . Document findings in the resident's medical record or EHR per standard protocol. Complete a new falls risk assessment and compare to the previous one for any changes . Post fall analysis items to be considered (not all inclusive) . The nurse's notes, review for med (medication) changes in the last 30-90 days . Review staff and witness statements . Review of care plan and CNA assignments that were in place at time of fall . Update the plan of care with the new or revised interventions .

This citation pertains to intake #MI 142. Based on observation, interview and record review the facility failed to ensure one [MEDICAL CONDITION] oxygen dependant resident (R#902) was provided physician ordered life-sustaining oxygen out of four residents reviewed for oxygen dependency, resulting in an Immediate Jeopardy (IJ) and the increased likelihood for respiratory complications, including serious injury, harm, impairment and/or death. Findings include: The Immediate Jeopardy (IJ) IJ was identified on 8/7/19 at approximately 11:29 AM, when on 8/7/19 at approximately 11:29 a.m., R#902 was observed in their room lying in bed. R#902 was observed to have [MEDICAL CONDITION]([MEDICAL CONDITION]- an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) collar on with [MEDICAL CONDITION] and mask connected to it. R#902's Oxygen concentrator was observed to be on and running at 2.5 liters. However, R#902's Oxygen tubing was observed to be disconnected from [MEDICAL CONDITION] and on the floor depriving R#902 of machine generated oxygen. This resulted in the potential for [MEDICAL CONDITION] (an abscence of enough oxygen in the tissue) that could lead to death. The facility Assistant Administrator was notified of the IJ on 8/7/19 at approximately 3:33 P.M. and a plan to remove the immediacy was requested. On 8/7/19 at approximately 11:55 AM, R#902 was observed in their room lying in bed. Resident was observed to [MEDICAL CONDITION] on [MEDICAL CONDITION] going to it. Residents Oxygen concentrator was observed to be running at 2.5 liters. Residents Oxygen tubing was observed to be disconnected [MEDICAL CONDITION] and on the floor depriving R#902 of machine generated oxygen. On 8/7/19 at approximately 12:48 p.m., R#902 was observed in their room lying in bed. R#902 was observed to have [MEDICAL CONDITION] on with [MEDICAL CONDITION] and mask connected to it. R#902's Oxygen concentrator was observed to be on and running at 2.5 liters. R#902's Oxygen tubing was observed to be disconnected from [MEDICAL CONDITION] and on the floor depriving R#902 of machine generated oxygen. On 8/7/19 at approximately 1:12 p.m., nurse B was observed coming into R#902's room. Nurse B was observed picking up R#902's oxygen tubing off of the floor and connecting it to R#902'[MEDICAL CONDITION]. A subsequent oxygen saturation reading for R#902 was observed to be at 75% (Blood oxygen levels under 90 percent are considered low and place residents at risk.) Nurse B was queried how often they check on their residents to ensure they are receiving oxygen and they stated between the CNA (certified nursing assistant) and the nurse it's every hour. Nurse B was queried when was the last time they were in R#902's room and they stated that it was forty minutes ago. Nurse B was queried if they had noticed R#902's oxygen tubing on the floor and they indicated that they had not. On 8/7/19 the medical record for R#902 was reviewed and revealed the following: R#902 was initially admitted to the facility on [DATE], was readmitted on [DATE] and had [DIAGNOSES REDACTED]. R#902's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/9/19 revealed R#902 was dependent on facility staff for almost all of their activities of daily living. R#902's cognition was documented as severely impaired. Section O indicated R#902 was receiving oxygen therapy. A physician's orders [REDACTED].@2L (liters)/[MEDICAL CONDITION] to maintain spo2 (oxygen saturation) > (greater than)=90%. A review of R#902's careplan revealed the following: Focus-The resident has oxygen therapy r/t (related to) Ineffective gas exchange Dx (diagnosis) [MEDICAL CONDITION] .Goal-The resident will have no s/sx (signs/symptoms) of poor oxygen absorption through the review date .Interventions-Give medications as ordered by physician. Monitor/document side effects and effectiveness .Monitor for s/sx of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate ([MEDICAL CONDITION], Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color .OXYGEN SETTINGS: O2 (oxygen) via (Trach) @ (2)L (Continuous). ADMINISTER OXYGEN PER ORDER . On 8/7/19 at approximately 1:24 p.m., nurse B was queried if R#902 needed continuous oxygen and they indicated that they did. Nurse B was queried regarding the dangers of R#902 being without oxygen and they indicated that it was life threatening and that going without oxygen could result in organ failure. Nurse B stated, I'm going to call the doctor to see what he wants to do, and see if he wants him sent out. On 8/8/19 at approximately 12:55 p.m., the Director of Nursing (DON) was queried if it was their expectation that all residents who are ordered continuous oxygen are provided it according to their Physician orders [REDACTED]. On 8/8/19 a facility document titled Oxygen Administration (last reviewed by facility administration on 8/7/19) was reviewed and revealed the following: Purpose-The purpose of this procedure is to provide guidelines for safe oxygen administration .Steps in the procedure-7. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter) .8. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .9. Securely anchor the tubing so that it dos not rub or irritate the resident's nose, behind the resident's ears, etc . The IJ began on 8/7/19. The IJ was identified on 8/7/19 at approximateley 11:30 am. The IJ was removed on 8/8/29 when the State Agency verified the facility implemented the following plan to remove the immediacy which included: 1. Resident # 902 has been assessed by the licensed nurse, VS 124/60, 70 BPM, 20 RR. The resident's O2 Saturation is 98%. Oxygen has been properly placed over the [MEDICAL CONDITION] and is secured. 2. 11 out of 11 Residents requiring continuous oxygen have been checked to ensure their oxygen tubing is secured, as well as assessed by a licensed nurse and remain in stable condition. 9 residents are receiving oxygen via nasal cannula and 2 residents are receiving oxygen [MEDICAL CONDITION]. Nurse Management team has verified that orders are correct for those residents receiving continuous oxygen via nasal cannula [MEDICAL CONDITION] on 8/7/19. All Care Plans have been reviewed and updated for those residents receiving continuous oxygen on 8/7/19. Nurse Management will monitor physician orders [REDACTED]. The facility failed to monitor the use of Oxygen on a resident that is dependent for Oxygen for life sustaining measures. 3. The Policy for Oxygen Administration has been reviewed by the Regional Director of Clinical and Regional Director of Operations and deemed appropriate. 18 out of 51 Nurses and 18 out of 78 Certified Nurse Aides have been re-educated on the Policy for Oxygen Administration including immediate notification to nurse if tubing is not attached to resident or oxygen delivery system. Any Nurse or Certified Nurse Aide not educated will receive education prior to their next scheduled shift. 4. Nurse Management or Designee will conduct random rounds to ensure oxygen tubing placement. Licensed nursing staff and Certified Nurse Assistants will be monitoring oxygen tubing placement every 2 hours with licensed nursing staff documenting via EMAR. Results will be reviewed by the QAPI Committee monthly for 3 months. 5. The Administrator is responsible to maintain compliance. Although the immediate jeapordy was removed on 8/8/19, the facility remained out of compliance at a scope of isolated and severity of potential for more than minimal harm that is not immediate jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

This citation pertains to MI 693: Based on observation, interview, and record review the facility failed to ensure bed mobility was performed per the resident's assessed needs while incontinence care was provided for one (#801) of three residents reviewed for falls from a total sample of three, resulting in the resident falling from the bed, sustaining a [MEDICAL CONDITION] femur, requiring emergency transport the hospital, expressions of pain, and the need for surgical intervention. Findings include: On 5/30/18 at 2:00pm, Resident #801 was observed laying in bed, and a catheter bag was observed to be present to the left side of the resident's bed. Resident #801 was queried as to how she was doing, and responded I'm in a lot of pain. Resident #801 was queried in regards to having fallen, and responded that she had been turned over to the (her) side and explained that she had a good hold. The resident expressed that a staff member had been changing her, and said that the staff member had come up behind the resident and had pushed. Resident #801 explained, I went over the bed was up high. I came down on my left side I turned that's how I got my right side .that floor hard and I fell hard the bone went through my leg at the top .I heard the bone pop. Per the resident, the staff member had raised the bed prior to providing care. Resident #801 was queried as to how many staff members were present at the time, and responded that there had been one CNA (Certified Nursing Assistant) in the room. Resident #801 stated,She knew better she knew she was supposed to have two. Resident #801 explained that there were usually two persons present when the resident was getting cleaned up in the bed. When queried in regards to her injuries, Resident #801 explained that not only did her leg break, but there was also a long cut down the leg and surgery had been performed. The resident stated, I got a rod and some screws, staples, and stitches. On 5/30/18 at 2:11pm a review of Resident #801's clinical record was reviewed and revealed the resident had been admitted into the facility on [DATE] and had been readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's annual minimum data set (MDS) assessment dated [DATE] the resident scored 15 out of 15 on a brief interview for mental status exam, which indicated the resident was cognitively intact. Continued review of this MDS assessment revealed the resident required the extensive assistance of two persons for bed mobility. On 5/30/18 at 2:20pm review of a facility reported incident summary provided by the facility pertaining to Resident #801 was reviewed and revealed, in part, the following: Reported Incident: (Resident #801) had a fall on 5/21/2018 that resulted in a fracture to her right femur Investigation: On 5/21/2018 (Resident #801) fell from bed while the cena was providing patient care. She sustained a laceration to her right shin with profuse bleeding. Resident was assessed and pain medication was given. Her vitals were within normal range post fall per the nursing assessment. Resident was transferred to the hospital and an x-ray was obtained and the results showed a fracture to the right femur Review of an Incident/Accident (I/A) report for Resident #801 dated 5/21/18 at 3:24pm was reviewed and revealed, in part, the following: Brief Description Resident receiving incontinence rolled out of bed. Head observed on dresser Laceration to RLE (right lower extremity, shin with bleeding. Foley cath (catheter) remained intact. This I/A report documented the resident's bed height as being up at the time of the incident, and documented the resident had a laceration. Review of a Fall Investigation Report for the resident's fall documented, in part, the following per Level of assistance resident requires (1,2,devices): x 2 +. Per this report, it was documented that CNA 'A' had been present at the time of the incident. Per the comments section of the report, it was documented that Resident #801 had increased anxiety, increased pain, and had a fracture to the right femur. Per the Investigation Report, the following box was checked to indicate the root cause of the resident's fall: Amount of assistance in effect. On 5/30/18 at 2:33pm CNA/Restorative Aide 'A' was queried regarding Resident #801's fall, and confirmed that she had been providing care to the resident at the time of the resident's fall. CNA 'A' explained that it was at the end of the shift, and the resident had a bowel movement and needed to be changed. Per CNA 'A', no other CNAs were available at the time, and CNA 'A' wanted to get the bowel movement off of the resident. CNA 'A' explained that the resident had turned, the resident was cleaned, and when tucking the brief under the resident the CNA may have given her a little push to apply the brief. CNA 'A' explained she saw the resident fall and was unable to stop the resident's fall. When queried as to how many people were to be present to assist the resident with bed mobility, CNA 'A' responded that the resident was a two person assist for bed mobility and transfers. Per CNA 'A' the resident fell right onto the resident's left side, and the resident had a cut on the right leg that was bleeding. CNA 'A' explained that she had stood in the doorway and had requested assistance, and other staff, including Unit Manager (UM) 'B' had responded. CNA 'A' acknowledged that she had known Resident #801 required the assistance of two persons prior to the resident's fall. Per CNA 'A', the resident could turn, and the two person assistance was for safety to have someone on the other side. On 5/30/18 at 3:02pm review of a progress note dated 5/21/18 at 4:06pm revealed the following: CNA called writer to room. Resident was observed on the floor laying with head against dresser, foley intact, laceration, tissue exposed, to RLE (right lower extremity) shin with profuse bleeding. Resident alert to self and situation c/o (complains of) pain to RLE. Pressured applied to RLE, Writer and staff x5 assisted resident into bed via mechanical lift, safety maintained. RLE dressing applied. PRN (as needed) [MEDICATION NAME] given. B/P (blood pressure) 120/90 P (pulse) 90 R (respirations) 22 SPO2 70% RA (room air) oxygen applied SPO2 100% O2 (oxygen) 3 L/min (liters per minute) applied r/t (related to) wheezing upon fall. Ambulance called . On 5/30/18 at 3:19pm review of an activities of daily living (ADL) plan of care dated 1/31/18 and last updated 5/30/18 for Resident #801 was reviewed and revealed, in part, the following: The resident has an ADL self-care performance deficit r/t impaired mobility, decreased strength and limited ROM (range of motion), [MEDICAL CONDITION] Per an intervention per the resident's plan of care dated 1/31/17 the following was documented: BED MOBILITY: The resident requires (assistance) by (2) staff to turn and reposition in bed and as necessary. On 5/30/18 at 3:25pm Unit Manager 'B' was queried regarding regarding Resident #801's fall. UM 'B' explained that when she entered the resident's room staff were already in the room and were applying pressure to the resident's RLE, and staff were waiting for additional staff to assist with placing the sling for the hoyer lift. UM 'B' explained that she had been in another resident's room and had been alerted by a CNA that Resident #801 had fallen. Per UM 'B' Resident #801 had her head leaned against the dresser, was propping herself up with her left arm, and blood was observed to the floor. UM 'B' explained that pressure was being applied, and when UM 'B' went to assess the resident and staff removed pressure the resident was sent to the hospital due to the blood and injury. When queried in regards to the level of assistance Resident #801 required for bed mobility, UM 'B' confirmed the resident required the assistance of two persons. On 5/30/18 at 3:55pm review of a Nurses' Note dated 5/26/18 at 9:37pm was reviewed and revealed, in part, the following: Resident came back from (Hospital Name) at 4:30pm by ambulance was accompany by four attendance, alert oriented x3, no acute distress noted, but complained of pain at incision site at right leg. Hospital [DIAGNOSES REDACTED]. Bil. (bilateral) lower [MEDICAL CONDITION] with skin discoloration, right hand [MEDICAL CONDITION], excoriation at left hip area On 5/30/18 at 4:16pm review of am OR Brief Operative Note from the hospital dated 5/22/18 was reviewed and revealed the following preoperative and postoperative [DIAGNOSES REDACTED]. Per the Procedures Section the following was documented: Retrograde Intramedullary Nail Right Femur. On 5/30/18 at 4:29pm review of a performance improvement form for CNA/Restorative Aide 'A' signed by the employee and dated 5/22/18 was reviewed and revealed, in part, the following as the reason for counseling/corrective action: The CNA failed to follow the appropriate bed mobility for a resident which resulted in a major injury. On 5/30/18 at 5:26pm the facility's Director of Nursing (DON) was queried regarding education provided to CNA 'A''. The DON responded that CNA 'A' had been suspended pending investigation. and had been brought back to work. The DON confirmed that the staff member had received education and disciplinary action., due to not following bed mobility. The DON explained that CNAs were told to check the resident's kardex, and if assistance was needed, staff were to go find staff members. The DON acknowledged that Resident #801 had been a two person assistance for bed mobility at the time of the resident's fall. The DON also explained that nursing staff could also assist in performing direct resident care. Review of a facility policy titled Falls-Clinical Protocol dated 2/17 was reviewed and revealed, in part, the following: .2. The Minimum Data Set (MDS) and subsequent CAAs (care area assessment) will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls .4. Interventions should be developed and implemented per the assessed needs .

This citation pertains to MI 381. Based on observation, interview, and record review, the facility failed to ensure timely treatment after a fall for one (#602) of three residents reviewed for falls from a total sample of seven, resulting in continued pain and the potential for further delay in treatment. Findings include: On 5/22/18 at 11:50 AM, Resident #602 (R602) was observed sitting in her wheelchair in her room. When an attempt was made to engage R602 in conversation, she did not respond. On 5/22/18 at 12:10 PM, a review of the clinical record for R602 was begun. R602 was originally admitted into the facility on [DATE] with a readmission date of [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented severely impaired cognition, total dependence upon staff for transfers, and extensive two-plus person physical assistance for toilet use. A MDS dated [DATE] documented moderately impaired cognition, supervised one-person physical assistance for transfers, and limited one-person physical assistance for toilet use. A facility incident report dated 3/23/18 documented the following: --Brief Description: Patient observed on floor lying on left hip outside of bathroom door, facing bed. --Time of incident: 3:45 AM The first nursing progress note on R602 following her 3:45 AM fall was documented on 3/23/18 at 8:04 AM: Patient was observed on floor in bedroom. Patient was found on left hip where she c/o (complained of) aching pain, prn (as needed) pain med was given. Patient stat (at once) hip x-ray was ordered to rule out fractures. Patient guardian was notified, along with DON (Director of Nursing) . Additional nursing progress notes documented: 3/23/18 at 6:58 PM: Bilateral hip x-ray ordered in addition to left hip. 3/24/18 at 12:21 AM: Resident is being sent to the hospital, family and doctor notified, resident has a left [MEDICAL CONDITION]. On 5/22/18 at 3:25 PM, during an interview with the DON the following was noted: When queried about the time R602 received her initial hip x-ray on 3/23/18, the DON stated there is no documentation in the medical record about that. I can find out for you. I would have expected the nurse to document that the x-ray was completed. Review of R602's hip x-ray results were reviewed with the DON, and the following was noted: --Results: There is a fracture involving proximal femur with displacement. The remainder of the femur is intact. --Conclusion: Acute proximal left femur fracture as described. --Date/Time: 3/23/2018 at 8:30 AM When the DON was queried, What time was the facility aware that R602 sustained a [MEDICAL CONDITION]?, the DON said, I would have to look into that. The DON agreed that typically for this type of x-ray result, the x-ray company would call right away. On 5/22/18 at 5:20 AM, a telephone interview was conducted with a manager from the mobile x-ray company, Witness B. Witness B stated the left hip x-ray on R602 was performed at 8:05 AM on 4/23/18. The facility was notified about R602's left [MEDICAL CONDITION] via a fax sent at 8:25 AM, a phone call made at 8:34 AM, and an alert email sent at 8:24 AM. When the DON was queried if she had concerns that R602 wasn't sent out to the hospital until 3/24/18 at 12:21 AM, she said, I feel like it was a significant amount of time between the time the x-ray was read and when she was sent out.

This citation pertains to intake MI 124: Based on observation, interview, and record review, the facility failed to ensure interventions to prevent skin breakdown were implemented for 2 (#603 & 606) of 3 residents reviewed for Pressure Ulcers (PU) out of a total of 7 sampled residents, resulting in the development of a new PU (#606) and the potential for the worsening of an existing PU (#603). Findings Include: Resident #606 On 5/22/18 at 1:49 PM, Resident #606 was observed lying in bed awake. Resident #606 had a [MEDICAL CONDITION] (a surgically inserted breathing tube in the lower front part of the neck), tube feeding infusing, and a Foley catheter (a tube that drains urine out of the bladder). Resident #606 was asked if she had a wound. Resident #606 moved her head up and down and audibly whispered Yes and revealed she had a wound on her back side (butt). Resident #606 revealed she had gotten the wound while at the facility. Resident #606 was asked if she was turned and repositioned frequently. Resident #606 audibly whispered Every other hour. Resident #606 revealed they started the turning and repositioning regularly after she got the wound. On 5/22/18 at 2:00 PM, observation of the PU was done with Unit Manager C and Nurse D. Resident #606 had a Stage 4 PU that had circular PU on the coccyx that had a pink base, no odor, and moderate amount of serosanguinous drainage. The facility's wound care consultant note, dated 5/17/18, documented The sacral wound stage 4 decubitus (pressure) ulcer measures 11 centimeter (cm) in length X 12 cm in width with the depth of 2.4 cm. The Wound base is 100% granulation. Heavy sero-sanguinous drainage. Wound edges are slightly irregular. There is no peri-wound excoriation. No malodor is noted today . A review of the clinical record revealed that Resident #606 was originally admitted into the facility on [DATE], was discharged to the hospital on [DATE] and readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #606 had severely impaired cognition and was totally dependent on staff for the completion of activities of daily living, including repositioning in the bed. The Norton Plus Pressure Ulcer Scale (used to determine the risk for the development of PU), dated 2/18/18, documented that Resident #606 had a score of 10 (a scores of 10 or below = high risk). The Norton score on 3/5/18 equal 5. A review of the hospital notes from a local hospital, dated 2/17/18, did not document that Resident #606 had a a PU. The admission nursing assessment, dated 2/17/18, documented that Resident #606's skin was intact on admission. A review of a Situation Background Assessment Recommendation (SBAR) Tool, dated 3/2/218, documented Resident #606 had some Skin peeling on the buttock that started on 2/27/18. A Skin Assessment, dated 3/2/18, documented that Resident #606 had an Area noted dark wound bed no drainage, no odor, presented with butterfly shape. However, a review of the 2/27/17 Nurse Practitioner note at 1:25 PM and the Addendum at 11:22 PM, did not documented information the area had been examined. The wound care nurse note, dated 3/1/18, documented that Resident #606 had an Open wound on the sacral/bilateral buttocks that measured 9.0 cm length X 12.5 cm width X depth was unable to be determined. The wound was from pressure, acquired in the facility, was unstageable, had necrotic/eschar tissue (dead tissue), with light sero-sanguinous drainage. A review of the hospital notes, dated 3/5/18, documented, Wound Care Consultation .Pressure Injury factors .prior pressure injury .Location: sacral, Measurement: 9 centimeters (cm) X 13 cm X unknown true depth; wound characteristics: 100% tan/brown necrotic (dead) tissue. Slightly moist .Bedside debridement per general surgery service 3/2/18 .Recommend Dakin's solution to bases to facilitate further removal of necrotic tissue . On 5/22/18 at 3:20 PM, Unit Manager C was asked about the above documentation and how Resident #606 got the wound. Unit Manager C revealed the PU developed while a Resident in the facility. Unit Manager C stated, On admission the nurses do the skin assessment. Unit Manager C was asked if the wound care nurse looks at the resident's skin on admission and replied, The wound care nurse only looks at the skin if the nurse finds something. Unit Manager C stated, When she was admitted she had nothing; Unit Manager C reviewed the electronic medical record and revealed a Standard of Care (S[NAME]) note that stated, 3/1 - notified the doctor with skin concerns . However, no note was revealed the resident was seen by the physician. Unit Manager C was asked about interventions that were in place to reduce the the risk of skin breakdown. Unit Manager C stated, We have the yellow dot program. Unit Manager C revealed a yellow dot is placed on the name tag outside the resident's room and informs the nurse aides the resident needs assistance with turning and repositioning. Unit Manager C was asked for documentation that was done and documentation of any other intervention that had been put in place between 2/17/18, the day of admission and 3/2/18 the day Resident #606 was sent to the hospital. On 5/22/28 at 5:30 PM, the DON and Unit Manager C revealed they had no documentation of interventions that had been utilized between 2/17/18 and 3/1/18. The nursing care plan was reviewed with them and revealed the intervention The resident needs assistance to turn/reposition only side to side at least every 2 hours, more often as needed or requested had been initiated on 3/1/18 and the intervention The resident requires low air loss mattress was initiated 2/27/18. The yellow dot program turn every 2 (hours) and prn repositioned side to side as tolerated was initiated on 3/1/18. Each intervention that involved rotation of the resident's position, had been initiated after Resident #606's skin broke down. The DON stated, She wasn't on the yellow dot program when she came in. She didn't have anything (skin breakdown). The (MONTH) (YEAR) physician orders [REDACTED].#606's PU had become infected and she was to receive antibiotic therapy from 5/17/18-6/1/18. Resident #603 On 5/22/18 at 10:41 AM, a review of the clinical record revealed that Resident #603 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident #603 had severely impaired cognition and require total physical assistance from staff for ADLs to be completed. The MDS revealed Resident #603 was admitted with a sacral PU that measured 9.0 cm long X 9.0 wide X 1.8 cm deep. The Norton Plus PU Scale, dated 2/2/18, documented that Resident #603 had a score of 10 and was at high risk for the development of PU. The nursing care plan documented, float heels with protective boots/and heels up as tolerated, yellow dot program turn and reposition every 2 (hours) and prn as tolerated. On 5/22/18, Resident #603 was observed in his room lying in the bed, on his back at 10:11 AM, 12:12 PM, 1:44 PM, 2:20 PM, 3:10 PM, and 3:53 PM. The pillow at Resident #603's side had been moved, but Resident #603's center of gravity remained on his buttocks. Resident #603 had on bilateral heel protectors, but his heels resident in the same positron with each observation. At 3:57 PM, Unit Manager E and Nurse F were asked about Resident #603's repositioning and his wounds. They revealed Resident #603 had a stage 4 sacral PU on his buttocks and a vascular wound on the left heel. The wound on the buttocks had a pink base, irregular edges, no odor, and moderate serosanguinous drainage. The wound on the left heel was leaking heavy sero-sanguinous drainage on the sheets and was malodorous with macerated edge. Though Resident #603 had on bilateral heel protector, the positron of his feet had not been changed during the above observations. Nurse F was asked why Resident #603 hadn't been positioned off the sacral PU and his feet repositioned. Nurse F revealed the resident had brief changes and the pillow had been moved from the other side of the bed. He can be quite active. We do the best we can. Unit Manager E had no explanation why Resident #603 had not been positioned off of the pressure ulcer on the sacrum or his feet repositioned. At 5:30 PM, the DON was asked about the turning and repositioning of Resident #603 off the PU. The DON offered no explanation why it had not been done. On 5/22/18 at 5:50 PM, a review of the facility's undated Turning & Reposition (Yellow Dot) Program stated, When a resident is at risk for skin breakdown based on the Norton Scale Score: 10 or below Follow Seven Steps Program 1. Place a yellow dot on the resident's door and/or wheelchair/gerichair when the resident is unable to reposition self, unable to turn self .2. Turn and reposition every 1 to 2 hours when in bed .6. Document turning and repositioning utilizing Point of care, progress notes, S[NAME] meetings .7. Complete walking rounds twice weekly to observe yellow dot program success, observed timing of turns, observed staff reminding residents to reposition, observe care plan interventions .

This citation pertains to MI 381. Based on observation, interview, and record review, the facility failed to adequately assess and ensure adequate pain management after a fall for one (#602) of three residents reviewed for falls from a total sample of seven, resulting in continued pain. Findings include: On 5/22/18 at 11:50 AM, Resident #602 (R602) was observed sitting in her wheelchair in her room. When an attempt was made to engage R602 in conversation, she did not respond. On 5/22/18 at 12:10 PM, a review of the clinical record for R602 was begun. R602 was originally admitted into the facility on [DATE] with a readmission date of [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented severely impaired cognition, total dependence upon staff for transfer, and extensive two-plus person physical assistance for toilet use. A MDS dated [DATE] documented moderately impaired cognition, supervised one-person physical assistance for transfer, limited one-person physical assistance for toilet use, and resident experienced frequent urinary incontinence. A facility incident report dated 3/23/18 documented the following: --Brief Description: Patient observed on floor lying on left hip outside of bathroom door, facing bed. --Time of incident: 3:45 AM The first nursing progress note on R602 following her 3:45 AM fall was documented on 3/23/18 at 8:04 AM: Patient was observed on floor in bedroom. Patient was found on left hip where she c/o (complained of) aching pain, prn (as needed) pain med was given. Patient stat (at once) hip x-ray was ordered to rule out fractures. Patient guardian was notified, along with DON (Director of Nursing) . The SBAR (Situation, Background, Assessment, Recommendation) document completed on 3/23/18 at 11:38 PM documented the following in the Assessment section: The resident appears more confused, in pain, fracture of left hip. On 5/22/18 at 3:10 PM, a review R602's hospital admission History and Physical, dated 3/24/18 documented the following: --Time of trauma evaluation: 1:13 AM -- .(R602) was found on the ground by the nursing staff and was complaining of left hip pain; an x-ray at the nursing home revealed a left femoral inter-trochanteric fracture and the patient was subsequently transferred here. Currently complaining of pain in her left hip. On 5/22/18 at 3:55 PM, the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 5/22/18 at 6:10 PM, when the DON was queried about the absence of pain management after a fall, she said, I think that's a problem because the resident should have received some type of pain medication for a fracture; even if we suspected a fracture. As was noted in the 3/8/18 MDS, R602 experienced frequent urinary incontinence. When the DON was queried if staff provided incontinence care for R602 any time after the fall, she said, I would assume incontinence care was given before she went to the hospital. When the DON was queried if she thought that would have been excruciating for R602, she said, I could imagine that it was very painful. On 5/22/18 at 6:45 AM, the facility policy titled, Administering Pain Medications, dated 3/22/11, was reviewed and documented the following: --The resident's experience of pain is highly individual and subjective. Pain is whatever the resident says it is. --Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained.

This Citation Pertains To MI 995 Deficient Practice #1: Based on interview, and record review the facility failed to ensure that one resident (#704) who had a history of [REDACTED].-smoking status when the resident was observed by staff on 5/27/17 smoking inside of his bedroom for one of twelve residents reviewed for smoking (#4, #6,#24,#27,#31,#38,#41,#51,#66,#80,#115), potentially affecting all 153 residents who reside at the facility, resulting in the potential for serious injury, harm, or death from burns and fire. This resulted in an immediate jeopardy to the health and safety of all residents residing in the facility. The immediate jeopardy was identified on 6/14/17. The administrator was notified on 6/14/17 at 12:22 PM and a plan of correction was requested to remove the immediacy. The immediacy was removed on 6/14/17 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 the potential for harm that is immediate jeopardy. Findings include: On 6/14/2017 at approximately 9:00 am, Resident #704 clinical record was reviewed and revealed an admission date of [DATE] with a readmission date of [DATE], [DIAGNOSES REDACTED]. A review of the Minimum Data Set reflected a brief interview status of 15 (cognitively intact) total dependence on two staff members for transfers and hygiene and bathing. A review of the behavior notes authored by Social Services Director E dated 3-15-2017 reflected in part Resident has been observed with smoking in the facility, and on facility grounds. Resident was provided education regarding safe smoking practices and facilities rules and regulations of facility as this is a non smoking facility.Resident was observed directly by staff and was redirected. Per resident he will leave facility grounds if he would like to smoke. Behavior notes authored by Social Worker I dated 3-24-2017 reflected Smoking in/on facility grounds Non adherent to treatment plan. Resident was provided education regarding safe smoking practices and facilities rules and regulations of facility as this is a non smoking facility.The behavior notes dated 5-12-2017 reflected in part, Behavior displayed smoking on facility grounds. Interventions attempted Re-education of facility smoking policy. Social Work progress notes dated 5-16-2017 Resident was re-educated on safe smoking. Resident was re-educated to leave the premises when going to smoke and also use a flag when moving through the parking lot to be visible to cars. The facility form titled Safe Smoking Evaluation completed for Resident #704 on 5-23-2017 reflected under the comment section Resident is aware of smoking policy. He knows to sign out and smoke off the property, however he has a history / incident of smoking on the facility premises that he has been educated on multiple occasions. The care plan for Resident #704 reflected Resident is a smoker with a goal of no injury related to smoking. Interventions were Educate resident about smoking risks and hazards and about smoking cessation aids that are available. Educate resident about the facility policy on smoking ; locations, times, safety concerns, etc. Notify nurse immediately if it is suspected the resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. Smoking paraphernalia will be kept secured at facility identified location. On 6-14-2017 at 9:38 am during a phone interview with Registered Nurse (RN) D he reported that on 5-27-2017 at approximately 4:00 am he was notified by Certified Nursing Assistant (CNA) H observed Resident #704 smoking in his room. RN D stated upon entering Resident #704's room it was hazy, filled with smoke and he observed Resident #704 inhale and exhale the cigarette twice and that Resident #704 refused to distinguish the cigarette. RN D was queried if he was aware of prior instances of Resident #704 smoking in the facility previously and replied Yes, he was smoking in the beauty shop a few months ago . RN D stated RN L observed that incident. On 6-14-2017 at 10:15 a.m. during a telephone interview with RN L she reported approximately six weeks ago she was starting her shift at 11:00 PM and smelled cigarette smoke. RN L stated she followed the smell and while walking down the hall she observed Resident #704 propel his wheelchair out of the beauty shop. You could see the smoke in the air and you could smell it too. RN L stated she discussed the issue with Resident #704 whom denied he was smoking in the beauty shop. On 6-14-2017 at 3:50 PM, during an interview with CNA H she reported on 5-27-2017 at approximately 4:00 am upon returning from her break, Resident #704's bedroom door was shut but she could smell cigarette smoke coming from the room and upon opening the bedroom door she observed Resident #704 in bed smoking. There was a cloud of smoke, he was trying to cuff his hand and hide the cigarette, I told the Nurse. When queried about other incidents of Resident #704 smoking in the facility Yes, somebody caught him in the soiled utility room. CNA H stated she was not sure who observed this or when the alleged incident of smoking in the soiled utility room occurred. Resident #704 was at the hospital during the abbreviated survey, and unable to be interviewed. On 6-14-2017 at approximately 10:45 am during an interview with Administrator A she reported the facility had no actual Smoking Policy but it is a nonsmoking campus and the practice was that residents that wish to smoke sign themselves out on a leave of absence, the receptionist holds all cigarettes and lighters and issues each resident there smoking paraphernalia upon signing out and collects the lighters upon their return. When queried about Resident #704 being observed by staff smoking inside the facility Administrator A reported she was aware and had provided education about needing to leave facility grounds to smoke and had staff periodically check his room for cigarettes and lighters. When asked if this plan was effective Administrator A agreed it was not. When queried what the plan was to protect Resident #704 and the other residents that reside in the facility, Administrator A stated I might have to involuntary discharge him. A copy of any incident and accident reports related to smoking and Resident #704 were requested, none were received. The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 6/14/17: Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The abatement is prepared and/or executed in accordance with federal and state law requirements. Resident #704 is currently not in the facility, he discharged [DATE] and will be re-assessed for smoking safety and sign the smoking policy and acknowledge the guidelines upon his return. To remain in the facility, Resident #704 will agree to turn over all smoking items (cigarettes, lighters etc.) to facility staff as soon as he returns to the facility or he will be discharged . The smoking policy is This facility is a non-smoking facility, resident must sign out on leave of a absence, leave the grounds and upon return the resident must turn in all smoking materials to the receptionist If at any time the resident does not follow the policy, the resident will be discharged . If at any time the facility believes that a resident has not followed the smoking contract, the Administrator or designee will complete a room and personal belongings search for smoking paraphernalia. Admissions on or after 6/14/2017 who chose to smoke, will be assessed for safe smoking practices and be presented the smoking agreement. On 6/14/17 other like residents who smoke have been re-assessed by their unit manager or designee for smoking safety and have been re-educated on and acknowledged the smoking agreement. These like residents will continue to leave the facility grounds while smoking and agree to turn over all smoking materials to facility staff upon return. Residents residing on the same unit as resident #704 were queried for any concerns by the social services department, none were noted on May 30, 2017. Residents who reside on the same unit as resident #704 with any type of respiratory [DIAGNOSES REDACTED]. The Administrator/designee will monitor residents that smoke while on LOA to ensure smoking materials have been turned over to the facility staff upon return and that these residents leave the facility grounds while smoking. On 6/14/17 Staff re-education on the resident smoking agreement and the above actions has been completed by the Staff Development Coordinator or designee; any staff not in serviced will receive the education prior to returning to work. The medical director was made aware of the plan to remove immediate jeopardy on 6/14/17 and agreed with the plan at 2:00 PM. Deficient Practice #2: This citation pertains to MI 001: Based on interview and record review the facility failed to ensure that one (#702) resident with a history of falls of 2 residents reviewed for falls from a total of eight residents was appropriately monitored based on assessed needs, resulting in a fall with a hematoma and bleeding to the forehead. Findings include: On 6/14/17 at 4:30pm the clinical record for Resident #702 was reviewed and revealed the resident had been admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed that the resident had severely impaired vision, sometimes was able to make herself understood, and sometimes was able to understand others. Per this MDS assessment, the resident scored 03/15 on a brief interview for mental status exam, which indicated that the resident was severely cognitively impaired. On 6/14/17 at 4:45pm, an Incident and Accident (I/A) report and Fall Investigation Report for Resident #702 for 5/7/17 was reviewed and revealed, in part, the following: Per an I/A report dated 5/7/17 at 8:35pm, Resident #702 had an observed fall in the TV (television) room. The Brief Description section of the I/A report documented, Resident fell to the floor from her wheelchair. She hit her forehead to the floor. 0 (no) injury. 0 Swelling. neurocheck in progress. Per this report, action taken included resident and staff education. Review of a Fall Investigation Report dated 5/7/17 pertaining to the resident's fall documented, Resident was trying to get up from her wheelchair. She fell to the floor. 0 injury. 0 swelling (she hit her forehead to the floor) neurocheck in progress. Per the section of the form which documented intervention to prevent future falls, the following was documented: Staff will continue to monitor resident to prevent future falls. On 6/15/17 at 4:36pm a Fall Risk Evaluation for May 30, 2017 for Resident #702 was reviewed and revealed that Resident #702 had highly or severely impaired vision, was not steady (related to balance), and was only able to stabilize with staff assistance. On 6/14/17 at 4:50pm, an I/A and Fall Investigation Report dated 6/4/17 for Resident #702 was reviewed and revealed, in part, the following: Per an I/A report dated 6/4/17 a 6:00pm, Resident #702 had an unobserved fall in the TV room. The Brief Description section of the I/A report documented, Resident was found on the floor. She was bleeding from her forehead. she had a hematoma on her forehead. 911 was called. she was taken to the hospital. Per the Injury Type section of the report, a box was checked which indicated the resident had a hematoma/bruise. Per the Treatment section of the report, an assessment was marked as having occurred. Per the I/A report Resident #702 had received Quetipine Fumarate (an antipsychotic medication) in the last 12 hours prior to the fall. Review of the Fall Investigation Report for Resident #702's fall on 6/4/17 documented that Resident #702 had slipped out of the wheelchair and was found face down. Per this report, the location of the resident's fall was the TV room. Per Question 7 of the report, What did the resident say they were trying to do just before they fell ? the following was documented: Resident was sitting on her wheelchair. Per Question 12 of the report, Did vision or hearing contribute to the fall? it was noted that a checkbox which indicated Yes was marked. An explanation to this question stated, Resident is blind. It was also documented that Resident #702 had received antipsychotic medication in the last 8 hours prior to the resident's fall. Per documentation of the initial root cause of the resident's fall was the following: Resident was found on the floor. She was bleeding from her forehead. She had a hematoma. 911 was called. Resident was transferred to (name of hospital). Per the section of the form which documented intervention to prevent future falls, the following was documented: 1.) PT (physical therapy) to screen for possible modification to w/c (wheelchair). On 6/15/17 at approximately 8:00am review of documentation of a follow-up visit for Resident #702 completed by the facility's psychiatric provider documented, in part, that Resident #702 was alert, oriented to person only, had impaired judgment, impaired insight, impaired impulse control, disorganized thinking, mild flight of ideas, and memory which appeared impaired. Per the Assessment & Plan section of the report the following was documented: .Plan: Profoundly confused at baseline. Her confusion is compounded by her visual limitations. Continue to use calm and gentle approach. On 6/15/17 at 10:32am Nurse 'J', who had completed the I/A reports for Resident #702 on 5/7/17 and 6/4/17, was queried in regards to Resident #702. Nurse 'J' stated that Resident #702 was always moving and bumping into things. On 6/15/17 at 10:30am care plans for Resident #702 were reviewed. Per a careplan initiated 5/30/17 the following was documented: The resident is at High risk for falls r/t (related to) Balance deficits, Confusion, History of falls, patient is blind, with poor safety awareness. Interventions per this plan of care included the following: *Anticipate and meet the resident's needs (initiated 5/8/17) *Determine causative factors of fall and resolve or minimize (initiated 5/8/17) *PT screen for possible modifications to w/c (initiated 6/6/17) *PT to treat 3x(three times per)/week x (times) 4 wee for theraputic exercises. Balance Training (initiated 6/6/17) *Staff will offer frequent orientation to time and place and situation. Resident is blind and offering a calm and clear voice may decrease her anxiety (initiated 5/8/17) *Therapy to assess resident for proper positioning in wheelchair/balance (initiated 6/5/17) Per a careplan dated 1/10/17 the following was documented: The resident has impaired cognition r/t her dx (diagnosis) of Dementia. Interventions per this plan of care included, in part, the following: *Cue, reorient and supervise as needed (initiated 1/10/17) On 6/15/17 review of a late entry physician assistant/nurse practitioner progress note dated 5/31/17 documented, in part, the following: She (Resident #702) is wheelchair bound and requires supervision and assistance with ADLs (activities of daily living) due to advancing dementia. On 6/15/17 at 8:31am and 12:40pm the Director of Nursing (DON) was queried in regards to Resident #702. Per the DON Resident #702 had moments of anxiety, and was kept in a supervised place unless the resident was ready to lay down. Per the DON Resident #702 was to be kept in a well-traveled area, where staff were able to keep an eye on her. When queried about Resident #702's cognitive ability the DON responded that the resident's cognition fluctuated throughout the day. Per the DON Resident #702 was able to tell other people who she was, and said that some days the resident's cognition would fluctuate related to anxiety and psychosis. When queried as to when the resident was last seen prior to the resident's fall on 6/4/17, the DON did not provide an answer. On 6/15/17 at 1:00pm review of a facility policy titled Falls-Clinical Protocol dated April 2016 revealed, in part, the following: 4. Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include; a. Resident's abilities and deficits b. Balance (sitting/standing) c. Adaptive equipment needs d. Proper use of mechanical lifts and transfer devices, shower beds, shower chairs, bathroom safety

This Citation Pertains To MI 018 Based on interview and record review the facility failed to prevent verbal and physical abuse by a family member for one (#703) of two Residents reviewed for abuse from a total sample of eight. Resulting in bilateral swollen red and purple eyes and mental distress. Findings include: On 6-14-2017 at 8:45 am a review of Resident #703's clinical record was reviewed and revealed she was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] reflected a brief interview status of 14 (cognitively intact) further review of the MDS reflected Resident #703 required assistance from staff for transfers, eating, dressing and she had limited range of motion in both upper and lower extremities. Nurses notes dated 5/30/2017 reflected Resident #703 was readmitted to the facility at 11:00 am escorted by three granddaughters. Instruct PM charge nurse to do skin assessment etc put all meds (sic) referred from PH in order entry. Nurses notes authored by RN K dated 5/30/2017 01:24 (late entry) read in part .3g/daughters (sic)were here and loud upon arrival . .the younger G/Dghter (sic) was loud and verbally abusive to staff and G/Mom (sic) as well, . Nurses notes dated 5-31-2017 02:48 read in part, Resident's granddaughter became upset and started yelling, screaming, cursing and hitting resident in her room. Family was escorted out of facility and resident began to calm down. Resident was sitting in her room crying and stating that she wanted to go to sleep. A review of the facility's investigation dated 5-31-2017 revealed Staff heard noise, when approached room, staff observed granddaughter on top of grandmother. Granddaughter was removed. Police notified-granddaughter escorted from center. The undated incident report reflected swelling and redness to both eyes. The undated facility summary reflected Resident #703's physician was made aware and and that Adult Protective Services were notified of the incident. A review of the witness statement authored by Licensed Practical Nurse (LPN) G reflected in part, staff nearby heard loud noises, about six staff staff members ran down and I seen granddaughter on top of her grandmother fighting with her (residents name) was screaming call the police. One female granddaughter pulled the girl off her . The three girls started yelling and moving quickly toward staff. While clenching her fist .I called the Administrator and the Police who were already called by other staff member .did a skin assessment has 2 swollen red/purple eyes related to being hit by granddaughter possibly. On 6-14-2017 at 10:00 am during an interview with Social Worker I she reported that Resident #703 was on her case load and the resident had been discharged home alone on 06-01-2017. When queried about verbal and physical abuse observed by LPN G Social Worker I stated she was only aware that the family members were loud but had no knowledge of any verbal or physical abuse. On 6-15-2017 at 9:45 am during an interview with the Director of Nursing she reported being on vacation during the time of the incident and that the resident had been discharged and had no real knowledge regarding the situation. On 6-15-2017 at 10:00 am during an interview with Administrator A she reported she was the facility's abuse prohibition coordinator and she conducted the investigation related to Resident#703. When queried why the investigation contained one statement when six staff persons witnessed the incident she stated it was not necessary because LPN G verified the occurrence and she felt it was sufficient. When queried if she had met or spoken to the family in order prevent further occurrences of abuse or implement supervised visits she replied she had not. Documentation from the clinical record was requested that the attending physician had been notified of the abuse was requested but not received. An attempt to interview LPN G and RN K were made via telephone on 6-15-2017 and 6-16-2017 messages left requesting a return call were made but not received. On 06-15-2017 at 12:08 PM during a telephone interview Resident #703's attending Physician N he reported that the facility had not notified him regarding any form of abuse related to Resident #703. According to the facility policy titled Reporting Abuse to Facility Management dated 3-20-2017 1. Abuse- The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental abuse including abuse facilitated or enabled by technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the the individual must have intended to inflict injury. According to the facility's Abuse and Neglect - Clinical Protocol with a revision date of 9-20-2012 2. The nurse will report findings to the physician According to the facility policy titled Abuse Investigations dated October 2012 under the heading Policy Statement 2. read in part, The individual conducting the investigation will, as a minimum: . c. Interview any witness to the incident; d. interview the resident (as medically appropriate); e. Interview the resident's Attending physician as needed to determine the resident's current level of cognitive function and medical condition; f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the resident's roommate, family members, and visitors; .i. Review all events leading up to the alleged incident. 4. Witnesses will be required to sign and date any witness report they make. 5. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator.

