Every finding on record at Medilodge of St. Clair

Based on observation, interview, and record review, the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:On 12/8/25 at approximately 7:50 AM, the facility's exterior trash refuse area was observed with Food Service Manager D. The dumpsters were observed to be overflowing with stacked up trash bags. The bags were piled up beyond the top edge of the containers, to the point where the lids could not be closed. When queried at that time, Food Service Manager D stated that the containers were usually overflowing after the weekend. When queried regarding how often the containers were emptied, Food Service Manager D stated, I believe once a week. According to the 2022 FDA Food Code section 5-501.110 Storing Refuse, Recyclables, and Returnables, REFUSE, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.According to the 2022 FDA Food Code section 5-501.113 Covering Receptacles, Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: .(2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by eliminating harborage conditions. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 12/8/25 at 7:35 AM, the facility's dish machine was observed. Underneath the soiled side drain board, there was a build-up of sludge on the floor tiles, and the flooring was damp. There was a cup and a small bowl which had accumulated on the floor along the back wall. There were numerous gnats observed on the pipes and the back wall under the soiled drain board. When queried at that time, Food Service Manager D confirmed the presence of the gnats and stated that the flooring was in need of a good cleaning. According to the 2022 FDA Food Code section 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A)Routinely inspecting incoming shipments of FOOD and supplies;(B)Routinely inspecting the PREMISES for evidence of pests;(C)Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12,7-206.12, and 7-206.13; and (D)Eliminating harborage conditions.

This citation pertains to Intake number 2660263.Based on observation, interview and record review, the facility failed to ensure sufficient staff were available to answer call lights and to provide timely resident care for four residents (R19, R20, R23, R131) and six group residents in a census of 120. Findings include: On 12/08/2025 at 8:47 AM, Certified Nursing Assistant (CNA) A was asked about staffing levels and reported staffing is horrible and reported they had twenty patients to care for over the weekend due to call ins and med techs not helping with patients on the floor. On 12/08/2025 at 9:04 AM, R23 reported that on average there is not enough staff to take care of the residents three times a week. R23 feels this happens most often on the midnight shift. R23 reported wait times up to 45 minutes for call lights to be answered. R23 further reported this was due to the aides working shorthanded. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented an admission into the facility on [DATE], intact cognition (15/15 Brief Interview for Mental Status score) and the need for substantial/maximal assistance with bathing, dressing and personal hygiene. Partial/Moderate assistance was needed for toileting. On 12/08/2025 at 11:31 AM, R131 reported the facility does not have enough employees to take care of patients and had been currently waiting for 15 minutes for assistance and has waited up to an hour. On 12/10/2025 at 8:50 AM, R20 reported multiple call ins reported by staff and the facility does not have enough additional staff to fill in. R20 reported this was told to them by staff when R20 complained about the wait times. R20 further commented the facility has had four Administrators in the last year and no one holds the staff accountable when they call in. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented an admission into the facility on [DATE], intact cognition (14/15 Brief Interview for Mental Status score) and R20 was dependent on staff for bathing, dressing and personal hygiene. A review of the resident council meeting minutes documentation revealed call light response concerns expressed by the group during the months of August and September 2025. On 12/9/25 at 1:15 PM, a resident council meeting with eight group members were asked about excessive wait times for staff when they activated their call light. Six of the group members, confirmed wait times could be up to an hour. On 12/9/25 at 3:22 PM, in the hallway of the 300 unit, R19 indicated they had been waiting close to twenty minutes for their call light to be answered. Observed was made of multiple staff members walking back and forth passing R19's room and did not respond to their call light. An additional observation of the call light screen located behind the nurse's station on the unit revealed R19's call light had been activated at 3:05 pm and staff responded at 3:30 PM, On 12/10/25 at 4:27 PM, the Administrator (NHA) was interviewed regarding their expectation for call light response time by staff. The NHA indicated within thirty minutes was their expectation.

Based on observation, interview, and record review, the facility failed to provide palatable food items per the resident's preference for four residents (R20, R55, R69 and R80) and eight resident council group members from a census of 120. Findings include: On 12/8/25 at 9:17 AM, R69 was interviewed about the food served to them at the facility and indicated the food was cold and didn't taste good. A review of R69's most recent minimum data set assessment (MDS) dated [DATE] revealed R69 had an intact cognition. On 12/9/25 at 1:15 PM, a resident council meeting was conducted between the surveyor and eight group members. All eight group members expressed concerns regarding the temperature and taste of the food served to them A review of the resident council meeting minute documentation revealed palatable food and temperature concerns expressed by the group during the months of July, October, November, and December 2025. A review of resident food committee meeting minute documentation revealed cold food concerns expressed by the group during the months of July, August, and September 2025. . R20 On 12/10/2025 at 8:50 AM, R20 reported concerns with the food service at the facility. R20 reported the facility did not order enough food as when they call for a substitute from the alternate menu it is not available and feels that corporate should not have control over the menu items served to the residents. R20 stated, If it is not on the tray, you are not going to get it. R 20 also reported they do not receive chips or bananas as often as the used to and they are lucky to receive any meat items such as sausage or bacon for breakfast. R20 reported they had been at the facility four years and the used to be able to get bacon and real eggs every morning. R20 further noted any complaints have not led to any real changes being made. R20 did not appear to have eaten the eggs on their breakfast plate and asked the aide to take the tray out. The Minimum Data Set (MDS) dated [DATE] documented intact cognition and the need for set up for eating. R55 On 12/08/2025 at 11:19 AM, R55 reported the food is served cold in both the dining room and when they eat in their room. R80 On 12/08/2025 at 11:29 AM, R80 reported the food is cold for most meals and they eat in the dining room. On 12/10/2025 at 4:27 PM, the Nursing Home Administrator (NHA) was asked about the food delivery process. The NHA explained the facility expectations is for the food to be delivered to the residents in a timely manner to maintain the temperature.

Based on observation, interview, and record review, the facility failed to honor the right to share a room with their spouse and failed to provide written notice, including reason for the change, prior to a room change for one sampled resident (R19) of nine reviewed for resident rights. Findings include: On 12/08/2025 at 9:36 AM, R19 reported that they were upset because the facility changed their room, which separated them from their spouse. During the interview R19 was observed to cry and be visibly upset due to the emotions they were feeling. R19 stated, They never should have divided us. R19 reported they had been married for three months and only had about three weeks together in the same room. R19 further explained the facility gave them about a 10 minute notice before the room change occurred. On 12/10/2025 at 2:44 PM, Social Services C was asked about the room change with R19 and reported they were not involved with the room change. Social Services C further explained, they talked to the couple on the day after to check on the couple. Social Services C was asked about the conversation and stated R19, and their spouse they were both upset. On 12/10/2025 at 4:47 PM, the Nursing Home Administrator (NHA) was asked about the room change and explained, the facility accepted a new resident we had to take (admit) and R19's room was the only option. The NHA acknowledged it was a last-minute decision for R19 to be moved away from their spouse. A review of R19's medical record census section revealed a room change on 11/28/25. Further review revealed there was no documentation regarding the notification of the room change to R19's guardian or to the resident. Further review of R19's medical record revealed, R19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Right femur fracture.A review of the facility's policy titled Change of Room or Roommate dated 10/30/2023, revealed, Policy: It is the policy of this facility to conduct room changes or roommate assignments when considered to be necessary by the facility and/or when requested by the resident or resident representative. Policy Explanation and Compliance Guidelines: 2. Reasons for a change in room or roommate could include but are not limited to: a. Incompatibility of residents in a shared room. 3. Requests for changes in room or roommate should be communicated to the Social Service Designee. 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such asresidents and their representatives, will be given advance notice of such a change as is possible. 5. The notice of a change in room or roommate will be provided, in a language and manner the resident and representative understand and will include the reason(s) why the move or change is required. 6. The social service staff can assist the resident to adjust to the new room or roommate by: a. Informing the resident and family as soon as possible of the room or roommate change. b. Involving the resident in the decision and selection of a room or roommate when possible. c. Allowing the resident to ask questions about the move. d. Showing the resident where the room is located. e. Introducing the resident to his/her new roommate and sharing information about the new roommate. 7. The Social Service designee or Licensed Nurse should inform the resident's sponsor/family in advance of a change in the resident's room or roommate. 8. A resident has the right to refuse a transfer to another room within the facility, if the purpose of the transfer is torelocate a resident from the Medicare section of the facility to a non-Medicare section of the facility solely for financial or change in payer status reasons .

This citation pertains to complaint number 2686759.Based on interviews/record review, the facility failed to protect one resident's (R106) right to be free from physical abuse by another resident (R104) of two residents reviewed for abuse. Findings include: A review of an incident and accident report dated 11/28/25 and involving R104 and R106 indicated the following, R104 was having a behavioral episode in the hallway, as another resident (R106) was walking down the hallway past them. R104 approached R106 and placed their hands around R106's neck and started squeezing. Licensed Practical Nurse (LPN) H intervened and R104 let go of R106's neck and pushed R106 causing them to fall on their knees and then on their buttocks. R104 was redirected away from the other residents. R106 stated, [R104] was choking me, almost killed me. Vital signs and skin assessment was completed on R106. Observation made of abrasion on R106's front of right knee and redness to elbow. R104A record review of social work progress notes in R104's electronic medical record (EMR) documented the following:-On 6/5/24[25] 4:23 PM, Social Work (SW) came down to [R104's] hall. [R104] and another resident were arguing with the nurse regarding one another. [R104] turned away from the nurse and stated, 'multiple swear words and die, die, die.' [R104] went to their room and was mumbling to themselves. [R104] exited their room and walked into another resident's room. SW escorted [R104] to dining room to eat. SW to meet with Interdisciplinary team (IDT) to discuss [R104] and interventions.-On 11/5/25 1:48 PM, SW was called down to resident's room due to resident slamming doors and stating, die, die, die. SW escorted resident to lunch. -On 11/7/25 2:50 PM, Resident was continuously slamming doors and stating, 'die, die, die, kill myself, happy, die, die, die. Resident was slamming furniture in their room and broke a panel on the dresser drawer. Other residents were verbally and visibly disturbed with resident's behavior. Resident was petitioned to [Hospital] for mental health evaluation and transported by emergency medical services (EMS). A review of R104's Behavior care plan indicated R104 had behaviors as evidenced by physical aggression towards residents. R104's goal was to display no evidence of behavioral problems through the next review period with a target date of 3/10/2026. Intervention indicated to keep the resident safe during episodes of behaviors. Further review of R104's EMR revealed R104 was originally admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and Chronic obstructive pulmonary disease (COPD). R104's most recent minimum data set assessment (MDS) dated [DATE] revealed R104 had a severely impaired cognition. R104 was transferred to the hospital on [DATE] for a metal health evaluation and returned to the facility on [DATE]. R106A review of R106's EMR revealed R106 was originally admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder and Dementia. R106's most recent MDS assessment dated [DATE] revealed R106 had a severely impaired cognition. On 12/8/25 at 3:00 PM: R106 was interviewed in their room regarding the incident which occurred on 11/28/25 involving them and R104. R106 indicated they had no recollection of the incident. On 12/8/25 at 3:10 PM, Certified Nurse Assistant (CNA) L was interviewed about the incident which occurred between R104 and R106. CNA H indicated they were summoned to the hallway by LPN H for assistance and observed R106 on the ground with red marks on their neck and an abrasion on their knee. CNA L and LPN H assessed the resident and CNA L assisted them to their room. CNA L was asked about R104's behaviors and confirmed at times R104 would become agitated and slam doors on the unit. On 12/10/25 at 1:45 PM, LPN H was interviewed about the incident which occurred between R104 and R106. LPN H confirmed R104 was agitated and grabbed R106 by the neck as they were walking by and push them down to the ground causing red marks on their neck and an abrasion on their right knee. LPN H indicated R104's behavior had been escalating and becoming increasingly aggressive over the past two or three months to which they notified the unit nurse manager, social services, and the Director of Nursing (DON). Nurse H was asked about any new interventions that were put in place in response to R106's escalating behaviors and indicated they were unsure about any new behavioral interventions. On 2/10/25 at 2:28 PM, R104 was interviewed regarding the incident which occurred between themself and R106. R104 indicated they had no recollection of the incident. At 3:31 PM, the Director of Nursing (DON) was interviewed about the incident between R104 and R106. The DON indicated R104's behavior had been escalating for the past two or three months and when staff noticed R104 escalating, staff could have taken them to a quiet area to calm down. A review of a facility policy titled Abuse .Date Reviewed/Revised: 01/10/2024 revealed the following, Policy: It is the policy of the 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 .Definition: Abuse means the willful infliction of injury .with resulting physical harm .which can include .certain resident to resident altercations. Willful means the individual must have acted deliberately .

Based on interview and record review the facility failed to ensure a PASARR (Preadmission Screening Annual Resident Review for mental health needs) was completed timely for two residents (R11, R75) of three reviewed for PASARR completion. Findings include: R11 A review of the facility records for R11 revealed R11 was admitted into the facility on [DATE]. Diagnoses included Schizoaffective Disorder, Stroke and High Blood Pressure. R11 has continued to reside at the facility. The PASARR form dated 09/24/25 documented it as a hospital exempted discharge which indicated R11 was expected to remain at the facility less than thirty days. An additional level one PASARR was required after 30 days. Further record review revealed no additional PASARR had been entered into the medical record. On 12/10/25 at 1:12 PM and 4:15 PM the additional level one PASARR was requested. At 4:35 PM the facility reported the additional level one PASARR had not been completed. R75 A review of R75's medical record revealed they were admitted into the facility on 7/22/25 with diagnoses which included Anxiety Disorder, Bipolar Disorder, current episode mixed, Major Depressive Disorder and Diabetes. Further review revealed the resident was cognitively intact and required 2-person assist for activities of daily living. Further review of the medical record revealed a Level 1 Pre-admission Screening form dated 7/16/25 which was completed by the hospital nurse that referred the resident to the facility. Further review of the screening form revealed screening criteria which noted the person had a current mental illness, received treatment for the mental illness, and had routinely received one or more prescribed antipsychotic or antidepressants in the last 14 days. The document further explained the person had moderate recurrent major depression and was prescribed Wellbutrin (anti-depressant) 150mg (milligrams), and Buspar (anti-anxiety) 30mg. On 12/10/25 at 1:58 PM, R75's PASARR completed by the facility was requested however, the form provided was the form completed by the referring hospital and not the facility. On 12/10/25 at 2:15 PM, Social Worker C was interviewed regarding the completion of PASARRs and explained that the corporate social worker was completing them, and they were in the process of changing the process for how the forms were being completed. A review of the facility's Resident Assessment-Coordination with PASARR Program (Michigan) policy revealed the following, .5. If a resident who was not screened due to an exception above and remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level 1 Screening process and refer any resident who as or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination.

This citation pertains to intake 2660263.Based on observation, interview, and record review, the facility failed to provide timely Activities of Daily Living (ADLs) for three sampled residents (R19, R55, and R80) of six reviewed for ADLs. Findings include: R19On 12/08/2025 at 9:36 AM, R19's bed was observed with a large wet area in the middle of the bed. R19 reported they were not changed during the midnight shift. R19 reported they have to wait a long time for assistance at times. Further review of R19's medical record revealed, R19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Right femur fracture. A review of R19's Minimum Data Set (MDS) assessment noted R19 with moderately impaired cognition and required assistance with activities of daily living. R55On 12/08/2025 at 11:19 AM, R55 reported that one day they waited over two hours to be cleaned after having a soiled brief. R55 also reported they had been told by staff they were too busy to provide their scheduled showers and then have documented R55 as refusing a shower when that was not the case. A review of R55's shower documentation noted refusals for showers, without a progress note indicating the reason or follow up by a nurse.A review of R55's medical record noted, R55 was admitted to the facility on [DATE] with diagnosis of Progressive Neurological Conditions. A review of R55's MDS assessment noted R55 with intact cognition and required assistance with activities of daily living. R80On 12/08/2025 at 11:29 AM, R80 reported they often wait a long time for their call light to be answered, and they don't always receive their showers as scheduled. R80 expressed that the call light wait time has been awful since the facility has switched to the pager system. A review of R80's medical record noted, R80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Chronic Obstructive Pulmonary disease, R80 was noted to have an intact cognition, and required assistance with activities of daily living. On 12/08/25 at 11:35 AM, Certified Nursing Assistant (CNA K) was asked about their ability to complete care for all their residents. CNA K gave a nonverbal look/gesture as if they were not able to complete their work in a timely manner. CNA K did not offer any other information. On 12/10/2025 at 4:27 PM, the Nursing Home Administrator (NHA) was asked about the call lights and made aware of the above concerns. The NHA reported that call lights and completing ADLs are being monitored on an ongoing basis.A review of the facility's policy titled, Call lights: Accessibility and Timely Response dated 12/28/2023, revealed Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines:. 7. Any staff member who sees or hears an activated call light is responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on interview and record review, the facility failed to administer pain medications as ordered for one resident (R63) of one resident reviewed for pain management. Findings include: On 12/08/2025 at 8:12 AM, R63 was observed in their room and asked about their care in the facility. They explained they had been dealing with pain and hadn't received their prescribed Oxycodone (narcotic pain medication) last night as they were told it was out of stock. R63 further explained they were provided with Tylenol but admits that it doesn't provide relief the way the Oxycodone does. A review of R63's medical record revealed they were admitted into the facility on 8/29/25 with diagnoses which included Chronic Pain Syndrome, Heart Failure, and Diabetes. Further review revealed the resident was cognitively intact and required one-person assist for activities of daily living. A review of R63's care plan revealed the following, Focus: .related to back pain, UTI (urinary tract infection). Date Initiated: 11/28/2025 .Interventions: Administer medications per orders and observe for side effects and effectiveness .Date Initiated: 11/28/2025.Further review revealed the following active physician's order dated 11/28/25, Oxycodone HCl Oral Capsule 5 MG (milligrams, Oxycodone HCl). Give 1 capsule by mouth every 4 hours as needed for pain. Further review revealed the medication was placed on order. A review of R63's December Medication Administration Record (MAR) revealed the resident received the prescribed medication on 12/7/25 at 12:57pm for a pain level of 10. On 12/09/2025 at 9:14 AM, Licensed Practical Nurse (LPN) B was observed in conversation with R63. R63 asked about cream for their chest and the nurse reported it was not available in the medication cart. R63 then asked for their oxycodone pain medication for 10/10 pain affecting their back and legs. LPN B looked at the electronic medical record and reported the pain medication was on order. LPN B asked if the medication was new and R63 replied it was not. LPN B offered acetaminophen, and R63 indicated it would have to do. LPN B gave R63 acetaminophen and applied a pain patch to the lower back. A review of the facility's back-up supply medications revealed the facility had R63's oxycodone medication available.On 12/10/2025 at 3:45 PM, the Director of Nursing (DON) was asked about R63's medication not being provided when it was available in the facility's back up and explained she would get back with surveyor as there appeared to be a discrepancy with how the prescription was written.On 12/10/25 at 5:40 PM, the DON explained after researching and speaking to the nurse practitioner, they figured out what occurred regarding the medication.A review of the facility's Medication Administration policy did not address pain management or obtaining medications available from the facility's back-up supply.

Based on interview and record review the facility failed to ensure medications were available for two residents (R8 and R132) of three reviewed for medications. Findings include: R132 On 12/08/2025 at 10:51 AM, R132 reported missing doses of their medication for a number of days when they first arrived at the facility. R132 They screwed up my meds. R132 reported they were supposed to get eye drops and didn't get them until about 12/7/25. R132 also reported there was a delay with getting their antibiotic medication. A review of R132's medical record noted, Progress note: 11/28/2025 18:08 (6:08 PM) Nursing Evaluation Summary. Res arrived via EMS (Emergency Medical Services) from [local] Hospital approx. 1445 (2:45 PM) with daughter. A review of R132's Medication Administration Record (MAR) for the month of November 2025 noted, Cefazolin Sodium Intravenous Solution Reconstituted 2 GM (gram) (Cefazolin Sodium). Use 2 gram intravenously three times a day for MSSA (Methicillin-Susceptible Staphylococcus aureus) Bacteremia for 57 Administrations until finished. start date: 11/28/25. Scheduled times 0600 (6:00 AM), 1400 (2:00 PM) 2200 (10:00 PM). There was no documentation noted on the 28th (2200), 29th at (0600 and 1400) to indicate the medication was administered. Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime related to Glaucoma -Start Date: 11/28/2025. There was a code of 'nine documented on 11/29/25, which indicated to see progress note. A review of the progress note revealed the medication was unavailable. Continued review of R132's November MAR revealed, there were 18 scheduled medications that were not documented as administered. Further review of R132's medical record noted, R132 was admitted to the facility on [DATE] with a diagnosis of Nonrheumatic aortic (valve) stenosis. A review of R132's Minimum Data Set (MDS) assessment noted R132 with an intact cognition and required assistance with activities of daily living. On 12/09/2025 at 3:54 PM, Nurse Unit Manager J was asked about R132 medications and reported that R132's medications were not delivered timely. A review of the pharmacy delivery manifest noted, R132 medications were delivered on 11/29/25 at 11:06 PM. Unit Manager J explained the medication would have usually been delivered at the 5:00 AM delivery. A review of Physician Assistant (PA) F note dated 11/29/25 documented, .(R8) was admitted to the hospital on [DATE] for urosepsis, altered mental status, abdominal pain, and dysuria . Regarding (R8's) pain control, (R8) is currently prescribed Lyrica (pregabalin) 200 (milligrams) mg every 12 hours for polyneuropathy. Patient has a history of lumbar spinal stenosis (stiffness) and diabetes, which are both likely contributing to (R8's) symptoms. (R8) is taking Xtampza (oxycodone opioid) ER (extended release) 9 mg up to twice daily for chronic severe pain and needs a refill. For less severe pain (R8) is prescribed Norco (opioid hydrocodone) 10/325 mg . A review of Physician E note dated 12/02/2025 at 10:02 AM, documented, (R8) was seen by request of the nurse. The patient was out of pain medication yesterday and I was not aware. Medications were sent immediately on request. The patient is still requesting to be sent out (to the hospital). The patient states the pain is in the suprapubic catheter (tube placed into the bladder to drain urine). The patient also has a left leg amputation and wounds to (their) right leg. When I walked into the facility the patient was resting comfortably. The patient has a history of diabetes. The patient has a left 5th nail bed avulsion (torn off). The patient stated to the nurse (R8) does not want wound care . Patient called EMS (emergency medical service) themself and is being transferred out . A review of the nursing progress note dated 12/02/2025 at 10:07 AM revealed, Resident transferred to (hospital) via EMS for uncontrolled pain. Non-pharmacological interventions were offered, but resident refused and stated that (they) wanted to go out to the hospital so (their) pain can be managed quickly . On 12/09/2025 at 12:19 PM and at 12:36 PM, Registered Nurse (RN) G reported R8 had chronic pain with an average pain rating of 6-8 out of ten. RN G reported there had been delays in getting pain medications for R8 and the Xtampza was not kept in the back up for medications. It was noted that no PRN (as needed pain medications) were given the day R8 went out to the hospital. RN G reported that if R8 did not have the Xtampza or could not take all the pain medications then would refuse the Norco and just want to go to hospital. A review of the facility records for R8 revealed R8 was at the facility from 10/28/25 to 12/02/25. Diagnoses included Arthritis, Left leg above the knee amputation, and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 14/15 Brief Interview for Mental Status score and severe pain frequently in the last five days. The vitals documented pain levels of zero to nine in the five days prior to discharge. A review of the medication administration records (MAR) for November and December 2025 revealed the Xtampza/Oxycodone was not given on 11/30, 12/01 and 12/02. The PRN hydrocodone/acetaminophen was also not given on 11/30, 12/1 and 12/2. A review of the medication orders revealed, hydrocodone-acetaminophen 10-325 mg tablet Give 1 tablet by mouth every 6 hours as needed for moderate-severe pain; methocarbamol (muscle relaxer) 500 mg tablet Give 1 tablet by mouth four times a day for Pain Give 0.5 tablet by mouth four times a day for pain; Xtampza(Oxycodone) ER Oral Capsule ER 12 Hour Abuse-Deterrent 9 MG (Oxycodone), every twelve hours, and Lyrica 200 mg Take one capsule by mouth two times per day. A review of the November 2025 Control Substance Records for the Xtampza revealed the last dose was given on 11/29/25 at 8 AM. On 12/10/25 at 1:00 PM the Director of Nursing (DON) reported medication should be ordered timely and administered as ordered. The DON further noted PA may not have been aware the oxycodone was taken twice a day and only ordered four pills. A review of the facility policy titled, Ordering and Receiving Non-Controlled Medications revised June 2024 revealed, Policy: Medications and related products are received from the pharmacy on a timely basis . A review of the facility policy titled, Controlled Substance Prescriptions revised August 2020 revealed: .Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe controlled substances. A chart order is not equivalent to a prescription for controlled medications. Therefore, the prescriber issuing the chart order must also provide the pharmacy with a valid prescription to ensure delivery of medication. The written prescription may be faxed to the pharmacy for long-term care facility residents .