This citation pertains to intake #MI 811 Based on interview and record review, the Facility failed to fully investigate and report an allegation of sexual abuse to the State Agency for two incompetent Residents (#905 and #906) out of five residents reviewed for abuse, out of a total sample of six, resulting in the potential for undetected and under-reported abuse. Findings include: On 5/28/17 a complaint was filed with the State alleging possible sexual abuse and failure to supervise a Resident. On 6/1/17 at a phone interview was conducted with the Resident's legal guardian. The Complainant/legal guardian stated that she had been notified by the Facility that Resident #905 was found in another Residents room with her pants down and a male Resident (#906) was behind her with his genitals exposed. The legal guardian stated that she was asked to fax a consent form to the Facility so that a rape kit could be performed. The legal guardian stated, I was and still am very upset by everything that went on. I was told that it could take one to two years to get the results of the rape kit. The Administrator never contacted me and I was never given any information regarding the police investigation. My mom is very confused and is not able to communicate what happened. On 6/1/17 at p.m., Resident #905 was observed in her room with a 1:1 aide at her bedside. Resident #905 was unable to answer any questions asked. On 6/1/17 at 1:30 p.m., a review of Resident #905's clinical record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #905's most recent Minimum Data Set (MDS) assessment completed 3/22/17 documented the Resident was severely cognitively impaired and was able to ambulate without assistance. Further review of the Resident's clinical record revealed a Risk of Elopement assessment dated [DATE] that documented: Resident is at risk for elopement/wandering at this time. Resident wanders continuously without direction. A nursing progress note authored by Nurse N documented the following At approximately 6:00 p.m. notified by CNA (certified nursing assistant) that male resident's penis was exposed when Resident #905 was in room. Notified MD about CNA's statement. Order: send resident to hospital for evaluation for inappropriate sexual behavior. Resident #906 On 6/1/17 at 2:25 PM, an interview was conducted with Resident #906. Resident # 906 was awake, dressed and walking in his room. Resident #906 appeared confused and when queried regarding incident of 5/27/17 with Resident #905, Resident #906 stated: I thought that I needed a lawyer. When queried further, Resident #906 stated: I'm years old. I was hoping to get help with social security. Resident #906 then pulled a blank piece of paper from his pocket and pointed at it. Resident #906 began to mumble they trying to make it seem like I did something. When Resident #906 was asked to explain comment, the resident mumbled and was incomprehensible. A review of Resident #906's clinical record had been conducted and revealed, Resident #906 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #906's quarterly minimum data set (MDS) assessment dated [DATE] documented that the resident had a 3 out of 15 BIMS (brief interview of mental status) score which indicated severely impaired cognitively. Resident #906 required minimal one person assistance from staff for all activities of daily living. A review of the nurses' note dated 5/27/17 was conducted on 6/1/17 at 2:40 PM. The nurses' note documented: Resident reported by CNA (certified nursing assistant) 'C' and laundry staff 'H' that Mr. (NAME REDACTED) #906 was in his room with a female resident standing with her pants and brief down. Mr. (NAME REDACTED) #906 had his zipper down according to the witnesses. An interview was conducted with CNA 'C' on 6/1/17 at 2:50 PM. When queried regarding incident that occurred between Resident #906 and Resident #905 on 5/27/17, CNA 'C' stated: Resident's pants were unzipped and female resident's pants were up. He (referring to Resident #906) was pulling on her pants like he was trying to fix them. I heard someone call out (referring to Laundry staff 'H') and I went to the room. An interview was conducted with Laundry staff 'H' on 6/1/17 at 3:13 PM. When queried regarding incident that occurred between Resident #906 and Resident #905 on 5/27/17, Laundry staff 'H' stated: I was delivering clothing and noticed female in resident's room (referring to Resident #906's room). Her clothing and diaper was down. He did pull up her pants and when he turned around, he said I didn't do nothing. His pants were unzipped. I did not see her when she entered his room. An interview was conducted with Social Worker 'A' on 6/2/17 at 12:12 PM. When queried regarding the incident that occurred with Resident #906 and #905, Social Worker 'A' indicated that she interviewed Resident #906 on 5/30/17. Social Worker 'A' stated: He was very confused and for the most part discussed blood sugars and was mumbling incomplete sentences. Social Worker 'A' stated: He was fixated on social security and waxing the floor. Social Worker 'A' explained that the facility was not aware of any history of this behavior from Resident #906 in the past. On 6/1/17 at 2:00 p.m. a request for an Incident and Accident report pertaining to the incident was requested. The Facility was not able to provide an I & A report. On 6/01/17 at 3:15 pm, an interview with the Facility's Administrator was conducted. The Administrator was asked why not I & A was completed. The Administrator stated that a full form investigation was not completed, but noted that she had notes pertaining to the incident. An undated/unsigned one page document with notes was provided. When queried as to whether any witness statements were obtained the Administrator stated that she did not have any. When queried as to why the incident was not reported to the State Agency, the Administrator stated, We thought the incident involved Residents who were exposing themselves. We did not consider exposure a form of sexual abuse that needs to be reported. When asked about CNA C's comment that she had witnessed Resident #906 with his zipper down and penis exposed standing behind Resident #905 who's pants were down. The Administer stated, Again, we had no reason to believe anything had happened. When further queried as to why the Facility felt a rape kit should be done. The Administrator stated, We just wanted to rule out that the Resident was not raped. But, we determined on our own that we had enough evidence to believe she was not raped. The Administrator was asked to confirm that she was notified that the results of the rape kit would not be available for one to two years, the Administrator stated, That is what we were told. On 6/02/17 at 4:15 pm, a review of the Facility's policy titled, Abuse Prevention Program (revised October 2012) documented, in part, the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary Sexual Abuse:non-consensual sexual contact of any type with a resident. 5. When an alleged or suspected case of .abuse is reported, the facility Administrator, DON, or individuals designated will immediately .notify the following persons or agencies of such incident as indicated by State or Federal Licensure Policy. 1. The State licensing/certification agency responsible for survey/licensing the facility

This citation refers for Intake #MI 387. Based on observation, interview, and record review, the facility failed to ensure one (#902) of four residents reviewed for abuse, from a total sample of five, was free from possible verbal abuse and physical abuse and free from intimidation from staff, resulting in hesitation to talk about the concerns, emotional distress, expression of fear, and a request to move from the nursing facility. Findings include: On 5/11/17 at 8:00 A.M., the intake information was reviewed and revealed on 5/3/17, the facility reported an allegation to the State Agency. It was reported that Resident #902's mother alleged some concerns to our Therapy Program Manager (TPM R) .She refused to give any information on the allegation, whether it was verbal or sexual. TPM R reported the allegation to the Administrator .(The Administrator) called (Resident #902's mother) and (Resident #902's mother) refused to discuss anything with her either. (The Administrator) went to interview Resident #902, who said that her mother told her not to talk to anyone in the facility regarding her concerns . On 5/11/17 at 10:15 A.M., Resident #902 was observed seated in a wheelchair in her room. When asked how things were going at the nursing facility, Resident #902 stated, I have had problems. When asked to explain, Resident #902 stated, I don't want to talk about it. I already talked to the police and the social worker. I don't want to answer any more questions. On 5/11/17 at 8:00 A.M., Resident #902's clinical record was reviewed and revealed the following: Resident #902 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #902 had intact cognition and required extensive physical assistance from one staff member for bed mobility and toilet use, and assistance from two staff members for transfers. Progress notes from May 2017 were reviewed and revealed the following: A Social Services Progress Note dated 5/3/17 at 5:30 P.M. written by the Social Services Director (SW K) documented, Writer met with resident briefly during the PM hours regarding the allegation made. Writer inquired how resident was doing and resident states she is just hanging in there .Writer asked more specifically if resident could inform writer about an allegation that her mother expressed to another staff member. Resident states that she has been informed not to discuss anything with any staff member present at this time . A social services note dated 5/4/17 at 5:34 P.M. written by SW K documented, .Resident inquired about possible allegation and resident states that she did not wish to discuss at this time .Writer asked resident how long has she been going through what she is going through and resident responded about a week. Writer asked resident i(f) she still felt safe in facility and resident stated in general I do not which is why my mother is looking for somewhere for me to transfer to . A behavioral health consultation dated 5/4/17 documented, .seen at bedside today for a supportive session as requested by social services. Per report, unspecified allegations of abuse were made by pt and her mother whom is her legal guardian. I am being asked to assess her mood state today .She is visibly tense and states 'something happened' but is unwilling to be specific with writer. She stated 'I will tell you when I am out of here' . A social services note dated 5/8/17 at 5:50 P.M. written by SW K documented, .With much encouragement from writer and daughter resident provided information regarding allegation expressed last week. Administrator, DON (Director of Nursing), and ADON (Assistant Director of Nursing) all notified and investigation in progress. Resident was visibly upset while speaking with writer . A Psychology progress noted dated 5/8/17 at 6:37 P.M. written by Psychologist X documented, Met with pt (patient) regarding her feelings of anxiety. Pt related her allegation of what had happened to her as she was being transferred by a female and a male aide. Pt alleged that the male aide made a sexually inappropriate gesture, taking a hold of a breast and then twisting it. She called out but the aide did not apparently say anything. The next day the same pair were to work with her, when he was in her room, she said she didn't want him in the room. She related he said I guess my hand went somewhere where it shouldn't have. She related she heard them talking inappropriately about sex, and also giving a veiled threat if someone were to get them fired. Pt felt conflicted about what to do she related. She stated her adult daughter encouraged her to speak up. Pt feels relieved that she did speak up. She feels some anxiety about possible retaliation however she feels safe now that the administrator and police know .She feels she has spoke up for those who cannot, who may have been possibly 'bullied' themselves by these two . On 5/12/17 at 11:30 A.M., Resident #902 was observed seated in a wheelchair in her room. After knocking on the door, Resident #902 requested that the surveyor did not enter the room. Through the doorway, Resident #902 stated, You have to talk to the police and the director if you want to know anything. I'm not answering anymore questions. I'm not going to talk anymore! The facility's investigation was reviewed and revealed the following: A signed statement from Therapy Program Manager (TPM) R dated 5/4/17 documented, .Resident mother stated that her daughter (Resident #902) was not safe at the facility and she wanted her moved .Mother claimed daughter was abused by male staff during ADL (activities of daily living) care, 'diaper change'. Also stating other staff knew and were making threatening claims from afar .Mother stated, 'I will not tell you' what happened and the details '(until) my daughter is out of there.' Resident mother states she was worried for her daughter's safety due to retaliation . A signed statement from SW K dated 5/8/17 documented, .During the conversation resident stated she has been going through a lot at the facility and is not happy nor (does) she feel safe today. Writer inquired why resident was experiencing these feelings; resident initially was apprehensive stating she will tell everything once she is discharged .With much encouragement resident states about 2 and a half weeks ago or so during a transfer she had a male and female caregiver present. Per resident the female caregiver (Certified Nursing Assistant - CNA Q) had her lower legs and the male caregiver (CNA J) had her upper body holding her under her arms to transfer her when the male caregiver got mad and grabbed her right breast and twisted it. Per resident the female caregiver never acknowledged her after she screamed out in pain nor responded to the unkind act of the male caregiver. Per resident she felt that the female caregiver should have (stood) up for her instead she acted like she did not see or know what occurred. Resident then states that the very next day there was two staff members standing right outside of her door saying vulgar things. Writer inquired what was the conversation that she overheard, per resident the male caregiver (CNA J) and female caregiver (CNA I) (were) speaking about sexual favors that they offer and how much those services cost .she felt uncomfortable with the conversation. Resident went on to say that she (does) not prefer male caregivers except for (another male CNA) and everyone knows this including CNA I. After said incident she had CNA I as her care giver and she needed assistance with transferring resident and she informed CNA I that she did not want the male staff on duty (CNA J) to assist with the transfer and if she could get a female. Per resident, CNA I ignored her request and got CNA J to assist her anyway. Per resident she felt uncomfortable with the interaction and then CNA I told her that 'people kill people if they lose their jobs. Per resident she believes CNA I intentionally got CNA J to assist her just to spite her. Resident also states she is fearful of both (CNA J and CNA I) and believe that they will try to kill her. She became visibly upset stating she wants to get out of here ASAP . A signed statement from CNA I dated 5/8/17 documented that CNA I had CNA J assist with transferring Resident #902 on 4/29/17. Resident #902 asked if there was anyone else to assist, but CNA Q was assisting with another resident. CNA I denied any inappropriate conversation where the resident could hear. It was documented that, Per CNA I resident may have overheard a conversation between staff members while in the hallway about what was on the news about all the recent killing. Per CENA, her mother called to the facility reporting that staff was saying staff was trying to kill her . A signed statement from CNA J dated 5/8/17 documented that the last time he worked with Resident #901 was over a month ago and denied assisting in the last two to three weeks. .CENA states at times when staff walks past resident will state 'You'll are trying to kill me' approximately 2 weeks ago . CNA I's personnel file was reviewed on 5/12/17 at 11:45 A.M. and it revealed multiple disciplinary action forms dating back to 2009 related to being insubordinate, impeding an investigation, talking on her cell phone in residents' rooms, and arguing with staff. CNA I refused to sign all of the documents. The Administrator (Abuse Coordinator) was interviewed on 5/12/17 at 12:00 P.M. and was asked what was done to protect Resident #902 from retaliation. The Administrator reported that CNA Q, CNA I, and CNA J were all suspended pending the investigation. CNA Q was brought back to work on 5/9/17 and CNA I and CNA J were still suspended. The Administrator stated, I did not substantiate any abuse. When queried about why CNA I and CNA J were still suspended if the investigation was completed and no abuse was substantiated, the Administrator reported that abuse was not substantiated, but they were suspended for the allegations of talking outside Resident #902's door. The Administrator was queried about why the information documented on the investigation summary was not the same as what SW K documented in her signed statement of the allegations reported by Resident #902 on 5/8/17 (The original statement given to SW K noted that CNA I said People kill people if they lose their jobs directly to Resident #902. However, the investigation summary noted staff speaking outside of the room.) The Administrator stated, Once I did the investigation we found out she overheard them talking outside of the room, not directly to her. They were talking about something on the TV, not threatening her. When asked about Resident #902's cognitive status, the Administrator reported she sometimes had paranoia, but could make her needs known. When queried about how it was determined that Resident #902's original statement was not substantiated, the Administrator stated, It was my conclusion after reviewing everything. She initially would not talk and said, 'My mom advised me not to say anything.' The Administrator was asked why someone might not want to report anything and did not offer a response. TPM R was interviewed on 5/12/17 at 12:40 P.M. TPM R reported that during a telephone conversation with Resident #902's mother regarding physical therapy, Resident #902's mother reported some concerns. TPM R stated, Her mom said she was concerned for Resident #902's safety and had a concern for care, staff were saying inappropriate, sexual things. I asked who it was and she did not want to tell me and said she wanted to wait until Resident #902 was out of the facility. I was very concerned . The facility's policy titled Abuse Prevention Program dated 11/28/16 was reviewed on 5/12/17 at 1:00 P.M. and it documented the following: Our resident have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion (collectively, hereinafter abuse) . .Abuse is the willful influction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .

This citation refers to Intake #MI 130. Based on interview and record review, the facility failed to ensure interventions were in place to ensure the safety of one (#901) of three residents reviewed for falls who was displaying repeated episodes of agitation, attempting to transfer without assistance, and attempts to decannulate his trachestomy tube and actual removal of PEG tube from a total sample of four, resulting in the resident being found on the floor unconscious with a head laceration and without vital signs. Findings include: On [DATE] at 11:50 A.M., Resident #901's clinical record was reviewed and revealed the following: Resident #901 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Nurse's Note dated [DATE] at 8:14 P.M. written by Nurse P documented, Resident was admitted from (local hospital) today and was very agitated, continuing pulling on his tracheostomy and PEG tube. He was placed on 1 to 1 holding his hand, then DON (Director of Nursing) and (Physician) were notified by phone and ordered to sen(d) him back to hospital . A Nurse's Note dated [DATE] at 11:09 P.M. written by Nurse O documented, Late entry: Resident was readmitted at 3:40 P.M Made comfortable in bed, alert but non verbal but able to communicate by writing .@ 9:00 P.M. assigned care giver informed the nurse (unknown abbreviation) that resident pull(ed) out the PEG tube feeding, same was replaced .made comfortable in bed, call light within reach and bed in lowest position. At 9:40 P.M., caregiver noted the resident on the floor in fetal position (at) the right side with laceration on the right side of the frontal head, non responsive, resident was put back to bed, CPR (cardio pulmonary resuscitation) was initiated, 911 was called and came in at 9:55 P.M. Resident was pronounced dead by the team at 10:07 P.M. by (doctor from hospital), Southfield police in attendance .the physician was informed, corpse still in the unit awaiting the Southfield police to make transfer to funeral home . An ED (Emergency Department) Note dated [DATE] (from the local hospital) documented, .sent from (facility name) with scant information provided. Per RN (registered nurse), (facility) reported he sometimes pulls at his trach and PEG tubes. They are worried they cannot provide a level of care adequate for him. (Facility) provides inadequate information with no history. Attempted to contact, however staff unable to provide information . On [DATE] at 1:10 P.M., Nurse O was interviewed about Resident #901 on [DATE]. Nurse O stated, He came back from the hospital. The CNA (certified nursing assistant) went in the room and his tube (PEG) was out and it was reinserted by me with another nurse. He was restless. Then I was on lunch and when I came back an aide said she found him on the floor and called another nurse from another floor. He was on the floor with a laceration and put him back to bed and a code was called because he was unresponsive. On [DATE] at 1:27 P.M., Nurse P was interviewed about Resident #901's transfer to the hospital on [DATE]. Nurse P stated, He was just transferred to the facility from the hospital. He was pulling at his trach and PEG tube. I called the DON and the physician and the doctor ordered for him to be sent back to the hospital. I had him on 1 to 1 and was holding his hands, but he was a strong man and was so agitated. After the doctor said to send him to hospital, I had an aide sit with him while I called the ambulance. Nurse P was queried about the facility's process for transferring residents to the hospital. Nurse P stated, I can't remember what I did. When queried about whether or not a transfer form was completed, Nurse P stated, I don't remember. When queried about whether or not report was given to the hospital, Nurse P stated, I don't remember what I did. Nurse P was asked about the hospital documentation that noted the facility reported they could not provide a level of care adequate for Resident #901. Nurse P said, That's not true. On [DATE] at 2:27 P.M., the DON was interviewed about the facility's process for transferring residents to the hospital. The DON stated, If staff notice a change, they notify the physician, and call me if they can't get a hold of the physician, let family and resident know. If it's an emergency 911 is called. If not, they would call the ambulance to transfer and monitor the resident until they arrived. When queried about whether or not a transfer sheet would be completed, the DON stated, A transfer sheet would go to the hospital with the resident and the nurses also sometimes call the ER to give report. The DON was asked to provide the transfer sheet from Resident #901's hospital transfer on [DATE]. The DON was queried about the facility's process for implementing fall interventions for residents when they are first admitted into the facility. The DON stated, We try to ask family and review the hospital records to see if there is a history of falls. If there was no family, we would have to rely on the hospital records. Everyone goes on a tentative fall risk until they can be assessed. On [DATE] at 3:15 P.M., the DON reported that there was no transfer sheet from Resident #901's transfer to the hospital on [DATE]. When queried about the information documented in the ED hospital records that noted, They are worried they cannot provide a level of care adequate for him and who the hospital received that information from, the DON stated, That would have been from the nurse who gave report to the ED. The DON was asked why the facility accepted Resident #901 back into the facility on [DATE] if they felt they were unable to provide adequate care. The DON reported she would find out. At 4:30 P.M., the DON reported that she spoke with the Administrator (who was not in the building at that time) and the Administrator reported that they accepted Resident #901 back into the facility because the hospital was able to manage him so we thought we could take him back. On [DATE] at 3:22 P.M., CNA Y was interviewed about Resident #901 on [DATE]. CNA Y stated, He was always getting up so we were monitoring him. He was fooling with his trach and stuff. When I went to check on him his PEG was out. I told the nurse and the nurse put it back in. She told me she was finished and I went back in to check on him and he was laying in bed, sleeping. I went back in and found him on the floor. I looked in the bed and didn't see him and saw him on the floor. I ran to the door and yelled for another aide to get a nurse. His nurse was on break. The nurse from the other floor came and called for help. We got him up into bed. On [DATE] at 9:20 A.M., Nurse N was interviewed via the telephone about Resident #901 on [DATE]. Nurse N stated, He was a new admission that day, just came back from the hospital. He had a PEG tube, kept getting up and trying to walk. A 1:1 would have worked well for him. On [DATE] at 12:45 P.M., Resident #901's clinical record was further reviewed and revealed the following: A History & Physical (H&P) from the hospital dated [DATE] documented, .presented to (hospital) on [DATE] for a chief complaint of agitation .fall in November with cervical spinal cord compression s/p (status [REDACTED].Since admission .was confused and trying to climb out of bed during the night .cervical collar in place .spinous process fx (spine fracture) . The facility's policy titled Falls - Clinical Protocol was reviewed and documented, As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falls .Interventions should be developed and implemented per the assessed needs .

Deficient Practice #1 This citation pertains to intake #MI 685 Based on interview and record review, the facility failed to address a change in condition and transfer one resident (Resident #704) to the emergency room in a timely manner, out of two residents reviewed for change in condition, out of a total sample of nine residents, resulting in the resident becoming unresponsive and requiring a 911 call and transfer to the hospital for emergency treatment. Findings include: On 3/29/17 at 11:30 am, a review of Resident #704's closed clinical record was conducted. During the review of the record it was discovered that Resident #704 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #704's Minimum Data Set assessment dated [DATE] indicated severely impaired cognition and extensive to total assistance of one to two staff members for all activities of daily living. A review of Resident #704's orders revealed an order placed for routine blood work on 1/18/17. A review of the results of the blood work was conducted at that time and indicated that the specimen was collected on 1/20/17 at 3:45 am, was received by the laboratory on 1/20/17 at 10:38 am, and was reported back to the facility on [DATE] at 12:42 pm. The results also indicated the resident had a sodium level greater than 165 (normal value 135-146, clinical manifestations of elevated sodium levels can include: lethargy, weakness, [MEDICAL CONDITIONS], coma, and death). It was noted the lab report contained un-dated initials from the physician. Continued review of Resident #704's progress notes was conducted and revealed a nursing note on 1/21/17 with an effective time of 7:30 pm, that read, .Res. (resident) received very lethargic .not responding. Writer transferred resident to (Hospital Name) . It was noted the resident was transferred to the hospital more than twenty-four hours after the results of the critical sodium level were reported to the facility. On 3/29/17 at 3:45 pm, an interview with Dr. 'J' was conducted. Dr. 'J' was asked about the critically high level of sodium and denied knowledge of the resident's high level on 1/20/17. When asked what should have been done about the level, Dr. 'J' replied, She should have been sent out immediately, I would have called 911 too if I had seen that level. When asked about the intials on the laboratory report, Dr. 'J' indicated that a physician has to initial every lab report, and responded with I think we could do better with that, when queried why the initials were not dated when the report was reviewed. She continued to explain that she could have initialed the report after the resident was discharged as she did not visit the facility daily. On 3/30/17 at 10:00 am, a conversation with the facility's Director of Nursing (DON) was conducted regarding the delay between the time the lab values were received and the time the resident was transferred to the emergency room . The DON indicated the Resident should have been transferred out at first knowledge of the laboratory value. On 3/30/17 at 11:30 am, a review of the facility's policy titled, Laboratory Diagnostic Tracking Guidelines dated 9/2014 read, .9. The facility should have a system to monitor lab/diagnostic test daily .to determine if tests were completed, results received as expected, reporting and follow up was completed . The facility was asked if they had any additional information to provide regarding Resident #704, none was received by the end of the survey. Deficient Practice #2 This citation pertains to MI 875 Based on observation, interview and record review, the facility failed to appropriately remove a [MEDICATION NAME] (pain) patch for one resident (#701) out of one resident reviewed for resident's desire of removal for pain patch from a total of nine sampled residents, resulting in pain and lack of confidence in nursing staff to remove pain patch. Findings Include: On 3/29/17 at 11:40 a.m., Resident #701 was observed sitting in a wheelchair with oxygen infusing from a nasal cannula connected to an oxygen concentrator. Resident #701 was observed with a [MEDICATION NAME] on the left chest/shoulder area that was dated 3/27/17. When asked about the incident that occurred on 1/26/17, Resident #701 stated, It (pain patch) is exactly where it was when the incident happened. The nurse (Licensed Practical Nurse - LPN) 'N' was with Certified Nurse Assistant (CNA) 'O'. There was a piece of tape over the patch because sometimes they (pain patch) come off. When he (LPN 'N') snatched the patch off, his arm went way back. He (LPN 'N') ripped it off, quick, not like anyone else. CNA 'O' said, 'I didn't know that he was going to do that, and she asked me if I was alright. Just thinking about it, makes me want to cry . A review of the clinical record revealed Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #701 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated she was cognitively intact for decision-making. A review of the facility's MAR (Medication Administration Record) for January 2017 revealed a physician's orders [REDACTED]. Further review of the MAR indicated [REDACTED] 01/11/17 - Removed 0628 (6:28 am), Applied 0629 (6:29 am) 01/17/17 - Removed 0709 (7:09 am), Applied 0708 (7:08 am) 01/20/17 - Removed 0535 (5:35 am), Applied 0536 (5:36 am) 01/26/17 - Removed 0558 (5:58 am), Applied 0558 (5:58 am) On 3/29/17 at 2:30 p.m., a review of the facility's investigation report revealed the following interviews between the Director of Nursing (DON) and staff: CNA 'O' on 1/31/17 via telephone - When asked about the incident pertaining to Resident #701 and LPN 'N', CNA 'O' stated, I believe you are talking about the nurse 'snatching' the patch off of (resident's name). I was in the room when the nurse removed the pain patch. The best way I can describe the incident is when you have a wax and they pull off the tape . He (LPN 'N') blamed 'the cheap tape'. I believe the nurse should know better, that it would hurt. I don't think the incident was intentional. LPN 'N' on 2/1/17 via telephone - Regarding removal of a dressing/pain patch with tape, verbalized understanding that he should attempt to lift the edges of the dressing/pain patch to loosen and remove as gently as possible On 3/29/17 at 4:55 p.m., a call was placed to CNA O' and a message was left on the voicemail. On 3/29/17 at 4:56 p.m., a call was placed to LPN 'N' and a message was left on the voicemail. On 3/30/17 at 9:30 a.m., CNA 'O' returned the call. During the telephone interview, when queried about the removal of Resident #701's [MEDICATION NAME] on 1/26/17, CNA 'O' stated, .It was like he (LPN 'N') snatched it (pain patch) off, versus peeling it off. (Resident's name) looked at him, and he said 'I'm sorry if it hurt, but it's better to snatch it off versus peeling it off . (Resident's name) said, 'from now on, I don't need you to take it (pain patch) off' . CNA 'O' further stated, Resident #701 looked pissed. On 3/30/17 at 10:07 a.m., an interview was conducted with the DON. When queried about the procedure for removing a [MEDICATION NAME], the DON stated, I would start on one end to try to peel to get off, causing as little discomfort as I can. If you can't get it, you could go get another nurse. A review of the facility's policy titled [MEDICATION NAME] Delivery Systems(Patches) dated 05/16 revealed To administer medication through the skin by continuous absorption while the patch is in place and maintaining proper placement of the patch and care of the application sites. However, the policy did not address removal of a [MEDICATION NAME].

This citation refers to intake #M 6227 Based on observation, interview and record the facility failed to implement a mobility transfer consistent with the plan of care for one of three residents (#601) sampled for falls, out a total sample of three residents, resulting in Resident #601 falling during a transfer from the bed to chair and sustaining a fracture to the proximal right tibia. Findings include: A complaint was received by the State Agency on 11/12/15 that alleged Certified Nursing Assistant (CNA A) transferred Resident #601 and the resident sustained [REDACTED]. On 11/12/15 at 11:00 a.m., a review of the I/A (Incident and Accident) report and attached investigation records revealed, in part, the following: Date of Incident: 11/5/15 Time of Incident: 5:30 p.m. Condition Prior to Incident: Alert/confused Location: Resident room Incident Type: Observed - Fall Brief Description: Resident slid with CNA (Certified Nursing Assistant) to the floor. CNA called me to room. Assisted Resident to bed X2 mechanical lift. Further review of a Facility document dated 11/11/15 and signed by the Administrator revealed, in part, the following: On November 5, 2015 .CNA A gave Resident #601 a bed bath. After giving Resident #601 a bed bath, Resident #601 requested CNA A transfer to chair next to bed. Resident slid to the floor with CNA A holding her from behind On November 6, 2015 it was determined that Resident #601 suffered a right lower leg fracture. The entire nursing staff was in-serviced on reviewing resident transfer orders. The DON (Director of Nursing) conducted an interview with CNA A. CNA A stated that at the time of the incident she was not aware of the resident's transfer status The Resident was a mechanical lift X2. CNA A should have never attempted to transfer the Resident by herself and without knowledge of her transfer order and status .Other nursing staff on the floor was not aware of resident's transfer status .the entire nursing staff was in-serviced . Radiology report dated 11/06/15 was reviewed and results indicated: There is a fracture involving the proximal tibia with probable fracture of the fibula-mild displacement of the tibia fracture. There is osteopenia (low bone density). On 11/12/15 at 12:15 p.m., Resident #601 was observed lying in bed slightly on her left side with a pillow behind her right leg. The Resident was asked how she was feeling and responded, Not so good. I broke my right leg. It hurts. The Resident was further queried as to what happened, Resident #601 stated, Honestly, I really don't remember. I think it happened in the hospital, but I don't know what happened. On 11/12/15 at 12:30 p.m., a review of Resident #801's clinical record was conducted and revealed the following: Resident #801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #601 had a Brief Interview for Mental Status(BIMS) score of nine (9') (moderately impaired) and was totally dependent on at least two staff members for physical assistance with bed mobility, transfers, bathing and toileting. The assessment also indicated, under functional limitation in range of motion section, Resident #601 had impairments to both upper and lower extremities. A review of the Resident's Plan of Care for ADLs (Activities of Daily Living) and Falls originally dated 11/4/15 and revised 11/9/15 revealed, in part, the following: ADL: Resident in newly admitted and she/he will require staff assistance with all ADLs Approaches/Interventions: · Provide extensive assist X2 (times two) with bed mobility, transfers and toileting · Pt. (patient) requires total assist with transfers. Mechanical lift X2 person assist. FALLS: At risk for FALLS related to Psycho Active Medication and generalized medication Approaches/Interventions: · Assist in transfer: Specific type of assistance A progress note dated 11/6/15 (7:33) was reviewed and revealed the following, C/O (complains of) pain in RLE (right lower extremity), due to an observed fall that occurred on the afternoon shift, of 7/10 on pain scale. Site is swollen and painful to touch and movement. Stat x-ray of Right femur, knee, Tibia and Fibula ordered On 11/12/15 at 2:14 p.m., a phone interview was conducted with CNA A regarding the Facility's policy on transfers and the incident that occurred on 11/5/15. CNA A stated, I am a fairly new employee at the Facility. I was hired the middle of October 2015. I got my CNA license in July 2015. I received orientation training when I started. I then precepted with a number of other CNA's when I first started to work. I would shadow them and watch what they did. I then started working on the floor. At first I did 1:1 care with just one Resident. Then I mostly worked on the second floor and was getting oriented to those residents. I was placed on the one north hall on 11/5/15. The prior staff CNA oriented me to all the Residents. I carried around a book so that I could write things down about each Resident. For Resident #601, I was told she needed a shower/bed bath. I was not told anything else about her. I gave her a bed bath, I also changed her brief. I asked Nurse B to help me change her and she came into the room and helped me and then left. The Resident's linens were a bit wet from the bed bath and I wanted to change them. I told the Resident and the Resident told me that she wanted to sit in the wheelchair. The Resident told me that she could sit at the edge of the bed and I could help put her in the chair. I went to lift her and transfer her to the chair and her legs buckled and I lowered her to the floor, I tried to hold her, but I couldn't and then I called for help. I also had the roommate press the call light so that staff could come and help me. I feel really bad that she broke her leg. If I would have known she needed a lift for transfer, I never would have listened to the Resident. When further queried as to how she would have known about the Resident's transfer assist status, CNA A stated, I was relying on the staff from the prior shift to let me know information about the Resident. I thought maybe Nurse B might have said something to me too, she was in the room with me. I now know that there is a book at the Nurse's station that let's us know the Resident's transfer status, but I don't think that book was there before and I was never told to go look at it. On 11/12/15 at 3:05 p.m., an interview was conducted with Nurse B regarding the incident involving Resident #601 that occurred on 11/5/15. Nurse B stated, I do remember that night because I went in to help her change the Resident's brief. When I left the room, the Resident was still in her bed. I came back after the Resident fell and helped her get into bed and called the DON, Physican and Family. When further queried as to how CNA staff, specifically CNA A would have known about Resident #601's transfer status, The staff working the prior shift informs the new shift about the Resident. Now we also have a log book about transfer status. On 11/12/15 at 4:00 p.m., an interview was conducted with the Director of Nursing The DON was queried about the incident that occurred on 11/5/5 and stated, It was just one of those things that should not have happpened. We self-reported the incident even though we knew the origin of the injury because we knew that we did not follow the Resident's care plan. We like to be transparent. As far as CNA A is concerned, I know she felt bad about what happened. We did suspend her pending investigation. I know CNA A was fairly new, but I would have hoped that she would have asked for help before transferring her if she was not sure about the Resident's status. She has been inserviced and I hope this won't happen again. The DON was asked to provide a Facility Policy pertaining to ADL's/Transfers. The DON stated, I do not believe we have any Policy like that, however we do have a Fall Prevention Policy and an A/I - Investigation Policy. On 11/12/15 at 4:20 p.m., a review of the Facility's Policy title, Fall Prevention Process Guidelines dated 8/17/13 revealed, in part, the following: Initial POC (Plan of Care): Verify and obtain orders if needed for fall prevention interventions, referrals, or devices as needed: including type, frequency and medical reason. Assessments: Complete MDS 3.0 Individualized Care Plan: Complete a Comprehensive based upon current individualized Assessment. Action Steps: Implement Orders and Care Plan interventions. ( )