Based on observation, interview, and record review, the facility failed to properly store medications for one resident (R6) of one reviewed for medication storage, ensure expired medications were discarded when opened, and inhalers were labeled with a resident identifier and/or an opened date in one of four medication carts. Findings include: R6 On 12/08/2025 at 7:32 AM, during a tour of the Dementia unit, R6 was observed in bed asleep. A medication cup containing two pills was observed on the resident's nightstand. On 12/08/2025 at 7:39 AM, an unidentified nurse was asked to observe the medications at R6's bedside and explained they had not begun to pass medications on the day shift and further explained they are not aware of how long those medications had been on the nightstand. A review of R6's medical record revealed they were admitted into the facility on 8/27/25 with diagnoses of Alcohol Dependence with Alcohol-Induced Persisting Dementia, Metabolic Encephalopathy, and Major Depressive Disorder. Further review revealed the resident was moderately cognitively impaired and required one-person assist with activities of daily living. Further review of R6's medical record did not reveal a self-administration of medications assessment. On 12/10/2025 at 3:25 PM, the Director of Nursing (DON) was asked about the observation made of R6's medications left at the bedside and explained that is not the practice of the facility, and they should not have been left there. On 12/09/2025 at 9:48 AM, the D wing medication cart was reviewed with Licensed Practical Nurse (LPN) B. A Humalog insulin pen for R67 had a date opened of 11/06/25 and had not been discarded; A Fluticasone Salmeterol Advair 250-50 mcg (microgram) inhaler for R66 was not dated when opened on the actual inhaler; and a Fluticasone-Salmeterol 250-50 mcg inhaler for R42 was not labeled with a resident identifier on the actual inhaler. On 12/10/25 at 1:00 PM, the Director of Nursing (DON) reported the expired insulin should have been discarded. A review of the facility policy titled, Medication Storage revised 01/20/24 revealed, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations . A review of the manufacturer's insert for the fluticasone/salmeterol inhaler revealed, How should I store (fluticasone/salmeterol)?Keep in a dry place away from heat and sunlight. Store {fluticasone/salmeterol) in the unopened foil pouch and only open when ready for use. Safely throw away (fluticasone/salmeterol) in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first. A review of the manufacturer's insert for the Humalog insulin pen revealed, .In-use pen: Store the pen you are currently using at room temperature Keep away from heat and light. Throw away the Humalog pen you are using after 28 days, even if it still has insulin left in it.

Based on observation, interview, and record review, the facility failed to ensure hand hygiene and medical device cleaning was completed during medication pass for one resident (R89) of four residents observed during observed. Findings include: On 12/10/2025 8:23 AM, Licensed Practical Nurse (LPN) I was observed during a medication pass for R89. LPN I was observed to remove five oral medications, a glucometer, a lancet, glucose (blood sugar) test strip and an alcohol pad from the medication cart. LPN I reported they wanted to recheck R89's blood sugar. The medications were dispensed into a small plastic cup. LPN I brought the items into the resident's room and donned gloves. The medication cup was handed to R89 by LPN I. The lancet was used to prick a finger on the left hand of R89 to get the blood sample for the meter onto the glucose test strip. LPN I doffed their gloves and returned to the medication cart. The glucometer was returned to the medication cart. LPN I prepared an insulin injection for R89 using an insulin pen. A needle was applied to the pen and the amount dialed onto the pen. LPN I entered R89's room donned gloves and administered the insulin into the back of R89's left arm. LPN I doffed their gloves and exited the room. LPN I then took the thermometer and a pulse ox device (to check oxygen level) from the cart and checked the temperature on the left temple of R89 and the pulse ox on a digit of the left hand. LPN I exited the room and placed the two devices on top of the cart. The glucometer, thermometer and pulse ox were not wiped down after use. No hand hygiene was observed to have been performed during the observation. LPN I was able to remove a bottle of hand sanitizer from their pocket. It was not accessed during the medication pass observation. A wall mounted dispenser for hand sanitizer a couple rooms down from R89's was tested and did dispense sanitizer when a hand was placed below the sensor. LPN I reported there were no sanitizing cloths for the devices on the medication cart, and none were observed.On 12/10/25 at 1:00 PM, the Director of Nursing (DON) reported the expectation was for the nurse to complete hand hygiene before and after each incidence of care. A review of the policy titled, Medication Administration revised 01/17/23, revealed, .Wash hands prior to administering medication per facility protocol and product . Observe consumption of medication . Wash hands using facility protocol and policy .'

This citation pertains to Intake: 2584046.Based on interview and record review, the facility failed to administer physician order medication in a timely manner for two (R900, R901) of two residents reviewed for medication administration. Findings include:R900A review of the Electronic Medical Record (EMR) revealed R900 was admitted to the facility on [DATE] with the following pertinent diagnoses: Right non-union intertrochanteric hip fracture after a fall, hypertension, hyperlipidemia (high cholesterol), legally blind, and anemia. Further review of the EMR revealed the resident was cognitively intact.On 9/4/25, a review of the August 2025 Medication Administration Record (MAR) revealed medications were administered later than one hour outside the window of one hour before and one hour after the designated scheduled time. The record revealed on the day shift (7:00 AM-3:30 PM) over a 10-day period (August 1 thru 10, 2025), R900's morning medication, which were due at 8:00 AM, was administered after 9:00 AM six of ten times. The medications included: Metoprolol (for blood pressure/rate control), Lisinopril (a blood pressure medication), Brimonidine Eye Drops (for Glaucoma), Iron (for anemia), Lysine (for cholesterol) in addition to over-the-counter medications such as Aspirin, Colace, Miralax, and Multivitamin. Further MAR review indicated one instance where a blood pressure medication was given at 0:40 AM on 8/8/25 when it should have been administered at 8:00 pm on 8/7/25.On 9/4/25, further review of the August MAR revealed medications on the afternoon shift (3:00 PM -11:30 PM) over the same 10-day period, revealed the 8:00 PM dose of medications; Metoprolol, Atorvastatin, and Brimonidine Eye Drops, and Aspirin were administered after 9:00 PM six of ten times. On 9/4/2025 at 11:52 AM, during an interview with R900 they confirmed their medications are late a lot. R900 further indicated they have reported this concern to their daughter.R901On 9/4/25, a review of the Electronic Medical Record (EMR) revealed R901 was admitted to the facility on [DATE] with the following pertinent diagnoses: Hypertension, Quadriparesis, Hyperlipidemia, Benign Prostatic Hypertrophy (BPH), and Major Depression. Further EMR review revealed R901 was cognitively intact.On 9/4/25, a review of the August 2025 Medication Administration Record (MAR) revealed medications were administered later than one hour outside the window of one hour before and one hour after the designated scheduled time. The MAR revealed on the day shift over a 10-day period (August 1 thru 10, 2025), R900's morning medication, due at 8:00 AM, was administered after 9:00 AM three of ten times. The medications included: Lisinopril (a blood pressure medication), Duloxetine (for Major Depression/Anxiety).Further review of August MAR revealed medications on the afternoon shift over the same 10-day period, revealed the evening dose of prescribed medications due at 8:00 PM, were administered after 9:00 PM nine of ten times. The medications included: Atorvastatin and Doxazosin. On 9/4/25 at 11:44 AM, in an interview with R901 they were asked about medication administration and said, they take care of me. At 1:50 PM, in an interview with Licensed Practical Nurse (LPN) B they were queried regarding late medications. LPN B stated sometimes nurses are late because residents may stop them or interrupt them requesting care or the nurse may be assigned to go to more than one unit, so their time can be limited, or administration may be taking longer. At 2:30 PM, an interview with the Director of Nursing (DON) was queried regarding their expectation regarding the timeliness of administration of medications. The DON revealed their expectation is that medications be administered one hour before to one hour after the scheduled time. They further revealed delays may occur such as being called to another room or part of the building and slow passing of medications secondary to resident requests.A review of the policy titled, Medication Administration, revised 1/17/2023, revealed . 11. Paragraph b: Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

This citation pertains to Intake MI00149376. Based on interview and record review, the facility failed to follow professional standards of practice for blood pressure medication hold parameters for one resident (R300) of three residents reviewed for medication administration. Findings include: A review of R300's admission facesheet revealed they were admitted to the facility on [DATE] with a diagnosis of Peripheral Vascular Disease (PVD). Further review of the medical record revealed R300 had a moderately impaired cognition. A review of R300's physician orders revealed the following active orders dated 11/6/24: 1. Metoprolol Succinate ER oral tablet Extended Release 24-hour 25 mg (milligram) Give 1 tablet by mouth one time a day related to essential primary hypertension (high blood pressure) and, 2. Losartan Potassium Oral tablet 100mg give 1 tablet by mouth one time a day related to essential primary hypertension. There were no orders to check the blood pressure prior to administering the blood pressure medication. There were no parameters indicated if a resident was below baseline to hold the medication. A review of R300's vital signs revealed the following blood pressures: -96/67 (normal range 120/80) on 11/20/24 at 10:06 AM and, -81/54 on 11/20/24 at 11:48 AM. A review of R300's Medication Administration Record (MAR) revealed the Metoprolol and Losartan were administered the morning of 11/20/24 prior to the blood pressures being taken. A review of R300's progress notes revealed the following nurses note dated 11/20/24 12:32 PM: Resident has an altered mental status, resident had a bowel movement and passed out on the toilet then after some minutes came to. (name of author) and CNA (certified nurse assistant) helped the resident back to bed. Vital signs were obtained and documented in (electronic medical record), resident was very weak and required a lot of help with ambulation. (They) could respond when called but is not able to answer any more questions appropriately. PA (physician assistant) was notified and (they) came and assessed the resident and advised to send resident to the hospital. Family of the resident was present at the bedside when it all happened. A physician's progress note dated 11/20/24: .during my evaluation, while speaking to the (family member) in the hallway, patient went to the bathroom and had large bowel movement which likely resulted in a vasovagal (a sudden drop in heart rate and blood pressure) episode. I immediately saw the patient who was awake but not responding to verbal questions. Vital signs and BG (blood glucose) taken. Pt (patient) hypotensive (low blood pressure) with pressure 88/60 and pulse 48. Patient was subsequently laid in (their) bed while I discussed the option of transporting this patient to the hospital for further evaluation. On 1/22/24 at 1:28 PM, during an interview with Registered Nurse (RN) A they explained a resident's blood pressure should be checked before giving blood pressure medication and if the blood pressure is abnormal the doctor should be notified.RN A confirmed they administered R300's blood pressure medication the morning of 11/20/24 and explained they thought they had rechecked R300's blood pressure prior to adminstering the medication. On 1/22/24 at 2:06 PM, the Director of Nursing (DON) explained when a physician orders a blood pressure medication, they usually include holding parameters. The DON explained if the physician does not include hold parameters in the order the nurses should call the physician and get holding parameters. The DON confirmed the nurse should have held the blood pressure medications and notified the doctor. A review of the facility's policy titled Administering Medications revealed the following: Medications shall be administered in a safe and timely manner, and as prescribed . 4. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns . 11. The following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; b. Vitals signs, if necessary. A review of the facility's policy titled Medication Administration revealed the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physicians' prescribed parameters.

Based on observation, interview, and record review, the facility failed to maintain a pest-free environment, resulting in flies in the facility and resident complaints. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/1/24 at 2:45 PM, there were several flies observed in the 100 hallway. On 10/1/24 at 2:50 PM, the window in room [ROOM NUMBER] was observed to be open. The exterior screen frame was observed to be bent, leaving an approximately 1 inch gap. The screen was not tight-fitting, to prevent pest entry into the room. On 10/1/24 at 3:00 PM, Maintenance Supervisor V confirmed the bent screen, and stated he would take care of it right away. Maintenance Supervisor V stated that he was unaware of any current fly issue in the facility. Review of a Quality Assistance Form dated 4/4/24 noted: Details: Rm 224-2 .screen has gap and not fitting frame of window. Would like to open window when weather permits .Plan of Action: .unable to bend frame back. 40330 On 10/01/24 at 10:12 a.m., R64 was observed in their room seated in a reclining manual wheelchair. Two flies landed on Resident 64, who reported this bothered them. R64 attempted to swat them away however had trouble moving their arms due to decreased range of motion of their elbows and hands, which were flexed. On 10/01/24 at approximatley 10:15 a.m., Certified Nurse Aide (CNA) S was asked about the flies landing on R64. CNA S stated R64's room (117) and the room across the hall (118) were really bad with the flies. CNA explained, I have noticed flies in these two rooms. CNA S reported they had told maintenance over a couple weeks ago, and it bothered R64. CNA S stated, I am not sure where they are coming from.

Based on observation, interview, and record review, the facility failed to meet professional standards of care for medication administration for two residents (R71, R107) of nine residents reviewed for medication administration. Findings include: On 10/2/24 at 7:40 AM, during the dining room observation, Registered Nurse (RN) J was observed administering medication from a cup which contained a yellowish fruit puree to R107. When RN J completed the medication administration with R107, the nurse subsequently administered medication from a different medication cup to R71, without first returning to the medication cart, sign off that R107 had received their medications, performed hand hygiene, and separately prepare R71's medications. The facility record revealed R71 was admitted on [DATE] with the following pertinent diagnoses: Cerebral Infarction (Stroke), Atrial Fibrillation, Dysphagia, Aphasia, and Alzheimer's Disease. The facility record revealed R107 was admitted on [DATE] with the following pertinent diagnoses: Injury of Head, Fatigue, Repeated Falls, and Major Depressive Disorder. On 10/3/2024 at 11:30 AM, the Director of Nursing (DON) was queried regarding their expectation when a nurse provides medication to two different residents without returning to the medication cart in between. The said that practice was unacceptable. On 10/3/24 at 12:00 PM, Infection Control Nurse I was asked if facility practice was to pass medications to two different residents without returning to the medication cart, their response was no.

Based on observation, interview, and record review, the facility failed to apply compression stockings as physician ordered for one (R111) of four residents reviewed for care standards. Findings include: Review of the facility record for R111 revealed an admitted [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Localized Edema. R111's Physician Orders included an active status order which stated Compression stockings to be applied to bilateral lower extremities before getting out of bed for the day and removed at bedtime one time per day for pedal edema. On 10/01/24 at 12:23 PM, R111 was observed in the dining room waiting for lunch. The resident's feet/ankles were visible as they were wearing slippers that only covered the toes and outer edge of the feet and the feet appeared to be swollen and more red in color than their skin otherwise. Compression stockings were notobserved to be in place. On 10/01/24 at 03:25 PM, R111 was asked about compression stockings and they stated They don't put them on anymore. Additional review of R111's record revealed the current care plan dated 08/28/24 with the Focus statement Resident has an impaired metabolic status related to Hyperkalemia, pedal edema and the associated Intervention statement Administer treatments and medications as ordered. The Activities of Daily Living (ADLs) portion of the care plan indicated that R111 required one-person assistance for lower body dressing. The Dietary Progress Note dated 10/01/24 included the statement [R111] continues with compression stockings. On 10/02/24 at 04:02 PM, R111 was interviewed in their room and the compression stockings were not on. R111 reported that they were not put on and stated I haven't had them on for probably three weeks or so. On 10/03/24 at 10:18 AM, R111 was observed in the morning coffee activity. Their feet were visible as they were wearing slippers and compression stockings were not on. Further review of R111's record revealed no documentation of resident refusals of the compression stockings or any clinical justification for the stockings not being applied. It was further noted the Treatment Administration Record (TAR) reflected that the compression stockings had been applied on 10/01/24, 10/02/24, and 10/03/24. On 10/03/24 at 12:40 PM, the facility Director of Nursing (DON) was made aware of the concern regarding R111 and said they were not aware of any reason why the compression stockings were not being used. The DON verified the use of the check mark symbol in the TAR indicated the compression stockings had been put on. The DON reported the expectation is the physician order for compression stockings should be followed and if there was a reason for the stockings not to be applied it should documented as such. A facility policy addressing physician orders was requested however the provided policy specifically addressed only initial processing of physicians orders received from consulting providers. A facility policy addressing clinical documentation was requested however the provided policy did not address accuracy of clinical documentation.

Based on observation, interview, and record review, the facility failed to update the status of wound from non-pressure to pressure classification and implement interventions (adequate seating and positioning) for a Stage 4 (full thickness skin loss that extends through the skin into the muscle, bone, tendon or joint) pressure ulcer for one Resident (R64) of three residents reviewed for pressure ulcers. Findings include: On 10/01/24 at 10:17 a.m., R64 was observed in their room seated in a high back manual wheelchair, in a reclined position. Their right leg was internally rotated, with their legs positioned up on elevating footrests. R64 reported they had pain all over, reported as 5/10 with 5 being moderate pain. R64 was seated directly on their buttocks and thighs on a pressure relief cushion in their wheelchair. On 10/01/24 at 10:31 a.m., Certified Nurse Assistant (CNA) S was asked about R64's care, and reported R64 was dependent for all care including feeding. Review of R64's Minimum Data Set (MDS) assessments, dated 12/17/23, 3/17/24, 6/16/24, and 9/15/24, revealed in Section M, Skin, R64 had MASD (Moisture-Associated Skin Damage - Inflamed, swollen, wrinkled skin susceptible to damage from moisture, which is non-pressure related). Each assessment showed no pressure ulcers. Review of R64's physician orders revealed a current wound care order, started on 5/23/24, which showed R64's wound was treated daily with calcium alginate (a wound care protective treatment) with honey (an antibacterial agent) applied to the wound bed on the left thigh/buttocks crease, and Calmoseptine (moisture barrier ointment) to the peri (outer) wound. The order showed the wound was covered with a border foam (protective) dressing for a full-thickness non-pressure injury, and as needed. On 10/01/24 at 10:33 a.m., the wound care nurse, Registered Nurse (RN) F, was asked about R64's left thigh wound. RN F reported the wound started a couple years ago as Moisture Associated Skin Damage (MASD) and was a non-pressure full-thickness skin injury. Review of R64's, Skin and Wound Note, dated 10/01/24, documented the left rear thigh wound was covered by 20% slough (dead tissue) and 80% granulation (healing tissue), with moderate exudate serosanguineous (healthy drainage from wound - no infection). The document noted the wound had increased in size in the past week. The Standards of Care, wound meeting note same date, described the wound as a full-thickness, non-pressure injury, had increased in size related to area and depth. The note further revealed R64 declined to offload (pressure), as they chose to stay up in their wheelchair throughout the day. Review of R64's Wound Evaluation note, accessed 10/03/24, revealed R64 had a current wound on their left thigh classified as Other [non-pressure]- Rear Left Thigh. Status: Stable - 2 years old. Acquired: In-House [facility] Acquired. The document showed the wound was at the left ischium (a pressure point of the lower pelvic bone), with the following measurements: 10/01/24: 3.2 cm2 (Sq centimeters). 1.91 cm (Length) x 1.96 cm (Width) x 2.3 cm (Depth). 9/24/24: 2.8 cm2 x 1.82 cm x 2.02 cm x 2.1 cm. 9/17/24: 4.34 cm2 x 2.39 cm x 2.13 cm x 1.3 cm. 9/10/24: 2.5 cm2 x 1.77 cm x 1.6 cm x 1.2 cm. On 10/01/24 at approximately 10:40 a.m., RN F stated the previous wound care provider never restaged the R64's wound, just below the gluteal (buttocks) cheek fold, when it opened and said to document it as MASD, and the current NP (Nurse Practitioner) wound care provider said to document it as a non-pressure area. RN F stated all the wound providers (nurse practitioners) had classified the left thigh wound as a non-pressure wound over a year. RN F acknowledged this could potentially be a pressure area. RN F also explained R64 was not compliant with offloading. Review of the facility matrix revealed R64 had a Stage 4 facility-acquired pressure ulcer. On 10/01/24 at 10:35 a.m., RN C reported they may have completed the matrix incorrectly, as R64's left thigh wound was a non-pressure wound. RN C explained for the past 15 months R64 frequently chose to stay up in their wheelchair daily, from 9:30 or 9:45 a.m. until 7:00 p.m. RN C reported R64 used a positioning wedge and a heels up device in their air bed, for offloading. On 10/01/24 at approximately 10:50 a.m., the Director of Nursing (DON) stated R64's wound was slowly healing due to being a smoker (vaping) and diagnoses including quadriplegia (paralysis of the arms and legs) with spasticity (increased muscle tone), diabetes, and respiratory failure. The DON described the wound as non-pressure, stating it started as MASD, and in the last two years it opened, and the wound was not on a pressure point. The DON reported all the wound care doctors had classified it as non-pressure. The DON clarified R64 was in an offloading recline wheelchair, and the therapy department was trying to get them a power tilt in space wheelchair but there were insurance issues. On 10/01/24 at approximately 11:00 a.m., the MDS (Minimum Data Set) assessment nurse, RN T, was asked why the wound showed as a Stage 4 pressure ulcer on the matrix yet there was no pressure ulcer noted on the past three MDS assessments. RN T reported the matrix the facility provided to the survey team was incorrect. On 10/03/24 at 9:20 a.m., R64 stated they received the wound about eight months ago from their wheelchair, when the chair hit [them] there, pointing to their left buttocks. R64 reported they were sometimes uncomfortable in their wheelchair, on their bottom, and confirmed they stayed up in their wheelchair most days due to vaping. Review of R64's MDS assessment, dated 9/15/24, revealed R64 was admitted to the facility on [DATE], with diagnoses including quadriplegia, respiratory failure, anxiety, depression, and diabetes. R64 was dependent for all self-care, bed mobility, and transfers. R64 was able to be understood and made herself understood. Review of R64's wound care provider notes revealed a left ischial (pelvic) pressure ulcer (left thigh wound), Stage 4, on 3/26/24, noted as 1.64 cm2 (centimeters squared) and on 4/02/24, noted as 6.43 cm2, showing the wound worsened significantly. Further review of the 3/26/24 wound care provider note revealed a wound history beginning on 1/16/24 of a Stage 4 pressure ulcer on the left ischial tuberosity (pressure point on the pelvis), with subsequent notation of the Stage 4 pressure ulcer on 2/13/24, 2/20/24, 3/12/24, and 3/19/24. Review of R64's surgical report, dated 5/22/23, documented their left inferior buttocks wound debrided. Review of R64's wound care provider report, dated 6/10/20, documented a Stage 3 pressure ulcer of the left buttocks. Review of R64's wound care provider report, dated 8/01/24, with a new wound care provider, documented the wound (prior noted as a Stage 4 pressure ulcer) was classified as left ischial non-pressure ulcer and not healed, with an area of 4.2 sq cm. Subsequent notes dated 8/12/24, 9/12/24, 9/19/24, 9/26/24, and 10/01/24 revealed the wound remained classified as a non-healing, non-pressure ulcer of the left ischium. On 10/03/24 at 9:30 AM, during an interview, Registered Nurse (RN F) explained that R64's wound started as MASD (moisture associated skin damage) and was continued to be labeled as MASD but at some point, the area had opened. RN F when they started working at the facility the wound was already open and was relabeled as full thickness non pressure. On 10/03/24 at 9:36 AM, R64 was observed lying flat on their back in bed with a pillow under their left arm. R64's heels were observed to be resting directly on the bed. R64 explained that the wound started from something from my wheelchair. On 10/03/24 at 9:41 AM, RN F and RN O were observed to turn R64 onto R64's right side. An approximately 2.5-centimeter circular full thickness wound extending to muscle tissue was observed on R64's left ischium (lower pelvis bone at base of buttocks). A large amount of brown purulent drainage was noted on the wound dressing and on R64's brief. RN F explained they do dressing changes on Tuesdays and also takes pictures and wound measurements at that time then also rounds with the wound doctor on Thursdays. RN F was then observed to ask R64 if the staff used R64's positioning wedge today. R64 stated no. RN F was observed to look around R64's room and in the closet. A positioning wedge was found on the floor in the opposite corner of the room by the doorway on R64's roommate's side. On 10/03/24 at approximately 11:55 p.m., the Rehabilitation Director, Occupational Therapist U, was asked if R64 had the ability to relieve pressure (offload) in their high-back, reclining manual wheelchair. OT U reported R64 was unable to relieve any pressure themselves, and they were dependent for positioning and pressure relief. OT U stated R64 needed a power, tilt in space wheelchair for offloading and noted there had been no efforts made to obtain alternative seating in the interim for R64. On 10/03/24 at approximately 12:00 p.m., R64 was observed in the dining room with (OT) U. R64 was seated in their high back recline wheelchair with an air pressure-relieving cushion. R64 was observed to have pressure fully on their bottom and thighs. OT U confirmed R64 the pressure areas. OT U stated, All areas are pressure. Review of R64's Care Plan, accessed 10/03/24, revealed R64 used a manual recline wheelchair for mobility, pressure relieving boots, a positioning wedge, and heels offloaded. The Care Plan showed R64 had MASD to their left rear thigh upgraded to a full-thickness non-pressure injury on 12/26/23. On 10/03/24 at 9:30 AM, during an interview, Registered Nurse (RN F) explained that R64's wound started as MASD (moisture associated skin damage) and was continued to be labeled as MASD but at some point, the area had opened. RN F when they started working at the facility the wound was already open and was relabeled as full thickness non pressure. On 10/03/24 at 9:36 AM, R64 was observed lying flat on their back in bed with a pillow under their left arm. R64's heels were observed to be resting directly on the bed. R64 explained that the wound started from something from my wheelchair. On 10/03/24 at 9:41 AM, RN F and RN O were observed to turn R64 onto R64's right side. An approximately 2.5-centimeter circular full thickness wound extending to muscle tissue was observed on R64's left ischium (lower pelvis bone at base of buttocks). A large amount of brown purulent drainage was noted on the wound dressing and on R64's brief. RN F explained they do dressing changes on Tuesdays and also takes pictures and wound measurements at that time then also rounds with the wound doctor on Thursdays. RN F was then observed to ask R64 if the staff used R64's positioning wedge today. R64 stated no. RN F was observed to look around R64's room and in the closet. A positioning wedge was found on the floor in the opposite corner of the room by the doorway on R64's roommate's side. Review of the policy, Pressure Ulcer Prevention and Management, revised 3/20/2024, revealed, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) .iii. Provide appropriate, pressure-redistributing, support surfaces .d. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. i. Pressure injuries will be differentiated from non-pressure injuries, such as arterial, venous, diabetic, moisture, or incontinence related skin damage. iv. Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate [wound drainage], and presence of pain, infection, or non-viable tissue .Monitoring. The attending physician will be notified of: i. The presence of a new pressure injury upon identification. ii. The progression towards healing, lack of healing, or worsening of any pressure injuries weekly . .