This citation pertains to intake MI 568 Based on observation, interview and record review, the facility failed to provide supervision to prevent the elopement(s) and ensure the safety of 1 resident (Resident #701) who was moderately cognitively impaired, out of three residents reviewed for elopement from a total sample of three, resulting in a left clavicle fracture and left lateral hematoma stemming from a fall in the Facility's 2 south exit stairwell. Findings include: On 8/25/15 at 10:15 a.m., a review of Resident #701's clinical record was conducted. Review of the face sheet indicated that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most the Resident Minimum Data Set ((MDS) dated [DATE] revealed the Resident had a Brief Interview for Mental Status (BIMS) score of nine 9 (moderately impaired). The MDS revealed that Resident #701 was a one person assist with all ADLs (Activities of Daily Living). Further review of the Resident's clinical revealed a nursing progress note dated 8/4/15 at 23:41 that read as follows: Resident observed opening the door to the stairwell around 6:45 p.m. on 2 South and was redirected to 2 North. Staff notified of incident. Double doors closed at that time. V/S (vital signs) with in normal limits. Resident monitored for safety. Review of the facility Summary of Investigation dated 8/10/15, revealed, in part, the following: On August 4, 2015 (about 6:45 p.m.), Resident #701 was observed by Certified Nursing Assistant (CNA) B on the 2 South opening the exit door. CNA B immediately redirected Resident #701 to her Unit on 2 North. No injury or harm resulted. The 2 North unit doors on the hallway were closed temporarily as an intervention and Charge Nurse including staff was notified of the incident .Later that same night at about 9:45 p.m., Resident #701 was observed on the landing of the 2 South stairwell after apparently going down four 4 stairs onto the landing in her wheelchair. CNA C on her way to the basement (while on break) immediately came to give assistance. CNA C heard Resident #701 asking for help after the staff rendered aid the Resident was then transferred to the Hospital .At the time of the incident CNA D was the aide assigned to Resident #701 to provide care. According to CNA D she was not able to immediately respond to the exit door alarm on 2 South because she was giving a shower to another Resident. Earlier that night after the first incident, CNA D stated that she had put Resident #701 to bed, but she kept insisting to get back up and into her wheelchair. Review of the Hospital records (entry dated 8/4/15 - discharge 8/7/15) revealed that Resident #701 sustained a left clavicle fracture and left lateral hematoma. Review of the Resident's Poor Safety Awareness Care Plan, provided by the Director of Nursing (last update 8/8/15, but developed prior to 8/4/15) revealed, in part, the following: * encourage and escort resident to activities * keep resident in visible areas Review of the At Risk For Elopement Plan related to exit seeking with not rational purpose, seemingly oblivious to safety needs, revealed, in part, the following: * evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings. * evaluate need for wandering management/elopement program * increase supervision and closely monitor to seek exit. 0n 8/25/15 at 11:40 a.m., an interview was conducted with Resident #701 regarding the fall and injury that occurred on 8/4/15. Resident #701 was presented as alert, but confused as to details regarding the incident that occurred on 8/4/15. However, Resident #701 stated, I hope that never happens to me again. I really hurt my shoulder. I have to wear a sling now sometimes. On 8/25/15 at 11:45 a.m., a tour of the Facility exit doors was conducted. The 2 South exit door leading had a sign posted that read, Please make sure door is completely closing after you go through it. An additional sign was posted on the 2 South interior door that read, Please shut door completely the buzzer will go off it it is not latched. Please close the door gently. None of the other exit doors in the Facility had this warning. An attempt to open and close the 2 South exit door was conducted. A code was entered into the code key pad next to the door. A green light illuminated. The door was able to open. The door did not close securely and was left slightly ajar and an alarm was sounded. On 8/25/15 at 12:00 p.m., an interview was conducted with Maintenance Assistant (MA) A regarding the 2 South door. MA A was asked why the door was not able to close after opening. MA A stated, I'm not sure why it is sticking. It is supposed to close all the way. I will have to have it fixed. We did have problems with this door before. MA A was further queried as to the elopement incident involving Resident #701. MA A stated, this is the door that she got out of. Before she fell you had to put a code in to have the door open, but if you didn't enter the code, the door had a 15 second release system meaning if you held on to it for at least that long you could open the door without putting in the code and the alarm was supposed to trigger. With respect to the Resident, I'm not sure she opened the door on her own. My guess would be that it was open and she got through the door. We changed everything and now the only way to open the door is to enter a code. An interview with the Maintenance Director and Acting Maintenance Director was attempted, but both staff members were not available for interview. On 8/25/15 at 1:00 p.m., an interview was conducted with the Director of Nursing (DON) regarding the elopement incident involving Resident #701 on 8/4/15. The DON stated, I'm not exactly sure of all of the details and times of what happened that night. I do know that after the Resident tried to go down the stairs the first time that evening. I wish the staff persons on duty would have contacted me and started an investigation. If I had known earlier, I would have put her on 1:1 supervision which probably prevented the second elopement that lead to her fall and the fracture. We all felt really bad about the situation. The staff was all in-serviced and educated on elopement and responding to door alarms. The DON was further queried as to how Resident #701 was able to open the 2 South Exit door. The DON stated, all our doors had a fifteen (15) second delayed egress. Resident #701 was probably able to open the door on her own. When asked if an alarm would sound when the Resident opened the door, the DON stated, it should trigger the alarm to all staff via a pager to initiate a response. The DON was asked to if the Facility had a policy on responding to door alarms, the DON was not able to provide a policy that specified door response time. The DON was also asked to provide alarm report records for 8/4/15. The Alarm Event Report Form ( 8/4/15) was provided and reviewed with the DON, Administrator and Acting Administrator regarding the alarm system in the Facility in an attempt to determine the time the 2 South door opened and the time of response from the alarm. The Report Form did not coincide with the times noted in the Facility Investigation. On 8/25/15 at 1:29 p.m., a phone interview was conducted with CNA B regarding the event that occurred on 8/4/15. CNA B stated, I remember that early that night, after dinner, I heard an alarm. I ran to the exit door on 2 South. She was in her wheelchair. She had gotten through the door. By the time I got there she was on the landing sitting in her wheelchair right before the stairs, just about to go down. I took her back to the unit (2 North) and told the charge nurse and aides. They closed the doors to Unit 2 North. I do remember the alarm went off again later that night, but I was helping another resident. As soon as I could get down there I saw that she had fallen down four steps. An attempt to contact CNA C and CNA D via telephone was conducted and a voicemail message was left and no return call was made. A written document dated 8/7/2015 and signed by CNA C read as follows: On August 4, 2015 (2nd shift), I was assigned to the 1 South Unit to provide care to residents. At the time of the alarm I was finishing my care to a resident in room 126 by the 1 South Exit Door. While going through the 1 South Exit Door to the break room downstairs I heard a resident calling out for help. I had received the page while I was finishing care to another resident. When I went up the stairs to see what had happened I observed a resident lying on the landing with the wheelchair on top of her. I immediately went up the stairs to 2 South and notified the nursing staff for assistance. Her vitals were taken. She was alert. The resident was transferred to the hospital. A written document dated August 7, 2015 and signed by CNA D read as follows: On August 4, 2015 (2nd shift), I was assigned to provide care to Resident #701 residing in room __ on 2 North unit. At the time of the alarm I was giving another resident a shower in the 2 South shower room, I received a page about the door alarm but was not immediately able to go to the 2 South Exit door because I was in the process of showering another resident. I had closed the doors to the unit on the 2N earlier that night as an intervention and had put her to bed. But Resident #701 insisted that she be put back in her wheelchair. The DON was asked to if the Facility had a policy on responding to door alarms, the DON was not able to provide a policy that specified door response time. At 3:30 p.m., an Elopement Policy dated May 2009 was provided and stated, in part, the following: Indoor search: To reduce the scope of the area to be searched, as support personnel leave, they are responsible to check their area to assure that no resident is present and to secure offices and work stations by locking access doors at the end of the day. Return of the Resident: Upon return, the resident is to be physically taken to the responsible charge nurse. The Charge Nurse will then announce an all clear. A physical assessment will be completed. Documentation: An incident report shall be completed by the responsible charge nurse for all elopements as defined previously (see incident/accident policy and procedure for detailed instructions) 1. The charge nurse and/or designee shall notify the following people in the event of an elopement: * Administrator * DON * Physician * Responsible party 2. The chart shall contain an accurate and detailed description of the occurrence. ( )

This pertains to intake MI 673. Based on interview and record review, the facility failed to properly assess, evaluate, document and treat arterial wounds for one (#601) of two sampled residents reviewed for wounds from a total of five, resulting in worsening of the wounds, hospitalization , and emergency surgery. Findings include: On 5/13/15 at 11:45 AM, the clinical record for resident #601 was reviewed with the Director of Nursing (DON), the Assistant DON (ADON), the facility's treatment nurse ('A') and nurse unit manager 'B'. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had moderately impaired cognition, and required extensive assistance for all activities of daily living (ADLs). Resident #601 was transferred to the hospital emergency room for worsening foot wounds on 5/5/15. The following related documentation was reviewed: 4/16/15-Primary Care Physician (PCP) progress note-The resident was seen in the hallway. There was no mention of palpating lower extremity pulses. 4/18/15-Bathtime Skin diagram-There were no documented open skin areas noted on this form by midnight shift staff, who were responsible for bathing the resident twice a week, assessing the skin, and documenting the diagram with each bath. 4/22/15-Bathtime Skin diagram-The right ankle had a large area of eschar (dead, leathery tissue) and blister. 4/22/15-Nurses note by midnight shift nurse 'C'-After the resident received a shower that morning by midnight shift staff: Observed with a large area of eschar on outer part of right foot, a large blister on sole of right foot. A dry, padded dressing was placed on the foot and protective boots. There was no mention of lower extremity pulses being palpated. 4/22/15 at 2:20 PM-PCP note-The resident was seen in the hallway. There was no mention of the foot wounds being assessed or palpating the pulses. There was no indication that the PCP was notified of the resident's foot wounds during this visit. 4/24/15-nurses note by treatment nurse 'A'-Right heel dry and black lateral heel/ankle/foot dry and black, right inner foot black and closed.dry dressing applied, will have (the contracted wound care Nurse Practitioner (NP) to evaluate. There were no documented measurements by nurse 'A', no mention of the blister, or pulses being palpated. When asked, nurse 'A' said, I didn't know about it until then (two days after discovery), even though she said she was on duty on 4/22/15. When asked why the blister was not mentioned and asked if she palpated the pedal (foot) pulse, nurse 'A' said, When I saw her, I didn't see a blister and I didn't check for the pulse. There was no further documentation by nurse 'A' until 4/30/15. 4/24/15-Physicians Log-Nurse 'C' requested that the PCP see the resident for complaint of necrotic (black, dead tissue) right foot. Staff did not respond why it was not logged on 4/22/15 when first discovered. 4/25/15-Bathtime Skin diagram-Side of right foot with big blister and right side (of outer ankle) with necrotic tissue (eschar) extending to sole. 4/28/15-Wound care note by NP-.has history of peripheral artery disease.found to have developed blackened areas on her right foot.She has pitting pedal [MEDICAL CONDITION]. I cannot palpate pedal or dorsal tibialis (ankle) pulses.Her toes are cold to touch.Her right medial foot has a blood blister measuring 12.5 centimeters (cm) by 10.5 cm. No drainage.Right heel has a dry stable blackened cap measuring 11.0 cm by 10.1 cm. Again no drainage.Blood blister. Heel ulcer. Arterial insufficiency with ischemic ulcer.we are going to have a dry (padded dressing) applied to protect the area. I have ordered lower extremity doppler (to determine artery blood flow).I will see her on my next visit, 1 week. The frequency of the dressing change was not noted. When asked, nurse 'A' stated that she did not ask the NP to see the resident right away, so the NP did not see the resident until Tuesday, 4/28/15, on her regularly scheduled, weekly visits every Tuesday. The DON, ADON, nurse 'A' and nurse 'B' did not respond why. They did not respond why the physician was not notified of the absent pulses and condition of the foot, to facilitate emergency care. The NP was unavailable for comment. 4/29/15-Bathtime Skin diagram-Large blister filled with fluid on the side of right foot.Right heel with necrotic tissue eschar.Right ankle with large area of eschar. 4/29/15-Doppler study for right lower extremity wound-Right (foot) artery could not be evaluated due to bandages.Due to the right foot wounds, ankle pressure.could not be obtained.suspect moderate to significant. narrowing in the right.femoral artery.right (pedal) artery could not be evaluated due to bandage materials.If the patient could tolerate (a CAT scan or MRI) this could help better assess the severity of the suspected (artery) narrowing. When asked why the dressings had not been removed for the doppler to be performed, the staff did not respond. 4/30/15 at 2:07 PM-progress note signed by nurses 'A' and 'B'-The right heel was black in color with scant serous drainage and measures 11.0 by 10.1 (cm).Her right mid foot is black in color.and measures 12.5 by 10.5 (cm).Treatment at this time is every three days.Arterial doppler is ordered. Nurse 'A' still did not mention the blister in her notes or that the doppler had actually been done, but was incomplete. Nurse 'B' did not respond. There was no documented order to only do the dressing every three days. 4/30/15 at 5:14 PM-PCP note-Patient seen in hallways. There was no mention of the foot wounds or the pulses being palpated. There were no further documented notes by nursing staff until 5/5/15. 5/4/15 PCP note-Patient seen in hallways. again, the foot was not mentioned. Per review of resident #601's wound treatment records, there was no indication that the dressing was changed again after the NP's visit on 4/28/15, until the NP's next on 5/5/15. 5/5/15-Wound care note by NP-Ordered doppler that showed moderately severe [MEDICAL CONDITION].When we came in, her dressing was found to be covered with some turbid drainage with malodor.and cold toes.She needs to go to the hospital for ischemic foot.to see if she can tolerate an amputation. I did write an order for [REDACTED]. On 5/5/15, resident #601 was transported to the hospital for right foot ischemia. The PCP was notified of the NP's order per nurses notes. Per review of hospital records dated 5/5/15, the resident's white blood count on arrival was 17.0, an indication of infection (normal range=3.3-10.7). On 5/5/15, the vascular surgeon noted: Pulses are not palpable in the foot.advanced tissue changes.Based on status of the patient's calf muscles, I do not believe (foot) amputation is possible. Therefore, best option for.wound management is a right above the knee amputation, which per hospital records, was performed on 5/8/15. When asked why the NP had to make the decision for emergency treatment, rather than the PCP, and why the resident was not sent to the hospital prior to 5/5/15, the DON and ADON said, The outcome would have been the same. When asked about her knowledge of the resident's foot condition, the DON did not respond. Documentation of the wounds' progression prior to 4/22/15, was requested. The DON looked at the available documentation and said, There should be more because this (the 4/28/15 note by the NP) is saying that the blister was already 12 by 10 (cm). That's over the entire foot. The DON then presented two, weekly reports listing all residents with wounds dated 4/28/15-4/30/15 and 5/5/15-5/7/15, and said, She (resident #601) is not on either one of them. On 5/13/15 at 1 PM, resident #601's PCP was queried by phone regarding her knowledge of the resident's ischemic foot. The PCP said, I didn't know about the foot until the resident was transferred to the hospital. She was being followed by the wound consultant. They are suppose to inform me. When told that a request to see the resident's foot, was placed on her log on 4/24/15, the PCP said, I didn't look at my log book. I don't always look at it. The nurses are suppose to tell me. On 5/13/15 at 4 PM, per review of the facility's undated Arterial Ulcers guidelines: Arterial/Ischemic Ulcer is an ulceration that occurs as the result of arterial occlusive disease when.blockage of the arterial blood flow to an area causes tissue necrosis; It is usually located over the ankle and the top or edge of the foot. The peripheral pulse is diminished or absent. Eschar and/or gangrene may be present; Assess and document wound characteristics at every dressing change, note on 24-hour log, and notify the physician. ( )

See Intake MI 583. Based on observation, interview, and record review, the facility failed to perform assessments and provide interventions for three (#501, #502, and #503) residents with an indwelling urinary catheter in a total of three sampled residents with a urinary catheter resulting in hospitalization of Resident #501 with a non-functioning catheter, purulent draining following catheter removal, [MEDICAL CONDITION], and erosion of the urethra. Resident #502 had drainage from a suprapubic catheter with a large amount of urinary sediment. Resident #503, with a urinary catheter, had drainage from the penis, pain at the catheter insertion site, and urinary sediment. Resident #501's medical record was reviewed 10/14/14 at 9:30 a.m. Resident #501, [AGE] years old, per an Admission Record, was initially admitted to the facility on [DATE]. A physician assistant's (PA) progress note on 9/5/14 indicated that Resident #501 had been hospitalized in July, 2014 for septic hardware used following a [MEDICAL CONDITION]. Resident #501 [DIAGNOSES REDACTED]. The progress note indicated that Resident #501 had an indwelling urinary catheter in place. In an interview on 10/14/14 at 4 p.m., L.P.N. Nurse Manager stated that Resident #501 had an indwelling catheter because of a sacral decubitus ulcer. Resident #501 was observed on 10/14/14 at 8:45 a.m. with L.P.N. (licensed practical nurse) "A". Resident #501 was alert and followed persons with his eyes. He nodded his head in response to questions and mouthed words which were undecipherable. According to a nursing note, Resident #501 had been hosptalized on [DATE] and, per the Admission Record, he had returned to the facility from the hospital on [DATE]. He was observed with an indwelling urinary catheter in place. He had on his thigh a device to secure the catheter. The urine from the indwelling catheter was dark amber and clear. An ADL Functional/Restorative Assessment documented that Resident #501 was disoriented. He required "two + people for bed mobility, transfers, and dressing". A 10/1/14 nurses note at 10:37 p.m. documented, "CENA (certified nursing assistant) called writer into resident's room to observe urine in drainage bag. Output 350 cc of dark red tinged urine w/secretions (with secretions) mild consistency. Foley intact, deterioration to penis noted." According to the nurses note, The PA was notified, and there was an order for [REDACTED]." There was no description of the "deterioration" to the penis, and no explanation as to why a urine specimen could not be collected. On 10/2/14 at 6:46 a.m. a nurses note documented that Resident #501's urine output was 400 cc, yellow in color, and without odor. No other nurses notes on 10/2/14 documented anything about Resident #501's urine or the condition of his penis. A nurses note on 10/3/14 at 10:24 p.m. documented that Resident #501 was "lethargic, weak, and unstable condition". His temperature was documented as 101.7 degrees Fahrenheit. The resident was transferred to the hospital, per the nurses note. There was no documentation about the urine or the condition of his penis. A urinalysis report was provided to the surveyor, dated 10/2/14. The urinalysis included the following advisement: "The above test was performed; evaluate the urinalysis results with caution. The urine specimen was received without a preservative. Deterioration of formed elements and/or alteration of chemical constituents may have occurred." An EMS (emergency medical service) run sheet documented that Resident #501 left the facility in the ambulance on 10/3/14 at 4:01 p.m. A hospital emergency room history & physical report (H&P) on 10/3/14 at 4:30 p.m. documented that Resident #501 was admitted with a temperature of 101.6 degrees Farenheit, a heart rate of 130 beats per minute (Normal: 60-100 bpm), and an elevated respiratory rate. "When foley catheter being changed patient noted to have ventral skin of urethra eroded. Urine noted to be thick and purulent. Bedside US (ultrasound) with hydro[DIAGNOSES REDACTED] (distention of the functioning units of the kidney causing destruction if allowed to continue). Subsequent CT (computerized tomography) scan demonstrated bilateral hydro[DIAGNOSES REDACTED]. Urgent urology consultation obtained. Urology resident evaluated the patient and determined that hydro[DIAGNOSES REDACTED] was secondary to Foley obstruction. Patient had not had his indwelling foley catheter tended to for a significant amount of time." Resident #501, per the H&P, was transferred to the medical intensive care unit for further evaluation and treatment. A hospital medical consultation on 10/4/14 included the following notation, "Erosion on ventral side of glans penis about 3x3 cm. Thick purulent discharge about 60 cc coming from urethra after indwelling Foley removed." Per Unit L.P.N. (licensed practical nurse) Manager "B", interviewed on 10/14/14 at 1:30 p.m., Resident #501, on 10/3/14, ate his lunch without problems about 12:30 p.m. About 3:30 p.m. on 10/3/14, per Unit Manager "B", Resident #501 had a mental status change, becoming more lethargic. She said his vital signs were "off". She said his urine was yellow with a little sediment. , Per the Unit Manager, there was no discharge from his penis and no [MEDICAL CONDITION] on the penis. The resident had no discomfort, per the Unit Manager. Unit Manager "B" said his indwelling catheter had not been changed since his admission on 8/12/14. The surveyor, when asked to observe catheter care for Resident #501, was referred to CNA (certified nursing assistant) "E". Resident #501's erosion extended from the urethra down one side of the penile shaft. At the glans penis the erosion extended very close to the urethra. There was a deep erosion down the shaft from which there was slight bleeding. The DON (director of nursing), the ADON (assistant director of nursing), L.P.N. Unit Manager "B", the Infection Control Nurse, and the wound care nurse were interviewed on 10/14/14 at 4 p.m. The surveyor observed the penile injury with the DON, the ADON, and the Unit Manager "B" during the interview when they said the wound had been described in the admission nursing assessment only as a "laceration". The DON, the ADON, and the Unit Manager had been unable to describe the wound. Following the observation the ADON and the Unit Manager said the penile wound was healed because it was not bleeding, and they did not believe it required any special care. They said the CNA was doing catheter care every shift as ordered which they considered sufficient. The Unit Manager could find no guidelines to direct CNA catheter care for Resident #501. When questioned why there were no physician orders to change the catheter, the management staff said the physician would write an order to change the catheter when he felt it was necessary. Unit Manager "B" said they do not change indwelling urinary catheters anymore on a monthly basis but instead change the drainage bags monthly, per CDC (Center for Disease Control) guidelines. The administration team were not able to identify a rationale for changing the drainage bag except that it would be good practice because they were not changing the catheter monthly. When questioned about opening a sterile system, the Unit Manager said that it was a safer practice than changing the catheter which went directly into the urethra. 2009 CDC Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections state, "Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised." On 10/14/14, on readmission to the facility, Resident #501 had the following physician orders; catheter care every shift and prn (as necessary), empty catheter every shift and prn and chart output, and change catheter bag once monthly and prn as needed, date and initial bag, 18 french (size of urinary catheter). There were no written orders to change Resident #501's urinary catheter even though discharge notes from the hospital recommended urinary catheter changes every month for Resident #501. Resident #502 Resident #502's medical record was reviewed on 10/14/14 at 1:30 p.m. Resident #502 was admitted to the facility on [DATE], per the Admissions Record. Resident #502 had been recently hosptalized on [DATE], per a nurses note. Resident #502 was observed in bed during an initial tour of the facility on 10/14/14 at 8:35 a.m. with L.P.N. (licensed practical nurse) Unit Manager "A". Resident #502 was sleeping and did not respond during the observation. Resident #502 had a suprapubic catheter (catheter inserted into the bladder to drain urine through an opening in the belly) in place. The catheter was not secured to prevent pressure at the site. There was a white tan drainage collected at the suprapubic site. The urine was amber with a large amount of large-sized sediment in the urine. Per a nurses note on 9/15/14 at 5:56 a.m., Resident #502 had no output from his suprapubic catheter, and a new size 30 french catheter was inserted. Urine was observed draining from the bladder. On 9/17/14 a nursing note documented that the suprapubic catheter was leaking, but the nurse could not determine the cause. The note said the nurse continued to monitor the situation and "endorsed to midnight nurse". A physician's assistant (PA) progress note on 9/18/14 at 4:56 p.m. documented that Resident #502's suprapubic catheter was leaking at the catheter site and was not draining well into the drainage bag. The catheter was changed. A 20 french catheter with a 30 cc balloon was inserted into the existing tract. Blood tinged urine returned, per the progress note. A physician's note on 9/18/14 at 8:39 p.m. indicated that Resident #502's suprapubic catheter was blocked again and leaking around the catheter. A new size 20 french catheter was inserted. A small amount of blood tinged urine was obtained. A nurses note on 9/18/14 at 11:11 p.m. documented that Resident #502's suprapubic catheter was leaking again with blood at the site and in the drainage bag. According to the note, the physician changed the catheter again. On 9/19/14 at 2:37 p.m., per a nurses note, Resident #502's catheter was leaking, and the resident was transferred to the hospital. Resident #502 returned to the facility on [DATE], per the Admission Record. The suprapubic catheter was draining clear yellow urine, per a nurses note on 9/24/14 at 6:25 p.m. A nurses note on 10/14/14 documented that Resident #502's urine was clear yellow. Sediment in the urine was not documented. There was no documentation that drainage was present at the suprapubic catheter insertion site. On 10/14/14 Resident #502 had the following physician orders; anchors secured in place, catheter care every shift and prn, empty catheter every shift and prn and chart output, change catheter bag once monthly and prn, 18 french catheter. Resident #503 Resident #503's medical record was reviewed on 10/14/14 at 11:30 a.m. Resident #503's last admission to the facility was on 2/12/14, per the Admissions Record. Resident #503 was observed on the initial tour of the facility on 10/14/14 at 9:15 a.m. with R.N. (registered nurse) Unit Manager "C". Resident #503 had an indwelling urinary catheter in place. Resident #503 had a white gauze covering the tip of the penis. There was a moderate amount of tan-brown drainage on the gauze. Resident #503 complained of pain when the penis was touched. There was no device in place to secure the catheter to the thigh. The resident's urine was light amber with a large amount of white sediment. Unit Manager "C" said Resident #503 goes to a urologist monthly to have his catheter changed. CNA "F", interviewed on 10/14/14 at 1:30 p.m., said he had cleaned Resident #503's penis with soap and water. The CNA said sometimes Resident #503 had drainage from the penis and sometimes he had pain at the catheter insertion site. A 9/29/14 nurses note documented that Resident #503 had visited his urologist on 9/29/14 and "had urethra dilated from 14 french to 16 french". A urology consultation, dated 9/29/14, stated that Resident #503 had a urethral false passage, right hydro[DIAGNOSES REDACTED], and [MEDICAL CONDITION]. The resident was to return in one month for another catheter change. There was no documentation from 10/1/14 - 10/14/14 that Resident #503 was having tan/brown discharge from his penis. The procedure for Catheter Care, Indwelling Catheter, dated 11/08, stated that staff are to "Spray the perineal area with periwash. Wash perineum well taking care to wash from front to back. (If male gently clean the inguinal area and scrotum). Dispose of wash cloth. Obtain fresh wash cloth. Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra. Clean the catheter from the meatus down the catheter. Dispose of dirty washcloth with each stroke. Pat dry gently with clean towel. Apply incontinence barrier if indicated. . . Ensure the tubing is secured to the resident's thigh with an anchor." Catheter Care was observed for Resident #501 on 10/14/14 at 2 p.m. CNA "E" used a washcloth and soap and water to clean the penis and catheter. One washcloth was used for the penis, and a clean washcloth was used for the catheter which was cleaned from the meatus down the catheter. The entire perineum was not cleaned as per policy. Resident #501 had an anchor in place attaching the catheter to the thigh. Catheter Care was observed for Resident #502 on 10/14/14 at 2:20 p.m. CNA "G" cleaned the penis and catheter with soap and water using one washcloth for the suprapubic insertion site and a clean washcloth for the catheter. No anchor was placed to secure the suprapubic catheter. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 834. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE 1 (#501) OF 6 SAMPLED RESIDENTS REVIEWED FOR QUALITY OF CARE FROM A TOTAL SAMPLE OF 6, THE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING, NAMELY, PROMPT EMERGENCY CARE, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #501 BEGAN TO EXPERIENCE DIFFICULTY BREATHING AND COULD NOT GET ASSISTANCE FROM STAFF. AN UNKNOWN AMOUNT OF TIME PASSED BEFORE A LICENSED NURSE RESPONDED TO THE EMERGENCY. RESIDENT #501 SUSTAINED RESPIRATORY ARREST AND SUBSEQUENTLY died . THIS DEFICIENT PRACTICE PLACED ALL 36 RESIDENTS WHO RESIDED ON THE ONE SOUTH UNIT AT RISK FOR SERIOUS INJURY, HARM, AND/OR DEATH. FINDINGS INCLUDE: RECORD REVIEW ON [DATE] AT 2:00 P.M., REVEALED THAT RESIDENT #501, A [AGE] year-OLD FEMALE, WAS ORIGINALLY admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MOST CURRENT MINIMUM DATA SET (MDS) ASSESSMENT, DATED [DATE], INDICATED THAT RESIDENT #501 HAD SEVERELY IMPAIRED COGNITION AND WAS TOTALLY DEPENDENT FOR ALL ACTIVITIES OF DAILY LIVING. ON [DATE] AT 10:00 A.M., DURING A TELEPHONE INTERVIEW, FAMILY MEMBER #10 EXPLAINED THAT SHE WAS VISITING RESIDENT #501 ON MOTHER'S DAY ([DATE]). FAMILY MEMBER #10 STATED THAT AT ABOUT 7:45 P.M., RESIDENT #501 BEGAN HAVING DIFFICULTY BREATHING. "SHE (#501) HAD FINISHED EATING HER SOUP." FAMILY MEMBER #10 SAID THAT SHE (#10) DID NOT BRING FOOD IN TO THE FACILITY FOR RESIDENT #501 TO EAT, BUT THAT "THE SOUP WAS FOOD PROVIDED BY THE NURSING HOME. WHEN WE CALLED OUT FOR ASSISTANCE, THE UNIT NURSE WAS NOT AROUND. WE ASKED THE CERTIFIED NURSING AIDE (CNA) (#7) TO GET HELP. WHEN A MALE NURSE (LICENSED PRACTICAL NURSE/LPN #8) FINALLY CAME TO THE ROOM, AT LEAST 10 MINUTES LATER, MY GRANDMOTHER'S CHIN STARTED TURNING BLUE AND HER TONGUE CAME OUT OF HER MOUTH. THE FACILITY STAFF WAS COMING IN THE ROOM BUT THEY DIDN ' T SEEM TO KNOW WHAT TO DO. THEY (FACILITY STAFF MEMBERS) WERE JUST STANDING AROUND. THE MALE NURSE TRIED TO SUCTION HER, AND WHEN THEY GOT THE OXYGEN MACHINE, IT WAS NOT WORKING." ON [DATE] AT 12:55 P.M., DURING A TELEPHONE INTERVIEW, REGISTERED NURSE (RN) #6 STATED THAT SHE WAS THE NURSE ASSIGNED TO PROVIDE CARE FOR RESIDENT #501 ON [DATE] FOR THE AFTERNOON SHIFT. RN #6 STATED, "I WAS ON MY LUNCH BREAK WHEN SHE (#501) CODED. I WAS THE ONLY NURSE WORKING ON THE 1 SOUTH UNIT THAT DAY. I WAS EATING LUNCH IN MY CAR. ONE OF THE AIDES CAME AND GOT ME. I RAN IMMEDIATELY TO THE RESIDENT'S ROOM. THERE WERE A LOT OF PEOPLE IN THERE (IN RESIDENT #501'S ROOM). I (#6) SAW (LPN #8) TRYING TO SUCTION HER, BUT I WAS THINKING THAT WE SHOULD BE DOING CPR (CARDIOPULMONARY RESUSCITATION)." RN #6 FURTHER STATED THAT BEFORE SHE LEFT FOR LUNCH SHE WENT TO NOTIFY THE 1 NORTH STAFF THAT SHE WAS LEAVING THE 1 SOUTH UNIT, BUT "NO ONE WENT TO MY SIDE TO MONITOR THE RESIDENTS WHILE I (#6) WAS AWAY." ON [DATE] AT 3:10 P.M., AN INTERVIEW WAS CONDUCTED WITH CNA #7. CNA #7 EXPLAINED THAT SHE WAS THE CNA ASSIGNED TO PROVIDE CARE FOR RESIDENT #501 ON [DATE]. "I WAS ON LUNCH, AND WHEN I CAME BACK, THE FAMILY OF THE RESIDENT (#501) SAID, 'I (FAMILY MEMBER) THINK SHE'S (#501) CHOKING.' (RESIDENT #501) WAS MAKING COUGHING SOUNDS. I ASKED HER (#501) IF SHE WAS OKAY AND SHE ANSWERED, 'NO, I ' M NOT OKAY.' THE NURSE ASSIGNED TO THE UNIT (RN #6) WAS ON HER LUNCH BREAK, SO I RAN TO 1 NORTH TO GET (LPN #8). I TRIED TO USE THE INTERCOM TO ANNOUNCE A CODE BLUE WHILE I WAS ON 1 NORTH, BUT I DIDN'T REALLY KNOW HOW TO PAGE, AND I DIDN'T HEAR MY VOICE OVERHEAD. WHEN WE (CNA #7 AND LPN #8) GOT BACK TO THE RESIDENT'S ROOM, SHE (#501) WASN'T TALKING TO US ANYMORE." CNA #7 CONFIRMED THAT SHE AND RN #6 WERE ON THEIR LUNCH BREAKS AT THE SAME TIME. ON [DATE] AT APPROXIMATELY 3:30 P.M., AN INTERVIEW WAS CONDUCTED WITH LPN #8. LPN #8 REPORTED THAT "(RN #6) DID TELL ME THAT SHE WAS GOING ON BREAK. I WAS GOING TO TELL THE OTHER NURSE (REGISTERED NURSE/RN #9) BUT SHE (RN #9) WAS IN THE BATHROOM AT THE TIME. I WAS IN THE BACK (OF THE 1 NORTH UNIT) PASSING MEDICATIONS WHEN A CNA FROM 1 SOUTH TOLD ME THAT (RESIDENT #501) WAS CHOKING. I HAD MEDICATION IN MY HAND. I WANTED TO MAKE SURE THAT THE RESIDENT THAT I WAS PASSING MEDS TO SWALLOWED THEM (MEDICATIONS). WHEN I GOT TO (RESIDENT #501 ' S) ROOM SHE WAS STILL CONSCIOUS AND BREATHING. I TOLD (RN #9) TO CALL 911 AND TO CALL A CODE BLUE (CODE USED TO INDICATE A PATIENT REQUIRING IMMEDIATE RESUSCITATION). I (LPN #8) GOT THE SUCTION MACHINE AND I SUCTIONED HER. I HAD TO RUN AND GET THE OXYGEN CONCENTRATOR. I PUT THE OXYGEN ON HER. SHE (#501) WASN ' T CHOKING ANYMORE, BUT SHE LOST CONSCIOUSNESS. WE STARTED CPR, MYSELF AND (RN #11), THEN EMS (EMERGENCY MEDICAL SERVICES) CAME AND TOOK OVER." ON [DATE] AT APPROXIMATELY 3:15 P.M. THE 1 SOUTH UNIT MANAGER, RN #3 WAS QUERIED ABOUT STAFFING ON THE FIRST FLOOR OF THE FACILITY. THE UNIT MANAGER STATED THAT THERE WERE USUALLY TWO NURSES ASSIGNED TO EACH UNIT ON THE FIRST FLOOR, "BUT WHEN SOMEONE CALLS OFF, WE HAVE ONE NURSE ON EACH UNIT AND A 'MIDDLER,' WHO IS ASSIGNED RESIDENTS ON BOTH UNITS." RN #3 STATED THAT ON [DATE], ONE OF THE NURSES HAD "CALLED-OFF," BUT DID NOT EXPLAIN WHY THE "MIDDLER" NURSE WAS NOT AVAILABLE TO ASSIST RESIDENT #501 WHEN SHE EXPERIENCED DIFFICULTY BREATHING. ON [DATE] AT APPROXIMATELY 3:45 P.M., AN INTERVIEW WAS CONDUCTED WITH RN #9 WHO EXPLAINED THAT SHE WORKED AS THE 'MIDDLER' ON [DATE], "BECAUSE ON THAT DAY, WE WORKED KIND OF SHORT. I WAS IN THE BATHROOM WHEN ONE OF THE AIDES FROM ONE SOUTH WENT TO GET HELP. (LPN #8) ASKED ME TO CALL FOR HELP, SO I PAGED OVER THE INTERCOM AND CALLED A CODE BLUE. I ALSO CALLED 911 (EMERGENCY SERVICES) AND STARTED TO PREPARE THE PAPERWORK FOR EMS (EMERGENCY MEDICAL SERVICES) BECAUSE THERE WERE OTHER NURSES WHO HAD COME FROM THE SECOND FLOOR IN THE ROOM TO ASSIST WITH THE RESIDENT (#501)." RN #9 FURTHER STATED SHE FOUND IT HARD TO WORK THE "MIDDLER" POSITION BECAUSE THAT THE NURSE IN THAT POSITION HAS THE RESPONSIBILITY OF MONITORING RESIDENTS ON BOTH UNITS. FACILITY STAFF MEMBERS, WHO ASKED NOT TO BE IDENTIFIED, REPORTED THAT NURSES FROM THE 1 NORTH UNIT DID NOT USUALLY COME TO THE 1 SOUTH UNIT TO RELIEVE THE NURSE DURING HER LUNCH BREAKS, AND THAT THE NURSE WHO WAS ASSIGNED TO WORK AS THE "MIDDLER" ONLY PASSED MEDICATIONS ON THE 1 SOUTH UNIT AND OTHERWISE WAS NOT AVAILABLE TO PROVIDE CARE TO RESIDENTS. ON [DATE] AT 12:23 P.M., AN INTERVIEW WAS CONDUCTED WITH RN #11 WHO EXPLAINED THAT HE WORKED ON THE SECOND FLOOR OF THE FACILITY ON [DATE] AND RESPONDED TO THE CODE BLUE. "I WAS ON BREAK DURING THAT TIME. I DIDN'T HEAR THE PAGE BUT I SAW (RN #9) COMING UP THE STAIRS LOOKING FOR OXYGEN TUBING. SHE TOLD ME THAT THERE WAS A CODE. WHEN I GOT TO THE ROOM, (LPN #8) WAS PREPARING TO SUCTION THE RESIDENT. (RN #14) WAS HELPING WITH THE OXYGEN." ACCORDING TO FACILITY STAFF, THE PARAMEDICS ARRIVED AND CONTINUED WITH CPR. PARAMEDICS STARTED AN INTRAVENOUS (IV) LINE AND RESIDENT #501 WAS TRANSPORTED TO THE HOSPITAL. ACCORDING TO DIRECTOR OF NURSING (DON) #2, THERE WERE 36 RESIDENTS ON THE 1 SOUTH NURSING UNIT ON [DATE]. THESE THIRTY-SIX RESIDENTS, WITH VARIOUS MEDICAL CONDITIONS, WERE LEFT UNSUPERVISED BY LICENSED STAFF DURING A ONE-HALF HOUR LUNCH BREAK. REVIEW OF A NURSE'S NOTE WRITTEN BY RN #6, DATED [DATE], REVEALED, "AT 2215, I WAS SITTING IN MY CAR ON MY BREAK, WHEN ONE OF THE CENA'S (CERTIFIED NURSING ASSISTANTS) STARTED POUNDING ON MY CAR WINDOW AND SAID THAT THERE WAS A CODE BLUE FOR (#501). I HAD TALKED TO HER DAUGHTER AT 2200 AS I WAS LEAVING FOR MY LUNCH BREAK. WHEN I GOT TO THE UNIT I WAS TOLD THAT ANOTHER NURSE HAD CALLED FOR AN AMBULANCE. IN HER ROOM TWO OF THE NURSES FROM OTHER UNITS WERE PREPARING TO SUCTION HER. HER DAUGHTER AND GRANDDAUGHTER WERE IN THE ROOM ALSO. HER GRANDDAUGHTER SAID SHE WAS FEEDING HER (#501) AND THAT SHE STARTED TO GURGLE. I SUCTIONED HER, BUT NOTHING CAME UP FROM THE BACK OF HER THROAT. AT THAT TIME A CPR BOARD WAS BROUGHT AND PLACED UNDER HER AND CPR WAS STARTED. THE AMBULANCE ARRIVED AT ABOUT 2225 AND THE EMT'S (EMERGENCY MEDICAL TECHNICIANS) TOOK OVER AND STARTED CPR. THEY LEFT AT ABOUT 2230. THE FAMILY LEFT WITH THEM." IT WAS UNCLEAR WHY RN #6 DOCUMENTED THAT THE INCIDENT OCCURRED AT 2215 (10:15 P.M.). REVIEW OF A NURSE'S NOTE WRITTEN BY LPN #8, DATED [DATE], REVEALED "LATE ENTRY [DATE], WRITER WAS AT room [ROOM NUMBER] IN ONE NORTH AND GIVING MEDICATION WHEN CENA FROM ONE SOUTH TOLD ONE OF THE RESIDENTS WAS HAVING BREATHING PROBLEM. WRITER LET THE OTHER ONE NORTH NURSE KNOW. THE RESIDENT WAS STILL CONSCIOUS BUT HAVING PROBLEM BREATHING AND HAD SOME YELLOW COLORED SECRETIONS COMING OUT FROM HER MOUTH. OXYGEN WAS INITIATED, AND TOLD TO THE OTHER NURSE TO CALL 911 AND CODE BLUE TO GET SOME HELP AND THEN SUCTIONING WAS INITIATED. OBSERVED RESIDENT WAS NOT BREATHING. CPR WAS INITIATED, THEN 911 CAME AND TOOK OVER." ACCORDING TO FAMILY INTERVIEW AND DOCUMENT REVIEW, A TIMELINE OF THE INCIDENT WENT AS FOLLOWS: 7:45 P.M., FAMILY MEMBER IDENTIFIED THAT RESIDENT #501 EXPERIENCED A CHANGE IN CONDITION. 7:50 P.M., CNA #7 RETURNED TO THE ONE SOUTH UNIT FROM LUNCH (SIGN-IN SHEET). 8:09 P.M., EMS WAS NOTIFIED (ACCORDING TO EMS RUN SHEET). 8:16 P.M., EMS ARRIVED AT THE FACILITY (EMS RUN SHEET). 8:43 P.M., EMS LEFT THE FACILITY. 8:50 P.M., EMS ARRIVED AT LOCAL HOSPITAL. 8:53 P.M., CPR STARTED AT HOSPITAL (HOSPITAL RECORDS). 8:54 P.M., CPR CONTINUED. 8:57 P.M., RESIDENT #501 PRONOUNCED DEAD, NO CARDIAC ACTIVITY. IT WAS UNCLEAR WHAT TRANSPIRED DURING THE TIME DELAY THAT OCCURRED BETWEEN 7:50 P.M. WHEN CNA #7 RETURNED FROM HER LUNCH BREAK, AND 8:09 P.M., WHEN THE FACILITY CALLED 911 FOR EMERGENCY HELP. ON [DATE] AT 11:45 A.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AS A RESULT OF THE FACILITY'S FAILURE TO PROVIDE RESIDENT #501 WITH PROMPT EMERGENCY ASSISTANCE WHEN SHE EXPERIENCED A CHANGE IN CONDITION AND WENT INTO RESPIRATORY ARREST. RESIDENT #501 SUBSEQUENTLY died . THIS DEFICIENT PRACTICE PLACED ALL 36 RESIDENTS WHO RESIDED ON THE 1 SOUTH UNIT AT RISK FOR SERIOUS HARM, INJURY OR DEATH. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY HAD TAKEN THE FOLLOWING ACTIONS TO REMOVE THE IMMEDIATE JEOPARDY: RESIDENT #501 IS NO LONGER IN THE FACILITY. RESIDENTS ON 1 SOUTH UNIT HAVE BEEN ASSESSED FOR IMMEDIATE NEEDS. ALL OTHER FACILITY RESIDENTS HAVE BEEN ASSESSED FOR IMMEDIATE NEEDS. ASSESSMENTS ON THE FACILITY'S CURRENT CENSUS OF 166 RESIDENTS WERE COMPLETED ON [DATE]. THE MAINTENANCE DIRECTOR HAS VERIFIED THAT THE OVERHEAD PAGING SYSTEM IS OPERATING AND THAT ALL SPEAKERS IN THE FACILITY ARE WORKING, COMPLETED [DATE]. FACILITY CPR POLICY HAS BEEN REVIEWED BY THE DIRECTOR OF NURSING AND DEEMED APPROPRIATE ON [DATE]. FACILITY POLICY FOR SUPERVISION OF RESIDENTS ON NURSING UNITS HAS BEEN REVIEWED AND REVISED BY THE DIRECTOR OF NURSING, ADMINISTRATOR AND MEDICAL DIRECTOR ON [DATE]. POLICY WILL BE SUBMITTED AND REVIEWED BY THE Q.A. COMMITTEE ON [DATE]. THE FACILITY POLICY OF GENERAL GUIDELINES FOR EMERGENCY CARE HAS BEEN REVIEWED AND REVISED BY THE DIRECTOR OF NURSING, ADMINISTRATOR AND MEDICAL DIRECTOR ON [DATE]. POLICY WILL BE SUBMITTED AND REVIEWED BY THE Q.A. COMMITTEE ON [DATE] TO INCLUDE SPECIFIC DIRECTION TO STAFF WHEN RESPONDING TO EMERGENCY SITUATIONS. IN-SERVICING OF FACILITY STAFF WAS INITIATED ON [DATE] WITH THE FOLLOWING STAFF COMPLETED BY 4PM, 32 OF 77 CENA, 21 OR 47 NURSES, 5 OF 8 ACTIVITY, 16 OF 25 DIETARY, 7 OF 14 HOUSEKEEPERS, 7 OF 9 LAUNDRY, 5 OF 5 MAINTENANCE, 6 OF 8 ADMINISTRATION AND 4 OF 4 SOCIAL SERVICES. IN-SERVICING OF THE MIDNIGHT SHIFT, 4 NURSES AND 12 CENA WILL BEGIN AT 11PM, [DATE]. IN-SERVICING WILL CONTINUE UNTIL ALL FACILITY STAFF HAVE BEEN EDUCATED. STAFF NOT IN-SERVICED WILL BE REMOVED FROM THE SCHEDULE. IN-SERVICING ON THE FACILITY POLICIES ON SUPERVISION OF RESIDENTS AND GENERAL GUIDELINES FOR EMERGENCY CARE WERE INITIATED ON [DATE] AND WILL CONTINUE UNTIL ALL STAFF HAVE BEEN EDUCATED. STAFF NOT IN-SERVICED WILL BE REMOVED FROM THE SCHEDULE UNIT MANAGERS OR DESIGNEE WILL CONDUCT DAILY AUDITS TO ENSURE NURSING STAFF ARE ON EACH UNIT TO PROVIDE ADEQUATE SUPERVISION, MONITORING AND PROMPT ASSISTANCE AS REQUIRED. AUDITS WILL BE CONDUCTED DAILY BEGINNING [DATE] X 14, WEEKLY X 4, MONTHLY X 3. AUDITS WILL BE SUBMITTED TO THE Q.A. COMMITTEE MONTHLY FOR REVIEW. THE ADMINISTRATOR IS RESPONSIBLE FOR COMPLIANCE. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON [DATE] WAS REMOVED ON [DATE]. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( )