This citation has two deficient practice statements. Deficient Practice #1. Based on interview and record review, the facility failed to provide recommended restorative therapy for one (R59) of three residents reviewed for restorative therapy services. Findings include: On 10/01/24 at 12:45 p.m., R59 was observed seated in their wheelchair in their room. On 10/01/24 at 12:48 p.m., R59 reported they were not walking with staff, or regularly receiving their restorative therapy exercises. R59 stated, .I don't even get it [restorative therapy] once a week. I ask them in the hallway what they are doing and say range of motion [with other residents]. That bothers me, I need to walk . Review of R59's Restorative Program referral, dated 7/29/24, revealed, Walking: Distance: 3' with 2 WW [two-wheeled walker]. Assistance Required: Min [minimal assistance]. Instruct to increase t [weight] on right [side] .ROM: Extremity: See exercise sheets. Frequency: 5x/ wk. [five times a week] . Review of R59 restorative therapy logs revealed during the past month (September 2024), R59 participated in walking one time out of eight opportunities. There were no refusals documented, and it was unclear why the sessions were missed or not offered, 7 of the entries showed, not scheduled this shift, and one showed response not required. Review of the range of motion logs showed R59 participated one time of ten opportunities. The other 9 of the entries documented, not scheduled this shift. There was no monthly summary provided for September 2024. Review of R59's, Restorative therapy monthly documentation, dated 9/3/24, revealed a program summary for one month, from 8/01/24 through 8/31/24. The document showed R59 participated 4 times in a walking program and 3 times in a range of motion program. There was one refusal of range of motion in August, and no refusals documented for that month with walking. Review of R59's Minimum Data Assessment (MDS) assessment, dated 9/01/24, revealed R59 was admitted to the facility on [DATE], with diagnoses including heart failure, anxiety, and depression. The assessment revealed R59 required moderate assistance with transfers, minimal assistance with walking, and maximal assistance with toileting, The Brief Interview for Mental Status (BIMS) assessment revealed a score of 13/15, which showed R59 was cognitively intact. The assessment revealed, Restorative Nursing Program, number of days each of the following restorative programs was completed (for at least 15 minutes a day in the last 7 calendar days): Technique: Range of motion, passive, 0 [minutes], Range of motion, active, 0 [minutes]. Training and skill practice in: E. Transfer, 0 [minutes]. F. Walking, 0 [minutes] . On 10/01/24 at 12:48 p.m., Restorative Aide, Certified Nurse Aide (CNA) K was asked why the logs showed R59 participated only one time in the restorative program in the last month. CNA K confirmed R59 was currently on their restorative program caseload, and this was an accurate reflection of R59's being offered restorative therapy, and their participation. CNA K stated they had not consistently offered R59 restorative therapy services, as they were sometimes pulled from the floor to assist residents with [providing their] showers. CNA K reported this concerned them, and they had spoken to their supervisors and nursing management regarding residents missing restorative services. On 10/03/24 at 2:21 p.m., the DON was asked about R59's missing restorative therapy. R59 stated, I will look into this. I would expect [CNA K] to go to [the Restorative Nurse] . Review of the policy, Restorative Nursing Program revised 1/1/2022, revealed, The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility. A Restorative Nursing Program, when appropriate is based on a the [sic] comprehensive assessment and resident .Re-visit at least quarterly to determine if the resident would still benefit .Determine resident and/or family goals for restorative care .Each facility should establish a monitoring program to ensure success .Each program must occur 6 out of 7 days a week for a minimum of 15 minutes in a 24 hour period .Restorative documentation requirements include .Comments if refused, withheld, or change in status (improvement/decline) as applicable .Each facility should establish a monitoring program to ensure success .Establish a daily review of documentation to discern delivery of care . 44750 Deficient Practice #2. Based on observation, interview, and record review, the facility failed to apply an immobilization devices (arm sling and cervical collar, c-collar) for two residents (R5 and R107) out of two reviewed for mobility. Findings Include: R5 On 10/1/2024 at 9:30 AM, R5 was observed in their room and sitting in their wheelchair. R5 stated they were getting dressed for bingo. R5 was observed in the room alone and attempting to put on shoes. R5 then wheeled in the hallway and received assistance putting shoes on from staff. No arm sling was observed in use. On 10/1/2024 at 11:38 AM, R5 was seen in the hallway asking for their arm sling to be applied. R5 was then observed going into their room with their nurse to apply their arm sling. A review of the medical record revealed that R5 admitted into the facility on [DATE] with the following medical diagnoses, Recurrent Dislocation, Left Shoulder and Pain in Left Shoulder. A review of the Minimum Data Set assessment (MDS) revealed a Brief Interview for Mental Status score (BIMS) of 12/15 indicating an impaired cognition. R5 also required staff assistance with transfers and bed mobility. Further review of the physician's orders revealed the following active orders, Sling and Swathe to left upper extremity at all times. May remove for skin checks and showers. Status: Active. Ordered:2/9/2023. Apply arm sling to left upper extremity when out of bed, adjust snug to chest. Check for circulation after each application. Only Apply when resident is out of bed. Status: Active. Ordered: 9/17/2024. On 10/3/2024 at 9:30 AM AM, R5 was observed in bed with no arm sling in use. On 10/3/2024 at 10:57 AM, R5 was observed in activities with no arm sling in use. On 10/2/2024 at 11:14 AM, R5 was observed leaving the activities room. R5 stated they were going to tell the staff to apply their arm sling. R5 was asked if they have to tell them often to apply it. R5 stated they always forget; I just remind them, and they apply it when out of bed. On 10/3/2024 at 9:17 AM, an interview was completed with Unit Manager (UM) A. UM A stated R5 should have the arm sling on when they are out of bed and the staff should be applying it. 50223 R107 On 10/01/24 09:56 AM, R107 was observed lying in bed with the head of their bed elevated approximately 30 degrees (not upright). A cervical collar (c-collar) was observed to be on a wheelchair across the room. Certified Nurse Assistant (CNA) L was observed to be sitting in the room saying, R107 just returned from the hospital. CNA L confirmed R107 wears a c-collar when they are out of bed. 10/02/24 at 7:48 AM, R107 was observed sitting up in their wheelchair at a table in the common area eating breakfast. R107 was observed to not be wearing a c-collar. On 10/2/24 at 8:23 AM, R107 was observed to still be sitting in a wheelchair at a table and was now observed wearing their c-collar. On 10/03/24 at 9:17 AM, R107 was observed in bed with head up 45 degrees (not upright). The c-collar was observed across the room in the wheelchair. A review of R107's Electronic Medical Record (EMR) revealed that R107 was admitted to the facility on [DATE] with the following diagnosis: Unspecified injury of head; Unspecified dementia; Fall on same level A review of R107's Brief Interview for Mental status revealed a score of 4 indicating cognitive impairment. A further review of R107's record revealed a hospital History and Physical dated 9/9/24 revealed the following: CT- C-spine: Nondisplaced anterior/inferior C4 vertebral body fx (fracture). A review of R107's physician orders revealed the following: Order dated 9/19/24 C-Collar on while out of bed. May have c-collar off when lying in bed. Must have on when sitting upright in bed. Discontinued 10/2/24. Order dated 10/2/24 3:00PM C-collar on while out of bed. May have C-Collar off when eating, showering or lying in bed. Must have on while sitting upright in bed. A review of R107's care plan revealed the following: Resident is at risk for falls/injury related to dementia, recent falls from standing. Resident removes (their) C-Collar (themselves), monitor resident to ensure (they) are wearing when up out of bed. Date initiated 9/18/24. I wear a C-collar on while out of bed. I may have C-Collar off when eating, showering or lying in bed. I must have on when sitting upright in bed. Date initiated 9/11/24 revised 10/3/24. A NP/PA (Nurse Practitioner/Physician Assistant) progress note dated 10/1/24 revealed the following: Per chart review (they) have taken multiple falls. (they) were taken to the hospital sometime after the fall for another fall in the bathroom where (they) fell backwards and hit (their) head. CT scan revealed possible C4 vertebral body fracture, but MRI demonstrated a non bridging enthesophyte calcification, confirming no fracture. (They) were evaluated by neurosurgery. (They) came back with a C-Collar in place. Physical exam: .C-collar in place: adjusted to support chin . Assessment/Plan .C-collar when out of bed .9/19 .keep C-collar on when OOB (out of bed or upright in wheelchair. 9/26 Recurrent attempts to self-transfer without staff. C-Collar not in appropriate position upon arrival for visit. Education provided to staff . On 10/2/24 at 8:25 AM, during an interview, Unit Manager (UM) C explained R107 is supposed to wear the C-collar when out of bed or if head of bed is elevated. UM C also explained the resident does not like to wear the c-collar when eating or lying down. On 10/3/24 at 10:53 AM, during an interview, Registered Nurse (RN M), explained R107 is confused and they have to wear a c-collar whenever they are out of bed because they had a fall. On 10/3/24 at 11:05 AM, during an interview, Physical Therapist (PT) N explained R107 has to wear the c-collar due to a nondisplaced C4 fracture of the cervical spine. PT N said R107 is unsteady and has poor balance and every time R107 stands up they fall backward and their reactions are delayed. PT N said if R107 was not wearing the c-collar R107 would be at risk for making the fracture worse or could injure a muscle or ligament and saying, I would hate for that to happen, that would be bad. When you're dealing with something that close to the central nervous system, we definitely want to take all the safety precautions. On 10/3/24 at 11:33 AM, during an interview, the Director of Nursing (DON) explained R107 is very impulsive and has to wear a c-collar because they fell and hit their head. The DON explained initially the resident had to wear the collar around the clock but stated I just had the PA (Physician Assistant) assess (them) and now (they) can have it off when (they're) eating and when they're lying down. When (they're) awake we try to keep it on. A review of a facility policy titled; Physician/Practitioner Orders-Consulting did not address applying mobility devices.