THIS CITATION HAS TWO DEFICIENT PRACTICES. DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION BASED ON THE ASSESSED NEEDS OF RESIDENTS AND FAILED TO ENSURE IMPLEMENTATION OF PROPER FUNCTIONING SAFETY DEVICES FOR THREE (#'S 804, 807 AND 820) OF 10 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 27, RESULTING IN FALLS, A LACERATION, A HEMATOMA, A FRACTURE, AND hospitalization S. FINDINGS INCLUDE: ON 3/26/13 AT 8:45 A.M., DURING THE INITIAL TOUR OF THE FACILITY WITH THE UNIT MANAGER FOR 2-SOUTH (NURSE "H") RESIDENT #807 WAS OBSERVED. RESIDENT #807 WAS LYING IN BED, WITH BED ALARM IN PLACE. NURSE "H" REVEALED THAT THE RESIDENT HAD POOR SAFETY AWARENESS, FALL PRECAUTIONS, A LOW BED, BED AND WHEELCHAIR ALARMS, DUE TO A HISTORY OF FALLS. ON 3/26/13 AT 12:40 P.M., RESIDENT #807 WAS OBSERVED LYING IN BED. THE RESIDENT'S BED WAS NOT IN A LOW POSITION AND THE BED ALARM WAS OBSERVED TO BE NOT FUNCTIONING. NURSE "H" CAME INTO THE ROOM AND OBSERVED THE BED ALARM. THE WIRE CONNECTING THE PAD ALARM TO THE ALARM BOX WAS DISCONNECTED FROM THE ALARM BOX. NURSE "H" STATED, "IT'S BROKEN." WHEN QUERIED IF THE RESIDENT'S BED WAS SUPPOSED TO BE IN A LOW POSITION, NURSE "H" STATED, "I AM NOT SURE IF SHE HAS TO HAVE A LOW BED, BUT I WILL CHECK," AND PROCEEDED TO MOVE THE RESIDENT'S BED INTO LOW POSITION. ON 3/28/13 AT 8:35 A.M., DURING RESIDENT #807'S WOUND OBSERVATION WITH NURSE "I" AND NURSE "H" THE RESIDENT'S BED ALARM DID NOT APPEAR TO BE DISCONNECTED. THERE WERE NO LIGHTS FLASHING INDICATING THAT THE ALARM BOX WAS TURNED ON OR TO INDICATE THAT THE ALARM NEEDED NEW BATTERIES. THE WIRE CONNECTING THE PAD ALARM TO THE ALARM BOX APPEARED TO BE STRIPPED, EXPOSING LOOSE WIRES. NURSE "H" ATTEMPTED AT LEAST FOUR TIMES TO PUSH THE EXPOSED WIRES BACK INTO THE ALARM BOX TO MAKE IT FUNCTION BUT WAS UNABLE TO. NURSE "H" THEN TOOK THE ALARM BOX AND WIRE AND LEFT THE ROOM. NURSE "H" LATER RETURN WITH ANOTHER ALARM BOX UNIT AND PLUGGED IT INTO THE PAD ALARM. THE ALARM BOX WAS OBSERVED TO BE FUNCTIONING WITH AN INTERMITTENT FLASHING GREEN LIGHT. RESIDENT #807'S MEDICAL RECORD WAS REVIEWED AND REVEALED A FACE SHEET INDICATING THE MOST RECENT RE-ADMISSION INTO THE FACILITY WAS 10/22/12. THE MOST RECENT HISTORY AND PHYSICAL, DATED 10/24/12, REVEALED [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM DATA SET ASSESSMENT, DATED 2/5/13, REVEALED THAT THE RESIDENT'S COGNITION WAS SEVERELY IMPAIRED AND REQUIRED EXTENSIVE ASSISTANCE FOR BED MOBILITY AND TRANSFER. RESIDENT #807'S MONTHLY SUMMARY DATED 5/18/12 REVEALED THAT THE RESIDENT WAS ON "FALL PRECAUTIONS," AND HAD "W/C (WHEELCHAIR) AND BED ALARMS" IN PLACE. THE MONTHLY SUMMARY REPORTED "RESIDENT ALERT AND RESPONDING VERBALLY WITH PERIODS OF CONFUSION. HAS WHEELCHAIR AND BED ALARMS FOR FALL PRECAUTIONS. EXTENSIVE ASSIST WITH ADL (ACTIVITIES OF DAILY LIVING)." RESIDENT #807'S MONTHLY SUMMARY DATED 6/26/12 REVEALED THAT THE RESIDENT WAS ON "FALL PRECAUTIONS," AND HAD "W/C ALARM." RESIDENT #807'S PROGRESS NOTES DATED 7/20/12 AT 8:03 A.M., REVEALED "DAY 1 FALL, RECEIVED RESIDENT IN BED ON COMMENCEMENT OF SHIFT GROANING, UNABLE TO MOVE LLE (LEFT LOWER EXTREMITY). STAT(IMMEDIATE) XRAY RESULT RECEIVED WITH LEFT TROCHANTERIC FRACTURE, COMMINUTED DISPLACEMENT....TRANSFERRED TO (HOSPITAL NAME) HOSPITAL." RESIDENT #807'S PHYSICIAN ORDER [REDACTED]." RESIDENT #807'S RADIOLOGY REPORT, DATED 7/19/12, REVEALED "S/P (status [REDACTED]. ACUTE INTERTROCHANTERIC FEMORAL FRACTURE, MILDLY COMMINUTED WITH DISPLACEMENT." RESIDENT #807'S "PATIENT TRANSFER FORM," DATED 7/20/12 UNDER DATE OF THIS TRANSFER REVEALED "[DIAGNOSES REDACTED]. ADDITIONAL PERTINENT INFORMATION: AMBULATES WITH (UNKNOWN WORD) OF W/C DUE TO UNSTEADY GAIT." RESIDENT #807'S "INCIDENT/ACCIDENT REPORT," DATED 7/19/12, REVEALED THE FOLLOWING RESIDENT STATEMENT OF WHAT OCCURRED: "I WENT TO BR (BATHROOM) TO USE TOILET." DESCRIBE WHAT HAPPENED: "RESIDENT USUALLY AMBULATES SELF TO THE BR. HER LEFT LEG GIVE WAY AND 'I fell . THIS IS MY BAD LEG.' FOUND LYING ON HER STOMACH. STEPS TAKEN TO AVOID IMMEDIATE REPETITION: "REMAINED ON W/C AND BED ALARM." OVERALL CONCLUSION: "ACC (ACCORDING) TO ROOMMATE RESIDENT FREQ (FREQUENTLY) AMBULATES TO BR INDEPENDENTLY AND THIS DAY SHE RETURNED TO ROOM AND FOUND RESIDENT ON BR FLOOR, NO W/C WAS IN BR, ALARMS WERE FUNCTIONAL, BUT NOT ALARMING AT THE TIME." RESIDENT #807'S HISTORY AND PHYSICAL DATED 7/27/12 REVEALED "ASSESSMENT: FALL L (LEFT) HIP (FEMORAL NECK) FX (FRACTURE) S/P ORIF (OPEN REDUCTION INTERNAL FIXATION)." RESIDENT #807'S CARE PLANS WERE REVIEWED AND REVEALED THE FOLLOWING: ADL: (RESIDENT #807) REQUIRES SUPERVISION TO LIMITED ASSIST WITH ADLS SECONDARY TO DEMENTIA, DATED 1/24/12. GOAL: (RESIDENT) WILL ATTAIN OPTIMUM PARTICIPATION WITH HER DAILY CARE WITH OVERSIGHT ASSIST PROVIDED BY STAFF. APPROACHES/INTERVENTIONS: REMIND RESIDENT TO USE CALL LIGHT AND ASK FOR ASSISTANCE AS SHE NEEDS. BED ALARM TO BE PLACED ON BED IN LOWEST POSITION. GAIT BELT CGA (CONTACT GUARD ASSIST) TIMES ONE PERSON FOR TRANSFER. WHEELCHAIR SENSOR ALARM PROVIDED." CARE PLAN TITLED "COGN: RESIDENT HAS SHORT/LONG TERM MEMORY DEFICITS... DATED 4/19/12." ON 3/28/13 AT 2:15 P.M. THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING RESIDENT #807'S FEMUR FRACTURE AND STATED, "(THE RESIDENT) WAS ON FALL PRECAUTIONS DUE TO RISK FOR FALLS. IT WAS AN UNWITNESSED FALL. SHE fell WHEN ATTEMPTING TO SELF TOILET. IT WASN'T RECOMMENDED THAT SHE AMBULATE INDEPENDENTLY, BUT SHE OFTEN DID. WE HAD ALARMS IN THE PLAN BUT THE ALARM WAS NOT ALARMING (AT TIME OF FALL)." THE DON WAS UNABLE TO ANSWER WHY THE ALARM WAS NOT ALARMING AT TIME OF FALL. WHEN QUERIED AS TO HOW SAFETY DEVICES WERE MONITORED TO ENSURE THAT THEY ARE ON AND FUNCTIONING THE DON STATED, "WE EXPECT THAT IT IS DONE (THE MONITORING) IN A MANNER OF ROUNDS, SOMETHING WE TRY TO CHECK AT THE BEGINNING OF SHIFT." WHEN QUERIED ABOUT THE TWO OBSERVATIONS OF RESIDENT #807'S NON FUNCTIONING ALARM ON 3/26/13 AND 3/28/13, THE DON STATED, "I HEARD THAT IT WAS NOT ON" BUT PROVIDED NO FURTHER COMMENT. THE FACILITY'S POLICY ON SAFETY/FALLS WAS REQUESTED AND REVEALED THE FOLLOWING UNTITLED DOCUMENT, INDICATED BY PAGE 5, "ADDITIONAL RISK FACTORS AND ONGOING ASSESSMENT: RESIDENTS WILL BE ASSESSED THROUGH THE RAI (RESIDENT ASSESSMENT INSTRUMENT) PROCESS TO IDENTIFY ANY CHANGES THAT WOULD IMPACT THEIR RISK FACTORS...THE TEAM WILL MONITOR, EVALUATE AND DETERMINE APPROPRIATE APPROACHES TO ENSURE RESIDENT SAFETY NEEDS ARE IDENTIFIED AND ADDRESSED." ( ) RESIDENT #804'S CLINICAL RECORD WAS REVIEWED. RESIDENT #804 WAS admitted on [DATE] AND HAD [DIAGNOSES REDACTED]. IN THE CLINICAL RECORD, THE MINIMAL DATA SET ((MDS) dated [DATE] INDICATED THAT PRIOR TO ADMISSION RESIDENT #804 WAS FALLING AT HOME, USED A WHEELCHAIR, AND WAS A CURRENT RISK FOR FALLING. THE MDS ALSO INDICATED THAT RESIDENT #804 WAS SEVERELY COGNITIVELY IMPAIRED, COULD NOT AMBULATE, AND NEEDED EXTENSIVE ASSISTANCE WITH TRANSFERRING. THE ADMISSION SAFETY INFORMATION CHECKLIST DATED 10/15/12 INDICATED RESIDENT #804 NEEDED CHAIR AND BED ALARMS. PER RECORD REVIEW OF THE NURSING NOTES DATED 10/15/12 TO 10/21/12 DESCRIBED RESIDENT #804 AS "AGITATED," "COMBATIVE," "IMPULSIVE," HAVING "PERIODS OF RESTLESSNESS," AND "ATTEMPTING TO AMBULATE WITHOUT ASSIST." THE INCIDENT AND ACCIDENT (I/A) REPORTS FOR RESIDENT #804 NOTED THE FOLLOWING: 1. PER THE NURSING NOTE DATED 10/21/12 THE CNA WAS TOLD TO TAKE RESIDENT #804 AND "LAY HER DOWN" IN BED. THE CNA PLACED THE RESIDENT IN HER ROOM AND LEFT HER IN TEH WHEELCHAIR UNATTENDED WHILE THE CNA LEFT TO RETRIEVE LINEN. WHILE THE CNA WAS OUT OF THE ROOM, RESIDENT #804 "fell on THE FLOOR ON BUTTOCK." PER THE I/A REPORT "RESIDENT #804 "MUST BE IN A SUPERVISED AREA WHILE IN W/C (WHEELCHAIR) DUE TO HER CONSTANT MOTION OF STANDING AND SITTING, SOMETIMES ATTEMPTING TO WALK, ALTHOUGH UNABLE. CNA (CERTIFIED NURSING ASSISTANT) DID NOT FOLLOW PRESCRIBED PLAN OF CARE." THE PLAN OF ACTION INCLUDED HAVING ONE TO ONE TRAINING WITH THE CNA ABOUT "HAVING ALL SUPPLIES READY BEFORE TAKING RESIDENT TO ROOM FOR CARE" 2. ON 11/5/12 AT 7:50 AM RESIDENT #804 "WAS FOUND ON FLOOR NEXT TO BED WITH HER HEAD NEXT TO THE NIGHT STAND." RESIDENT #804 HAD A "LACERATION TO THE RIGHT BACK SIDE OF HEAD." A BED ALARM AND FLOOR MAT WAS ROUTINELY REQUIRED BUT WAS NOT NOTED TO BE UTILIZED AT THE TIME OF THE FALL PER THE INCIDENT /ACCIDENT REPORT OR THE NURSING NOTE DATED 11/5/12 AT 12:44 PM. PLAN OF ACTION WAS "TO HAVE THE RESIDENT UP EARLIER IN THE AM TO PROVIDE MORE CONTACT WITH STAFF." RESIDENT #804 WAS TAKEN TO THE HOSPITAL emergency room WHERE SHE RECEIVED TWO STAPLES TO THE BACK OF HER HEAD. PER RECORD REVIEW OF THE CARE PLANS INITIATED 10/16/12, RESIDENT #804 WAS TO HAVE ONE TO ONE SUPERVISION DURING MEALTIME, A MATTRESS TO THE LEFT SIDE OF THE BED WITH A FLOOR MAT TO THE RIGHT SIDE OF THE BED, A WHEELCHAIR SENSOR ALARM, AND TRANSFER ASSISTANCE. ON 10/22/12 "BED ALARM TO LOW BED," WAS ADDED TO THE CARE PLAN. PER INTERVIEW ON 3/28/13 AT 2:35 PM, STAFF MEMBER 'M' STATED THAT RESIDENT #804'S BEHAVIOR WOULD INCLUDE AGITATION, UNDRESSING, ALTERNATING BETWEEN STANDING AND SITTING AND FLUCTUATING "FROM VERY ACTIVE TO DOCILE." STAFF MEMBER 'M' SAID THAT RESIDENT #804 WAS KEPT CLOSE TO THE NURSE STATION TO BE OBSERVED. STAFF MEMBER 'M' SAID THAT "BY THE WAY IT'S (THE NURSING NOTE) WRITTEN IT DOESN'T SAY THE FLOOR MAT WAS USED." STAFF MEMBER 'M' DID NOT COMMENT ON THE LACK OF DOCUMENTATION THAT THE ALARM WAS IN USE. THE DIRECTOR OF NURSING (DON) STATED DURING AN INTERVIEW ON 3/29/13 AT 8:30 AM THAT THE AIDE THAT LEFT RESIDENT #804 UNSUPERVISED WAS A "REGULAR AIDE ON THE FLOOR" AND WOULD HAVE KNOWN THAT RESIDENT #804 HAD NEEDED SUPERVISION. THE DON WAS UNABLE TO RESPOND WHY THE RESIDENT WAS LEFT UNATTENDED IN THE WHEELCHAIR. THE CNA WAS NOT AVAILABLE FOR COMMENT. PER INTERVIEW WITH THE ADMINISTRATOR ON 3/29/13 AT 12:25 PM, THE ADMINISTRATOR SAID HE COULD NOT ANSWER AS TO WHY THE ALARM AND FLOOR MAT WERE NOT IN USE DURING THE INCIDENT ON 11/5/12. ( ) ON 3/28/13 AT 12:00 P.M., RESIDENT #820'S CLINICAL RECORD WAS REVIEWED AND REVEALED A NURSING NOTE DATED 12/01/12 AT 11:05 P.M., "SHOWER/SKIN ASSESSEMENT: DURING SKIN ASSESSMENT, OBSERVED A HEMATOMA (SWELLING WITH BRUISING) ON LEFT SIDE OF FOREHEAD. RED IN COLOR. MESSAGE LEFT FOR WEEKEND SUPERVISION TO CONSIDER PLACING PADDING ON THE WALL FOR PROTECTION WHEN ROLLING. MEDICAL DOCTOR NOTIFIED OF HEMATOMA ." ON 3/29/13 AT 9:30 A.M., RESIDENT #820 WAS OBSERVED IN BED IN THE ROOM. THE RESIDENT WAS ALERT WITH AN ANXIOUS FACIAL EXPRESSION, AND DID NOT MOVE INDEPENDENTLY OR RESPOND TO QUESTIONS. A SAFETY MAT WAS PLACED AGAINST THE WALL BY THE BED. CHARGE NURSE "I " AND CERTIFIED NURSING ASSISTANT (CNA) "W" WERE OBSERVED PROVIDING WOUND CARE TO THE RESIDENT. THE RESIDENT MADE NO INDEPENDENT MOVEMENTS AND DID NOT ASSIST STAFF WITH REPOSITIONING DURING CARE. NURSE "I " AND CNA "W" REPORTED THAT RESIDENT #820 DID NOT MOVE INDEPENDENTLY. WHEN QUERIED ABOUT INJURIES AND ACCIDENTS AT THAT TIME, NURSE "I " REPORTED THAT RESIDENT #820 HAD HAD A FOREHEAD HEMATOMA DISCOVERED BACK IN DECEMBER. BOTH CNA "W" AND NURSE "I " REPORTED THEY HAD SEEN THE HEMATOMA ON RESIDENT #820'S HEAD, BUT WERE UNABLE TO PROVIDE ADDITIONAL INFORMATION, STATING, "IT WAS THERE WHEN I CAME ON SHIFT." ON 3/29/13 AT 1:00 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ABOUT RESIDENT #820'S FOREHEAD INJURY ON 12/1/12. REVIEW OF RESIDENT #820'S CLINICAL RECORD AND FACILITY INCIDENT/ACCIDENT REPORTS (I&A) WITH THE DON AT THIS TIME REVEALED THE FOLLOWING: A FACE SHEET DOCUMENTED THAT RESIDENT #820 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. A MINIMUM DATA SET assessment dated [DATE] REVEALED THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT (DEMENTIA) AND COMMUNICATION IMPAIRMENT. THE MDS ALSO DOCUMENTED THE RESIDENT WAS PHYSICALLY DEPENDENT ON TWO STAFF FOR MOVEMENT IN BED, AND TRANSFERS TO THE GERI CHAIR (ROLLED RECLINER), AND WAS DEPENDENT FOR ACTIVITIES OF DAILY LIVING. THE MDS DOCUMENTED THE RESIDENT HAD RESTRICTED JOINT MOBILITY ON BOTH SIDES OF THE BODY. A FACILITY I&A DATED 12/1/12 AT 6:30 P.M., DOCUMENTED , "BEFORE SHOWER WAS GIVEN, WRITER WAS SUMMONED BY CNA WHO OBSERVED A RED HEMATOMA TO THE LEFT SIDE OF FOREHEAD. MAY NEED A PADDED WALL FOR PROTECTION WHEN ROLLING RESIDENT." TYPE OF WOUND WAS NOTED AS "NEW FOREHEAD BRUISE." THE I&A CONCLUSION WAS DOCUMENTED AS, "WHILE RESIDENT WAS BEING TURNED FOR CARE, FOREHEAD WAS PRESSED AGAINST WALL. RESIDENT IS VERY COMBATIVE DURING CARE." PLAN OF ACTION WAS NOTED AS, "ONE TO ONE VERBAL INSERVICE GIVEN TO CNA ABOUT SAFETY OF TURNS." ON 3/29/13 AT 1:00 P.M., THE DON WAS REQUESTED TO PROVIDE DOCUMENTATION OF THE FACILITY INVESTIGATION INTO RESIDENT #820'S FOREHEAD BRUISE. THIS WAS NOT PROVIDED BY EXIT, BUT THE DON REPORTED THAT CNA "X" , "BUMPED THE RESIDENT'S HEAD AGAINST THE WALL BY ACCIDENT WHEN TURING HER OVER TO PROVIDE CARE." WHEN QUERIED, THE DON REPORTED THAT CNA "X" WAS THE ONLY WITNESS TO THE INJURY, AND DID NOT PROVIDE DOCUMENTATION OF STAFF INTERVIEWS, A WRTTEN STATEMENT FROM CNA "X", OR OF A FACILITY INVESTIGATION INTO THE INJURY, WHEN REQUESTED. REVIEW OF A NURSING CARE PLAN FOR RESIDENT #820, TITLED, "ADLS (ACTIVITIES OF DAILY LIVING)', DATED 10/27/11, REVEALED THE FOLLOWING INSTRUCTIONS TO STAFF (DATED 10/27/11), "REPOSITION AS NEEDED WITH TWO STAFF TO ASSIST, AS RESIDENT MAY BECOME RIGID." THERE WERE NO NOTATIONS OR INSTRUCTIONS INDICATING RESIDENT #820 BECAME COMBATIVE WITH CARE, AS DOCUMENTED IN THE I&A REPORT. WHEN QUERIED, THE DON WAS UNABLE TO EXPLAIN HOW A NON VERBAL RESIDENT WITH QUADRIPLEGIA (PARALYSIS) COULD BE COMBATIVE. WHEN REQUESTED, THE DON WAS UNABLE TO PROVIDE DOCUMENTATION OF THE ONE TO ONE INSERVICE WITH CNA "X", AND STATED, "I DIDN'T PUT ANYTHING IN WRITING." THE DON WAS UNABLE TO EXPLAIN WHY CNA "X" DID NOT FOLLOW INSTRUCTIONS AND OBTAIN ASSISTANCE FROM ANOTHER CNA TO REPOSITION RESIDENT #820, PER NURSING CARE PLAN INSTRUCTIONS. ON 3/29/13 AT 1:00 P.M.,THE DON WAS REQUESTED TO PROVIDE A RECORD OF STAFF INSERVICES (TRAINING) FOR CNA "X" ON RESIDENT REPOSITIONING AND TRANSFERS, ACCIDENT PREVENTION AND SAFETY, AND ON ABUSE PREVENTION. THIS WAS NOT PROVIDED BY SURVEY EXIT. CNA "X" WAS UNAVAILABLE FOR INTERVIEW. THE FACILITY'S POLICY ON SAFETY/FALLS WAS REQUESTED AND REVEALED THE FOLLOWING UNTITLED DOCUMENT, INDICATED BY PAGE 5, "ADDITIONAL RISK FACTORS AND ONGOING ASSESSMENT: RESIDENTS WILL BE ASSESSED THROUGH THE RAI (RESIDENT ASSESSMENT INSTRUMENT) PROCESS TO IDENTIFY ANY CHANGES THAT WOULD IMPACT THEIR RISK FACTORS...THE TEAM WILL MONITOR, EVALUATE AND DETERMINE APPROPRIATE APPROACHES TO ENSURE RESIDENT SAFETY NEEDS ARE IDENTIFIED AND ADDRESSED." ( ) DEFICIENT PRACTICE #2. BASED ON OBSERVATION INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO MONITOR FOR USE OF EXTENSION CORDS FOR ONE SUPPLEMENTAL RESIDENT (# 46 )AND FAILED TO MONITOR FOR PATIENT CARE EQUIPMENT PLUGGED INTO POWERSTRIPS FOR THREE SUPPLEMENTAL RESIDENTS (# 100, # 132 AND #167) RESULTING THE POTENTIAL FOR FIRES. ON 03/27/13 AT 2:30 P.M., DURING THE ENVIRONMENTAL TOUR WITH THE MAINTENANCE DIRECTOR, A WHITE TWO PRONG EXTENSION CORD WAS OBSERVED PLUGGED IN TO A WALL OUTLET WITH A CELLPHONE CHARGER PLUGGED INTO THE EXTENSION CORD IN RESIDENT #46'S ROOM. WHEN QUERIED THE MAINTENANCE DIRECTOR STATED, "IT SHOULDN'T BE THERE." A LOW AIR LOSS MATTRESS FOR RESIDENT #100 WAS OBSERVED PLUGGED INTO A POWER STRIP WHICH WAS PLUGGED INTO THE WALL OUTLET. WHEN QUERIED THE MANITENANCE DIRECTOR STATED, " IT SHOULD NOT BE PLUGGED INTO A POWERSTRIP, THERE ARE OUTLETS AVAILABLE." A TUBE FEED PUMP WAS OBSERVED PLUGGED INTO A POWERSTRIP WHICH WAS PLUGGED INTO A WALL OUTLET IN RESIDENT # 167'S ROOM. WHEN QUERIED THE MAINTENANCE DIRECTOR STATED, " THE TUBE FEED PUMP IS NOT SUPPOSED TO BE PLUGGED INTO A POWERSTRIP." AN OXYGEN CONCENTRATOR FOR RESIDENT #132 WAS OBSERVED PLUGGED INTO A POWERSTRIP WHICH WAS PLUGGED INTO A WALL OUTLET. WHEN QUERIED THE MAINTENANCE DIRECTOR STATED, " IT IS NOT SUPPOSED TO BE PLUGGED INTO A POWERSTRIP AT ALL." THE MAINTENANCE DIRECTOR CONFIRMED NONE OF THE POWER STRIPS WERE HOSPITAL OR COMMERCIAL GRADE. ON 3/28/13 AT 1:45 P.M., WHEN QUERIED THE MAINTENANCE DIRECTOR STATED THERE WAS NO DOCUMENTATION FOR SURVEILLANCE FOR PATIENT CARE EQUIPMENT PLUGGED INTO POWER STRIPS." ON 03/28/13 AT 2:20 P.M., THE ADMINISTRATOR WAS QUERIED AS TO THE POLICY ON POWER STRIPS AND EXTENSION CORDS STATED, " WE DO NOT HAVE A POLICY THAT SPECIFICALLY ADDRESSES POWER STRIPS OR EXTENSION CORDS." ( / )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROPERLY ASSESS AND TREAT AN OPEN WOUND FOR ONE (#807) OF 15 RESIDENTS REVIEWED FOR WOUNDS FROM A TOTAL SAMPLE OF 27, RESULTING IN A HOSPITAL TRANSFER FOR PARASITIC (MAGGOT) INFESTATION OF THE WOUND. FINDINGS INCLUDE: ON 3/26/13 AT 8:45 A.M., DURING AN INITIAL TOUR OF THE FACILITY, RESIDENT #807 WAS OBSERVED LYING IN BED ASLEEP. THE RESIDENT WAS LYING ON HER BACK WITH BILATERAL HEELS ELEVATED ON A CUSHION. RESIDENT #807'S MEDICAL RECORD WAS REVIEWED AND REVEALED A FACE SHEET INDICATING AN ADMISSION INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], REVEALED THAT THE RESIDENT'S COGNITION WAS SEVERELY IMPAIRED AND REQUIRED EXTENSIVE ASSISTANCE FOR BED MOBILITY AND TRANSFER AND WAS DEPENDENT ON STAFF FOR HYGIENE. REVIEWED OF RESIDENT #807'S ADL (ACTIVITY OF DAILY LIVING) FUNCTIONAL/RESTORATIVE ASSESSMENT, DATED 10/6/12, DOCUMENTED: "ALTERATIONS IN SKIN INTEGRITY: FISTULA:FOREHEAD." RESIDENT #807'S HISTORY AND PHYSICAL, DATED 10/10/12, REVEALED "CRANIOTOMY WITH FISTULA TUNNELING. HEAD: FOREHEAD WITH TUNNELING SECONDARY TO FISTULA FROM CRANIOTOMY." REVIEW OF RESIDENT #807'S PROGRESS NOTES REVEALED: ON "10/7/12 AT 1:31 A.M., PRESENCE OF FISTULA AT FOREHEAD; DRY AND NO DRAINAGE NOTED." ON 10/07/12 AT 02:32 A.M., AD, ADMISSION:WOUND CONSULT MADE. DR (RESIDENTS PHYSICIAN) NOTIFIED VIA VOICEMAIL." ON 10/12/12 AT 11:16 P.M., "PRESENCE OF OLD FISTULA AT THE FRONTO AREA OF THE FOREHEAD, WITH YELLOWISH DISCHARGE NOTED." ON 10/13/12 AT 4:47 A.M., "C/O (COMPLAINTS OF) PAIN...WHILE DOING TXT TO FOREHEAD...WOUND CARE: FISTULA AT THE FOREHEAD OPEN AND DRAINAGE WITH FOYL (FOUL) ODOR NOTED, WD (WOUND) CONSULT ORDERED AND TX (TREATMENT) WITH NS (NORMAL SALINE) AND WET TO DRY UNTIL SEEN BY MD AND TXT Q SHIFT ENCOURAGE RESIDENT NOT TO TOUCH THE TXT AREA." ON 10/13/12 AT 8:17 A.M., "ENDORSED BY PM NURSE FISTULA ON THE FOREHEAD IS OPENED AND DRAINAGE NOTED AND WRITER CHECKED THE FISTULA AND SMALL WHITISH DRAINAGE AND NO ODOR NOTED, CLEANSE WITH NS TO FISTULA AND WET TO DRY DRESSING COVER WITH GAUZE AND TAPE IT, CONTINUE TO MONITOR." ON 10/13/12 AT 3:30 P.M., "GENERAL LATE ENTRY FOR 10/12/12. 22:30 PATIENT'S FISTULA NOTED WITH PARASITIC ACTIVITY; SUPERVISOR NOTIFIED. FISTULA CLEANSED WITH WOUND CLEANER AND DRAINED; ATTEMPTED TO COLLECT THE PARASITES THAT ARE SURFACED AND OBTAINABLE; COVERED THE FISTULA WITH GAUZE; PATIENT COMPLAINS OF TOLERABLE PAIN...ENDORSED TO THE INCOMING NURSE AND THE SUPERVISOR REGARDING THE TREATMENT AND THE STATUS OF THE PATIENT..." ON 10/13/12 AT 8:56 A.M., "UPON ARRIVAL AT 7 AM SUMMONED TO ROOM BY STAFF TO ASSESS SITE IN THE CENTER OF FOREHEAD. UPON OBSERVATION NO ODOR DETECTED HOWEVER THE PRESENCE OF PARASITE ACTIVITY WAS EVIDENT MODERATE-LARGE AMOUNT RESIDENT WAS AGITATED AND CONTINUOUSLY DIGGING AT THE SITE WITH FINGERS...MD AND SUPERVISOR NOTIFIED UNABLE TO REACH PHYSICIAN SENT TO (HOSPITAL NAME) HOSPITAL DUE TO NURSING JUDGEMENT..." REVIEW OF RESIDENT #807'S "PATIENT TRANSFER DOCUMENTS (FROM THE HOSPITAL)," DATED 10/13/12 AT 23:30" NOTED THE FOLLOWING: "REASON FOR CONSULT: FOREHEAD WOUND INFECTION WITH LIVE MAGGOTS. THIS IS A [AGE] year OLD FEMALE WHO WAS BROUGHT INTO THE HOSPITAL FROM THE NURSING HOME WITH COMPLAINTS OF INCREASED TENDERNESS IN THE FOREHEAD CHRONIC WOUND WITH EVIDENCE OF MAGGOT INFESTATION OF THE WOUND. THE PATIENT APPARENTLY HAD A [MEDICAL CONDITION] AND HAD SURGERY OF THAT AND HAD A DRAIN PLACED THROUGH HER FOREHEAD. ONCE THE DRAIN WAS REMOVED, THE PATIENT HAD A NONHEALING WOUND IN THE FISTULA. IMPRESSION: MID FOREHEAD INFECTED WOUND WITH LIVE MAGGOTS AND SURROUNDING [MEDICAL CONDITION]. RECOMMENDATIONS: WE WOULD RECOMMEND A SURGICAL DEBRIDEMENT AND MANUAL REMOVAL OF THE MAGGOTS." ON 3/26/13 AT 2:20 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED WHETHER AND UNUSUAL OCCURRENCE/INCIDENT REPORT WAS FILLED OUT FOR THE INCIDENT WITH RESIDENT #807 AND THE PARASITES. THE DON STATED, "I DON'T REMEMBER. SHE HAD COME BACK FROM THE HOSPITAL BEFORE THAT. WHEN WE NOTICED AN ISSUE WE SENT HER TO THE HOSPITAL. THERE WAS NO REPORT BECAUSE SHE HAD ALREADY HAD AN OPEN AREA." ON 3/27/13 AT 9:23 A.M., RESIDENT #807'S NURSE (NURSE "I") WAS QUERIED REGARDING THE SEQUENCE OF EVENTS THAT TOOK PLACE LEADING UP TO RESIDENT #807'S DISCHARGE TO THE HOSPITAL DUE TO MAGGOT INFESTATION OF THE FOREHEAD WOUND. NURSE "I" STATED, "I WAS TOLD BY THE CNA (CERTIFIED NURSING ASSISTANT) THERE WAS ACTIVITY. WHEN I SEEN IT, THE DRESSING WAS OFF. IT WAS HORRIFYING. WHEN I SAY HORRIFYING, I MEAN IT WAS HORRIFYING! THE NURSE WAS TRYING TO CONTAIN THE SITUATION. THE AREA (FOREHEAD WOUND) WAS OPEN, THEY (THE MAGGOTS) WERE TRYING TO GET OUT. THERE WAS...A LOT. I CALLED THE AMBULANCE AND ARRANGED FOR HER DISCHARGE." ON 3/27/13 AT 10:55 A.M., THE DON WAS QUERIED REGARDING THE INCIDENT WITH RESIDENT #807 AND THE PARASITES AND REVEALED "WE DIDN'T DEAL WITH THE FISTULA BECAUSE THE FAMILY SAID IT WAS FROM SURGERY FROM A TUMOR THAT WOULDN'T HEAL. THE EDGES OF THE WOUND WERE ROLLED OVER AND DRY, YOU COULD SEE INTO IT. THERE WAS NO TREATMENT IN PLACE. SHE STARTED TO HAVE DRAINAGE. WHEN THEY ATTEMPTED TO CLEAN IT OUT (THE FISTULA), THEY SEEN MAGGOTS AND SENT HER OUT." THE DON WAS QUERIED REGARDING THE PLAN OF CARE FOR THE FOREHEAD AREA PRIOR TO DISCHARGE AND STATED, "I AM NOT SURE WHEN THE AREA STARTED TO DRAIN. I AM UNSURE IF IT WAS DRAINING UPON RE-ADMISSION. IF IT WAS DRAINING WOUND CARE WOULD BE CONSULTED. IF THERE WAS TUNNELING THERE WOULD HAVE TO BE A TREATMENT." THE DON WAS QUERIED AS TO WHY THERE WAS NO TREATMENT ORDERED WHEN THE PHYSICIAN NOTED THE FISTULA WITH TUNNELING ON 10/10/12 AND STATED, "THAT'S WHEN YOU THINK A TREATMENT WOULD BE ORDERED. THE WOUND CONSULT WOULD TAKE PLACE AND ORDER FOR TREATMENT PUT IN PLACE. I WOULD HAVE THOUGHT THAT A TREATMENT ORDER WOULD HAVE BEEN WRITTEN THEN. REVIEW OF RESIDENT #807'S PHYSICIAN ORDERS [REDACTED].M. ON 3/27/13 AT 2:35 P.M., WOUND CARE NURSE, NURSE "G" WAS ASKED TO PROVIDE DOCUMENTATION OF THE SIZE AND CHARACTERISTICS OF RESIDENT #807'S FOREHEAD WOUND AND STATED, "I KNEW ABOUT THE AREA BUT NEVER GOT A REFERRAL FOR IT. I WOULDN'T HAVE ANY WOUND DOCUMENTATION IF I DID NOT HAVE A REFERRAL." NURSE "G" WAS FURTHER QUERIED REGARDING THE WOUND CONSULT ORDERS NOTED IN THE NURSING NOTES ON 10/7/12 AND STATED, "SHE WAS NOT SEEN BY WOUND CARE." ON 3/28/13 AT 2:50 P.M., ACTIVITY ASSISTANT (EMPLOYEE "K") WAS QUERIED REGARDING AN INCIDENT THAT HAPPENED DAYS PRIOR TO RESIDENT #807'S TRANSFER TO THE HOSPITAL. EMPLOYEE "K" STATED, "WE WERE IN THE DINING ROOM DOING ACTIVITIES. I SEEN A FLY CIRCLING (RESIDENT #807'S) HEAD. I KNEW SHE HAD THAT OPENING IN THE MIDDLE OF HER FOREHEAD SO I BROUGHT HER TO THE DESK TO LET THEM KNOW. I JUST KNEW IT WAS NOT GOOD TO HAVE FLIES AROUND OPEN WOUNDS. I JUST WANTED THEM TO PUT A BANDAGE ON IT OR SOMETHING." ON 3/29/13 AT 12:10 P.M., RESIDENT #807'S NURSE PRACTIONER, NP "Q" WAS QUERIED REGARDING THE AREA TO RESIDENT #807'S FOREHEAD. NP "Q" WAS FAMILIAR WITH RESIDENT #807'S FOREHEAD WOUND, AND HAD LAST SEEN HER IN SEPTEMBER PRIOR TO HER RE-ADMIT IN OCTOBER. NP "Q" STATED, "(THE RESIDENT) HAD THAT AREA FOR MANY YEARS. IT WAS A WOUND THAT WOULDN'T HEAL. THERE WAS ALWAYS A SCAB OR YELLOWISH/GREENISH DISCHARGE. THE WOUND LOOKED LIKE AN OPEN LESION THAT WAS DRAINING." ON 3/29/13 AT 3:25 P.M., THE FACILITY'S MEDICAL DIRECTOR WAS QUERIED REGARDING THE INCIDENT WITH RESIDENT #807 AND THE PARASITES. THE MEDICAL DIRECTOR STATED, "I WAS NOT INFORMED. THERE ARE PROTOCOLS AS THE MEDICAL DIRECTOR THAT I NEED TO FOLLOW. IT WAS NOT BROUGHT TO MY ATTENTION. TYPICALLY, A FULL SKIN SWEEP IS DONE IN THE FIRST 24 HOURS. THE PHYSICIAN WILL SEE THE RESIDENT IN THE FIRST 24-48 HOURS. IF AN OPEN WOUND IS FOUND WITH THE PHYSICIAN'S ASSESSMENT, THE FIRST THING WOULD BE TO KEEP IT CLEAN. START WITH SOAP AND WATER. AN ANTIBIOTIC MAY BE PUT INTO PLACE, TO BUY SOME TIME UNTIL SEEN BY THE WOUND SPECIALIST. THEN FOLLOW WITH THE TREATMENT RECOMMENDATIONS FROM THE WOUND CARE SPECIALIST." THE FACILITY'S POLICY TITLED, "ADMISSION SKIN ASSESSMENT," NO DATE, REVEALED "ALL NEW ADMISSIONS WILL HAVE A COMPLETE SKIN ASSESSMENT BY A LICENSED NURSE. LICENSED NURSE WILL: COMPLETE A FULL HEAD-TO-TOE ASSESSMENT OF THE RESIDENT WITHIN 24 HOURS OF ADMISSION. IF ANY ABNORMALITIES ARE NOTED BY THE ADMITTING NURSE, TREATMENT ORDERS WILL BE EITHER VERIFIED OR OBTAINED PER PROTOCOL." THE FACILITY'S POLICY TITLED, "treatment of [REDACTED]. CHARGE NURSE WILL: EVALUATE THE WOUND CHARACTERISTICS. MEASURE THE WOUND. NOTIFY PHYSICIAN AND GET ORDER FOR TREATMENT. INITIATE TREATMENT ADMINISTRATION RECORD AND DOCUMENT WOUND MEASUREMENT AND CHARACTERISTICS. PROVIDE TREATMENT AS ORDERED. MAKE APPROPRIATE REFERRALS...DOCUMENT ON 24-HOUR REPORT AND NURSES NOTES." ( )