Based on observation, interview, and record review, the facility failed to safely and properly store portable oxygen for one (R27) of four residents reviewed. Findings include: Review of the facility record for R27 revealed an admitted [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. R27's current physician orders include O2 two liters continuous with humidification. On 10/01/24 at 10:03 AM, during initial interview R27 was using their oxygen concentrator. A portable oxygen tank was observed in a tank holder attached to the resident's four wheeled walker. A second portable tank was observed in a wheeled cart near the bathroom. R27's roommate was not using oxygen and when asked about the second tank R27 stated That's mine. They keep an extra one sometimes so they don't have to go get it but I'm not sure why its over by [R27's roommate]. On 10/02/24 at 01:09 PM, the extra oxygen tank observed on 10/01/24 remained stored in R24's room near the bathroom. On 10/03/24 at 10:30 AM, the oxygen tank previously observed remained stored in a wheeled cart near R27's bathroom. On 10/03/24 at 12:33 PM, the facility Director of Nursing (DON) reported the expectation is that an extra oxygen tank should not be stored in the resident's room and should only be in the oxygen storage room that is on that unit. Review of the facility policy Oxygen Safety dated 01/01/22 revealed the entry 4. Oxygen Storage - a. Oxygen storage locations shall be in an enclosure or within an enclosed interior space of non-combustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry.

This citation pertains to Intake: MI 053. Based on observation, interview and record review, the facility failed to prevent employee to resident abuse for one sampled Resident (R3) of 2 reviewed for abuse, resulting in the likelihood for further abuse towards R3, additional residents including those who may yell or scream, and those who were cognitively impaired (from a reasonable person's concept) that were provided care by the employee. Findings include: A review of the facility's reported incident summary noted, On 12/04/2021 at approximately 3:20pm, [CNA C] reported to [Nursing Home Administrator NHA] that she witnessed [Nurse D] say F*ck This, F*ck you, I can't F*cking do this anymore, Hitler had the right idea to resident [R3] . On 5/24/22 at 1:00 PM, R3 was observed in their room laying in bed that was positioned low to the floor, with a mattress on the floor next to the bed. R3 was unable to recall the incident when questioned. No other concerns were reported at that time from R3. A review of R3's medical record revealed, R3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R3's quarterly Minimum Data Set (MDS) assessment noted, R3 with an impaired cognition and that R3 required extensive assistance with activities of daily living. A review of progress notes for R3 noted, 12/5/2021 14:55 (2:55 PM) Nurses' Notes Text: Notified MD (Medical Director) and R/P (responsible party) (son) via phone (left message) of an incident that occurred yesterday afternoon between an employee and resident . [Nurse E]. On 5/25/22 at 2:46 PM, Nurse E was interviewed and asked about the incident that was mentioned in the progress note dated 12/5/21. Nurse E explained, that she didn't remember and that she thinks it was something that happened with a staff person. On 5/25/22 at 2:56 PM, the NHA was asked about the incident that happened with R3 and a staff member in December 2021. The NHA provided the incident report and investigation. A review of the incident report noted, a verbal incident that occurred with R3 and Nurse D that was witnessed by CNA C. On 5/25/22 at 3:25 PM, CNA C was asked about the incident and stated, [R3] went to the hospital and came back on another unit, [R3] is one of my favorites so I went to go check on [R3]. I walked on the unit (F wing) hallway and I heard him [Nurse D] say 'F*ck this, F*ck you, I can't f*cking do this anymore, Hitler had the right idea.' I attempted to take [R3] out of the hallway to my unit which was the Dementia unit. We were going there and [R3] did not want to go on the unit, so we went into the day room and got [R3] a soda. I went back to my unit and told my nurse (Nurse H) and texted the [NHA], this was on a Saturday. He said he would handle it. CNA C was asked if Nurse D worked the rest of the shift Saturday and stated, Yes. Sunday he came back but was sent home around noon or lunch. My unit Nurse (Nurse H) said if they didn't handle it she was quitting. She quit that day. On 5/26/22 at 9:00 AM, the NHA was asked about the incident and stated, So when I was notified some pieces were missing, I was told he (Nurse D) was having some inappropriate language, it wasn't communicated that it was at a resident. CNA C Did not tell me that he was talking to [R3]. I was told [Nurse D] is cussing in the building, CNA C did not mention that it was at a resident or around a resident. Sunday I came in and the Nurse (Nurse H) told me more, that it was towards [R3] I called the Unit Manager to cover and Human Resources and Payroll to do some interviews with me. The NHA was asked the reason Nurse D was not sent home after the incident. The NHA explained, it was not reported that it was towards a resident. After getting the full story and interviews Nurse D was suspended pending the investigation. The NHA continued and stated, [R3] was interviewed and said he was cussing at [R3]. Nurse D did say that [R3] kept coming to the cart and antagonized him. Nurse D asked the other Nurse (Nurse E) to take care of [R3] on Saturday and Sunday and had no other contact with [R3]. The NHA was asked if this Nurse had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He has used inappropriate language with staff. On 5/26/22 at 9:13 AM, Nurse E was asked if they took over the care of R3 and stated, Yes Saturday he (Nurse D) asked me to take over for him with [R3] and on Sunday. A review of the facility's investigation and staff interviews revealed, Statement of Staff Member. Staff member interviewed: [CNA C] Interview 12/5/21 . 1. Was there an incident that happened between [Nurse D] and [R3]? I went down to unit 3 to setup visitation between residents, this around 3pm. As I was walking up I heard [Nurse D] say F*ck this, F*ck you, I can't f*cking do this anymore, Hitler had the right idea. 2. What happened next? [CNA G] was attending to [R3], and then I notified you. 3. Who was [Nurse D] talking to ? I believe it was to [R3]. 4. Was there any other witnesses? [CNA F] and [CNA G] were in the general area. 5. Where was this general area? At the end of F wing on desk 3, right after the shower room. Signature: 12/5/21. Statement of Staff Member. Staff member interviewed: CNA G called. Interview: 12/5/21. Location of interview: Phone interview. 1. Did you witness an incident with [R3] and [Nurse D] yesterday? Yeah. 2. What did the incident entail? I was talking to [Nurse D] at his cart around 3:15pm [R3] came up asking about a shower. I don't recall the full conversation, but I know [CNA C] came up to [Nurse D] and said that was inappropriate. I don't know about what. So I just removed [R3] from the situation of whatever [CNA C] and [Nurse D] were arguing about. 3. Did you hear [Nurse D] say anything about Hitler? I personally didn't hear anything. Signature: CNA Date: 12/9/21. Statement of Resident [R3] interviewed: Interview: 12/5/21. 1. Was there an incident between you and [Nurse D] yesterday? He was cussing and had a nasty attitude. 2. What did he say? F*ck you. 3. Why did he say that? He didn't give me my medication. I asked him why he didn't give me my medication and he didn't say nothing. 4. So what made him swear? I don't know. We were just talking and he said that. 5. Did he say anything about Hitler? I didn't hear that. No why? He believes in Hitler? 6. Did he touch you physically? Yeah he touched my chair and pushed it down. 7. Were you injured? No I wasn't injured. 8. Did this effect you emotionally? No not at all. 9. Do you feel safe in the facility? I feel safe yeah. Signed 12/6/21. Statement of Staff Member. Staff member interviewed [Nurse D] Interview: 12/5/21 1. Did you say the words F*ck this, F*ck you, I can't f*cking do this anymore, Hitler had the right idea? No that is not accurate. 2. You say that I (sic) not accurate, what along the lines of this did you say? I don't recall what was said, I know the word F*ck came out of my mouth, but not that many times. I do not recall saying anything about Hitler. I do recall saying I can't take this anymore. 3. Do you recall where this took place? Right at the med cart on F wing. 4. Was there people around? Yes there were several people, I know [CNA G] was there. She was trying to tell me something, I don't recall who else was there. 5. Was what you were saying directed at [R3]? No it was directed at the concept of the situation, I cannot take more of trying to do my job while someone yells and screams. 6. What time did this place? Around 3pm, just a little after, approximately. Signature: Nurse Date: 12/5/21. Performance improvement Form [CNA D] Date: 12/5/2021. Reason for Counseling/Corrective Action: Witness provided statements involving (Nurse D) and a resident. used foul language and racial inappropriate comments. Alleged violation of code of conduct 6.14 violation the company's polices , including . harassments discriminations, violence prevention, etc 6.11 violation the rights of resident . including abuse, etc. Has this concern been previously discussed with the employee Yes. Counseling sessions/corrective action. Admin and HR collected witness statements. Suspend pending investigation Nurse D Personal Action Request (PAR): Separation Last day of work 12/05/2021. Separation Date: 12/7/21. Reason for separation: Terminated. Code of Conduct violation. Inappropriate language. signed 12/7/21 administrator. A review of the facility's policy titled Abuse, Neglect and Exploitation dated 01/01/2021 noted, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: . Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of there age, ability to comprehend, or disability . VI. Protection of Resident The facility will make efforts to ensure all resident are protected from physical and psychological harm 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 . VII. Reporting/Response. A. 3. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for services .