THIS CITATION REFERS TO INTAKE NUMBER MI 365. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO TURN AND REPOSITION 4 (#102, #103, #106, #108) OF 5 SAMPLED RESIDENTS REVIEWED FOR PRESSURE ULCER FORMATION, FROM A TOTAL SAMPLE OF 9 RESIDENTS, RESULTING IN THE DEVELOPMENT OF A PRESSURE ULCER WHICH PROGRESSED TO AN INFECTION IN THE BONE (OSTEO[DIAGNOSES REDACTED]) FOR RESIDENT #102. FINDINGS INCLUDE: DURING A TELEPHONE INTERVIEW WITH THE DAUGHTER OF RESIDENT #102 (FAMILY MEMBER/FM #22) ON 2/5/2013 AT 1:00 PM, FM #22 SAID THAT THE FACILITY DID NOT INFORM HER (#22) OF THE ONSET OF A WOUND TO RESIDENT #102'S FOOT DURING A CARE CONFERENCE, PRIOR TO RESIDENT #102'S DISCHARGE TO THE hospital on [DATE]. FM #22 SAID WHEN THEY GOT TO THE HOSPITAL, THE FAMILY WAS INFORMED BY THE HOSPITAL STAFF THAT RESIDENT #102 HAD SEVERAL WOUNDS "ALL OVER HER BACK, ONE SORE AS BIG AS A FIST." FM #22 SAID THEY (THE FACILITY) LEFT HER (RESIDENT #102) IN BED ALL DAY AND NEVER TURNED HER OR REPOSITIONED HER (RESIDENT #102). AN UNANNOUNCED COMPLAINT INVESTIGATION WAS BEGUN ON 2/4/13. THE PROTOCOL FOR THE ABBREVIATED SURVEY WAS FOLLOWED IN CONDUCTING THE INVESTIGATION. RESIDENT #102 ACCORDING TO THE FACILITY FACE SHEET, THE RESIDENT OF CONCERN WAS A [AGE] year OLD WOMAN, INITIALLY admitted to the facility on [DATE] AND MOST RECENTLY REadmitted on [DATE]. THE HISTORY AND PHYSICAL DATED 12/20/2012 INDICATED THAT RESIDENT #102 had a history of [REDACTED]. RESIDENT #102 WAS NOT IN THE FACILITY AT THE TIME OF THE INVESTIGATION. A MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #102 WAS SEVERELY COGNITIVELY IMPAIRED AND UNABLE TO MAKE HER NEEDS KNOWN. THE RESIDENT WAS TOTALLY DEPENDENT ON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING. THE FACILITY TRANSFER FORM INDICATED THE RESIDENT #102 WAS TRANSFERRED TO THE LOCAL HOSPITAL AS A DIRECT ADMISSION ON 12/6/2012 FOR "WOUND INFECTION." THE physician progress notes [REDACTED]. TRANSFER TO LOCAL HOSPITAL FOR F/U (FOLLOW-UP) E (EVALUATION) AND T (TREATMENT.)" ACCORDING TO THE WOUND CARE SPECIALIST DOCUMENTATION DATED 12/5/2012, RESIDENT #102 HAD TWO (2) NON-HEALING WOUNDS, ONE ON THE RIGHT HEEL MEASURING 4 CM X 3.5 CM AND ONE ON THE RIGHT LATERAL FOOT, MEASURING 3 CM X 2.5 CM. BOTH WOUNDS ARE "UNSTAGABLE WITH GREATER THAN 50% NECROTIC TISSUE," AND "HAD PARTIAL THICKNESS DISTRIBUTION." THE DURATION WAS INDICATED AS "FOR OVER ONE MONTH." THE TIMING INDICATED THAT THE WOUND DEVELOPED AT THE NURSING FACILITY. DURING AN INTERVIEW WITH THE LICENSED PRACTICAL NURSE (LPN) WHO SERVED AS THE FACILITY WOUND NURSE (WCN) #3 ON 2/4/2013 AT 10:40 AM, WCN #3 SAID THAT STAFF NOTIFIED HER (#3) WHEN ANY RESIDENT WAS FOUND TO HAVE ANY NEW WOUNDS, DOCUMENTED ON THE SHOWER SHEETS COMPLETED BY THE CERTIFIED NURSE AIDES (CNA). WCN #3 SAID THAT SHE MEASURED ALL WOUNDS AND RECORDED THEM ON A WOUND SHEET WEEKLY FOR EACH INDIVIDUAL RESIDENT. WCN #3 SAID THAT SHE MONITORED THE EFFECTIVENESS OF WOUND TREATMENT BY THE REDUCTION IN SIZE OF THE WOUND. WCN #3 SAID THAT THE WOUND CARE PHYSICIAN ALSO SAW RESIDENTS ON A MONTHLY BASIS. WCN #3 PROVIDED A LIST OF RESIDENTS IN THE FACILITY WITH WOUNDS. ACCORDING TO WCN #3, RESIDENT #102 HAD A COCCYX WOUND, IDENTIFIED ON 9/27/12 THAT RESOLVED ON 11/14/2012. RESIDENT #102 ALSO HAD A RIGHT BUTTOCK WOUND MEASURING 1.0 X 1.0 CM THAT WAS RESOLVED ON 7/19/2012. WCN # 3 SAID THAT RESIDENT #102 DID NOT HAVE ANY OPEN WOUNDS OTHER THAN THE ONE ON HER RIGHT HEEL WHEN THE RESIDENT left the faciity on [DATE]. WCN #3 SAID THE PRESSURE ULCER DEVELOPED FROM USE OF A POSITIONING DEVICE THAT WAS USED ON RESIDENT #102'S RIGHT FOOT AND LEG. WCN #3 SAID THAT WHEN RESIDENT #102 RETURNED to the facility on [DATE], THE RESIDENT HAD SEVERAL OPEN WOUNDS WHICH HAD BEEN DEBRIDED AT THE HOSPITAL. WCN #3 WAS NOT ABLE TO EXPLAIN HOW RESIDENT #102 WAS FOUND TO HAVE PRESSURE ULCERS ON HER (#102) BACK WHEN SHE WAS admitted TO THE LOCAL ACUTE CARE HOSPITAL. RESIDENT #102'S HOSPITAL RECORDS INDICATED THE INITIAL HISTORY AND PHYSICAL WERE DICTATED ON 12/6/2012 AT 11:46 PM, BY THE ATTENDING PHYSICIAN, WHICH INDICATED THAT RESIDENT #102 WAS A "DIRECT ADMISSION (BY-PASSED THE emergency room ) TO THE HOSPITAL FOR [MEDICAL CONDITION] (ELEVATED BLOOD SODIUM) AND A FOOT ULCER." THE PHYSICAL EXAMINATION INDICATED "PRESSURE ULCER OF THE RIGHT HEEL, FROM HEEL UP THE POSTERIOR ANKLE." HIS NOTE INDICATED THE PRESSURE ULCER DEVELOPED AT THE NURSING FACILITY. NURSE PRACTITIONER NOTES, DATED 12/7/2012 AT 7:29 AM, DOCUMENTED THAT THE PHYSICAL EXAMINATION OF RESIDENT #102 INCLUDED "RIGHT FOOT SWOLLEN AND WITH ODOR. RIGHT LATERAL HEEL WITH BLACK, MUSHY WOUND. MEASURING 5.0 X 5.5 CM. RIGHT LATERAL FOOT WITH DRY BLACK ESCHAR MEASURING 2.5 X 3.5 CM. COCCYX AREA WITH STAGE 2 SUPERFICIAL PINK BASED WOUND MEASURING 2.0 X 2.0 CM. RIGHT HIP WITH DARKER BROWN SKIN COMPARED TO REST OF BODY SKIN DOES NOT BLANCHE. MEASURES 5.0 X 2.0 CM. RIGHT ISCHIAL WITH MOIST DARK RED/BLACK BASED WOUND MEASURING 3.0 X 3.0 CM." THE HOSPITAL OPERATIVE NOTE OF 12/12/12 FOR RESIDENT #102, INDICATED "STAGE IV DECUBITUS ULCERS OF RIGHT ISCHIUM, RIGHT LATERAL FOOT AND RIGHT HEEL. EXCISION AND DEBRIDEMENT OF RIGHT ISCHIAL DECUBITUS ULCER OF DEFECT 4 CM X 5 CM , RIGHT HEEL ULCER WITH CALCANECTOMY (REMOVAL OF CALCANEAL BONE) SIZE OF DEFECT 6 CM X 5.5 CM, RIGHT LATERAL FOOT DECUBITUS ULCER WITH OSTECTOMY (REMOVAL) OF 5TH METATARSAL BONE WITH SIZE OF DEFECT 4 CM X 3 CM." RESIDENT #103 ACCORDING TO THE FACILITY FACE SHEET, RESIDENT #103 WAS A [AGE] year OLD WOMAN, LONG TERM RESIDENT, MOST RECENTLY REadmitted on [DATE]. THE FACILITY HISTORY AND PHYSICAL DATED 1/11/2013 NOTED [DIAGNOSES REDACTED]. A MINIMUM DATA SET (MDS) ASSESSMENT DOCUMENTED THAT RESIDENT #103 REQUIRED EXTENSIVE ASSISTANCE OF THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING. RESIDENT #103 WAS NON-AMBULATORY. A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORE OF 3 INDICATING SIGNIFICANT COGNITIVE IMPAIRMENT. ACCORDING TO NURSING NOTES DATED 12/22/2012 THROUGH 2/3/2012, RESIDENT #103 WAS ALERT TO NAME ONLY. RESIDENT #103 WAS OBSERVED ON 2/4/2013 AT 12:03 PM LYING IN HER BED WITH THE HEAD OF THE BED AT A 30 DEGREE ANGLE. AT 12:30 PM, A CERTIFIED NURSING ASSISTANT (CNA) WAS OBSERVED SITTING AT THE BEDSIDE, FEEDING RESIDENT #103. RESIDENT #103 REMAINED IN THE SAME POSITION AT THE FOLLOWING TIMES: 1:03 PM, 1:33 PM, 2:05 PM AND 2:45 PM. RESIDENT #106 ACCORDING TO THE FACILITY FACE SHEET, RESIDENT #106 WAS A [AGE] year OLD MAN, admitted to the facility on [DATE]. THE HISTORY AND PHYSICAL DATED 12/28/2012 INDICATED THAT RESIDENT #106 HAD [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) ASSESSMENT INDICATED THAT RESIDENT #106 WAS UNABLE TO UNDERSTAND OR BE UNDERSTOOD OR MAKE HIS NEEDS KNOWN. HE WAS TOTALLY DEPENDENT ON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING. ACCORDING TO THE physician progress notes [REDACTED]. RESIDENT #106 WAS INCONTINENT OF BOWEL AND BLADDER. ON 2/4/2013, RESIDENT #106 WAS OBSERVED AT LYING ON HIS BACK, WITHOUT A PILLOW OR WEDGE AND REMAINED IN THAT SAME POSITION AT CHECKS AT 12:00 PM, 1:30 PM, 2:00 PM, AND 2:40 PM. RESIDENT #108 ACCORDING TO THE FACILITY FACE SHEET, RESIDENT #108 WAS A [AGE] year OLD MAN admitted to the facility on [DATE]. THE HISTORY AND PHYSICAL DATED 1/29/2012 INDICATED THAT RESIDENT #108 HAD [DIAGNOSES REDACTED].\STROKE), [MEDICAL CONDITION] (A MALFUNCTION OF THE BRAIN), HYPERTENSION (HIGH BLOOD PRESSURE), AND [MEDICAL CONDITION] DISORDER. THE RESIDENT HAD A [MEDICAL CONDITION] IN PLACE. THE MINIMUM DATE SET (MDS) assessment dated [DATE], INDICATED THAT RESIDENT #108 WAS UNABLE TO UNDERSTAND OR BE UNDERSTOOD OR MAKE HIS NEEDS KNOWN. THE RESIDENT WAS NON-VERBAL AND UNABLE TO COMPLETE A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS). RESIDENT #108 WAS TOTALLY DEPENDENT ON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING. THE RESIDENT WAS INCONTINENT OF BOWEL AND BLADDER, AND USED A CONDOM CATHETER. ON 2/4/2013, RESIDENT #108 WAS OBSERVED LYING ON HIS BACK WITH HIS HEAD AT A 30 DEGREE ANGLE AND REMAINED IN THAT SAME POSITION AT EACH CHECK AT 12:02 PM, 1:02 PM, 1:31 PM, 2:02 PM, AND 2:44 PM. OBSERVATION AT 2:02 PM REVEALED THAT RESIDENT #108 HAD NOT BEEN DRESSED OR GOTTEN OUT OF BED SINCE 12:02 PM. THE CARE PLAN FOR RESIDENT #108 INDICATED THE "RESIDENT WILL BE WELL GROOMED AND DRESSED APPROPRIATELY DAILY," AND "IN STREET CLOTHING DAILY." THE PAIN CARE PLAN INDICATED INTERVENTION "REPOSITION AS NEEDED FOR COMFORT." ON 2/4/13, AT 2:45 PM, DURING AN INTERVIEW WITH REGISTERED NURSE (RN) #6, THE UNIT MANAGER, SHE WAS ASKED WHY RESIDENTS #103, #106 AND #108 HAD NOT BEEN TURNED. RN #6 SAID THAT SHE WOULD HAVE TO CHECK WITH THE CNA ASSIGNED. RN #6 SAID THAT RESIDENT #108 "COULD NOT BE TURNED BECAUSE HE HAS A [MEDICAL CONDITION]." AT 3:00 PM ON 2/4/2013, DURING AN INTERVIEW WITH THE CERTIFIED NURSE ASSISTANT (CNA) #9, WHO WAS RESPONSIBLE FOR GIVING CARE TO #103 AND #106, SHE SAID THAT SHE DID NOT TURN RESIDENT #106 " BECAUSE HE MOVES ALL AROUND IN THE BED." WHEN ASKED WHY SHE DID NOT TURN RESIDENT #103, CNA #9 SAID, "SHE'S (#103) NOT USUALLY IN THE BED ALL DAY. I GUESS I FORGOT (TO REPOSITION HER)." ON 2/4/2013 AT 3:20 PM, DURING AN INTERVIEW WITH DIRECTOR OF NURSING (DON) #2, DON #2 SAID THAT EVEN WITH A [MEDICAL CONDITION], RESIDENT #108 STILL NEEDED TO BE TURNED. DON #2 SAID "THERE IS NO EXCUSE FOR NOT TURNING THE RESIDENTS." DON #2 HAD NO EXPLANATION AS TO WHY RESIDENTS #103 OR #106 HAD NOT BEEN TURNED AND REPOSITIONED DURING THE AFTERNOON.

THIS CITATION PERTAINS TO INTAKE NUMBER (S): MI 526, MI 558 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE WOUND CARE AND TIMELY NURSING INTERVENTION FOR THREE RESIDENTS (#501, #503, #504) OF 4 SAMPLED RESIDENTS, ALL REVIEWED FOR WOUND CARE FROM A TOTAL SAMPLE OF 4, IN ACCORDANCE WITH THE physician's orders [REDACTED].#501'S WOUND. FINDINGS INCLUDE: #501 A REVIEW OF THE FACILITY ADMISSION SHEET REVEALED THAT RESIDENT #501 WAS AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. AN "ADMISSION PHYSICIAN HEALTH & PHYSICAL FORM," DATED 7/23/11 NOTED THAT #501 WAS admitted WITH CHRONIC STASIS ULCERS, CHRONIC BILATERAL LOWER EXTREMITY MALLEOLAR WOUNDS AND HAD ADDITIONAL [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED THAT #501 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE FROM STAFF WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, LOCOMOTION ON AND OFF THE UNIT, DRESSING, TOILETING, PERSONAL HYGIENE AND BATHING. RESIDENT #501 WAS NON AMBULATORY. A COMPLAINT ON FILE ALLEGED "...THE RESIDENT WAS admitted to the hospital with [REDACTED]. ACCORDING TO A FAXED DOCUMENT, DATED 6/20/12, RELATED TO treatment for [REDACTED].#501) IS GETTING SKIN GRAFTS TO HER LEFT FOOT/ANKLE AND THE WRAP CANNOT BE REMOVED. ANY QUESTIONS PLEASE CALL US..." UPON REVIEW OF THE CLOSED CLINICAL RECORD FOR RESIDENT #501, THE "REPORT OF CONSULTATION" DOCUMENTS REVEALED THE FOLLOWING: 6/4/12 "...VENOUS STASIS WITH ULCERS, LEFT. DERMAGRAFT (WOUND CARE PRODUCT) WAS APPLIED AT THIS VISIT. PLEASE KEEP DRESSINGS CLEAN, DRY AND INTACT UNTIL FOLLOW UP VISIT NEXT WEEK..." 6/25/12 "...DIABETES WITH ULCERS (LEFT), VENOUS STASIS (BILATERAL), KEEP DRESSINGS INTACT..." 7/2/12 "...DIABETES WITH ULCER, DERMAGRAFT APPLIED, KEEP DRESSING CLEAN DRY AND INTACT..." 7/9/12 "...KEEP DRESSING CLEAN DRY AND INTACT, FOLLOW UP IN ONE WEEK..." 7/16/12 "...DIABETES WITH ULCERATION, [MEDICAL CONDITION], DERMAGRAFT APPLICATION TODAY, KEEP DRESSINGS CLEAN, DRY AND INTACT..." 7/23/12 "...DERMAGRAFT APPLIED, UNNA (COMPRESSION BANDAGE FOR treatment of [REDACTED]. 7/30/12 "...DERMAGRAFT APPLIED, UNNA TO BILATERAL EXTREMITIES, ELEVATION WITH PILLOWS TO HELP WITH DECREASING DRAINAGE. FOLLOW UP IN ONE WEEK..." 8/6/12 "...DIABETES WITH ULCERATIONS, [MEDICAL CONDITION], WE HAVE COMPLETED ALLOTTED DERMAGRAFTS. DRESSING APPLIED, COVERED WITH MEDI-HONEY (MEDICAL GRADE HONEY USED FOR CHALLENGING WOUNDS), 4 X 4'S (GUAZE), KLING (DRESSING WRAP), UNNA BOOT BILATERAL. CHANGE DRESSING ON THURSDAYS - MEDI-HONEY TO ULCER BASES COVERED WITH UNNA BOOT..." 8/13/12 "...PLEASE CHANGE DRESSING THURSDAY. ELEVATE BILATERAL LOWER EXTREMITIES, FOLLOW UP ONE WEEK..." 8/20/12 "...DEBRIDEMENT TODAY - CLEANSED WITH WOUND CLEANSER, MEDI-HONEY AND UNNA BOOT. CONTINUE WITH DRESSING CHANGES..." NURSE'S NOTES REVIEWED FOR THE MONTH OF JULY 2012 REVEALED NO DOCUMENTED EVIDENCE THAT DRESSINGS WERE CHANGED OR REINFORCED TO ENSURE THAT THEY WERE KEEP CLEAN DRY AND INTACT IN ACCORDANCE WITH THE physician's orders [REDACTED]. A NURSE'S NOTE DATED 8/19/12 DOCUMENT, "...PER THE DOCTOR'S REQUEST I (WOUND CARE COORDINATOR/LICENSED PRACTICAL NURSE # 1) CHANGED THE WRAPPING ON (RESIDENT #501'S) LEFT ANKLE. THE AREA IS RED AND YELLOW, MOIST WITH SEROUS DRAINAGE, NO ODOR DETECTED. THE LEFT LATERAL ANKLE MEASURES 7.9 X 8.0, LEFT MEDIAL ANKLE 5.0 X 4.5..THE ANKLE WAS RE-WRAPPED WITH 4 X 4'S AND MEDI-HONEY, KERLIX (DRESSING) AND COBALT (BANDAGE), NO PAIN NOTED..." THERE WAS NO DOCUMENTED EVIDENCE THAT ANY OTHER DRESSING CHANGES WERE PERFORMED FOR THE MONTH OF AUGUST 2012. FURTHER, THERE WAS NO DOCUMENTED EVIDENCE THAT #501'S DRESSINGS HAD BEEN ASSESSED AND KEPT CLEAN AND DRY. A REVIEW OF THE FACILITY'S "ADMINISTRATION RECORD" FOR JULY 2012 REVEALED THAT INITIALS HAD BEEN PLACED IN THE BOX DATED 7/1/12, HOWEVER, THERE WAS NO DOCUMENTED EVIDENCE THAT RESIDENT #501'S DRESSINGS HAD BEEN CHANGED ON THAT DATE. A REVIEW OF THE FACILITY'S "ADMINISTRATION RECORD" FOR AUGUST 2012 REVEALED THAT INITIALS HAD BEEN PLACED IN THE BOX DATED 8/12/12, HOWEVER, THERE WAS NO DOCUMENTED EVIDENCE THAT RESIDENT #501'S DRESSINGS HAD BEEN CHANGED ON THAT DATE. A REVIEW OF THE "PATIENT TRANSFER FORM" DATED 8/26/12, REVEALED THAT RESIDENT #501 WAS TRANSFERRED TO A NEARBY HOSPITAL FOR "...WOUND INFECTION BILATERAL FEET AS EVIDENCED BY FOUL SMELLING ODOR, PAIN AND DRAINAGE..." A REVIEW OF THE HOSPITAL "EMERGENCY DEPARTMENT REPORT SHEET" DATED 8/26/12 REVEALED, "...admitting [DIAGNOSES REDACTED]. WOUND IRRIGATED WITH HYDROGEN PEROXIDE TO ELIMINATE MAGGOTS AND REDRESSED..." AN "EMERGENCY DEPARTMENT NOTE-PHYSICIAN" DATED 8/26/12 DOCUMENTED, "...THE LEFT FOOT HAS VERY MALODOROUS DRAINAGE AND THEN REVEALING ULCERATION IN THE LEFT MEDIAL HEEL WITH MAGGOTS AND THEN SOME SURROUNDING FLIES. THE PATIENT HAS A VERY MALODOROUS FOR INFECTION WITH MAGGOTS. THE PATIENT INITIALLY HAD WOUND CULTURES, [MEDICATION NAME] (ANTIBIOTIC) GIVEN. THE NURSE DID CLEAN OUT THE MAGGOTS WITH HYDROGEN PEROXIDE AFTER RECOMMENDATION FROM PODIATRY..." THE REPORT FURTHER NOTED, "...DISPOSITION: THE PATIENT IS admitted . PLEASE NOTE THAT DUE TO THE PATIENT HAVING MAGGOTS IN HER HEEL AND SKIN, THERE WAS A QUESTION AS TO POSSIBILITY OF NEGLECT DUE TO LACK OF BANDAGE CHANGES. THERE HAS BEEN A NURSING REPORT MADE TO ADULT ABUSE FOR POSSIBILITY OF NEGLECT GIVEN THE PATIENT'S CONDITION..." A "REPORT OF CONSULTATION" DATED 3/20/12 REVEALED, "...LEFT ANKLE: LATERAL ULCER MEASURES 4.3 X 5.2 X 0.2 CM (CENTIMETERS). MEDIAL ULCER MEASURES: 3.4 X 3.1 X 0.2 CM. NO SIGNS OF INFECTION. RECOMMENDATIONS: CONTINUE DRESSING CHANGES WEEKLY..." ON 9/12/12 AT 11:30 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) WAS QUERIED ABOUT WHY RESIDENT #501 WAS TRANSPORTED TO THE HOSPITAL. THE DON REPORTED, "...HER WOUND WAS WORSENING AND DRAINING. SHE HAD WOUNDS TO HER LOWER EXTREMITIES (LE) AND SHE HAD GRAFTS DONE, AND THEN WAS ORDERED TO HAVE PRESSURE DRESSINGS ONCE A WEEK. SHE HAD POOR CIRCULATION AND HER CONDITION WAS CHANGING..." ON 9/13/12 AT 11:20 A.M., THE DON WAS QUERIED ABOUT RESIDENT #501'S LAST DRESSING CHANGE BY NURSING STAFF PRIOR TO BEING SENT OUT TO THE HOSPITAL. THE DON REPORTED, "...HER (#501) WOUNDS WERE BEING ADDRESSED BY THE WOUND CLINIC. THE NURSES DID THE DRESSINGS IF ORDERED BY THE WOUND CLINIC DOCTOR..." THE DON REVIEWED THE FACILITY'S NURSE'S NOTES DATED 8/19/12, WHICH REVEALED THAT LICENSED PRACTICAL NURSE (LPN) #1 WAS INSTRUCTED TO CHANGE RESIDENT #501'S DRESSINGS. ACCORDING TO THE DON, NO FURTHER DRESSING CHANGES WERE PERFORMED PRIOR TO #501 BEING TRANSFERRED TO THE hospital on [DATE]. ON 9/13/12 AT 11:45 A.M., DURING AN INTERVIEW, THE MEDICAL DIRECTOR REPORTED, "...HER (#501) WOUNDS GOT WORSE AND INITIALLY, HER DRESSINGS WERE TO BE CHANGED BY THE PHYSICIAN ONLY. THE NURSES SHOULD STILL LOOK AT THE WOUND AND ASSESS FOR ODOR, DISCHARGE AND REDNESS..." THE MEDICAL DIRECTOR FURTHER REPORTED, "...THE ORDER WAS FINALLY CHANGED AFTER A YEAR AND A HALF. THE NURSES ONLY CHANGED THE DRESSING ONCE IN THE LAST THREE WEEKS. THE WOUND CARE SPECIALIST CHANGED THE ORDERS TO CHANGE THE DRESSINGS ON THURSDAY, BUT THEY DIDN'T SPECIFY WHEN (TIME OF DAY)...WHEN THE NURSE (REGISTERED NURSE #2) CALLED ME, I ASSUMED THAT SHE ACTUALLY ASSESSED THE WOUND BEFORE SHE CALLED ME FOR ORDERS TO SEND HER OUT TO THE HOSPITAL. NURSES HAVE TO DO THEIR PART..." WHEN QUERIED ABOUT THE MAGGOTS FOUND IN #501'S WOUND, THE MEDICAL DIRECTOR REPORTED, "...THAT'S JUST DISGUSTING! I'M GOING TO HAVE TO SPEAK WITH THE NURSES REGARDING ASSESSING THE RESIDENT AND THEIR SKIN (CARE)..." ON 9/13/12 AT 12:17 P.M., DURING A SUBSEQUENT INTERVIEW, THE DON WAS ASKED WHY #501'S DRESSINGS HAD NOT BEEN CHANGED IN ACCORDANCE WITH THE physician's orders [REDACTED]. THE DON FURTHER REPORTED, "...THE NURSE (REGISTERED NURSE #2) WHO SENT HER (#501) OUT DIDN'T EVEN TELL ME SHE WAS SENDING HER OUT. (RESIDENT #501) WAS SENT OUT BECAUSE HER WOUND WAS DRAINING..." WHEN ASKED IF RESIDENT #501'S WOUND HAD BEEN ASSESSED PRIOR TO SENDING HER TO THE HOSPITAL, THE DON REPORTED, "...NO. AT THE VERY LEAST, YOU SHOULD ASSESS THE ACTUAL WOUND. I MEAN, SHE'S (RN #2) AN RN (REGISTERED NURSE)..." WHEN ASKED WHY THE RECOMMENDATIONS/ORDERS ON THE PHYSICIAN'S CONSULT FORMS WERE NOT CARRIED OUT, THE DON REPORTED, "...THE ORDERS GOT MISSED BECAUSE THERE WERE NO ORDERS WRITTEN IN THE physician's orders [REDACTED]. SHE (MEDICAL DIRECTOR) COULD HAVE WRITTEN ORDERS TOO, BUT THERE WERE NO ORDERS WRITTEN..." ON 9/13/12 AT 12:50 P.M., DURING AN INTERVIEW, THE WOUND CARE COORDINATOR (LPN #1) REPORTED, "EARLIER IN THE YEAR, I WAS CHANGING THE DRESSINGS BUT WHEN SHE (#501) GOT THE DERMAGRAFT ON, WE STOPPED CHANGING THEM. THE CONSULT SHEET CAME IN AND I DIDN'T SEE THE ORDERS THAT WERE WRITTEN TO CHANGE THE DRESSINGS UNTIL THE FOLLOWING SUNDAY. IT WASN'T MY UNDERSTANDING THAT IT WAS TO BE CHANGED WEEKLY. IT WAS AN UNFORTUNATE OVERSIGHT. THE MEDICAL DIRECTOR BROUGHT IT TO MY ATTENTION AFTER SHE (#501) WENT TO ANOTHER FACILITY. THE MEDICAL DIRECTOR ALSO INFORMED ME THAT MAGGOTS HAD BEEN FOUND IN (RESIDENT #501'S) WOUND..." UPON REVIEW OF THE CLINICAL RECORD, THE LAST WOUND CARE NOTE ENTERED BY THE WOUND CARE COORDINATOR (LPN #1) WAS DATED 5/28/12. ON 9/13/12 AT 1:45 P.M., DURING AN INTERVIEW, RN #2 REPORTED, "...I SENT (RESIDENT #501) OUT TO THE HOSPITAL BECAUSE OF THE STENCH THAT WAS IN HER ROOM. I WAS PASSING MEDICATIONS AND SOMEONE TOLD ME THAT (RESIDENT #501) WAS COMPLAINING OF PAIN TO HER LEGS SO I WENT INTO HER ROOM. I ALSO WENT INTO HER ROOM BECAUSE WHEN I PASSED BY HER ROOM, THERE WAS A VERY STRONG ODOR..." RN #2 FURTHER REPORTED THAT "WHEN I WENT IN (ROOM OF RESIDENT #501), I SAW THAT HER DRESSING WAS SOAKED. I DIDN'T SEE AN ORDER TO CHANGE IT SO I DIDN'T UNWRAP IT. THE SMELL WAS SO BAD THAT I STARTED TO GAG SO I LEFT THE ROOM AND CALLED THE DOCTOR AND SHE (MEDICAL DIRECTOR) SAID TO SEND HER OUT TO THE HOSPITAL..." WHEN ASKED WHY SHE DID NOT REMOVE THE DRESSING IN ORDER TO ASSESS #501'S WOUND, RN #2 REPORTED, "...I THOUGHT ABOUT IT, BUT THE SMELL WAS SO BAD. IT WAS SO BAD THAT YOU COULD SMELL IT ALL THE WAY DOWN THE HALL..." ON 9/24/12 AT 1:50 P.M., DURING A TELEPHONE INTERVIEW, THE WOUND CARE SPECIALIST REPORTED, "...I WASN'T VERY HAPPY WITH THE WOUND CARE AT THE FACILITY AT TIMES..." WHEN ASKED ABOUT HIS ORDERS FOR SCHEDULED DRESSING CHANGES TO BE DONE BY NURSING STAFF, THE WOUND CARE SPECIALIST REPORTED, "...WHEN WE STARTED PUTTING THE DERMAGRAFT ON, THE DRESSINGS WERE NOT TO BE TOUCHED SO AS NOT TO INTERRUPT THE DERMAGRAFT APPLICATION. WHEN WE STOPPED THE DERMAGRAFT, SHE (#501) HAD SO MUCH DRAINAGE AND SHE HAD SOME SPOTTING...WE COMPLETED THE DERMAGRAFT ON JULY 30, 2012 AND WE SAW HER ON 8/6/12 (MONDAY) AND WROTE AN ORDER TO BEGIN DRESSING CHANGES ON THAT THURSDAY. WE SAW HER ON MONDAYS SO THAT WOULD MAKE HER DRESSING CHANGES TWICE A WEEK..." THE WOUND CARE SPECIALIST FURTHER REPORTED, "...I MEAN, THERE'S A REASON WE WANTED THE DRESSINGS TO BE CHANGED. SHE HAD SO MUCH DRAINAGE AND THE WOUND WOULD BECOME MACERATED. WE WANTED TO AVOID THAT. I DIDN'T KNOW THEY WEREN'T CHANGING THE DRESSINGS. I ASSUMED THEY (NURSING STAFF) WERE FOLLOWING THE ORDERS TO CHANGE THE DRESSINGS ON THURSDAYS..." A REVIEW OF A FAXED REPORT RECEIVED FROM THE WOUND SPECIALIST, DATED 8/6/12 REVEALED, "...THERE IS A SLIGHT INCREASE IN MACERATION. DIABETES WITH ULCERATIONS, LEFT LOWER EXTREMITY. [MEDICAL CONDITION], BILATERAL. ORDERS WERE WRITTEN FOR THE DRESSINGS TO BE CHANGED WEEKLY ON THURSDAYS BY HER ASSISTED LIVING CENTER. THEY WILL APPLY MEDI-HONEY AND AN UNA BOOT TO BOTH LOWER EXTREMITIES..." #503 ACCORDING TO THE CLINICAL RECORD, #503 WAS REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ON 9/12/12 AT 11:15 A.M., RN #1 (UNIT MANAGER) REPORTED THAT SHE WAS ON HER WAY TO CHANGE #503'S DRESSING. OBSERVATION REVEALED RESIDENT #503 IN HIS ROOM LYING IN BED. IT WAS FURTHER OBSERVED THAT #503 HAD A LARGE UNCOVERED FLUID FILLED BLISTER TO HIS LOWER RIGHT ANTERIOR LEG. THE SKIN SURROUNDING THE BLISTER WAS RED AND CHAFFED AND HIS LEG WAS [MEDICAL CONDITION] (SWOLLEN). WHEN ASKED IF RESIDENT #503 HAD A DRESSING ON, RN #1 SAID, "...YES, HE SHOULD HAVE HAD ONE ON BUT IT MUST HAVE COME OFF DURING CARE..." FURTHER ASSESSMENT REVEALED #503'S DRESSING WHICH WAS LAYING UNDERNEATH HIS RIGHT LEG. THE DRESSING WAS DATED 9/9/12 (THREE DAYS OLD). A physician's orders [REDACTED]. RN #1 COULD NOT EXPLAIN WHY #503'S DRESSING HAD NOT BEEN CHANGED IN ACCORDANCE WITH THE physician's orders [REDACTED]. ON 9/12/12 AT 12:20 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED, "...THERE IS NO REASON OR EXCUSE WHY THE DRESSING WASN'T CHANGED..." #504 ACCORDING TO THE CLINICAL RECORD, RESIDENT #504 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ON 9/12/12 AT 3:00 P.M., #504 WAS OBSERVED PROPELLING HIMSELF IN HIS WHEELCHAIR IN THE HALLWAY. RESIDENT #504 HAD A DRESSING TO HIS RIGHT FOREARM THAT WAS DATED 9/5/12 (SEVEN DAYS OLD). THE DON WHO WAS PRESENT AT THE TIME REPORTED THAT RESIDENT #504 SUSTAINED A SKIN TEAR TO HIS RIGHT FOREARM AS RESULT OF A FALL BUT DID NOT EXPLAIN WHY THE RESIDENT'S DRESSING WAS DATED 9/5/12. A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT" DATED 9/5/12 REVEALED ON THAT RESIDENT #504 HAD A FALL ON 9/5/12 AND SUSTAINED A SKIN TEAR TO HIS RIGHT FOREARM. A physician's orders [REDACTED]. CHECK Q (EVERY) SHIFT AND PRN FOR BLEEDING AND INFECTION." #504'S DRESSING HAD NOT BEEN CHANGED SINCE 9/5/12. A REVIEW OF THE FACILITY'S "SKIN INTEGRITY POLICY" REVISED 12/11 REVEALED THE FOLLOWING: "...TREATMENTS WILL BE PROVIDED THAT MEET CURRENT STANDARDS OF PRACTICE..." "...PURPOSE: TO PROMOTE WOUND HEALING WITHOUT COMPLICATIONS..." "...EVALUATE WOUND CHARACTERISTICS..." "...NOTIFY PHYSICIAN AND GET ORDER FOR TREATMENT..." "...PROVIDE TREATMENT AS ORDERED..." "...ADDITIONALLY, ALL TEAM MEMBERS ARE EXPECTED TO AGGRESSIVELY CONTRIBUTE TO THE PREVENTION OF SKIN CONDITIONS..."

BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SKIN CARE FOR 2 (#302 & #303) OF 3 SAMPLED RESIDENTS REVIEWED FOR ALTERED SKIN INTEGRITY FROM A TOTAL SAMPLE OF 5, RESULTING IN POTENTIAL FOR DELAYED WOUND HEALING AND COMPLICATIONS. FINDINGS INCLUDE: RESIDENT #302 ACCORDING TO THE FACE SHEET DATED 10/11/2012, RESIDENT #302 WAS A [AGE] year OLD FEMALE WHO HAD LIVED AT THE FACILITY SINCE 9/19/2012 AND HAD [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE], REVEALED RESIDENT #302 HAD NO COGNITIVE IMPAIRMENTS, NO MEMORY LOSS, DID NOT WALK, REQUIRED STAFF ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING AND REQUIRED treatment for [REDACTED]. A PHYSICIAN'S HISTORY AND PHYSICAL DATED 9/20/2012 DOCUMENTED THAT ON ADMISSION TO THE FACILITY, RESIDENT #302 HAD A LEFT LEG WOUND. A physician's orders [REDACTED]. DURING AN INTERVIEW 10/26/2012, RESIDENT #302 SAID THAT "SOMETIMES" NURSING STAFF COMPLETED THE LEFT LEG DRESSING DAILY AND "SOMETIMES THEY MISS (DOING IT)." ON 10/26/2012 AT 12:45 P.M., REGISTERED NURSE (RN) #1 WAS OBSERVED AS SHE PROVIDED WOUND CARE FOR RESIDENT #302. PRIOR TO BEGINNING WOUND CARE, RN #1 WASHED HER HANDS AND PUT ON CLEAN GLOVES. SHE THEN REMOVED THE OLD DRESSING FROM THE 9 CM (CENTIMETER) BY 9 CM DRAINING WOUND ON THE RESIDENT'S LEFT LOWER LEG. RN #1 HANDLED THE CONTAMINATED OLD DRESSING MATERIALS WITH BOTH GLOVED HANDS, PRYING THE DRESSING AWAY FROM ADHERED TISSUE INSIDE THE WOUND BED. WITHOUT REMOVING HER CONTAMINATED GLOVES, RN #1 THEN PICKED UP A COMMUNAL SPRAY BOTTLE USED FOR THE WOUND CARE OF MULTIPLE RESIDENTS AT THE FACILITY, AND PASSED IT BETWEEN HER TWO CONTAMINATED HANDS BEFORE SHE WIPED THE OUTSIDE EDGES OF THE WOUND WITH A 4X4 (GAUZE PAD) TOWARD THE CENTER OF THE WOUND BED. WHILE USING THE SAME CONTAMINATED GLOVES, RN #1 THEN TOUCHED BOTH SIDES OF THE NEW HYDRAFERA BLUE DRESSING, WHILE ATTEMPTING TO STRETCH IT TO SIZE, MANIPULATED ITS POSITION INSIDE THE WOUND BED, AND COVERING THE ENTIRE AREA WITH AN ABDOMINAL PAD. RN #1 THEN REMOVED THE ONE AND ONLY PAIR OF GLOVES USED FOR THE DRESSING CHANGE AND PLACED THEM IN THE TRASH. RESIDENT #303 ACCORDING TO THE FACE SHEET DATED 9/13/2012, RESIDENT #303 WAS A [AGE] year OLD FEMALE WHO HAD LIVED AT THE FACILITY SINCE 9/13/2012 AND HAD [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE], NOTED THAT RESIDENT #303 HAD NO COGNITIVE IMPAIRMENTS, NO MEMORY LOSS, DID NOT WALK, REQUIRED STAFF ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING AND REQUIRED treatment for [REDACTED]. THE PHYSICIAN'S HISTORY AND PHYSICAL DATED 10/17/2012 REVEALED THAT RESIDENT #303'S FIRST WOUND WAS A 0.3 CM BY 0.3 CM DRY BLISTER OVER THE JOINT OF HER RIGHT BABY TOE. THE SECOND WOUND WAS A 0.8 CM BY 1.1 CM DRAINING BLISTER OVER HER LEFT HEEL. THE THIRD WOUND WAS 2 CM BY 1 CM DRAINING EROSION ON HER ABDOMINAL WALL. PHYSICIAN ORDERS [REDACTED]. THE ABDOMINAL WOUND REQUIRED CLEANSING WITH 1 GRAM OF [MEDICATION NAME] POWDER (MEDICATION) BEFORE A DRY DRESSING WAS APPLIED. ON 10/26/2012 AT 1:45 P.M., RN #2 WAS OBSERVED AS HE PROVIDED WOUND CARE FOR RESIDENT #303. PRIOR TO BEGINNING WOUND CARE, RN #2 LIFTED THE CLOTHING FROM RESIDENT #303'S ABDOMEN AND FOUND THE DAILY ABDOMINAL DRESSING ORDERED FOR RESIDENT #303 WAS DATED 10/24/2012, TWO DAYS PRIOR. AFTER CLEANSING THE ABDOMINAL WOUND WITH THE COMMUNAL WOUND CLEANSER, RN #2 DRIED THE AREA, APPLIED THE [MEDICATION NAME] POWDER TO A 4X4 (GAUZE PAD), WET THE MEDICATION WITH THE WOUND CLEANSER AND APPLIED A WET DRESSING TO THE AREA. AFTER COMPLETING THE ABDOMINAL WOUND RN #1 REMOVED THE LEFT HEAL DRESSING, PLACED THE OPEN, DRAINING WOUND, DOWN ONTO THE BEDROOM CARPET WHERE HE LEFT IT WHILE PREPARING HER TREATMENT. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD BETWEEN 10/18/2012 AND 10/26/2012, FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE RESIDENT #303 RECEIVED THE ORDERED DRESSING CHANGES ON HER LEFT HEAL ON DATES 10/24/2012 AND 10/25 /2012, ON HER RIGHT FOOT ON DATES 10/19/2012, 10/24/2012 AND 10/25/2012, AND TO HER ABDOMINAL WOUND ON DATES 10/18/2012, 10/20/2012, 10/23/2012, 10/24/2012, AND 10/25/2012. ADDITIONALLY, THE TWO DRESSING DOCUMENTED FOR THE ABDOMINAL WOUND ON 10/22/2012 AND 10/26/2012 WERE NOT ACCORDING TO CURRENT PHYSICIAN ORDERS. DURING AN INTERVIEW 10/26/2012 AT 2:30 P.M., THE DIRECTOR OF NURSING (DON) #1 SAID THAT AUDITS FOR WOUND CARE DOCUMENTATION BETWEEN 10/18/2012 AND 10/26/2012 HAD DEMONSTRATED CONTINUAL INACCURATE ENTRIES IN THE MEDICAL RECORD, IF AN ENTRY WAS MADE AT ALL, DESPITE THE EDUCATION RECEIVED BY STAFF. DON #1 SAID STANDARDS OF PRACTICE AND THE FACILITY'S WOUND CARE POLICY/PRACTICE REQUIRED NURSING STAFF TO CHANGE GLOVES TO AVOID WOUND CONTAMINATION, AFTER ALL SOILED MATERIALS WERE REMOVED (THE OLD DRESSING), BETWEEN WOUNDS, AND ANY TIME THE GLOVES BECAME CONTAMINATED WHILE CLEANING THE WOUNDS. WHEN THE DIRECTOR OF NURSING WAS INFORMED OF THE STEP BY STEP PROCESS RN #1 AND RN #2 USED DURING THE AFOREMENTIONED WOUND CARE, SHE SAID, "THEY (THE DRESSINGS) WILL ALL BE REDONE" BECAUSE "THAT (THE NURSES' WOUND CARE TECHNIQUE) IS GROSS. "

THIS CITATION PERTAINS TO INTAKES MI 185 AND MI 327. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SKIN CARE FOR TWO (#502 AND #506) OF SIX SAMPLED RESIDENTS WITH ALTERED SKIN INTEGRITY FROM A TOTAL SAMPLE OF NINE RESIDENTS, RESULTING IN THE DEVELOPMENT OF A FACILITY ACQUIRED PRESSURE ULCER FOR #502 AND LACK OF CONSISTENT WOUND TREATMENTS FOR RESIDENT #506. FINDINGS INCLUDE: NEITHER RESIDENT #502 NOR #506 RESIDED IN THE FACILITY AT THE TIME OF THE COMPLAINT INVESTIGATION. ON 07/12/2012 AT 9:00 A.M., THE DIRECTOR OF NURSES (DON) #1WAS QUERIED ABOUT WOUND TREATMENT IN THE FACILITY. DON #1 EXPLAINED THAT THE FACILITY HAD A WOUND TREATMENT NURSE WHO PROVIDED treatment for [REDACTED]. RESIDENT #502 ON 07/12/12 REVIEW OF THE CLOSED RECORD FOR RESIDENT#502 REVEALED THE RESIDENT WAS AN [AGE] year OLD FEMALE WHO WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE SIGNIFICANT CHANGE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED A BIMS SCORE OF 3 WHICH INDICATED A SEVERE COGNITIVE IMPAIRMENT. THE MDS ALSO INDICATED THAT THE RESIDENT REQUIRED EXTENSIVE TO TOTAL DEPENDENCE ON NURSING STAFF WITH BED MOBILITY, TRANSFERS, DRESSING, TOILET USE, BATHING AND HYGIENE. THE MOST RECENT BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK FOR RESIDENT #502 WAS DATED 09/30/2011 AND THE SCORE WAS 16. (A TOTAL SCORE OF 12 OR LESS REPRESENTED HIGH RISK.) ON 07/16/2012 AT 11:30 A.M., THE FACILITY TREATMENT NURSE, LICENSED PRACTICAL NURSE (LPN) #3 WAS QUERIED ABOUT THE CONDITION OF RESIDENT #502'S SKIN BEFORE HER DISCHARGE FROM THE FACILITY ON 03/09/2012. THE TREATMENT NURSE EXPLAINED THAT THE RESIDENT'S SKIN WAS ASSESSED ON 03/08/2012 AND SHE (LPN #3) FOUND THAT THE RESIDENT HAD A WOUND THAT MEASURED 9 X 5 X 0.1 CENTIMETERS ON HER SACRUM, AND AN IRREGULAR SHAPED PRESSURE WOUND ON HER SHOULDER. 0N 07/16/2012 AT 11:35 A.M., REVIEW OF THE PHYSICIANS ORDERS IN THE PRESENCE OF THE TREATMENT NURSE LPN #3 REVEALED A physician's orders [REDACTED]." ADDITIONALLY THERE WAS AN ORDER DATED 03/05/2012 WHICH READ "CLEANSE OPEN AREA TO LEFT COCCYX WITH NORMAL SALINE THEN APPLY DRY DRESSING DAILY AND AS NEEDED UNTIL HEALED, WOUND CARE TO EVALUATE." LPN #3 WAS QUERIED ABOUT THE WOUNDS MENTIONED IN THE ORDERS AND SHE EXPLAINED THAT THEY WERE THE SAME WOUNDS THAT SHE ASSESSED ON 3/8/12. LPN #3 WAS ASKED WHY IT TOOK HER UNTIL 3/8/12 TO ASSESS WOUNDS THAT WAS DISCOVERED BY THE NURSING STAFF ON 3/3 AND 3/5. LPN #3 REPORTED THAT THEY (THE WOUNDS) HAD NOT BEEN BROUGHT TO HER ATTENTION UNTIL 3/8/12. LPN #3 DID NOT ANSWER WHEN ASKED WHY THE SACRAL WOUND WAS NOT ADDRESSED BEFORE IT REACHED THE SIZE OF 9 X 5 CM. LPN #3 WAS ASKED ABOUT THE FREQUENCY OF SKIN ASSESSMENTS FOR THE RESIDENTS, AND SHE STATED THAT NURSES PERFORM SKIN ASSESSMENT FOR THE RESIDENTS TWICE A WEEK ON THEIR SHOWER DAYS. 0N 07/16/2012 AT 11:35 A.M., RESIDENT #502'S SHOWER SHEETS WERE REVIEWED. THIS REVIEW REVEALED THAT RESIDENT #502 WAS NOT ASSESSED FOR SKIN INTEGRITY ON A REGULAR BASIS. ON 07/16/2012 THE CNA (CERTIFIED NURSE AIDE) CARE TRACKER WAS REVIEWED FOR SHOWERS FOR RESIDENT #502. THE CARE TRACKER REVEALED THAT THE RESIDENT RECEIVED SHOWERS, BED BATHS OR PARTIAL ASSIST ON THE FOLLOWING DATES: ON 02/28/2012 SHOWER ON DAY SHIFT ON 02/29/2012 SHOWER ON DAY SHIFT ON 03/01/2012 PARTIAL ASSIST ON NIGHT SHIFT ON 03/03/2012 SHOWER ON DAY SHIFT ON 03/06/2012 BED BATH WAS GIVEN, AND ON 03/07/2012 SHOWER WAS GIVEN. THE MOST RECENT SKIN AND PAIN REPORT (SHOWER SHEETS) PROVIDED BY THE DIRECTOR OF NURSING (DON) WERE DATED 02/18/2012 AND 03/03/2012. THE DON EXPLAINED THAT THEY WERE NOT ABLE TO FIND ADDITIONAL SHEETS FOR THE RESIDENT. THE SKIN AND PAIN REPORT DATED 02/18/2012 NOTED, "NO OPEN AREAS, SKIN IS INTACT." THE SHEET DATED 03/03/2012 NOTED, "RESIDENT HAS OPEN AREA ON RIGHT BACKSIDE SHOULDER." THERE WERE NO ADDITIONAL SKIN AND PAIN REPORT SHEETS THAT CORRESPONDED TO THE SHOWERS/BATHS NOTED ON THE CARE TRACKER. ON 07/16/2012 AT 11:35 A.M., THE TREATMENT ADMINISTRATION RECORD (TAR) WAS REVIEWED FOR THE MONTH OF MARCH 2012. THERE WERE NO TREATMENTS LISTED AS HAVING BEEN ADMINISTERED FOR THE SACRAL WOUND, AND THERE WAS ONLY ONE TREATMENT PROVIDED FOR RESIDENT #502 ON HER RIGHT POSTERIOR SHOULDER ON 03/07/2012 AT 12:15 P.M. THE URINARY CARE PLAN DATED 01/04/2012 FOR RESIDENT #502 DOCUMENTED, "FULL SKIN ASSESSMENT PER PROTOCOL WITH SHOWER." ON 07/17/2012 AT 9:30 A.M., WHEN ASKED, DON #1 WAS UNABLE TO EXPLAIN WHY CONSISTENT SKIN ASSESSMENTS WERE NOT PROVIDED TO RESIDENT #502 OR WHY TREATMENT WAS NOT PROVIDED CONSISTENTLY ONCE THE WOUNDS WERE ASSESSED. THE FACILITY POLICY ENTITLED "IDENTIFICATION/NOTIFICATION OF ALTERATION IN SKI N INTEGRITY" DATED 11/05, NOTED, "THE FACILITY WILL ENSURE THAT CHANGES IN RESIDENT SKIN INTEGRITY WILL BE IDENTIFIED AND COMMUNICATED UPON DISCOVERY." ( ) RESIDENT #506 RECORD REVIEW ON 07/12/2012 AT 12:30 P.M REVEALED THAT RESIDENT #506 WAS A [AGE] year OLD FEMALE admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS ASSESSMENT DOCUMENTED THAT THE RESIDENT WAS ALERT, ORIENTED, AND COGNITIVELY INTACT WITHOUT MEMORY LOSS. THE RESIDENT ONLY RESIDED IN THE FACILITY UNTIL 04/26/12 WHEN SHE LEFT THE FACILITY AGAINST MEDICAL ADVICE (AMA). REVIEW OF THE ADMISSION assessment dated [DATE] REVEALED THAT RESIDENT #506 WAS admitted WITH "EXTENSIVE LEFT GLUTEAL OPEN AREA EXTENDING TO THE PERINEAL AREA ....RESIDENT admitted WITH [DIAGNOSES REDACTED]." THE HISTORY AND PHYSICAL REPORT FOR RESIDENT #506, DATED 04/12/2012 NOTED "[AGE] year OLD FEMALE WITH EXTENSIVE [MEDICAL CONDITION] OF THE LEFT GLUTEAL AND THIGH AREA status [REDACTED]. ON 07/12/2012 AT APPROXIMATELY 12:15 A.M., THE FACILITY TREATMENT NURSE, LPN #3 WAS QUERIED ABOUT THE WOUND CARE FOR RESIDENT #506. LPN #3 STATED THAT SHE AND THE UNIT NURSES PROVIDED WOUND treatment for [REDACTED]." LPN #3 FURTHER STATED THAT THE WOUND HAD LARGE AMOUNTS OF DRAINAGE AND WAS DIFFICULT TO MANAGE. ON 07/12/2012 AT 12:25 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH RESIDENT #506, WHO EXPLAINED THAT SHE WAS admitted INTO THE FACILITY FOR THE PURPOSE OF RECEIVING DAILY WOUND TREATMENT, BUT SHE DID NOT RECEIVE CONSISTENT TREATMENT BY THE NURSING STAFF. RESIDENT #506 SAID THAT HER WOUND WAS VERY LARGE AND HAD PERSISTENT DRAINAGE; THE DRESSING WOULD COME OFF WHENEVER SHE (THE RESIDENT) USED THE TOILET AND WOULD NEED TO BE RE-APPLIED. STAFF WOULD NOT ALWAYS BE AVAILABLE TO PROVIDE A DRESSING CHANGE SO SHE (THE RESIDENT) WOULD HAVE TO REQUEST SUPPLIES FROM CENTRAL SUPPLY TO COVER THE WOUND DRAINAGE UNTIL A NURSE COULD PROVIDE TREATMENT TO THE WOUND. RESIDENT #506 SAID THAT THERE WERE ONLY TWO NURSES THAT WOULD PROVIDE treatment for [REDACTED]. RESIDENT #506 STATED THAT THE FACILITY TREATMENT NURSE NEVER PROVIDED A DRESSING CHANGE FOR HER WOUND. LPN #4 WAS INTERVIEWED ON 07/12/2012 AT 12:35 P.M. LPN #4 REPORTED THAT SHE (#4) WOULD PROVIDE WOUND treatment for [REDACTED]. LPN #4 CONFIRMED THAT THE WOUND HAD LOTS OF DRAINAGE AND THE DRESSING WOULD COME OFF EACH TIME THE RESIDENT USED THE TOILET. A PHYSICIAN ORDER [REDACTED].M. -3 P.M. AND ON 3 P.M. TO 11 P.M. SHIFT." ADDITIONALLY, ANOTHER WOUND TREATMENT ORDER, DATED 4/13/2012 READ "APPLY DRESSING, ALLEVYN, TO LEG EVERY 3 DAYS AND AS NEEDED. CHANGE ALLEVYN TO LEFT THIGH AND LEG EVERY 3 DAYS AND AS NEEDED ON DAYSHIFT. CHANGE ON 04/15/2012." THE TREATMENT ADMINISTRATION RECORDS (TAR) WERE REVIEWED FOR RESIDENT #506 WHICH REVEALED THAT FROM 4/13/12 UNTIL 4/26/12 (DATE OF DISCHARGE), RESIDENT #506 ONLY HAD BUTTOCKS DRESSING CHANGES ON THE FOLLOWING DATES: ON 04/13/2012, WOUND TREATMENT WAS PROVIDED ON DAY SHIFT ONLY. ON 04/14/2012, WOUND TREATMENT WAS PROVIDED ON DAY SHIFT ONLY. ON 04/16/2012, WOUND TREATMENT WAS PROVIDED ON AFTERNOON SHIFT ONLY. ON 04/17/2012, WOUND TREATMENT WAS PROVIDED ON DAY SHIFT ONLY. ON 04/19/2012, WOUND TREATMENT WAS PROVIDED ON DAY SHIFT ONLY. NO TREATMENT WAS DOCUMENTED AS PROVIDED ON 04/20/2012, 04/21/2012, AND 04/22/2012. ON 04/23/2012 WOUND TREATMENT WAS PROVIDED ON DAY SHIFT ONLY. NO TREATMENT WAS DOCUMENTED AS PROVIDED ON 04/24/2012. THERE WAS NO EVIDENCE FROM THE TAR THAT TREATMENTS WERE PROVIDED FOR RESIDENT #506 FOR HER LEG WOUND WHICH REQUIRED THE ALLEVYN TREATMENT. ALSO, THERE WAS NO DOCUMENTATION SHOWING THAT THE LPN #3 PROVIDED treatment for [REDACTED]. DON #1 HAD NO EXPLANATION WHEN QUERIED AS TO WHY TREATMENT WAS NOT PROVIDED TO THE RESIDENT ON A CONSISTENT BASIS. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CARE FOR THE HIGHEST WELL-BEING BY ENSURING ADEQUATE DIABETES MANAGEMENT AS PRESCRIBED FOR TWO (#202 AND #203) OF THREE RESIDENTS WITH DIABETES FROM A TOTAL SAMPLE OF FIVE RESIDENTS RESULTING IN POTENTIAL FOR DIABETIC COMPLICATIONS AND POSSIBLE hospitalization . FINDINGS INCLUDE: ON 10/11/12, AT 11:00 AM, OBSERVATION OF BLOOD GLUCOSE (SUGAR) READINGS BY GLUCOMETER (ACCUCHECK BRAND) FOR RESIDENTS IN THE FACILITY REVEALED THAT EACH RESIDENT HAD DIFFERENT SLIDING SCALE ORDERS FROM THEIR RESPECTIVE PHYSICIANS. THE PHYSICIAN ORDERS [REDACTED]. UPON REVIEW OF THE CLINICAL RECORD FOR RESIDENTS #202 AND #203, IT WAS NOTED THAT THE RESIDENTS' BLOOD SUGAR LEVELS WERE NOT CONSISTENTLY MONITORED AND RECORDED. BLOOD SUGAR READINGS USING THE ACCUCHECK GLUCOMETER WERE NOT DONE AS ORDERED. INSULIN SLIDING SCALE ADMINISTRATION WAS NOT RECORDED AS GIVEN OR NOT GIVEN, SINCE THERE WERE NO RESULTS OF BLOOD SUGAR LEVELS RECORDED. RESIDENT #203: RESIDENT #203 WAS admitted to the facility on [DATE]. ACCORDING TO ADMISSION PHYSICIAN HEALTH AND PHYSICAL FORM, DATED 9/15/12, RESIDENT #203 HAD TYPE 2 DIABETES MELLITUS, [MEDICAL CONDITION] [MEDICAL CONDITIONS] AND MULTIPLE LOWER EXTREMITY WOUNDS, IN ADDITION TO OTHER DIAGNOSES. RESIDENT #203 WAS ALERT, ORIENTED, AND ABLE TO MAKE HER NEEDS KNOWN. OBSERVATION ON 10/12/12 AT 12:20 PM REVEALED THAT RESIDENT #203'S BLOOD SUGAR LEVEL WAS 194 MG/DL (NORMAL BLOOD SUGAR IS 90 TO 144 MG/DL). ACCORDING TO PHYSICIAN ORDERS, RESIDENT #203 WAS TO RECEIVE INSULIN COVERAGE ([MEDICATION NAME] 100 UNIT/ML BY SUBCUTANEOUS INJECTION) PER "SLIDING SCALE," FOUR TIMES DAILY, FOR ELEVATED BLOOD SUGAR LEVELS GREATER THAN 130 MG/DL, BEGINNING ON 9/17/12 AND ENDING ON 10/26/12. REVIEW OF THE (MEDICATION) ADMINISTRATION RECORD, DATED 10/1/12 THROUGH 10/11/12 REVEALED THAT ON 10/1/12 AT 6:00 AM; 10/7/12 AT 11:30 AM; AND ON 10/10/12 AT 11:30 AM, NO BLOOD SUGAR MEASUREMENTS WERE DOCUMENTED AND IT WAS UNCLEAR IF ANY INSULIN HAD BEEN ADMINISTERED. REVIEW OF NURSING NOTES CONTAINED NO EVIDENCE THAT RESIDENT #203 HAD HER BLOOD SUGAR LEVEL MEASURED AT THOSE TIMES. RESIDENT #202: RESIDENT #202 WAS admitted to the facility on [DATE]. ACCORDING TO THE ADMISSION PHYSICIAN HEALTH AND PHYSICAL FORM DATED 9/20/12, RESIDENT #202 HAD OSTEO[DIAGNOSES REDACTED] OF THE LEFT LEG, DIABETES MELLITUS REQUIRING INSULIN AND HYPERTENSION (ELEVATED BLOOD PRESSURE) IN ADDITION TO OTHER DIAGNOSES. RESIDENT #202 WAS ALERT, ORIENTED X3 AND ABLE TO MAKE HER NEEDS KNOWN. OBSERVATION ON 10/11/12 AT 11:45 AM, REVEALED THAT RESIDENT #202'S BLOOD SUGAR LEVEL WAS 235. RESIDENT #202 WAS ADMINISTERED 2 UNITS OF [MEDICATION NAME] R(EGULAR INSULIN) WAS GIVEN AS ORDERED BY THE PHYSICIAN'S SLIDING SCALE. ACCORDING TO PHYSICIAN ORDERS, RESIDENT #203 WAS TO RECEIVE INSULIN COVERAGE ([MEDICATION NAME] 100 UNIT/ML BY SUBCUTANEOUS INJECTION) PER "SLIDING SCALE," FOUR TIMES DAILY, FOR ELEVATED BLOOD SUGAR LEVELS GREATER THAN 201 MG/DL, BEGINNING ON 9/20/12 AND ENDING ON 10/29/12. REVIEW OF THE (MEDICATION) ADMINISTRATION RECORD, DATED 10/1/12 THROUGH 10/11/12 REVEALED THAT ON 10/1/12, AT BOTH 6:30 AM AND AT 11:30 AM; AND ON 10/2/12, AT 6:30 AM, AT 11:30 AM AND AT 9:00 PM, NO BLOOD SUGAR MEASUREMENTS WERE DOCUMENTED AND IT WAS UNCLEAR IF ANY INSULIN HAD BEEN ADMINISTERED. REVIEW OF NURSING NOTES CONTAINED NO EVIDENCE THAT RESIDENT #202 HAD HER BLOOD SUGAR LEVEL MEASURED AT THOSE TIMES. WHEN NURSE #5 WAS INTERVIEWED ON 10/11/12 AT 11:30 AM, HE NO EXPLANATION OF WHY RESIDENT #202'S BLOOD SUGAR MEASUREMENTS HAD NOT BEEN CONSISTENTLY DOCUMENTED AS COMPLETED. NURSE #5 STATED THAT THE ACCUCHECK MEASUREMENTS MAY HAVE BEEN CHANGED (BY THE PHYSICIAN) FROM 4 TIMES DAILY TO TWICE A DAY INSTEAD, BUT THE ORDER WAS NOT CLEAR ON WHEN IT WAS TO BE DISCONTINUED. WHEN THE DON (DIRECTOR OF NURSING) WAS INTERVIEWED ON 10/12/12 AT 11:30 AM, SHE admitted THAT BLOOD SUGAR MEASUREMENTS, AS READ BY THE ACCUCHECK GLUCOMETER, WERE NOT CONSISTENTLY RECORDED FOR RESIDENTS #202 AND #203 BY STAFF AND THAT NURSES FAILED TO FOLLOW THE DOCTOR'S ORDERS. SHE AGREED THAT NURSES STILL WERE NOT DOING BLOOD GLUCOSE MEASUREMENTS ACCURATELY, AS ORDERED. THE MANAGERS WERE SUPPOSED TO DO AUDITS ON A DAILY AND WEEKLY BASIS, BUT THE AUDITS HAD NOT BEEN APPROPRIATELY IMPLEMENTED. ( )

THIS CITATION PERTAINS TO INTAKE #MI 226 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CARE FOR THE HIGHEST WELL-BEING BY ENSURING ADEQUATE DIABETES MANAGEMENT FOR ONE (#505) OF FIVE RESIDENTS WITH DIABETES FROM A TOTAL SAMPLE OF NINE RESIDENTS RESULTING IN RESIDENT #505'S hospitalization FOR HYPEROSMOLAR NONKETOTIC COMA. FINDINGS INCLUDE: ON 7/17/12 AT 10:45 A.M., REVIEW OF RESIDENT #505'S MEDICAL RECORD REVEALED THAT THE RESIDENT WAS AN [AGE] year OLD MALE admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS TRANSFERRED OUT OF THE FACILITY ON 06/09/2012 AND DID NOT RESIDE IN THE FACILITY AT THE TIME OF THE ONSITE INVESTIGATION. ON 06/09/2012, RESIDENT #505 HAD BEEN SENT TO A LOCAL ACUTE CARE HOSPITAL WITH SYMPTOMS OF [MEDICAL CONDITION] (HIGH BLOOD SUGAR) AND AN ABNORMALLY HIGH BLOOD SUGAR READING OF 474 MG/DL. REVIEW OF RESIDENT #505'S CLOSED RECORD DID NOT REVEAL A CARE PLAN THAT ADDRESSED THE RESIDENT'S DIABETES OR BLOOD SUGAR CONTROL. WHEN A CARE PLAN FOR DIABETES MANAGEMENT WAS REQUESTED, THE SURVEYOR WAS INFORMED THAT THE FACILITY HAD NO TRADITIONAL INDIVIDUAL CARE PLAN FOR DIABETICS. REGISTERED NURSE (RN) #18 STATED, "WE FOLLOW THE STANDARD OF PRACTICE FOR DIABETIC MONITORING AND MANAGEMENT." THE GOALS FOR RESIDENT #505'S DIABETES MANAGEMENT COULD NOT BE DETERMINED FROM THE RESIDENT'S CLINICAL RECORD. REVIEW OF THE CLINICAL RECORD REVEALED THE FOLLOWING physician's orders [REDACTED]. ACCUCHECK (METHOD OF MEASURING BLOOD SUGAR) BID (TWICE DAILY) WITH SLIDING SCALE COVERAGE AT 6:00 A.M. AND 4:30 P.M. SCALES (FOR INSULIN COVERAGE): (BLOOD SUGAR MEASUREMENT) FROM 0 TO 200 = 0 UNITS; FROM 201 TO 250 = 2 UNITS; FROM 251 TO 300 - 4 UNITS; FROM 301 TO 350 - 6 UNITS; FROM 351 TO 400 - 8 UNITS; FROM 401 TO 450 - 10 UNITS; CALL MD IF BS (BLOOD SUGAR) < (LESS THAN) 60, OR > (GREATER THAN) 451." IT WAS NOT CLEAR FROM EITHER PHYSICIAN ORDERS [REDACTED]. DIETARY NOTES DATED 05/29/2012 DOCUMENTED, "...RESIDENT ON A PUREED DIET WITH THIN LIQUIDS...CURRENT TUBE FEEDING: GLUCERNA 1.2 @ 90 CC/HR X 15 HOURS (START 6 P.M., STOP 9 A.M.), 1350 CC, 1620 KCAL, 81 G PRO, 1087 CC FREE WATER. AUTO FLUSH 25 CC/HR X 15 HOURS=375 CC. [MEDICATION NAME] FLUSH 100 CC EVERY SHIFT=300 CC. TOTAL H20=[MEDICATION NAME] INCREASED RECENTLY R/T (RELATED TO) ELEVATED BS AND HGBA1C (TEST FOR LONG TERM BLOOD SUGAR CONTROL)..." REVIEW OF BLOOD GLUCOSE MONITORING REVEALED THAT RESIDENT #505 ROUTINELY REQUIRED ADDITIONAL INSULIN DUE TO ELEVATED BLOOD SUGAR LEVELS (NORMAL BLOOD SUGAR IS 90 TO 144 MG/DL): ON 6/01/2012 AT 5:27 A.M., "BLOOD SUGAR (BS) 388MG/DL=8 UNITS [MEDICATION NAME] INSULIN GIVEN PER SLIDING SCALE. " AT 6:18 P.M, "BS 248...2 UNITS OF INSULIN GIVEN." AT 10:53 P.M., "BS 238 MG/DL=2 UNITS INSULIN GIVEN." THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. [MEDICATION NAME] WAS ADMINISTERED. IT WAS UNCLEAR WHY THE NURSE DID ANOTHER ACCUCHECK ON THAT DATE AND GAVE TWO ADDITIONAL UNITS OF [MEDICATION NAME] AT 10:53 P.M. ON 06/02/2012 AT 7:25 A.M., "BS 248 =2 UNITS [MEDICATION NAME] GIVEN PER SLIDING SCALE." AT 10:23 P.M. "BS-173 2 UNITS OF INSULIN GIVEN." IT WAS UNCLEAR WHY THE NURSE ADMINISTERED THE SLIDING SCALE COVERAGE SO LATE IN THE EVENING WHEN THE physician's orders [REDACTED].M. AND 4:30 P.M. ON 6/03/12 IN THE MORNING, THE RESIDENT'S BLOOD SUGAR WAS DOCUMENTED AS 449, WITH NO DOCUMENTED COVERAGE, AND AT 10:04 P.M., "BS 444." AGAIN, THERE WAS NO SLIDING SCALE INSULIN COVERAGE DOCUMENTED AS HAVING BEEN ADMINISTERED. ON 06/04/2012 AT 7:08 A.M., "BS 440." INSULIN COVERAGE WAS NOT DOCUMENTED AS GIVEN. AT 8:20 P.M., "BS 234," AND AT 10:56 P.M. (THE SAME DAY), "LATE ENTRY, BS 215." HOWEVER, THE SCHEDULED [MEDICATION NAME] WAS DOCUMENTED AS ADMINISTERED AT 9:00 P.M. IT WAS UNCLEAR IF THE LATE ENTRY BLOOD GLUCOSE READING WAS FOR THE SCHEDULED ORDER AT 4:30 P.M., AND IF ANY INSULIN COVERAGE WAS ADMINISTERED. ON 06/05/2012 7:17 A.M., "BS=353 MG/DL=8 UNITS [MEDICATION NAME] GIVEN SQ (SUBCUTANEOUS) PER SLIDING SCALE." THERE WAS NO DOCUMENTED BLOOD GLUCOSE MONITORING FOR RESIDENT #505 ON 06/05/2012 IN THE AFTERNOON. ACCORDING TO THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. AT 7:53 P.M., "BS=183." THERE WAS NO BS MONITORING AT OR AROUND 4:30 P.M., PER THE physician's orders [REDACTED]. ON 06/07/2012 AT 7:02 A.M., "BS=343 MG/DL=6 UNITS [MEDICATION NAME] GIVEN PER SLIDING SCALE." AT 10:44 P.M., "BS-353." THERE WAS NO DOCUMENTED BLOOD SUGAR MONITORING AT OR AROUND 4:30 P.M. ON THAT DATE. ON 06/08/2012 AT 7:21 A.M., "BS=294 MG/DL-4 UNITS [MEDICATION NAME] GIVEN PER SLIDING SCALE." ON 06/09/12 AT 8:17 A.M., "BS 441." THERE WAS NO INSULIN COVERAGE DOCUMENTED FOR THE HIGH BLOOD GLUCOSE READING. ACCORDING TO NURSES' NOTES DATED 06/09/2012 AT 11:58 A.M., "AT 11 A.M., PER ADMISSION PERSONNEL, RESIDENTS WIFE WAS IN LOBBY CRYING THAT RESIDENT WAS NOT BEING TAKEN CARE OF HIS SUGAR WAS HIGH, HE HAS THRUSH, AND HE IS BREATHING FUNNY. ADVISED ADMISSION PERSONNEL THAT IT IS IN THE DOCTORS' BOOK ABOUT HIS TONGUE BEING COATED. HE WAS GIVEN INSULIN THIS MORNING BY MIDNIGHT NURSE. I ALSO ADVISED HER THAT I PLANNED TO GIVE HIM A BREATHING TREATMENT AFTER EATING...." ACCORDING TO NURSES' NOTES DATED 06/09/2012 AT 3:06 P.M., "ACCUCHEK (METER FOR MEASURING BLOOD SUGAR LEVEL) DONE AT 2:45 B/S (BLOOD SUGAR) AT 481 CALLED (DOCTOR) FOR ORDERS OF INSULIN AWAITING CALL BACK FROM DOCTOR." THERE WAS NO EVIDENCE THAT THE BLOOD GLUCOSE READING OF 481 WAS COVERED WITH SLIDING SCALE INSULIN. ON 07/17/2012 AT 12:46 P.M. AN INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) #9 WHO WAS THE NURSE ON DUTY 06/09/12, RESPONSIBLE FOR PROVIDING CARE TO RESIDENT #505. LPN #9 STATED THAT AFTER SHE HAD OBTAINED THE MORNING ACCUCHEK BLOOD SUGAR READING, SHE DID NOT CHECK IT AGAIN. LPN #9 WAS QUERIED ABOUT THE AFTERNOON BLOOD SUGAR OF 481 AND WHY IT WAS NOT COVERED WITH INSULIN. NURSE #9 SAID, "ONCE THE BLOOD SUGAR IS PAST 400 YOU HAVE TO CALL THE DOCTOR TO FIND OUT HOW MUCH INSULIN TO GIVE. THE DOCTOR DID NOT CALL BACK. HE WAS SENT OUT TO THE HOSPITAL THAT DAY." ACCORDING TO NURSES' NOTES DATED 06/09/2012 AT 3:12 P.M., "RESIDENT VITALS ARE AS FOLLOWS: BLOOD PRESSURE 73/54, TEMPERATURE 99.9, PULSE RATE 111, O2 87% AND O2 WAS INCREASED TO 3 LPM (LITERS PER MINUTE) FOR THE LAST HOUR AND RESIDENT IS BREATHING RAPID. CALLED (DOCTOR) AND AWAITING CALL BACK..." NURSES' NOTES DATED 6/9/2012 AT 4:37 P.M. DOCUMENTED, "RESIDENT SENT TO (HOSPITAL) FOR ACUTE RESPIRATORY DISTRESS..." ACCORDING TO THE ACUTE CARE HOSPITAL EMERGENCY DEPARTMENT (ED) NOTE DATED 06/09/12 19:10 P.M., "THE PATIENT CONTINUES TO GET FLUID RESUSCITATION...GLUCOSE IS RECHECKED AT 475. WE WILL GIVE HIM ANOTHER 6 UNITS OF REGULAR INSULIN. HE WAS GIVEN FLUIDS. HE IS HYPEROSMOLAR (A MEDICAL EMERGENCY CAUSED BY A VERY HIGH BLOOD GLUCOSE LEVEL). HIS SERUM OSMOLALITY IS 384 (THE NORMAL RANGE OF SERUM OSMOLALITY IS 285 TO 295)...IMPRESSION HYPEROSMOLAR NONKETOTIC COMA (A TYPE OF DIABETIC COMA)..." THE DIRECTOR OF NURSING WAS QUERIED ON 07/17/2012 ABOUT THE LACK OF INSULIN COVERAGE FOR RESIDENT #505. THE DIRECTOR OF NURSING STATED, "THE NURSE CALLED ME AND TOLD ME THAT THE RESIDENT'S BLOOD PRESSURE WAS VERY LOW SO I INSTRUCTED HER TO SEND HIM OUT TO THE HOSPITAL. HE WENT TO THE HOSPITAL WITHIN TWO HOURS." THE DIRECTOR OF NURSING DID NOT EXPLAIN WHAT MEASURES HAD BEEN TAKEN BY THE FACILITY TO ENSURE THAT RESIDENT #505 DID NOT EXPERIENCE A HYPEROSMOLAR NONKETOTIC COMA AS A CONSEQUENCE OF POOR BLOOD SUGAR CONTROL. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 145. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT 1 OF 4 SAMPLED RESIDENTS (#103), ALL REVIEWED FOR FALLS, BY NOT PROVIDING ADEQUATE SUPERVISION DURING TOILETING RESULTING IN A FALL WITH INJURY (ACUTE LEFT PUBIC RAMI FRACTURES (PELVIC FRACTURES) AND INCREASED PAIN). FINDINGS INCLUDE: RESIDENT #103'S MEDICAL RECORD CONTAINED A FACE SHEET DATED 11/01/11 THAT SAID RESIDENT #103 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. RESIDENT #103'S MEDICAL RECORD CONTAINED PROGRESS NOTES DATE 11/16/11 AT 9:37 AM ELECTRONICALLY SIGNED BY LICENSED PRACTICAL NURSE (LPN) #4 THAT SAID, "DAY OF FALL, RESIDENT (#103) OBSERVED ON FLOOR AT APPROXIMATELY 4:00 AM...SHE (CNA #3) LEFT RESIDENT (#103) ALONE FOR A WHILE AND BY THE TIME SHE (CNA #3) GOT BACK TO THE ROOM (RESIDENT #103'S ROOM) RESIDENT (#103) WAS OBSERVED ON THE FLOOR IN THE ROOM AT THE END OF ROOMMATE'S BED LAYING ON HER (RESIDENT #103) BACK...PREVIOUSLY KNOWN TO ATTEMPT WALKING WITH UNSTEADY GAIT...UNABLE TO DO ROM (RANGE OF MOTION) OF LLE (LEFT LOWER EXTREMITY) DUE TO PAIN AND SCREAMING." THE FACILITY PROVIDED A COPY OF AN INCIDENT/ACCIDENT REPORT SIGNED AND DATED BY THE ADMINISTRATOR (ADM) AND DIRECTOR OF NURSING (DON) ON 11/17/11 THAT RESIDENT #103 fell on [DATE] AT 4:00 AM IN HER ROOM. ACCORDING TO THE REPORT, RESIDENT #103 WAS UNABLE TO EXPLAIN WHAT OCCURRED. THIS REPORT SAID, UNDER THE HEADING ENTITLED DESCRIBE WHAT HAPPENED, "ASSIGNED CNA (CNA #3) CALLED ATTENTION TO NURSE (LPN #4) TO OBSERVE RESIDENT (#103) ON THE FLOOR AT THE FOOT OF ROOMMATE'S BED, LAYING ON HER BACK AND GROANING." THIS REPORT SAID, UNDER THE HEADING ENTITLED DESCRIPTION OF ASSESSMENT, "UNABLE TO DO ROM (RANGE OF MOTION) ON LLE (LEFT LOWER EXTREMITY) DUE TO PAIN AND SCREAMING." THIS REPORT SAID, UNDER THE HEADING ENTITLED STEPS TAKEN TO AVOID IMMEDIATE REPETITION, "CNA #3 IS REPRIMANDED FOR SAFETY VIOLATION." THE FACILITY PROVIDED A COPY OF AN INCIDENT/ACCIDENT REPORT (FALLS) DATED AND SIGNED BY THE DIRECTOR OF NURSING (DON) ON 11/18/11 AND SIGNED BY THE ADMINISTRATOR (ADM) ON 11/21/11 THAT SAID, UNDER SECTION 4 OVERALL CONCLUSION, "RESIDENT (#103) fell OFF OF TOILET AND APPEARED TO BE IN PAIN FOLLOWING THE INCIDENT AND SINCE PAIN WAS UNRELENTING, X-RAYS OF PELVIS WERE ORDERED WHICH SHOWED FRACTURE OF PUBIC RAMI." RESIDENT #103'S MEDICAL RECORD CONTAINED PHYSICIAN ORDERS [REDACTED].#103'S HIP AND LOWER LEG AREAS AND PRESCRIBED A CONTROLLED SUBSTANCE MEDICATION FOR PAIN CONTROL. RESIDENT #103'S MEDICAL RECORD CONTAINED RADIOLOGY REPORT FROM OUTSIDE PROVIDER DATED 11/16/11 THAT SAID RESIDENT #103 HAD NO DEFINITIVE EVIDENCE OF ACUTE FRACTURE OR DISLOCATION. "IF SYMPTOMS PERSIST, CONSIDER FOLLOW-UP RADIOGRAPHS IN ORDER TO EVALUATE." RESIDENT #103'S MEDICAL RECORD CONTAINED PHYSICIAN ORDERS [REDACTED].#103'S PUBIC RAMI (PELVIS). ACCORDING TO THE RADIOLOGY REPORT FROM AN OUTSIDE PROVIDER DATED 11/18/11, RESIDENT #103 HAD ACUTE LEFT PUBIC RAMI FRACTURES. RESIDENT #103'S MEDICAL RECORD CONTAINED PHYSICIAN ORDERS [REDACTED]." ATTEMPTS TO INTERVIEW RESIDENT #103 ON 11/30/11 AT 10:50 AM AND 2:30 PM WERE UNSUCCESSFUL. DURING THESE TIMES RESIDENT #103 DID NOT PRODUCE CLEAR LANGUAGE AND WAS CRYING AT SHORT INTERVALS. RESIDENT #103 WAS UNABLE TO PROVIDE ANY INFORMATION RELATED TO THE FALL. DURING THESE TIMES, THE SURVEYOR OBSERVED RESIDENT #103 TO BE IN A LOW BED WITH A FUNCTIONAL BED ALARM. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 11/30/11 AT 11:00 AM, THE DON SAID ON 11/16/11 AT APPROXIMATELY 4:00 AM CERTIFIED NURSE AIDE (CNA) #3 LEFT RESIDENT #103 ALONE AND UNASSISTED ON THE TOILET INSIDE ROOM 239. THE DON SAID DURING THE TIME RESIDENT #103 WAS LEFT ALONE AND UNASSISTED ON THE TOILET, THE RESIDENT HAD AN UNWITNESSED CHANGE IN SURFACE FROM THE TOILET TO THE FLOOR. THE DON SAID CNA #3 DISCOVERED RESIDENT #103 ON THE FLOOR OUTSIDE BATHROOM "FLAT ON HER BACK." THE DON SAID RESIDENT #103 DISPLAYED SIGNS OF PAIN AND X-RAYS WERE TAKEN ON 11/16/11. THE DON SAID, AS A RESULT OF THE FALL, PAIN MEDICATIONS WERE ORDERED AND ADMINISTERED TO RESIDENT #103. THE DON SAID THE INITIAL SET OF X-RAYS TAKEN POST-FALL SHOWED NO CLEAR EVIDENCE OF FRACTURE TO HIPS OR LEGS BUT DID SHOW FRACTURES TO THE PELVIS AREA (PUBIC RAMI) THAT MAY BE OLD. THE DON SAID SINCE THE INITIAL PELVIC X-RAYS WERE UNCLEAR REGARDING TIME FRAME OF THE PUBIC RAMI FRACTURES, THE PLAN WAS TO RECHECK THE PELVIC AREA IF SYMPTOMS PERSISTED. THE DON SAID RESIDENT #103 CONTINUED TO DISPLAY PAIN SYMPTOMS AND A SECOND SET OF X-RAYS WAS OBTAINED ON 11/18/11 WHICH SHOWED CLEAR EVIDENCE OF ACUTE LEFT PUBIC RAMI FRACTURES WHEN COMPARED TO PREVIOUS X-RAYS. THE DON SAID CLINICIANS DETERMINED THAT NO SURGICAL TREATMENT WAS REQUIRED FOR THE FRACTURES. THE DON SAID CNA #3 SHOULD NOT HAVE LEFT RESIDENT #103 ALONE AND UNASSISTED ON THE TOILET. THE DON SAID SHE ADMINISTERED CORRECTIVE ACTION TO CNA #3 FOR LEAVING RESIDENT #103 ALONE AND UNASSISTED ON THE TOILET. THE DON SAID CNA #3 WAS DISCIPLINED FOR A SAFETY VIOLATION. THE DON SAID RESIDENT #103 WAS A HIGH RISK FOR FALLS AT THE TIME THE FALL OCCURRED BASED ON THE RESIDENT ' S MDS (MINIMUM DATA SET) ASSESSMENT AND DIAGNOSIS. DURING AN INTERVIEW WITH PHYSICIAN ASSISTANT (PA) #5 ON 11/30/11 AT 12:30 PM, PA #5 SAID RESIDENT #3 HAD COMPLAINTS OF PAIN TO THE PELVIC AREA POST-FALL. PA #5 SAID PAIN MEDICATION WAS ADMINISTERED TO RESIDENT #103 ON A CONSISTENT BASIS POST-FALL. PA #5 SAID INITIAL X-RAYS TAKEN ON 11/16/11 WERE NEGATIVE FOR FRACTURES TO THE HIPS AND LEGS BUT UNCLEAR REGARDING PUBIC RAMI FRACTURES. PA #5 SAID THE PLAN WAS TO RECHECK RESIDENT #103'S PELVIC AREA IF SYMPTOMS PERSISTED. PA #5 SAID RESIDENT #103 CONTINUED TO DISPLAY PAIN SYMPTOMS AND A SECOND SET OF X-RAYS WAS OBTAINED ON 11/18/11 WHICH SHOWED CLEAR EVIDENCE OF ACUTE LEFT PUBIC RAMI FRACTURES WHEN COMPARED TO PREVIOUS X-RAYS. PA #5 SAID NO SURGICAL TREATMENT WAS REQUIRED FOR THE PUBIC RAMI FRACTURES. DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) #4 ON 11/30/11 AT 1:55 PM, LPN #4 SAID ON 11/16/11 AT APPROXIMATELY 4:00 AM CNA #3 NOTIFIED HER THAT RESIDENT #103 WAS ON THE FLOOR AND THAT AN ASSESSMENT WAS NEEDED. LPN #4 SAID SHE IMMEDIATELY ENTERED RESIDENT 103'S ROOM AND OBSERVED RESIDENT #103 ON THE FLOOR JUST OUTSIDE BATHROOM DOOR, ON HER BACK, MOANING AND DISPLAYING FACIAL GRIMACING CONSISTENT WITH PAIN. LPN #4 SAID THERE WERE NO ALARMS SOUNDING. LPN #4 SAID, DURING HER ASSESSMENT RESIDENT #103 SCREAMED IN PAIN WHEN RANGE OF MOTION WAS ATTEMPTED ON HER (#103) LOWER LEFT LEG. LPN #4 SAID SHE NOTIFIED THE PHYSICIAN AND ADMINISTERED PAIN MEDICATION TO RESIDENT #103. LPN #4 SAID CNA #3 LEFT RESIDENT #103 ALONE AND UNASSISTED ON THE TOILET AND THAT CNA #3 FOUND RESIDENT #103 ON THE FLOOR WHEN COMING BACK INTO THE ROOM. LPN #4 SAID CNA #3 LEFT RESIDENT #103 ALONE AND UNASSISTED ON THE TOILET TO OBTAIN FURTHER CLEANING SUPPLIES AS RESIDENT #103 WAS HAVING DIARRHEA. LPN #4 SAID SHE ADMINISTERED AN ANTI-DIARRHEAL MEDICATION TO RESIDENT #103 ON 11/16/11 AT APPROXIMATELY 3:30 AM. LPN #4 SAID CNA #3 PLACED RESIDENT #103 ON THE TOILET "RIGHT AFTER" THE ANTI-DIARRHEAL MEDICATION WAS ADMINISTERED. LPN #4 SAID, "WE NEVER LEAVE RESIDENTS THAT ARE A HIGH RISK TO FALL ALONE IN THE BATHROOM." LPN #4 SAID SHE ADMINISTERED CORRECTIVE ACTION TO CNA #3 FOR VIOLATING A SAFETY STANDARD. LPN #4 SAID RESIDENT #103 SHOULD NEVER HAVE BEEN LEFT ALONE AND UNASSISTED ON THE TOILET BECAUSE SHE WAS A HIGH RISK TO FALL, WAS DISORIENTED, DID NOT UNDERSTAND HOW TO ACTIVATE THE BATHROOM ALARM, COULD NOT WALK WITH A STEADY GAIT, AND COULD NOT VERBALIZE HER NEEDS CLEARLY. LPN #4 SAID CNA #3 SHOULD HAVE PREPARED THE CLEANING SUPPLIES IN ADVANCE OR CALLED OTHER STAFF MEMBERS FOR ASSISTANCE PRIOR TO LEAVING RESIDENT #103 ALONE AND UNASSISTED ON THE TOILET. LPN #4 SAID THERE WAS SUFFICIENT STAFF AVAILABLE TO ASSIST ON 11/16/11 DURING THE MIDNIGHT SHIFT. DURING AN INTERVIEW WITH CERTIFIED NURSE AIDE (CNA) #3 ON 11/30/11 AT 2:10 PM, CNA #3 SAID THAT ON 11/16/11, AT AROUND 3:30 AM SHE PLACED RESIDENT #103 ON THE TOILET AFTER LPN #4 ADMINISTERED ANTI-DIARRHEAL MEDICATION TO THE RESIDENT. CNA #3 SAID RESIDENT #103 WAS RESTLESS AND HAVING LOTS OF DIARRHEA WHILE SITTING ON THE TOILET. CNA #3 SAID SHE USED ALL THE AVAILABLE CLEANING SUPPLIES AND LEFT RESIDENT #103 ON THE TOILET FOR "A FEW SECONDS" TO OBTAIN MORE CLEANING SUPPLIES. CNA #3 SAID SHE DID NOT PROVIDE RESIDENT #103 WITH DIRECTIONS TO OPERATE THE BATHROOM ALARM PRIOR TO LEAVING THE RESIDENT ALONE AND UNASSISTED IN THE BATHROOM. CNA #3 SAID WHEN SHE RE-ENTERED THE ROOM SHE OBSERVED RESIDENT #103 ON THE FLOOR. CNA #3 SAID RESIDENT #103 APPEARED TO BE IN PAIN. CNA #3 SAID SHE WAS DISCIPLINED BY THE FACILITY FOR LEAVING RESIDENT #103 ALONE AND UNASSISTED ON THE TOILET. RESIDENT #103'S MEDICAL RECORD CONTAINED A NURSING assessment dated [DATE] THAT SAID, UNDER THE FALLS SECTION, THAT RESIDENT #103 "HAS INCREASED DEMENTIA, UNSTEADY GAIT, AND WILL GET UP ON HER OWN." THIS ASSESSMENT ALSO SAID, UNDER NURSES ' NOTES SECTION, RESIDENT #103 "HAS [DIAGNOSES REDACTED]." RESIDENT #103'S MEDICAL RECORD CONTAINED A MINIMUM DATA SET (MDS) assessment dated [DATE] THAT SAID, UNDER SECTION C-COGNITIVE PATTERNS, RESIDENT #103 "IS RARELY/NEVER UNDERSTOOD." THIS MDS SAID, UNDER SECTION G.-FUNCTIONAL STATUS, RESIDENT #103 "NEEDS EXTENSIVE ASSISTANCE AND TWO PERSON PHYSICAL ASSIST TO USE TOILET," AND , UNDER G0300, RESIDENT #103 "IS NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE WHEN MOVING ON AND OFF THE TOILET." THIS MDS SAID, ON CARE AREA FOR FALL RISK, CARE AREA TRIGGERED RELATED TO RESIDENT #103'S "PRESENTING WITH IMPAIRED BALANCE UPON TRANSITIONS," BUT, "WILL NOT DEVELOP CARE PLAN AS RESIDENT HAS HAD NO FALLS AND HAS HAD NO ATTEMPTS AT SELF AMBULATION AND THAT PRECAUTIONARY SAFETY MEASURES ARE INTEGRATED INTO ADL CARE PLAN SECONDARY TO RESIDENTS ADVANCED DEMENTIA." RESIDENT #103'S MEDICAL RECORD CONTAINED A CARE PLAN FOR COMMUNICATION WITH A DATED ONSET OF 05/26/11 THAT SAID, UNDER PROBLEMS, RESIDENT #103 "IS RARELY TO NEVER UNDERSTOOD AND APPEARS TO SOMETIMES UNDERSTAND OTHERS BY FOLLOWING SIMPLE COMMANDS AND DIRECTIONS." THIS CARE PLAN SAID, UNDER APPROACHES, "GIVE RESIDENT 1-2 STEP DIRECTIONS/COMMANDS DURING INTERACTIONS, AND REDIRECT RESIDENT AS NEEDED." RESIDENT #103'S MEDICAL RECORD CONTAINED A CARE PLAN FOR ADL'S (ACTIVITIES OF DAILY LIVING) WITH A DATED ONSET OF 10/09/11 THAT SAID, UNDER PROBLEMS, RESIDENT #103 "IS NONVERBAL AND HAS SIGNIFICANT COGNITIVE AND PHYSICAL LIMITATIONS SECONDARY TO [DIAGNOSES REDACTED]." THIS CARE PLAN INCLUDED APPROACHES SUCH AS "ANTICIPATE RESIDENT (#103'S) NEEDS, BED ALARM WITH BED TO BE IN LOWEST POSITION, WHEELCHAIR SENSOR ALARM WITH SEAT CUSHION, APPROPRIATE FOOTWEAR/NON-SKID SOCKS." RESIDENT #103'S MEDICAL RECORD CONTAINED A MONTHLY SUMMARY DATED 10/12/11 THAT SAID, UNDER NURSING NOTES SECTION, RESIDENT #103 "HAS A WHEELCHAIR AND BED ALARM FOR FALL PREVENTION." RESIDENT #103'S MEDICAL RECORD CONTAINED A CERTIFICATION AND RECERTIFICATION FORM DATED AND SIGNED BY PHYSICIAN ON 11/04/11 THAT SAID "CONTINUED SKILLED NURSING FACILITY INPATIENT CARE IS NECESSARY FOR RESIDENT #103 FOR MUSCLE WASTING AND GAIT ABNORMALITY ..." CERTIFIED NURSE AIDE (CNA) #3'S PERSONNEL FILE CONTAINED A DISCIPLINARY ACTION, NOTICE OF PERFORMANCE PROBLEM FORM DATED 11/17/11 THAT SAID CNA #3 LEFT RESIDENT #103 "ALONE ON THE TOILET UNATTENDED TO" AND, UNDER REASON UNACCEPTABLE SECTION, "THIS IS A SAFETY VIOLATION; RESIDENTS SHOULD NEVER BE LEFT ALONE IN THE BATHROOM UNATTENDED." THE FACILITY PROVIDED A WRITTEN STATEMENT FROM CERTIFIED NURSE AIDE (CNA) #3 DATED AND SIGNED BY CNA #3 ON 11/16/11 THAT SAID, "RESIDENT (#103) WAS RESTLESS DURING THE NIGHT AND HAD DIARRHEA AND I DECIDED TO SIT HER ON THE TOILET...BEFORE I CAME BACK TO THE ROOM, THE RESIDENT (#103) HAD GOTTEN OFF THE TOILET AND WAS ALREADY ON THE FLOOR."

This citation pertains to MI 8112 Based on observation, interview, and record review the facility failed to prevent the re-development of a clinically avoidable pressure ulcers in 1 of 3 sampled residents (#101), from a total sample of 3 residents, resulting in the development of multiple new facility acquired pressure ulcer Stage I and Stage II pressure ulcers. Findings include: Resident #101 was a resident at the facility at the time of the investigation. According to the facility face sheet Resident #101 was admitted to the facility on [DATE] with readmission following hospitalization from a closed dislocation of the knee occurring on 4/4/2011. Resident #101 had a medical history of [REDACTED]. Review of the Facility Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was able to make herself understood sometimes and usually understood others, was unable to make cognitive decisions regarding daily life, was totally dependent on staff for moving side-side in bed, moving from bed to chair and vice versa, dressing, eating, bathing and was incontinent of both bowel and bladder. Resident #101 also had impairment of both upper and lower extremities. The MDS identified resident #101 to be at risk for developing pressure ulcers with no current pressure ulcers listed. Skin and ulcer treatments listed were pressure reducing device for the chair and bed with turning and repositioning program listed. An observation on on 10/25/11 at 8:45 AM revealed Resident #101 was lying in bed in her room, flat on her back. A breakfast tray was present on the over bed table next to the bed still covered unopened fluids. The room was dark with the curtains unopened. The diet slip on the tray documented "pureed diet". Resident #101 was observed at 9:55 AM still in bed with a family member present with two facility CNA's. Resident #101 was turned, this surveyor observed a thick pink ointment smeared on the buttocks. There was no ointment on the open areas. There were two open, red, raw areas noted on Resident #101's buttocks and coccyx approximately the size of 25 cent pieces. There was no drainage was noted. Review of the Facility Admission Nursing assessment dated [DATE] revealed Resident #101 was readmitted to the facility with an open area on the left inner buttocks measuring 4 cm long. Review of facility nursing notes dated from 4/6/11 to 5/31/11 revealed no documentation regarding the open area on the left inner buttocks from the 4/4/11 admission. Review of the Facility Braden Scale dated 4/4/11 revealed Resident #101's documented score was "12" (12 or less represents High Risk). Review of the Braden Scale dated 5/1/11 revealed Resident #101''s score was 13. Review of the Facility Wound Note dated 5/2/11 revealed Resident #101's "wound meeting held today, area is resolved will continue to follow plan of care". Review of the Facility Wound Note dated 5/23/11 revealed "wound care meeting held today all areas are improving will continue to follow plan of care". Review of the Facility Wound Assessment Summary dated 5/19/11 revealed documentation of Resident #101's Wound Etiology: Other Coccyx close scar tissue. No other documentation was present on the summary. Review of the Nurses notes revealed on 5/31/11 resident #101 complained of pain to the buttocks and a pain appraisal was started. Nursing Notes dated 6/28/11 revealed "treatment done to coccyx open area about a dime size. Cleanse with wound cleanser and apply [MEDICATION NAME], to change every 3 days and prn (as necessary). Put in doctor's log and wound care book continue to monitor". Review of the Facility Wound Assessment Summary dated 7/7/11 revealed Resident #101's Wound Etiology: Pressure Ulcer "coccyx resolved". Review of the Facility Wound Note dated 7/11/11 revealed Resident #101's "area on coccyx resolved will continue to treat as ordered". Review of the Braden Scale dated 7/11/11 revealed Resident #101's documented score was 11, indicating a high risk for skin breakdown. Review of the Facility treatment record dated 7/1/11 to 7/31/11 revealed Resident #101 was to have treatment that included: "coccyx: cleanse with wound cleanser. Apply [MEDICATION NAME] every 3 days and prn 6/28/11". Review of the Facility Treatment Record dated 9/1/11 to 9/31/11 revealed Resident #101 was to have "chamosyn ointment every shift and as needed, coccyx clean with wound cleaner apply [MEDICATION NAME] every 3 days and prn". Review of the Facility Skin and Pain Report dated 9/29/11 revealed "no sign of breakdown treatment to coccyx". Review of the Facility Skin and Pain Report dated 10/3/11 revealed "no skin breakdown". Review of the Facility Skin and Pain Report dated 10/6/11 revealed "no open sore treatment in progress for the buttock for protection, patch for protection". Review of the Facility Skin and Pain report dated 10/10/11 and 10/13/11 revealed "no sign of breakdown". Review of the Facility Skin and Pain Report dated 10/17/11 revealed "dressing on left and right buttock treatment in progress. Two areas were circled on the body figure "reddened with #2 indicating open areas". Review of the Facility Nursing Notes dated 10/19/11 at 6:30 PM revealed Resident #101's "family requested DON (Director of Nurses) assess resident's buttocks area due to recently opened areas. This nurse noted several open areas, appear red and healing, top layer of skin excoriated. Barrier cream applied. Certified Nurse Aides (CNA's) said had changed resident at 3:45 PM when she was laid down. Family noted resident to be very wet with soaked linen and patch in place. This nurse explained that wound doctor had changed treatment to barrier cream only and that this treatment would allow the wound to heal along with pressure off-loading. Another nurse had spoken to family on Monday re: open areas due to patch removal and explained treatment plan at that time". Review of the Facility Wound Note dated 10/19/11 revealed Resident #101 had a "Noted open red areas on her sacral bilateral buttock, wound doctor assessed and orders noted". Review of the Physician Wound Care Services consultation dated 10/19/11 revealed Resident #101 had "Onset of wounds was at the Nursing Home. Wound started 2 days ago. The wound severity is of partial thickness. Over the last week, [MEDICATION NAME] layer (outer layer of skin) was stripped from the sacral area. Wound lesion #1 wound is located on the sacrum area. Wound type: pressure. Stage 2 measure length 7 x 2 cm. There are multiple scattered areas within a zone of altered skin integrity measure 10 x 10 cm. Color: red. There is a stage 2 area on the left sacrum that measures 1.5 x 1 cm. there is a stage 2 area on the right sacrum that measures 1 x 0.5 cm. Lesion #2: wound is located on the left buttock area. Wound type: pressure Stage 1, 6 x 3 cm. Assessment: Diagnosis: [REDACTED]. Pressure Ulcer left buttock Stage 1, New. Pressure Ulcer Stage 2 sacral wounds, New. Plan: Treat with barrier creme twice daily, no adhesives, avoid prolonged sitting, frequent position changes". Review of the Facility Skin and Pain Report dated 10/24/11 revealed Resident #101 had: "#2 Open area, Open area coccyx treatment in progress". Review of the Facility Braden Pressure Sore Risk dated 10/25/11 revealed Resident #101 had a risk score of 10. Review of the Activities for Daily Living (ADL) Care Plan dated 4/19/11 noted that on 6/28/11 Resident #101 had an "wound open on coccyx stage 2 D/C (discontinue)." On 7/7/11, "keep skin clean and dry, turn and reposition every 2 hours and PRN, check resident every 2 hrs for episodes of incontinence". There were no additional updates to Resident #101's ADL care plan or a care plan specifically for Resident #101's skin in the medical record until 10/25/11, 8 days after Resident #101 was noted to have a breakdown in her skin. Review of the Skin Care Plan dated 10/25/11 revealed Resident #101 had: Approaches: assess skin per protocol, administer treatment as ordered, chair cushion on wheelchair, turn and reposition every 2 hours and PRN, low air loss mattress, Float heels on pillows as tolerated, lay down after meals, elevate legs as tolerated with pillows, wound care services as needed, Hospice care services, Pillow to alignment as tolerated to allow to accommodate turning and repositioning. Keep skin clean and dry, Provide perineal care per protocol, dietary consult prn. In an interview on 10/25/11 at 1:45 PM the Wound Care Physician #1 stated that the patch ([MEDICATION NAME]) was used "for protection". Wound Care Physician #1 stated that when Resident #101 was readmitted from the hospital in April with skin tear to the left buttocks that issue resolved. Wound Care Physician #1 stated, "From April to October it was OK but with friction and shearing Stage 1 and Stage 2 Pressure Sores developed. It is imperative to avoid skin adhesives which have been used. The facility sought a 2nd opinion when the wound was not responding". In an interview on 10/26/11 at 11:08 AM Registered Nurse (RN) # 6 reported that when she saw Resident #101 buttocks on 10/6/11 the skin was intact. RN #6 stated, "We used the [MEDICATION NAME] then the dermaysn without covering the area, then we went to a barrier creme without covering the area. On 10/24/11 we continued to use barrier creme without covering." When asked by this surveyor to show the Skin Care Plan that documented the problem along with the course of treatments and interventions RN #6 was unable to locate a Care Plan. In an interview on 10/26/11 at 12:15 PM the Director of Nursing stated, "I see the preventative measures for skin in the ADL care plan, but there is no skin care plan. We were doing stuff but the thinking behind what we were doing is missing and no care plan is there. Why that decision was made to use that preventative measure caused more issues to the resident that must have been during our annual survey and it was dropped through the cracks". ( )