Based on observation, interview and record review, the facility failed to administer nonpsychiatric and/or [CONDITION(S)] behavior medications and manage behaviors appropriately per physician orders, for one Resident (Resident #23) of four residents reviewed for behaviors, resulting in mental anguish, uncontrolled anger and impulsiveness. Findings include: On [DATE] at 11:19 AM, Resident #23 was observed in the room next to their room, helping set up a meal tray for another resident. Resident #23 was dressed and groomed and talking in a very quiet tone. The Resident was calm and smiling. During this time, an interview was attempted but the Resident did not answer questions appropriately. On [DATE] at 07:45 AM, Resident #23 was up in the lobby wearing the same outfit as the previous day. The Resident was yelling and screaming, I'm starving to death! The staff around were attempting to console the Resident without success. The Resident then exited the lobby, and could be heard screaming down the hallway. Staff followed the Resident. On [DATE] at 08:00 AM, Resident #23 was continuing to pace up and down multiple hallways screaming and accusing other random residents of hitting them. The Resident then began to follow this Surveyor down the hallway screaming, Who is she? What is she doing here? Staff were following behind the Resident attempting to distract the Resident. The Resident continued to pace back and forth up and down hallways threatening staff and refusing all assistance from staff. There were two staff members following the Resident. Resident #23 was yelling, I want to go to the kitchen! , I hate it here! and Leave me alone! I'm tired of this! The Resident would stop at random doorways of resident rooms and offices and yell and scream. On [DATE] at 08:22 AM, Resident #23 continued to yell and scream in the hallways. The Resident quickly approached this Surveyor screaming, Who are you? When answered, the Resident yelled, I don't care! Now there were three staff members following the Resident. The Resident quickly left the room, went down a hall yelling. A voice was heard yelling that Resident #23 had hit them. At that time, Resident #23 yelled, I hate this place! On [DATE] at 08:42 AM, a scuffle could be heard from the adjacent hallway with Resident #23 and staff yelling that the Resident was trying to hit them and they were petitioning the Resident out to the hospital. The Resident yelled, I am not going to [local hospital]! Resident #23 continued the same behaviors until 08:54 AM ([DATE]), when three police officers had to handcuff the Resident onto a stretcher to exit the building. A record review of the Physician Orders for Resident #23 revealed the following: [MEDICATION(S)] 50 mg (milligrams) Q (every) 12 hrs (hours) Dx (diagnosis) Paranoia [CONDITION(S)], Anxiety D/o (disorder), ordered [DATE]. Labs: CBC (complete blood count) with Diff weekly one time a day every Thu (Thursday) for [MEDICATION(S)] monitoring related to [CONDITION(S)] DISORDER, UNSPECIFIED. A record review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #23 did not receive their prescribed dose of [MEDICATION(S)] on [DATE]-[DATE] and [DATE]-[DATE]. A CBC was documented as being drawn on [DATE] only. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #23 was most recently admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following behaviors were coded on the MDS: trouble falling asleep, delusions, physical behaviors, verbal behaviors, rejection of care, and wandering. Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, indicating and intact cognition. A record review of the Progress Notes for Resident #23 revealed the following: [DATE] 11:30 (AM) .Resident walking up and down the hallways. Refusing to put grip socks or shoes on. Resident stating .is 'pregnant & will need an abortion'. Going across hall to another resident's room & shutting off .TV. Attacked another nurse & stated she is 'evil'; Spoke to NP (Nurse Practitioner) & making arrangements to send resident out. [DATE] 16:00 (04:00 PM) .Pacing back and forth yelling at this writer and throwing things if in reach all afternoon . [DATE] 17:46 (05:46 PM) .discharged at this time to .neuro behavior center .Combative upon transport arrival. Yelling, screaming, kicking ,hitting. Physical assist onto the stretcher at that time transport staff had to put soft restraints on her wrists and ankles . [DATE] 08:01 (AM) Yelling down the hallway 'My inside organs are falling out' .resident is lying in .bed nude from the waste down refusing to put on pull ups. Going to .doorway wrapping the privacy curtain around .continues yelling out 'I have [CONDITION(S)] of the bowels.' [DATE] 14:23 (02:23 PM) .Resident, this afternoon did swing at the CNA (Certified Nurse Assistant) again and is yelling in the hall. Resident is returning to .behaviors .had prior to being sent to Indiana. Every shift this writer works the behaviors in report and the behaviors .displays are no different then before .send out. [DATE] 16:34 (04:34 PM) .Call made and message left with residents guardian to discuss alternate placement. Awaiting return call. Will continue to follow PRN (as needed). [DATE] 18:48 (06:48 PM) .Resident became aggressive and threatening towards other residents whose room are across the hall .When I attempted to redirect [Resident #23] .became aggressive and combative towards me. As I was stepping away .began to punch me in the shoulder several times until I was able to get some distance away from (Resident #23). DON (Director of Nursing) and Administrator were notified, resident was petitioned out to [local hospital]. EMS (Emergency Medical Services) arrived and was able to convince .to go the hospital. Resident left building via EMS. [DATE] 06:01 (AM) .Resident needs supervision r/t (related to) .behaviors. Is a danger to .self and others. Temper and ability to change moods quickly. Nothing has really changed with this resident . steady on (their) feet .Verbally abusive to others and since .return this week has not been physically abusive to anyone yet. Did refuse . medication this morning. [DATE] 18:55 (06:55 PM) .returned to facility from [local hospital] Psychiatric unit on [DATE]. Patient refuses physical exam patient states 'I went to [local hospital] and they dyed my hair red, and now its on fire so I can't talk to you'. Patient clearly through observation did not have .hair colored. Nursing reports patient refuses oral medications today [DATE] .CBC with diff weekly for [MEDICATION(S)] monitoring .Reorient Redirect to environment as needed. Continue with supportive measures Encourage compliance with medications and care. Follow closely with psych . [DATE] 13:51 (01:51 PM) .Behaviors are more than daily. Residents new behavior is to throw . tray with all the food on it out in the hall then scream that its not the way (Resident #23) likes it. [DATE] 16:00 (04:00 PM) .Yelling and chasing the house keeper this afternoon. unknown reason. Yelling across the hallway at another resident. Continues to complain about all foods. Poor food and fluid intake. [DATE] 02:00 (AM) Resident upset with wall panel in hallway by dinning room [ROOM NUMBER] that alerts staff that a call light is on and residents need assistance. Resident is screaming that it needs to be turned off now it is driving resident crazy resident up and down the hallway yelling. Resident asked to please not yell and was educated on what it was and why it is there and that it can not be turned off. Resident received a one time IM (intramuscular injection) [MEDICATION(S)] per Doctor after multiple attempts to redirect patient. [DATE] 16:00 (PM) .Will constantly ask for food and then when it is given .will just storm away stating something was wrong with it. Yet then yell down the hallway 'I am starving'. Many substitutes offered and rejected so .can have something to yell about. Or make staff run back and forth to the kitchen for all of their efforts are in vein. [DATE] 16:00 (04:00 PM) .Pacing back and forth down the hallway. Looking upset and agitated. When asked what was wrong .yelled 'I don't know the DEVIL took over.' [DATE] 13:02 (01:02 PM) Resident running up and down D hall. Writer has told (them) to stop several times and .continues to .reply .'I can't stop its controlling me'. [DATE] 13:05 (01:05 PM) .Follow up of behaviors that occur daily. Today its running up and down the hall 'it' is making (them) do it and .can't stop. Resident has been redirected several times today and the behavior continues. [DATE] 08:05 (AM) behaviors getting increasingly worse this a.m. Constant complaints and yelling about ALL food. Running up and down the hallway yelling and becoming anxious. Screaming 'I have anorexia' New order for [MEDICATION(S)] (an antianxiety medication) . [DATE] 11:05 (AM) Resident continues to get upset with staff and others easily. Resident does not like bed, so took it upon .self to go to another hall and bring a different bed back with (them). Unable to redirect ., so allowed (Resident #23) to switch .beds at this time. Resident is content at this time after beds switched. Will continue to monitor. [DATE] 11:59 (AM) See MAR, which has been reviewed, for a list of the current nonpsychiatric medications-[MEDICATION(S)] 50 mg Q12 hours .Complaint: Refusing medications at times; Eccentric behavior .seen today for follow-up psychiatric evaluation at the request of the primary team and social work, to evaluate acute psychiatric symptoms and assess the effectiveness of the current [CONDITION(S)] drug regimen in relation to these acute symptoms. At the previous psychiatric evaluation, no [CONDITION(S)] medication changes were made. The patient has developed a significant new problem which requires immediate attention. The Patient is being seen in close follow up to ensure .is remaining compliant with .medications. Today .presents in a very good mood and speaks with me in a normal fashion. Not demonstrating any uncontrolled [CONDITION(S)] or delusions or hallucinations at this point in time .is also reported by staff to be more calm and interactive with no issues .Plan: [MEDICATION(S)]-Monitor mood, behavior, delusions, paranoia, hallucinations. Document concerns. Notify service of any changes . [DATE] 08:05 (AM) .Resident mood has changed often and drastically throughout the shift. Has had pressured speech most of the day when speaking to others. At one moment .is yelling and stating .hates others and multiple things about the facility, the next moment .comes out of (their) room, (Resident #23) is telling others that .loves them. Resident is also refusing to brush .teeth today, stating it will 'kill me'. Resident is often seen quickly walking up and down the hallways. [DATE] 16:00 (04:00 PM) .Running up and down the hallway at lunch time yelling about food .will request things to eat and then .will refuse. Yelling, 'I got nothing to eat' 'I am going to starve'. Screaming 'I am going crazy.' Yelling that .mother and father are in 'Hell' and 'That is where I am going'. [DATE] 16:00 (04:00 PM) .resident began to get restless this afternoon. pacing up and down the hallway mumbling/talking to .self. [DATE] 15:06 (03:06 PM) .Behavior occurred - interventions ineffective. Resident has behavior issues daily. No intervention has proven to be effective. Currently .has been out of .medication that was prescribed for such issues. [DATE] 17:44 (05:44 PM) Nurses' Notes .Resident continues with unresolved behaviors that maybe .medication was starting to help but .no longer has this medication and is regressing back to so many behaviors a day its becoming impossible to keep them straight, Every meal,that the resident tells kitchen what .wants,resident throws on the floors or [NAME] that (they are) not eating that slop. Today every meal .went in all the residents rooms on D hall telling them that this place is starving (them) and .has nothing to eat .ordered tuna fish then smashed it in .hands and took it in the rooms like that to show what they give (them) to eat. At supper .ran up and down d hall yelling .was being starved ,then down A hall and writer found .in the dining room by the kitchen yelling .was starving and nobody gives (them) any food. [DATE] 10:10 (AM) .Resident was pacing up and down the hallways this morning yelling out. Resident stating 'I want a Betty Crocker cook book'. This writer approached resident with a notepad and pens to write recipes. Resident began yelling at this writer 'I hate you [staff name]'. Resident pacing back and forth screaming up and down the hallways at staff. Unable to re-direct. Resident approached this writer in the office, ripping the phone out of this writers hand. Resident sweeped the desk of this writer throwing all objects off of the desk. Social Service Director completed petition for mental health. This writer contacted (company name) EMS (Emergency Medical Services) to set up transport to [local hospital] for mental health treatment. Resident was resistive to going with (contracted company name) EMS. Three officers assisted with transport. This writer contacted residents Guardian .CMH (community mental health) also notified of transfer. [DATE] 15:59 (03:59 PM) .Resident stated to staff member, 'I hit you lst time but i will kill you this time' . A review of the care plan for Resident #23 revealed the following: Focus-Altered thought process r/t paranoia, delusions, hallucinations. (Resident #23) may see .deceased father whom .believes is the anti-Christ .has a history of accusing staff of trying to kill (them) .makes accusations against staff due to delusions and memories from her past; res (resident) may feel there's cement dust coming in through .window and declines to close .window. res perceives the carpeting as dirty despite carpets being cleaned and will lay towels about the floor to walk on; res may yell at others in the hallway- typically delusional, confused content. res fixated on refusing new shoes, threw out black tennis shoes that use to fit .declines larger sizes, refuses slippers and slipper socks to wear. res caring partner has purchased multiple socks, slippers, gripper socks - res refuses to wear. res will go barefoot in facility despite multiple attempts to provide and education. Date Initiated: [DATE]. Revision on: [DATE]. Goal-(Resident #23) resident and others will not experience negative outcomes related to altered thought processes. Intervention-Provide medications as ordered .Date Initiated: [DATE] . On [DATE] at 07:43 AM, an interview was completed with the DON and Nursing Home Administrator (NHA). They were asked about the medication not available for Resident #23. The DON explained that the facility has recently switched providers (psychiatry) and pharmacy and that they were not able to get the medications without a weekly CBC draw. The DON stated, They (the pharmacy) used to send us a seven day supply but they don't do that anymore. The DON explained that they did not draw the correct CBC initially. The DON also stated, (Resident #23) refuses labs to be drawn sometimes and they (the pharmacy) won't send it (the medication). The DON was asked about utilizing different medications that did not require blood draws and stated, (Resident #23) has been on everything. A review of the facility policy titled Behavior Management Program dated [DATE] revealed the following: .Residents on an antipsychotic residents exhibiting behaviors negatively affecting self or other residents will be reviewed by the Behavior Management team .the team will examine the root cause of behaviors/mood .The team will identify target behaviors .b. Social Service team will monitor behaviors .