THIS CITATION REFERS TO INTAKE NUMBER MI 756 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PREVENT STAFF FROM MISTREATING 1 OF 4 (#501) RESIDENTS REVIEWED FOR ABUSE/NEGLECT FROM A TOTAL SAMPLE OF 5, RESULTING IN THE RESIDENT SUSTAINING BRUISING AND [MEDICAL CONDITION] TO LEFT HAND AND BEING FRIGHTENED. FINDINGS INCLUDE: RESIDENT #501, A [AGE] year OLD FEMALE, WAS admitted to the facility on [DATE], discharged on [DATE] AND REadmitted [DATE]. PER THE PHYSICIAN ADMISSION "HEALTH AND PHYSICAL FORM" DATED 8/31/11, [DIAGNOSES REDACTED]. THE RESIDENT'S FACE SHEET DOCUMENTED SHE WAS APHASIC (INABILITY TO SPEAK). THE ADL (ACTIVITIES OF DAILY LIVING) CARE PLAN DATED 7/27/11 DOCUMENTED SHE COMMUNICATED WITH A COMMUNICATION BOARD, AND REQUIRED 1 PERSON AND A GAIT BELT ASSISTANCE FOR TRANSFERS. THE CARE PLAN WAS UPDATED ON 8/8/11 TO 2-PERSON AND GAIT BELT ASSISTANCE FOR TRANSFER. THE "FACILITY INCIDENT/ACCIDENT REPORT" FORM DATED 8/7/11, DOCUMENTED RESIDENT HAD A "CHANGE IN SKIN." IT DOCUMENTED THAT A CNA (CERTIFIED NURSING ASSISTANT) IDENTIFIED IN REPORT AS (CNA # 6) HAD REPORTED TO THE REGISTERED NURSE (RN) (#7) THAT THE RESIDENT WAS FIGHTING DURING CARE. CNA #6 FURTHER REPORTED THAT RESIDENT #501 HAD REFUSED TO LET THE CNA CHANGE HER BRIEF AND DRESS HER. THE NURSE (RN #7) WAS CALLED INTO THE ROOM TWICE AND WAS ABLE TO CHANGE AND DRESS THE RESIDENT WITHOUT RESISTANCE. THE REPORT FURTHER DOCUMENTED THAT (RN #7) WAS LATER APPROACHED BY ANOTHER CNA (#8), WHO INFORMED HER (#7) THAT RESIDENT #501 HAD BRUISING AND SWELLING TO HER LEFT HAND. A NURSE'S NOTE DATED 8/7/11, AND SIGNED BY NURSE #7, DOCUMENTED THAT SHE WAS INFORMED BY CNA #8 OF THE INJURY TO RESIDENT # 501'S HAND. RN #7 DOCUMENTED THAT SHE (#7) IMMEDIATELY ASSESSED THE RESIDENT AND FOUND HER LEFT HAND "SWOLLEN, BRUISED AND WITH PAIN." RN #7 DOCUMENTED SHE ASKED THE RESIDENT WHAT HAPPENED AND THE RESIDENT POINTED TOWARDS THE CNA TAKING CARE OF HER. ON 10/5/11 AT 9:55 AND 1:20 P.M., THE SURVEYOR QUERIED RESIDENT #501 REGARDING THE INCIDENT. RESIDENT #501 ANSWERED QUESTIONS APPROPRIATELY BY NODDING HER HEAD, POINTING, FACIAL EXPRESSION, BODY LANGUAGE AND USE OF A COMMUNICATION BOARD. USING THESE COMMUNICATION TECHNIQUES SHE WAS ABLE TO IDENTIFY THE STAFF MEMBER, POINT AT THE DATE AND TIME THAT THE INJURY OCCURRED. RESIDENT #501 INDICATED THAT SHE FELT THE INJURY WAS INFLICTED INTENTIONALLY AND THAT SHE WAS AFRAID OF THE STAFF MEMBER. WHEN THE RESIDENT WAS ASKED IF A STAFF MEMBER HAD HURT HER, RESIDENT #501 HELD UP HER LEFT ARM. THE SURVEYOR OBSERVED A 1.5 CM HEALED SCAR ON THE TOP OF HER HAND BETWEEN THE THUMB AND INDEX FINGER. RESIDENT #501 THEN USED HER COMMUNICATION BOARD TO SPELL A NAME. THE RESIDENT WAS ABLE TO DEMONSTRATE, PUTTING HER LEFT ARM ON THE SURVEYORS LEFT ARM, PLACING HER THUMB ON THE BACK OF THE SURVEYOR'S HAND BETWEEN THE THUMB AND INDEX FINGER AND TWISTING THE ARM INWARD. A REVIEW OF RESIDENT # 501'S CLINICAL RECORD REVEALED A FACILITY physician progress notes [REDACTED]. RESIDENT CONFIRMS INJURY OCCURRED YESTERDAY DURING CARE." AN 8/8/11 A SOCIAL WORK NOTE DOCUMENTED RESIDENT # 501 HAD MODERATELY IMPAIRED COGNITIVE ABILITIES, BUT WAS ABLE TO MAKE INFORMED DECISIONS. THE NOTE INDICATED THAT THE RESIDENT RESPONDED TO QUESTIONS WITH HEAD AND BODY GESTURES, POINTING, FACIAL EXPRESSIONS AND USE OF A COMMUNICATION BOARD. THE NOTE DOCUMENTED THAT THE SOCIAL WORKER HAD INTERVIEWED RESIDENT #501 REGARDING THE INCIDENT. RESIDENT #501 INDICATED TO THE SOCIAL WORKER SHE HAD BEEN RESISTANT TO CARE WHILE IN THE BATHROOM AND A STAFF MEMBER HAD HIT HER. USING THE COMMUNICATION BOARD, RESIDENT #501 HAD SPELLED OUT A PARTIAL NAME TO IDENTIFY THE STAFF MEMBER. RESIDENT #501 INDICATED THAT SHE HAD PAIN IN HER ARM. THE NOTE DOCUMENTED THAT ALTHOUGH RESIDENT #501 DID NOT DISPLAY ANY SIGNS OR SYMPTOMS OF DISTRESS, A PSYCHOTHERAPIST WOULD FOLLOW AS WARRANTED. AN 8/8/11 PSYCHOLOGIST'S PROGRESS NOTE DOCUMENTED THAT AN INCIDENT HAD OCCURRED IN WHICH RESIDENT # 501'S LEFT HAND HAD BEEN INJURED. THE TOP AND BOTTOM OF THE RESIDENTS HAND LOOKED INJURED AND SHE REPORTED PAIN AS AN 8 ON A SCALE OF ZERO (0) TO 10. THE NOTE FURTHER DOCUMENTED THAT SHE INDICATED TO THE PSYCHOLOGIST THAT AN AIDE HAD INJURED HER AND SPELLED THE NAME ON HER COMMUNICATION BOARD. ACCORDING TO THE NOTE, RESIDENT #501, HAD INDICATED THE INCIDENT HAD OCCURRED "SUNDAY MORNING" (87/11) WHEN THE CNA WHO WAS ASSISTING HER LOST HER TEMPER, "YANKED HER" UP AND HIT HER HAND. THE NOTE FURTHER INDICATED THAT RESIDENT #501 FELT SAFE AND WAS RELIEVED THE CNA WOULD NO LONGER PROVIDE CARE TO HER. FURTHER REVIEW OF THE CLINICAL REVEALED A CONSULTATION REPORT FROM THE RESIDENT'S OUTSIDE ATTENDING PHYSICIAN DATED 8/15/11, WHICH DOCUMENTED "SWELLING, TENDERNESS AND A BLISTER ON THE LEFT HAND." THE [DIAGNOSES REDACTED]." THE PHYSICIAN MADE A RECOMMENDATION TO SEND RESIDENT TO AN ACUTE CARE HOSPITAL. A NURSES NOTE DATED 8/15/11 DOCUMENTED THAT RESIDENT #501 WAS TRANSFERRED TO AN ACUTE CARE HOSPITAL. ON 10/6/11 AT 9:40 A.M., RN #7 WAS INTERVIEWED PER PHONE REGARDING THE INCIDENT. RN #7 STATED THAT ON 8/7/11 AT APPROXIMATELY 5:00 AM., WHILE SHE (#7) WAS PASSING MEDICATIONS, CNA #7 APPROACHED HER TWICE TO INFORM HER THAT RESIDENT # 501 WAS COMBATIVE. RN #7 STATED THAT ON BOTH OCCASIONS, SHE (#7) ASSISTED CNA #6 AND RESIDENT #501 RECEIVED CARE WITHOUT PROBLEMS. HOWEVER, ACCORDING TO RN #7, SHE COULD SEE FROM RESIDENT # 501'S FACIAL EXPRESSION THAT SHE (#501) WAS UPSET WITH THE CNA. SHE SAID SHE ASKED CNA #6, "WHAT DID YOU DO? WHY IS SHE UPSET WITH YOU?" SHE (#7) STATED THE CNA DENIED DOING ANYTHING. SHE THEN ASKED RESIDENT #501 WHAT WAS WRONG AND THE RESIDENT JUST SHOOK HER HEAD. RN #7 SAID SHE DID NOT SEE ANY PROBLEM WITH THE RESIDENT'S HAND. FIVE (5) TO 10 MINUTES AFTER THE SECOND TIME SHE (#7) LEFT THE ROOM, ANOTHER CNA (#8) ASKED HER TO LOOK AT RESIDENTS # 501'S LEFT HAND AND SHE FOUND IT BRUISED. RN #7 SAID WHEN SHE ASKED CNA #6 WHAT HAPPENED, THE CNA REPLIED "NOTHING." WHEN RN #7 ASKED CNA #6 HOW THE RESIDENT'S HAND BEEN BRUISED, CNA # 6 SAID SHE HIT IT ON THE LIFT DURING A TRANSFER. ON 10/6/11 AT 9:15 A.M., PER PHONE AND AT 3:40 P.M., IN PERSON, CNA #6 WAS INTERVIEWED. SHE STATED THAT ON 8/7/11 ABOUT 5:00 A.M. SHE HAD ATTEMPTED TO TRANSFER RESIDENT #501 WITH A GAIT BELT. WHEN THE RESIDENT BECAME COMBATIVE, SHE INFORMED THE NURSE (#7). CNA #6 STATED THAT SHE THEN UTILIZED A LIFT AND ASSISTANCE FROM ANOTHER CNA( # 9) TO TRANSFER RESIDENT #501. CNA # 6 SAID THE RESIDENT CONTINUED TO BE COMBATIVE, "FIGHTING, HITTING AND PULLING AT THE STRAPS OF THE LIFT," AND THAT A THIRD CNA( #8) ASSISTED ONCE THE RESIDENT WAS IN THE WHEELCHAIR. CNA #6 DENIED TWISTING THE RESIDENT'S ARM AND STATED "THE MARK WAS FROM HITTING HER HAND ON THE LIFT WHEN SHE TRIED TO PULL THE STRAP OFF." ON 10/5/11 AT 10:00 A.M., CNA #8 WAS INTERVIEWED PER PHONE. CNA #8 STATED THAT ON 8/7/11 ABOUT 6:00 A.M., SHE WAS IN THE RESIDENT #501'S ROOM ASSISTING HER ROOMMATE WHILE CNA #6 ASSISTED RESIDENT #501. CNA #8 STATED THAT FROM RESIDENT # 501'S FACIAL EXPRESSIONS SHE COULD SEE SHE (#502) "WASN'T HAPPY." SHE (#8) STATED RESIDENT #501 WAS REFUSING TO GET UP AND THAT 3 CERTIFIED NURSING ASSISTANTS USED THE LIFT TO GET HER INTO THE WHEELCHAIR. THEN, CNA #6 TOOK HER (#501) INTO THE BATHROOM. CNA #8 DENIED SEEING THE RESIDENT DISPLAY ANY COMBATIVENESS OR OBSERVE HER TO STRIKE HERSELF ON ANYTHING. CNA #8 SAID SHE RETURNED AND ASSISTED RESIDENT #501 OUT OF THE RESTROOM AND WHEN THE RESIDENT "HELD HER LEFT HAND UP," HER HAND WAS ALL BRUISED AND VERY BLACK. CNA #8 STATED WHEN SHE (#8)ASKED HER (#501) WHAT HAPPENED, THE RESIDENT POINTED AT ROOM DOOR. CNA #8 STATED "I KNEW (CNA #6) HAD JUST LEFT...I GOT THE NURSE...THE NURSE ASKED HER WHAT HAPPENED AND SHE TRIED TO SAY (CNA # 6)'S NAME." ON 10/6/11 AT 10:20 A.M., CNA #9 WAS INTERVIEWED PER PHONE. CNA #9 STATED THAT ON 8/7/11 BETWEEN 5 AND 6:00 A.M., SHE WAS IN ANOTHER RESIDENT ROOM AND HEARD CNA #6 CALL FOR HELP. CNA #9 SAID THAT CNA #6 TOLD HER RESIDENT # 501 WAS BEING COMBATIVE. SHE STATED TOGETHER THEY USED THE LIFT TO GET THE RESIDENT UP. RESIDENT #501 HAD REACHED UP, GRABBED FOR THE STRAP AND TRIED TO UNDO IT. CNA #9 SAID SHE (#9) TOLD HER (#502), "DON'T DO THAT. PUT YOUR ARM DOWN" AND THE RESIDENT DID, "NO PROBLEM." SHE (#9) DENIED SEEING THE RESIDENT COMBATIVE OR STRIKE HER ARM. SHE STATED SHE ENTERED THE ROOM APPROXIMATELY 45 MINUTES LATTER AND THE RESIDENT HAD A "RAG ON HER HAND" SHE (#9) SAID SHE ASKED RN #7 IF SHE WAS AWARE OF THE BRUISE. THE NURSE SAID SHE WAS AND THAT THE RESIDENT HAD TOLD HER CNA #6 DID IT. ON 10/5/11 RESIDENT # 501'S ROOMMATE (RESIDENT # 503) WAS INTERVIEWED BY THE SURVEYOR. RESIDENT # 503 WAS UNABLE TO RECALL THE INCIDENT. ON 10/5/11 AND 10/6/11 THE ADMINISTRATOR AND DIRECTOR OF NURSING, STATED THAT A FACILITY INVESTIGATION, INTERVIEWS OF RESIDENT # 501, HER ROOMMATE AND STAFF INVOLVED HAD BEEN CONDUCTED. THEY STATED THAT THEY WERE NOT ABLE TO SUBSTANTIATE ABUSE. THEY HAD DETERMINED THE INJURY HAD OCCURRED AS A RESULT OF THE RESIDENT BECOMING COMBATIVE DURING CARE. IT WAS UNCLEAR HOW THEY HAD COME TO THEIR CONCLUSION WHEN BOTH CERTIFIED NURSING ASSISTANTS #8 AND #9 STATED THEY HAD BEEN IN THE ROOM, BUT HAD NOT SEEN RESIDENT #501 STRIKE THE LIFT WITH HER HAND DURING THE TRANSFER. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO PROMOTE THE HEALING OF AN EXISTING PRESSURE ULCER FOR ONE (#802) OF EIGHT RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL OF 27, RESULTING IN THE DEVELOPMENT OF INFECTION, GANGRENOUS NECROTIC TISSUE, ACUTE OSTEO[DIAGNOSES REDACTED] THAT REQUIRED HOSPITAL- BASED SURGICAL DEBRIDEMENT AND TREATMENT. FINDINGS INCLUDE: ON 6/7/11 AT 8:50 A.M., DURING THE INITIAL TOUR, RESIDENT #802 WAS OBSERVED LAYING IN BED POSITIONED ON HER BACK. THE RESIDENT WAS AWAKE AND ALERT. AT 9:30 A.M., RESIDENT #802 WAS OBSERVED SITTING IN A WHEELCHAIR IN THE DINING ROOM. ON 6/8/11 AT 8:30 A.M., RESIDENT #802 WAS OBSERVED LAYING IN BED POSITIONED ON HER BACK. AT 9:50 A.M., 10:30 A.M., AND 11:00 A.M., RESIDENT #802 WAS OBSERVED SITTING IN A WHEELCHAIR. ON 6/8/11 AT 1:45 P.M., RESIDENT #802'S SKIN AND WOUND CARE OBSERVATIONS WERE CONDUCTED. NURSE (D) REMOVED THE OLD DRESSING DATED 6/8/11. THE OLD DRESSING HAD A SCANT (SMALL) AMOUNT OF SEROUS DRAINAGE. THE RESIDENT HAD A STAGE FOUR (IV) PRESSURE ULCER WITH FULL THICKNESS SKIN LOSS AND DESTRUCTION TO THE MUSCLE. THE SACRAL BONE WAS EXPOSED. THE ULCER MEASURED APPROXIMATELY 5.0 CENTIMETERS (CM) BY 4.0 CM BY 4.0 CM. NO ODOR WAS NOTED. THERE WAS GRANULATION IN THE ULCER AND THE WOUND BED WAS RED. ON 6/8/11 AT 9:15 A.M., REVIEW OF RESIDENT #802'S MEDICAL RECORD FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #802 WAS REadmitted on [DATE] WITH THE ADDITIONAL [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #802'S MINIMUM DATA SET (MDS), dated [DATE] INDICATED THE RESIDENT'S COGNITION WAS SEVERELY IMPAIRED AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS, DRESSING, EATING, HYGIENE AND MOBILITY. REVIEW OF THE INITIAL"WOUND ASSESSMENT SUMMARY", DATED 3/8/11, NOTED RESIDENT #802 HAD A "STAGE II WOUND ON THE COCCYX THAT MEASURED 0.8 CENTIMETERS (CM) BY 0.4 CM BY 0 CM (FLAT)." REVIEW OF THE PRESSURE ULCER RISK ASSESSMENT, DATED 3/8/11, DOCUMENTED RESIDENT #802'S SCORE WAS 15, (TOTAL SCORE OF 12 OR LESS REPRESENTS HIGH RISK). REVIEW OF RESIDENT#802 ' S SKIN/PRESSURE ULCER CARE PLAN, DATED 3/8/11, INCLUDED THE FOLLOWING INTERVENTIONS: 1." MONITOR SKIN PER FACILITY PROTOCOL 2. KEEP RESIDENT CLEAN AND DRY 3. WOUND CARE SERVICES 4. PRESSURE RELIEVING CUSHION IN WHEELCHAIR 5. LOW AIR LOSS MATTRESS " THERE WAS NO DOCUMENTED INTERVENTIONS THAT INCLUDED TURNING AND REPOSITIONING OF THE RESIDENT. ON 6/8/11 AT 10:00 A.M., A REVIEW OF THE FACILITY'S POLICY ENTITLED, "treatment of [REDACTED]. 1. RELIEVE PRESSURE, I.E. TURN AND POSITION OFF BONY PROMINENCE 2. REPOSITION/POSITION FREQUENTLY 3. MONITOR RESIDENTS WHO HAVE DECREASED MENTAL STATUS THEY MAY NOT FEEL DISCOMFORT FROM PRESSURE." ON 6/8/11 AT 10:37 A.M., RESIDENT #802'S MEDICAL RECORD AND WOUND RECORDS WERE REVIEWED WITH THE WOUND CARE COORDINATOR AND SECOND FLOOR DIETARY TECHNICIAN. THE REVIEW REVEALED THE FOLLOWING: ON 3/8/11, THE WOUND ASSESSMENT SUMMARY (COMPLETED BY THE WOUND CARE COORDINATOR) DOCUMENTED THAT RESIDENT #802'S " COCCYX WOUND MEASURED 0.8 CM BY 0.4 BY 0 CM. THE WOUND WAS A STAGE II PRESSURE ULCER WITH NO NECROTIC (DEAD) TISSUE. TREATMENT INCLUDED WOUND CLEANER AND [MEDICATION NAME] (ABSORBERS DRAINAGE AND PROTECTS FROM OUTSIDE CONTAMINANTS) EVERY THREE DAYS. " ON 3/10/11, THE WOUND ASSESSMENT DOCUMENTED (WOUND PHYSICIAN) THAT RESIDENT #802'S " COCCYX WOUND WAS MEASURED 0.8 CM BY 0.4 BY 0. THERE WAS NO SIGNS OF INFECTION OR NECROTIC TISSUE. " ON 3/24/11, THE WOUND NOTE (WOUND CARE COORDINATOR) DOCUMENTED, COCCYX WOUND "CONTINUES TO IMPROVE." THE WOUND ASSESSMENT RECORD, DATED 3/24/11, DOCUMENTED THE COCCYX WOUND WAS 1.0 CM BY 0.2 CM BY 0.1 CM. GRANULATION WAS PRESENT, THERE WERE NO SIGNS OF INFECTION OR NECROTIC TISSUE. " ON 3/31/11 AT 2:00 P.M., THE NURSES NOTES DOCUMENTED, " WOUND MEETING ...COCCYX WOUND IMPROVING. " THE WOUND ASSESSMENT SUMMARY, DATED 3/31/11, DOCUMENTED A STAGE II COCCYX WOUND WAS 4.0 CM BY 1.5 CM BY 0.2 CM. THERE WAS NO SIGNS OF INFECTION OR NECROTIC TISSUE. " ON 4/7/11, THE WOUND ASSESSMENT RECORD DOCUMENTED, " THE COCCYX ULCER IS UNSTAGEABLE (NECROTIC TISSUE IS PREVENTING OBSERVATION OF THE WOUND BASE), MEASUREMENTS WERE 5.5 CM BY 2.5 CM WITH A NECROTIC CORE. ON 4/8/11, (RESIDENT ' S #802 ' S WOUND NOTE DOCUMENTED, " WOUND CARE MEETING, COCCYX AREA ...NO IMPROVEMENT. " ON 4/14/11, THE WOUND ASSESSMENT RECORD DOCUMENTED, " THE COCCYX ULCER WAS UNSTAGEABLE. MEASUREMENTS WERE 3.5 CM BY 1.5 CM WITH A NECROTIC CORE. THE WOUND HAD HIGH A AMOUNT OF SEROUS DRAINAGE AND NECROTIC SLOUGH. THE WOUND WAS YELLOW, BLACK AND BROWN IN COLOR. THE WOUND HAD A MUSTY ODOR. " ON 4/20/11, THE TREATMENT RECORD REVEALED THAT RESIDENT #802'S WOUND TREATMENTS WERE CHANGED TO SANTYL AND ALGINATE DRESSING (PROMOTES AUTOLYTIC DEBRIDEMENT) TWO TIMES DAILY AND AS NEEDED. ON 4/21/11, THE PHYSICIANS PROGRESS NOTE DOCUMENTED, " COCCYX DECEITS WITH NECROTIC CENTER ...FOUL SMELL. " ON 4/23/11, THE WOUND ASSESSMENT DOCUMENTED, "THE COCCYX ULCER IS UNSTAGEABLE ...WOUND MEASUREMENTS 4.0 CM BY 2.5 CM WITH A NECROSIS CENTER. THERE IS MODERATE DRAINAGE THAT IS SEROUS AND THERE IS A MUSTY ODOR. TREATMENT IS SANTYL AND ALGINATE. " ON 4/27/11, THE PHYSICIAN' S PROGRESS NOTE DOCUMENTED, " COCCYX DECEITS REMAINS FOUL SMELLING, NECROTIC CENTER ...WAITING WOUND CARE TEAM FOR DEBRIDEMENT. " ON 4/27/11 THE WOUND CARE PHYSICIAN DOCUMENTED, " (RESIDENT #802) WAS RE-EVALUATED FOR COCCYX ULCER, WOUND IS FAILING TO RESPOND AS EXPECTED AND EXTENT OF TISSUE INVOLVEMENT IS GREATER THAN EXPECTED, THEREFORE WILL TRANSFER TO HOSPITAL FOR DEBRIDEMENT. " ON 4/28/11, THE PHYSICIAN ' S PROGRESS NOTES DOCUMENTED, " SACRAL DECEITS STAGE IV WITH NECROTIC CENTER ...PLAN TO TRANSFER TO HOSPITAL TODAY FOR WOUND DEBRIDEMENT. " REVIEW OF THE HOSPITAL CONSULTATION FORM DATED 4/28/11, DOCUMENTED,"(RESIDENT #802) WAS admitted WITH A COCCYX WOUND WITH MEASUREMENTS OF 5.0 CM BY 3.1 CM BY 2.4 CM ...SOME OF THE TOP LAYER ESCHAR WAS SHARPLY DEBRIDED AT BEDSIDE ...WOUND CULTURES OBTAINED. RECOMMENDATION, (RESIDENT #802) WILL NEED OPERATING ROOM DEBRIDEMENT. REVIEW OF THE OPERATING ROOM RECORD DATED 5/13/11, DOCUMENTED " THIS IS A STAGE IV ULCER ...IT IS ALL THE WAY DOWN TO THE BONE. IT WAS FILLED WITH NECROTIC TISSUE. WE WILL CHECK TO FIND OUT IF (RESIDENT #802) HAD UNDERLYING OSTEO[DIAGNOSES REDACTED] (BONE INFECTION). " REVIEW OF THE HOSPITAL ' S SURGICAL PATHOLOGY REPORT DOCUMENTED, " (RESIDENT #802 ' S) SACRUM BONE BIOPSY - SOFT TISSUE WITH GANGRENOUS NECROSIS, BONY TISSUE WITH ACUTE OSTEO[DIAGNOSES REDACTED] OF THE SACRUM. " THE WOUND CARE COORDINATOR WAS QUERIED AND WAS UNABLE TO EXPLAIN WHY THERE WAS NO DOCUMENTED EVIDENCE OF A TURNING AND REPOSITIONING OF RESIDENT #802. THERE WAS NO SURGICAL DEBRIDEMENT WHEN NECROTIC TISSUE WAS FIRST IDENTIFIED IN THE RESIDENT #802' S PRESSURE ULCER AND THERE WAS NO DOCUMENTATION REGARDING WOUND WORSENING UNAVOIDABILITY. ON 6/10/11, THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING THE RESIDENT #802'S PRESSURE ULCERS. THE DON STATED, " WE HAVE A LOT OF WORK TO DO WITH OUR NURSING STAFF. I HAVE ONLY BEEN THE DON FOR THREE DAYS, I WAS NOT AWARE OF THE RESIDENT ' S PRESSURE ULCER HISTORY. " ON 6/10/11 AT 10:36 A.M., THE MEDICAL DIRECTOR (MD) WAS QUERIED REGARDING RESIDENT #802 ' S PRESSURE ULCER. THE MD STATED " I WAS AWARE FROM THE SYMPTOMS THAT THE RESIDENT COULD HAVE DEVELOPED OSTEO[DIAGNOSES REDACTED]. I BELIEVE SURGICAL DEBRIDEMENT SHOULD HAPPEN AT THE FACILITY, THERE IS NO REASON WHY IT CAN'T. HER (RESIDENT #802) WOUND BECAME SEPTIC ...SHE WAS BEING FOLLOWED BY WOUND CARE." ( )

THIS CITATION PERTAINS TO INTAKE #MI 880BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT RESIDENTS WITH URINARY CATHETERS RECEIVE THE APPROPRIATE TREATMENT AND SERVICES NECESSARY TO PREVENT URINARY TRACT INFECTIONS AND TO RESTORE AS MUCH NORMAL BLADDER FUNCTION AS POSSIBLE IN 1 OF 4 SAMPLED RESIDENTS (#101), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHEN THE FACILITY FAILED TO PROVIDE THE FUNDAMENTAL NURSING RESPONSIBILITIES OF MONITORING THE INDWELLING URINARY CATHETER FOR COMPLICATIONS, LEADING TO A BLOCKAGE IN HER URINARY CATHETER, PROLONGED [MEDICAL CONDITION], A URINARY TRACT INFECTION, BACTEREMIA, UROSEPSIS AND DEATH.FINDINGS INCLUDE:RESIDENT #101ACCORDING TO THE FACE SHEET DATED [DATE], RESIDENT #101 WAS A [AGE] year-old-FEMALE LIVING AT THE FACILITY SINCE [DATE]. HER [DIAGNOSES REDACTED].ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 HAD SEVERELY IMPAIRED DECISION MAKING WITH SHORT-TERM MEMORY LOSS. SHE COULD NOT WALK AND DEPENDED ON MINIMALLY ONE STAFF MEMBER TO PROVIDE ALL ACTIVITIES OF DAILY LIVING. SHE WAS ALWAYS INCONTINENT OF STOOL AND HAD AN INDWELLING URINARY CATHETER.ACCORDING TO THE ADMISSION NURSING NOTES DATED [DATE], THE FACILITY admitted RESIDENT #101 WITH AN INDWELLING URINARY CATHETER.ACCORDING TO THE ADMISSION PHYSICIAN ORDERS [REDACTED].THE INITIAL CARE PLAN DATED [DATE], DID NOT ADDRESS URINARY CATHETER CARE FOR RESIDENT #101.A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD BETWEEN [DATE] AND [DATE], REVEALED NO EVIDENCE THAT STAFF KNEW RESIDENT #101 HAD A URINARY CATHETER ON 15 OF THE 20 DAYS SHE RESIDED AT THE FACILITY. THESE DAYS INCLUDED [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] AND [DATE]. THERE WAS NO EVIDENCE OF ANY ASSESSMENTS OR MONITORING FOR URINARY CATHETER COMPLICATIONS SUCH AS OBSTRUCTION, AND NO MONITORING FOR SIGNS OF BACTERIA DURING THE ENTIRE TWENTY DAYS SHE RESIDED AT THE FACILITY. THERE WAS NO EVIDENCE THAT ANYONE PROVIDED RESIDENT #101 CATHETER CARE DURING THE TWENTY DAYS SHE LIVED AT THE FACILITY.ON [DATE] AT 11:35 A.M., UNIT MANAGER FOR RESIDENT #101 SAID THE FACILITY DID NOT HAVE A POLICY FOR MONITORING URINARY CATHETER COMPLICATIONS. THE UNIT MANAGER SAID NOT ALL CATHETERIZED RESIDENTS REQUIRE STAFF TO MONITOR AND OBTAIN URINARY VOLUMES. SHE SAID THIS IS ONLY DONE WHEN THE PHYSICIAN ORDERS [REDACTED]. AT THIS POINT A NURSE WOULD BECOME INVOLVED. ON [DATE] AT 12:30 P.M., EMPLOYEE "D" SAID SHE WAS THE LICENSED NURSE ASSIGNED TO CARE FOR RESIDENT #101 ON [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] AND [DATE]. EMPLOYEE "D" SAID SHE DID NOT KNOW RESIDENT #101 HAD A URINARY CATHETER. EMPLOYEE "D" SAID AS A LICENSED NURSE SHE DELEGATES URINARY CATHETER ASSESSMENTS TO CERTIFIED NURSING ASSISTANTS AND THEN DOCUMENTS THEIR FINDINGS.ON [DATE] AT 1:10 P.M., EMPLOYEE "I" SAID AS A REGISTERED NURSE HE MAY NEVER MONITOR AND/OR ASSESS URINARY CATHETER COMPLICATIONS BECAUSE THE CERTIFIED NURSING ASSISTANTS ARE "OUR EYES AND EARS FOR URINE." EMPLOYEE "I" WAS THE REGISTERED NURSE ASSIGNED TO CARE FOR RESIDENT #101 ON [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] AND [DATE]. AFTER EMPLOYEE "I" REVIEWED RESIDENT #101'S MEDICAL RECORD, HE SAID THAT OF THE EIGHT DAYS HE WAS ASSIGNED TO RESIDENT #101 HE HAD NO EVIDENCE THAT HE ASSESSED HER URINARY CATHETER OR PROVIDED CATHETER CARE. EMPLOYEE "I" SAID SIX OF THESE EIGHT DAYS HE FOUND EVIDENCE OF DOCUMENTED URINARY INCONTINENCE. EMPLOYEE "I" SAID URINE INCONTINENCE IN THE PRESENCE OF A URINARY CATHETER IS AN ABNORMAL FINDING THAT REQUIRED IMMEDIATE INTERVENTION TO ENSURE THE RESIDENT DID NOT HAVE A URINARY OBSTRUCTION. HE SAID HE WAS REQUIRED TO DOCUMENT ALL URINARY CATHETER CARE INCLUDING OUTPUT AND ANY ASSOCIATED INTERVENTIONS, BUT WAS NOT ABLE TO EXPLAIN WHY THIS DOCUMENTATION WAS ABSENT. EMPLOYEE "I" SAID, "IF IT IS NOT DOCUMENTED IT IS NOT DONE." HE BLAMED HIS LACK OF ACTION ON INACCURATE DOCUMENTATION. ON [DATE] AT 12:45 P.M., EMPLOYEE "E" SAID AS A CERTIFIED NURSING ASSISTANT, SHE HAD THE RESPONSIBILITY OF EMPTYING URINARY CATHETERS EACH SHIFT BUT STATED THAT SHE DID NOT KNOW WHAT ADDITIONAL SYMPTOMS REQUIRED MONITORING WHEN RESIDENTS HAD CATHETERS. EMPLOYEE "E" DID NOT KNOW WHAT VOLUME OF URINE PRODUCED WOULD INDICATE THE CATHETER HAD NO OBSTRUCTION OR THAT THE KIDNEYS HAD ADEQUATE PROFUSION. SHE SAID SHE PROVIDED CATHETER CARE FIVE DAYS A WEEK FOR RESIDENT #101 BETWEEN [DATE] AND [DATE]. THREE TIMES DURING THE INTERVIEW EMPLOYEE "E" DESCRIBED THE CATHETER CARE SHE DELIVERED TO RESIDENT #101 SAYING SHE CLEANED HER WITH SOAP AND WATER "ALWAYS" WIPING FROM "BACK TO FRONT." ON [DATE] AT 1:30 P.M., EMPLOYEE "F" SAID AS A CERTIFIED NURSING ASSISTANT SHE HAD THE RESPONSIBILITY OF EMPTYING URINARY CATHETERS EACH SHIFT BUT STATED THAT SHE DID NOT KNOW WHAT ADDITIONAL SYMPTOMS REQUIRED MONITORING WHEN RESIDENTS HAD CATHETERS. EMPLOYEE "F" DID NOT KNOW WHAT VOLUME OF URINE PRODUCED WOULD INDICATE THE CATHETER HAD NO OBSTRUCTION OR THAT THE KIDNEYS HAD ADEQUATE PROFUSION. EMPLOYEE "F" SAID THE "RESIDENT ADL RECORD AND IMPLEMENTATION OF CARE PLAN" WAS WHERE CERTIFIED NURSING ASSISTANTS DOCUMENTED THEIR DAILY PROVISION OF CARE BUT IT DID NOT PERTAIN TO URINARY CATHETERS BECAUSE NURSES WERE RESPONSIBLE FOR DOCUMENTING THOSE TREATMENTS AND SERVICES.ON [DATE] AT 1:40 P.M., EMPLOYEE "G" SAID AS A CERTIFIED NURSING ASSISTANT SHE HAD THE RESPONSIBILITY OF EMPTYING URINARY CATHETERS EACH SHIFT BUT STATED THAT SHE DID NOT KNOW WHAT ADDITIONAL SYMPTOMS REQUIRED MONITORING WHEN RESIDENTS HAD CATHETERS. EMPLOYEE "G" DID NOT KNOW WHAT VOLUME OF URINE PRODUCED WOULD INDICATE THE CATHETER HAD NO OBSTRUCTION OR THAT THE KIDNEYS HAD ADEQUATE PROFUSION. EMPLOYEE "G" SAID WITHOUT an order for [REDACTED]. ACCORDING TO THE PHYSICIANS HISTORY AND PHYSICAL DATED [DATE], RESIDENT #101 EXPERIENCED A NEW ONSET OF LETHARGY (A LOWERED LEVEL OF CONSCIOUSNESS) AND THE PHYSICIAN ORDERED FACILITY STAFF TO SEND A URINE SPECIMEN FROM RESIDENT #101 TO THE LABORATORY FOR TESTING/ANALYSIS. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD DID NOT PROVIDE ANY EVIDENCE THAT THE ORDERED URINE TEST HAD EVER BEEN OBTAINED OR SENT FOR TESTING/ANALYSIS. ON [DATE] AT 11:35 A.M., THE UNIT MANAGER FOR RESIDENT #101 SAID THE SPECIMEN DID NOT APPEAR TO HAVE BEEN OBTAINED OR SENT FOR TESTING.ACCORDING TO NURSING NOTES DATED [DATE] AT 3:00 A.M., STAFF FOUND RESIDENT #101 IN BED AFTER SHE HAD VOMITED. SHE WAS IN RESPIRATORY DISTRESS. SHE WAS TRANSFERRED TO A LOCAL HOSPITAL FOR FURTHER EVALUATION. ON [DATE] AT 3:59 A.M., RESIDENT #101 ARRIVED AT THE LOCAL EMERGENCY DEPARTMENT BY AMBULANCE. RESIDENT #101 WAS IMMEDIATELY ASSESSED TO HAVE LIFE-THREATENING VITAL SIGNS WITH A RESPIRATORY RATE OF 50 BREATHS PER MINUTES, A BLOOD PRESSURE OF ,[DATE] MMHG, AND A RAPID AND IRREGULAR HEART BEAT OF 138 BEATS PER MINUTE. emergency room PHYSICIANS INTUBATED RESIDENT #101 AND, AT 4:54 A.M. NURSING DOCUMENTED "PT (PATIENT) ARRIVED WITH FOLEY IN PLACE, NO URINE OUTPUT IN FOLEY, FOLEY CATH (CATHETER) REMOVED AND NEW CATHETER INSERTED, 1300 CC CLOUDY, RED, MUCOUS URINE RETURNED."ON [DATE] AT 6:13 A.M., THE EMERGENCY DEPARTMENT PHYSICIAN DOCUMENTED, RESIDENT #101 "ARRIVED ...FOLEY IN PLACE " WITH A "PALPABLE SUPRAPUBIC MASS." THE SAME PHYSICIAN WROTE " + (POSITIVE) GROSS PURULENT URINE OUT ON FOLEY CHANGE." THE EMERGENCY DEPARTMENT PHYSICIAN diagnosed RESIDENT #101 WITH "[MEDICAL CONDITION] (BACTERIA IN THE BLOOD STREAM), UTI (URINARY TRACT INFECTION)" AND "[MEDICAL CONDITION]."ON [DATE] AT 8:30 A.M., A CONSULTING PHYSICIAN DOCUMENTED "[MEDICAL CONDITION] WITH MULTIPLE ORGAN SYSTEM DYSFUNCTIONS, ALMOST CERTAINLY UN-SURVIVABLE." THE SAME PHYSICIAN WROTE "URINARY TRACT INFECTION DUE TO (AN) OBSTRUCTED DRAINAGE CATHETER AS (THE) PRIMARY SOURCE OF (HER)[MEDICAL CONDITION]" AND "ACUTE [MEDICAL CONDITION]."ON [DATE] AT 8:40 P.M., DESPITE MULTIPLE MEDICAL INTERVENTIONS, RESIDENT #101'S BLOOD PRESSURE, HEART RATE AND RESPIRATORY FUNCTION DECLINED AND SHE COULD NOT BE REVIVED. A PHYSICIAN PRONOUNCED HER DEAD AT 8:47 P.M.ON [DATE] AT 12:10 P.M., THE DIRECTOR OF NURSING SAID RESIDENTS WITH URINARY CATHETERS REQUIRED NURSING ASSESSMENTS EVERY SHIFT. SHE SAID THESE ASSESSMENTS SHOULD BE DOCUMENTED AND MUST INCLUDE THE CATHETERS PATENCY, URINARY VOLUME EXCRETED, COLOR, ANY ODOR AND ANY FILAMENTS PRESENT. THE DIRECTOR OF NURSING SAID RESIDENTS WITH URINARY CATHETERS ARE AT GREATER RISK FOR URINARY TRACT INFECTIONS AND COMPLICATIONS. SHE SAID ALL ABNORMAL FINDINGS REQUIRED FOLLOW-UP AND THAT URINARY INCONTINENCE IN THE PRESENCE OF A RESIDENT WITH A URINARY CATHETER IS AN ABNORMAL FINDING THAT MAY INDICATE OBSTRUCTION. SHE REVIEWED THE MEDICAL RECORD FOR RESIDENT #101 FOUND NO EVIDENCE THAT RESIDENT #101 EVER RECEIVED CATHETER CARE, ASSESSMENTS OR MONITORING FOR URINE OUTPUT, CATHETER PATENCY OR INFECTIONS. SHE SAID, "WOW ...IT SEEMS DIFFERENT HERE. I WILL HAVE TO FIND OUT HOW THIS FACILITY DOES THINGS." ON [DATE] AT 2:45 P.M., THE DIRECTOR OF NURSING SAID SHE INVESTIGATED AND FOUND NO ADDITIONAL EVIDENCE THAT STAFF FOLLOWED STANDARDS OF PRACTICE FOR CATHETER CARE TO MINIMIZE THE RISK OF RESIDENT #101 ' S URINARY TRACT INFECTIONS AND COMPLICATIONS. THE DIRECTOR OF NURSING SAID SHE FOLLOWED UP ON THE URINE TEST ORDERED ON [DATE] AND SAID THE FACILITY AND THE LABORATORY HAD NO EVIDENCE THAT THE ORDERED URINE SPECIMEN HAD EVER BEEN COLLECTED, RECEIVED OR tested . THE SURVEYOR THEN NOTIFIED THE DIRECTOR OF NURSING THAT RESIDENT #101 REQUIRED URINARY CATHETER REPLACEMENT WITHIN AN HOUR OF BEING admitted TO THE LOCAL EMERGENCY DEPARTMENT ON [DATE] AND THAT SHE HAD 1300 CC'S DRAIN IMMEDIATELY INTO THE NEW BAG. THE DIRECTOR OF NURSING SAID THAT "SHOULD BE ABOUT TWO SHIFTS OF URINE BACKED UP."ON [DATE] AT 3:00 P.M., THE ADMINISTRATOR REVIEWED OTHER RESIDENT RECORDS AND SAID "AT LEAST" THE PROBLEM "IS NOT WIDE SPREAD."ON [DATE] AT 12:05 P.M., THE FACILITY'S ADMINISTRATOR AND DIRECTOR OF NURSING WERE NOTIFIED THAT THIS DEFICIENT PRACTICE PLACED THEM IN IMMEDIATE JEOPARDY.ON [DATE], THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING MEASURES BY [DATE] TO REMOVE THE IMMEDIATE JEOPARDY:RESIDENT #101 NO LONGER LIVES AT THE FACILITY. 1. ON [DATE], THE FACILITY IDENTIFIED NINE CATHETERIZED RESIDENTS AT RISK. THE NURSING ADMINISTRATIVE TEAM IMPLEMENTED THE FOLLOWING CORRECTIVE MEASURES FOR ALL NINE RESIDENTS REMAINING AT RISK WITH INDWELLING URINARY CATHETERS: 2. ON [DATE], EACH RESIDENT WAS REASSESSED FOR URINE OUTPUT AND CHARACTERISTIC OF THE URINE. STAFF RECEIVED EDUCATION ON THE SAME. EACH RESIDENT HAD THESE ASSESSMENTS DOCUMENTED. STAFF RECEIVED EDUCATION ON THE SAME. 3. ON [DATE], EACH NURSING STAFF MEMBER RECEIVED NOTICE OF WHO THE RESIDENTS WERE THAT HAD URINARY CATHETERS. STAFF RECEIVED EDUCATION ON THE SAME. 4. ON [DATE], EACH RESIDENTS CARE PLAN WAS REVIEWED AND REVISED WHEN INDICATED TO ENSURE APPROPRIATE MONITORING AND ASSESSMENTS FOR CATHETERIZED CARE AND COMPLICATIONS. STAFF RECEIVED EDUCATION ON THE SAME. 5. ON [DATE], 173 OF 173 RESIDENTS LIVING AT THE FACILITY HAD THEIR MEDICAL RECORDS AUDITED FOR COMPLIANCE WITH LABORATORY ORDERS AND SPECIMEN COLLECTION. ALL LABORATORY ORDERS WERE RECONCILED AND ONE SPECIMEN WHICH HAD NOT BEEN COLLECTED WAS SENT FOR TESTING. STAFF RECEIVED EDUCATION FOR GOING FORWARD ON THE SAME. 6. ON [DATE], THE DIRECTOR OF NURSING DEVELOPED A PROTOCOL FOR TRANSCRIBING AND NOTING LABORATORY ORDERS AND PROVIDED STAFF EDUCATION ON THE SAME. 7. ON [DATE], THE ADMINISTRATOR DEVELOPED A FORM TO BE UTILIZED TO ENSURE SPECIMEN COLLECTION AND TRACK LAB PICK UP. STAFF RECEIVED EDUCATION ON THE SAME. 8. ON [DATE], CERTIFIED NURSING ASSISTANTS NOW HAVE A URINARY ASSESSMENT TOOL FOR DAILY COMMUNICATION WITH THE CHARGE NURSE. THIS FORM DOES INCLUDE OUTPUT, COLOR, APPEARANCE, ODOR AND OTHER VISUAL ABNORMALITIES. STAFF RECEIVED EDUCATION ON THE SAME.MEDICATION ADMINISTRATION RECORDS WERE REVIEWED AND REVISED TO REQUIRE NURSE VERIFICATION EACH SHIFT FOR ALL URINARY CATHETER PLACEMENTS AND THEIR PATENCY. STAFF RECEIVED EDUCATION ON THE SAME. 9. ON [DATE], THE FACILITY DEVELOPED A CATHETER OUTPUT MEASUREMENT POLICY AND STAFF RECEIVED EDUCATION ON THE SAME. 10. BEGINNING [DATE], ALL NURSES, CERTIFIED NURSING ASSISTANTS AND WARD CLERKS RECEIVED EDUCATION PRIOR TO RETURNING TO RESIDENT CARE ON THE FOLLOWING PRACTICES/POLICIES:FOLEY CATHETER CAREPHYSICIAN ORDERS [REDACTED]. AS OF [DATE] 123 OF 135 NURSING STAFF HAD RECEIVED THEIR IN-SERVICES. TWO NURSING STAFF MEMBERS ON LEAVE OF ABSENCE RECEIVED THE IN-SERVICE BY CERTIFIED MAIL. THE REMAINING TEN EMPLOYEES WHO REQUIRE THE EDUCATION WILL RECEIVE THEIR EDUCATION PRIOR TO REINSTATEMENT TO DUTY.WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE] THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY BECAUSE SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

REFER TO INTAKE MI 819. BASED ON INTERVIEWS AND CLOSED RECORD REVIEW, FACILITY STAFF FAILED TO PROVIDE ADEQUATE SUPERVISION IN TRANSFERRING 1 (#502) OF 6 SAMPLED RESIDENTS DURING A MECHANICAL LIFT TRANSFER RESULTING IN A FALL FROM THE MECHANICAL LIFT WITH RESULTANT EAR LACERATION AND SMALL ACUTE SUBDURAL HEMORRHAGE (A BLOOD CLOT DEVELOPING BETWEEN TWO MENINGEAL LAYERS WHICH ENVELOP THE BRAIN). FINDINGS INCLUDE: RESIDENT #502, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE ADMISSIONS FORM. ACCORDING TO AN 11/10/10 PHYSICIAN ' S PROGRESS NOTE, RESIDENT #502 HAD A TRACHEOSTOMY AND A FEEDING TUBE. A 10/29/10 ADL (ACTIVITIES OF DAILY LIVING) RAP (RESIDENT ASSESSMENT PROTOCOL) INDICATED THAT RESIDENT #502 REQUIRED TOTAL ASSISTANCE WITH ADL ' S RELATED TO WEAKNESS SECONDARY TO CHRONIC RESPIRATORY FAILURE. THE 10/27/10 COMMUNICATION RAP STATED THAT THE RESIDENT SPOKE AND UNDERSTOOD SOME ENGLISH. HE WAS NOT ABLE TO VERBALLY COMMUNICATE BUT USED HAND GESTURES TO COMMUNICATE . HE WAS ABLE TO " UNDERSTAND OTHERS WITH SIMPLE CONCRETE REQUEST/YES AND NO " . A FACILITY INVESTIGATION REPORT, DATED 11/16/10, INDICATED THAT RESIDENT #502 WAS BEING TRANSFERRED WITH A MECHANICAL LIFT USING TWO PERSON ASSISTANCE ON 11/10/10 AT APPROXIMATELY 2:50 P.M. THE RESIDENT fell OUT OF THE MECHANICAL LIFT AND SUSTAINED A LACERATION TO HIS RIGHT EAR. THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL. CNA (CERTIFIED NURSING ASSISTANT) #1 WAS INTERVIEWED ON 11/19/10 AT 12:25 P.M. SHE SAID SHE ASSISTED CNA #2 WITH THE TRANSFER OF RESIDENT #502 ON 11/10/10 USING THE MECHANICAL LIFT. CNA #1 SAID CNA #2 WAS OPERATING THE LIFT. CNA #2, ACCORDING TO CNA #1, BACKED HIMSELF AND THE LIFT, WITH THE RESIDENT IN THE SLING (PAD PLACED UNDERNEATH RESIDENT TO SUPPORT BODY DURING TRANSFER), INTO A SPACE NEXT TO THE BED. CNA #2 ' S BACK WAS AGAINST THE WALL. CNA #1 SAID SOME CORDS FROM A MATTRESS WERE UNDER THE BED AND OBSTRUCTING THE PATH WHERE THE LEGS OF THE LIFT WOULD NEED TO GO. CNA #1 SAID SHE TOOK HER HANDS OFF THE RESIDENT AND BENT DOWN TO MOVE THE CORDS OUT OF THE WAY. CNA #1 SAID THE RESIDENT WAS ON THE FLOOR WHEN SHE TURNED BACK AROUND. CNA #2 WAS INTERVIEWED ON 11/19/10 AT 1:30 P.M. HE SAID RESIDENT #502 HAD BEEN IN A GERI CHAIR (PADDED RECLINER WITH WHEELS), AND HE WAS TRANSFERRING HIM BACK INTO BED. CNA #2 SAID THE RESIDENT ' S LEGS ARE STIFF, AND THE RESIDENT MOVES ONE LEG AROUND. THE CNA SAID THE RESIDENT WAS PROPERLY PLACED IN THE SLING ON THE HOYER AND THE STRAPS WERE APPROPRIATELY PLACED WHEN THE RESIDENT WAS LIFTED IN THE SLING FROM THE GERI CHAIR. HE SAID THE MECHANICAL LIFT WAS WORKING WELL. CNA #2 SAID HE WAS OPERATING THE MECHANICAL LIFT AND BACKED HIMSELF AND THE LIFT BACK AGAINST THE WALL AND NEXT TO THE BED. CNA #2 SAID THE RESIDENT BEGAN TO TILT AND fell OUT OF THE SIDE OF THE SLING DURING THE TIME CNA #1 WAS ON THE FLOOR MOVING THE CORDS UNDER THE BED. DURING THAT TIME CNA #2 SAID HE WAS STANDING BEHIND THE LIFT AND DID NOT HAVE HOLD OF THE SLING OR THE RESIDENT. THE RESIDENT, ACCORDING TO THE CNA fell on TO HIS RIGHT SIDE IN BETWEEN THE LEGS OF THE MECHANICAL LIFT. RESIDENT #502, ACCORDING TO A 11/10/10 NURSE ' S NOTE, SUSTAINED A LACERATION TO THE " RIGHT POSTERIOR HEAD BEHIND EAR " . THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL, PER A physician's order [REDACTED]. A 6/17/09 FACILITY POLICY FOR USE OF THE MECHANICAL LIFT STATED THAT, " DURING TRANSFER, ONE ASSISTANT MUST HOLD STABILIZING HANDLES OF SLING AND HAVE CONTACT WITH THE RESIDENT AT ALL TIMES. " ( )