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19 by allowing an employee, that reported positive symptoms of COVID-19 (a severe and highly contagious respiratory infection) during screening and who subsequently tested positive for COVID-19 the same day, to enter into a resident care area and interact with two residents (R#510 and R#513). The facility has had 21 residents and 8 staff test positive for COVID-19 since 11/10/20. Eight residents (R#504, R#505, R#506, R#507, R#508, R#509, R#510, R#511) on the unit where the symptomatic employee entered into, have since tested positive for COVID-19. This deficient practice resulted in sustained spread of COVID-19 and the likelihood for continued transmission of COVID-19 to all facility residents and staff, decline in overall health, serious illness, and/or death. The Immediate Jeopardy (IJ) started on 11/12/2020 and was identified on 12/2/2020. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 12/2/2020 and was asked for a plan to remove the immediacy. The IJ was removed on 11/13/2020, based on the facility's implementation of the removal plan as verified onsite on 12/2/2020. Although the immediacy was removed, the facility's deficient practice remained as a pattern, actual harm that is not immediate jeopardy. Findings include: On 12/1/20 at 9:45 AM, during a tour of the facility, the locked dementia unit was observed to be without residents and staff present. On 12/1/20 at 9:53 AM, Certified Nursing Assistant (CNA) A was queried regarding the empty dementia unit and indicated that during the past week, all of the residents on the unit were, Moved to the G wing because of a COVID outbreak. CNA A was queried regarding the outbreak and stated, It was a couple (residents) at a time. They noticed they were getting sick and then we found out they had COVID one by one during testing. We had 16 residents over here .They ended up moving (all the residents) down to Desk 3 (300 unit, separate section on the other side of the building from the dementia unit) isolation. This unit was different because of the dementia residents, it's hard to keep them isolated around here. When asked if the residents were kept isolated in the dementia unit when they began showing symptoms of illness, CNA A stated, We tried to keep them separated from the rest but it's difficult, everyone was around everyone already. There (are people that wander), you can't make them sit and stay. We tried. When asked if all the residents on the dementia unit tested positive for COVID-19, CNA A stated, There are a few left that hadn't become positive yet and they put them in isolation, too. When asked about staff on the dementia unit who had tested positive for COVID, CNA A stated, I know of two nurses that worked that tested positive. When queried regarding set-up and dining in the dementia unit when it was open, CNA A stated, We had residents out in the lobby area. We only have one aide anymore so we set people up to feed them. If we have two staff we will put them in the dining room to feed them. We have lots of wanderers, hard to redirect, and very difficult to keep in their rooms. It's hard to keep them still, there's no personal space and there's no bubble. They lay on each other's beds .it's hard to keep people separate .I'm sure that's how it spreads fast. When queried regarding the source of the infection on the dementia unit, CNA A stated, When we are short we need to go where we need to go. I think girls down on Desk 3 (previously the transition area for new admissions and [MEDICAL TREATMENT] residents) originally had ended up working down here within the last 2-3 weeks, so people normally (in the COVID area) I think worked down here. Scheduling is a struggle. On 12/1/20 at 10:16 AM, the interim Director of Nursing (DON) was interviewed and indicated that Desk 3 was now split into three hallways: the F hall with positive COVID-19 residents, G hall with residents who were exposed to COVID-19, and H hall with new admissions and [MEDICAL TREATMENT] residents/residents who frequently have to leave the building. The DON indicated that in November, there were residents in Desk 3 who tested positive for COVID-19 but were sent out to a COVID-19 hub facility. The DON then stated, Then the dementia unit had an outbreak. We took eight people who had it and (turned) F (hall) to the COVID positive area. At this time, an unidentified female resident was observed walking down the G hallway with no mask, and a second unidentified female resident was observed sitting in a geri chair in the lobby area of Desk 3, in front of the television, with no mask on. The DON stated, It has been difficult to displace the dementia unit .these are the first positives (COVID cases), we went a long period without. The DON indicated that the most recent resident to test positive for COVID was R#511 (positive 11/30/20), who was previously on the dementia unit, then moved to the G hall on 11/27/20 due to exposure, and was now in F hall. The DON indicated that the entire dementia unit was relocated to Desk 3 on 11/27/20. At this time, CNA G and CNA H were observed preparing to enter the F hall with COVID positive residents. Both CNAs indicated they were working on all three hallways, F, G, and H. When queried if they only worked on Desk 3, both CNAs indicated that they have recently worked shifts in other, non-COVID parts of the building when necessary. The majority of room doors on all three hallways, F, G, and H, were noted to be open at this time. Nurse I indicated she was currently the only nurse on Desk 3 and was taking care of all three hallways with a total of 26 residents. On 12/1/20 at 11:05 AM, the Infection Control Preventionist (ICP) was queried regarding COVID outbreak status in the facility. The ICP indicated that on 11/10/20, multiple residents on Desk 3 tested positive for COVID. The facility's respiratory surveillance line list was reviewed and showed six residents in the Desk 3 area who tested positive for COVID-19 on 11/10/20. The ICP indicated that the first resident the facility knew of being positive had gone to the hospital and tested positive there (11/10/20) and explained that the facility subsequently tested the entire unit and found five more residents to be positive for COVID. The ICP stated, The [MEDICAL TREATMENT] clinic had positive cases and we weren't alerted to it, our residents were exposed, so it started with [MEDICAL TREATMENT] residents but they were already in quarantine on the 300 unit. We have had positives ever since then. Further review of the surveillance line list revealed that the first staff member to test positive for COVID-19 was CNA B, who tested positive on 11/12/20. CNA B's Primary floor assignment, was listed as Unit 3. On 12/1/20 at 12:24 PM, CNA B was called and interviewed via phone regarding where she had worked leading up to her positive COVID-19 test and information regarding testing positive for COVID-19. CNA B stated, I worked (the dementia unit) on Thursday or Friday before that Monday (11/9). I normally worked Desk 3. Then had the weekend off, came back 11/9 (worked Desk 3), was off Tuesday and Wednesday (11/10 and 11/11), then Thursday (11/12) I was positive (for COVID). When queried if she had experienced any symptoms of COVID-19, CNA B stated, On Monday (11/9) I started to have a sore throat in the evening hours. That's all I had until Thursday started having diarrhea. When asked if she had been screened upon coming into the building on Thursday, 11/12, CNA B stated, I was temped in (got temperature taken). I told them I had a sore throat on Monday and then had diarrhea and that's when I went to get rapid tested . Then they sent me home right after that test came back positive before 8 AM on Thursday. I took care of two people on (the dementia unit) on 11/12. When asked if she remembered who they were, CNA B responded, (R#510 and R#513). When asked if they had her go get tested for COVID-19 and then go to work on the dementia unit, CNA B stated, I guess ideally I probably should've just sat in that lab .I punched out at 7:45 (AM) and was tested at 7:30 AM. A review of the November 2020 staff schedule revealed that CNA B was scheduled on Friday, 11/6/20 to work eight hours on Desk 3 and four hours on the dementia unit, scheduled on Monday, 11/9/20 to work 12 hours on Desk three, and scheduled on Thursday, 11/12/20 to work on the dementia unit. A review of time punches revealed that CNA B punched in at 7:06 AM on Thursday 11/12 and punched out at 7:45 AM. On 12/1/20 at 12:50 PM, CNA F was interviewed regarding working 11/12 and CNA B. CNA F indicated that she had spoke with CNA B and CNA B had informed her about her symptoms. CNA F stated, (CNA A) was screened and came in. Had to put a mask on and get tested .(CNA B) asked me to get her food and stuff from (dementia) unit, she had dropped her stuff off back there before her test .(CNA B) normally worked on Desk 3 with the isolation rooms. The next Friday, I was down (on the dementia unit) then the day after that was when residents were showing signs and symptoms and they were testing them. When queried regarding staff working on Desk 3 as well as non-COVID units, CNA F stated, I have seen it, yes, nurses and CNAs. The facility's respiratory surveillance line list was reviewed and showed the following positive COVID-19 test results for the residents on the dementia unit: R#504 - 11/26/20 R#505 - 11/23/20 R#506 - 11/23/20 R#507 - 11/23/20 R#508 - 11/24/20 R#509 - 11/24/20 R#510 - 11/26/20 R#511 - 11/30/20. On 12/1/20 at 1:28 PM, the ICP was interviewed regarding CNA B testing positive for COVID-19 on 11/12. The ICP stated, (CNA B) was an employee that worked that unit, had symptoms 11/12, the day she was tested . She had (gastrointestinal) upset and a headache. When asked if CNA B came into the building to be tested , the ICP stated, Yes, came in, did the test, told me she was going to (the dementia unit) to put her stuff away and then come back for test results. Then we found out she was positive. It was instantly positive so I called her right back. She had on a mask and goggles when she went back. The ICP then went over the mapping of the outbreak and stated, (Dementia unit) was closed on Friday 11/27 because we had more residents come up positive. We didn't have positive staff in the building until the positive [MEDICAL TREATMENT] residents (on Desk 3). With the (dementia unit) outbreak, if you look at the dates it's 10-14 days after (CNA B) and (CNA C) were both there. (CNA C) is a contingent CNA who worked here one day .(CNA B) worked on Unit 3 but also worked on (dementia unit). The ICP explained CNA C worked on the dementia unit but had no symptoms, and tested positive for COVID-19 after working in the building. The ICP stated, We tested all of the residents on (dementia unit) after (CNA B's) positive test. First one (positive) was 11/22. The ICP continued and indicated that R#508 and R#509 were symptomatic and tested positive on the same night and stated, (R#508) sits in the common area on the unit and (R#509) is all over the place. A big thing that shouldn't have happened was (CNA B) went back to (dementia unit) on the day she was tested . And when (CNA C) was down there she said she wore a mask the whole time but did she? I don't know. When queried regarding staffing Desk 3 and other parts of the building, the ICP stated, We have designated nurses and CNAs that work that unit but they don't cross between units during one shift. As long as people aren't crossing between units on the same shift that's okay. On 12/1/20 at 3:36 PM, the DON was interviewed and queried regarding the facility's policy for staffing on the Desk 3 hallways. The DON indicated the facility tries to keep people on the same units all the time. When queried regarding the policy and procedure when someone comes into the building with signs and symptoms of illness, the DON stated, We have them stay off the unit, don't let them through the doors, then test them. The DON indicated that staff with symptoms of illness should not be let back onto the units at all and that ideally, staff would be calling in to notify the facility of symptoms before they even arrive to work. The DON stated, We do drive-bys now, they go outside and do the test. When queried if it is the expectation for someone with COVID-like symptoms to interact with residents, the DON stated, No. When queried regarding the COVID-19 outbreak in the facility, the DON indicated she felt it was two separate incidents, that the first started with the [MEDICAL TREATMENT] residents on Desk 3. When queried about the outbreak on the dementia unit, the DON stated, Well, the residents don't leave that unit. (R#504) went to the doctor two separate times, but for infrequent appointments we don't isolate, so (they) didn't get isolated. (CNA B) tested positive in the middle of the first outbreak situation, the other staff member (CNA C) tested positive 11/18 and is (an as needed) employee who had not worked in a while. When queried regarding CNA B being let back into the building after screening positive for symptoms of illness, the DON stated, I was not aware of that. (CNA B) called that week to tell us she can't work on the COVID unit (Desk 3) because she takes care of home care people but then came in the next day positive. A review of the entry screening log dated 11/12/2020 revealed: Staff Name: (CNA B), Staff - Do you work at another facility (Yes/No) If Yes, follow legend below: N (No) .Do you have any of the following: Fever, new onset cough, new onset shortness of breath or difficult breathing, chills, muscle or body aches, headache, sore throat, new loss of taste/smell, repeated shaking with chills, congestion/runny nose, nausea/vomiting/diarrhea, new production of sputum, or hemoptysis? Y/N, Any YES must have supervisor review: sore throat, stuffy nose, diarrhea (sic) (Y/N was not written but these symptoms were written in) .Screener signature: (Business Office Manager) .Note - Symptomatic employees should put on a mask clock out and contact Infection Preventionist/DON/RDC immediately. On 12/1/20 at 3:52 PM, the ICP was queried regarding staff experiencing symptoms of illness and working with residents. The ICP indicated she would not expect staff to be working with residents if they are not feeling well. On 12/1/20 at 4:02 PM, the DON approached regarding the earlier conversation about CNA B and screening symptoms. The DON stated that the Business Office Manager screened CNA B with symptoms and let her back into the building, where she punched in. The DON stated that they did an education with their entire staff about not entering the building with signs and symptoms and that this was discussed with the Office Manager. On 12/2/20 at 9:00 AM, the Business Office Manager was queried regarding screening CNA B for COVID-19 symptoms on 11/12/20. The Office Manager stated, Yes, I did screen her on 11/12, that was the last day she worked. She wasn't back there too long but when I did screen her for symptoms I had her go back to get tested , I hadn't been told to do anything different at that point, just made sure she had a mask and goggles on. On 12/2/20 at 12:10 PM, the NHA was interviewed and queried regarding the outbreak of COVID-19 in the facility, specifically regarding the outbreak that happened on the dementia unit. The NHA responded, I think that's what we recognized on the screening log, we did recognize the issue. Would not have expected staff with symptoms to go back to a care area. When queried regarding how the outbreak started in Desk 3, followed by an outbreak on the dementia unit, the NHA stated, We weren't really sure how it got back there, just knew exactly when it happened to isolate and do everything we can to prevent further spread. We recognized on 11/13 what happened and started (educating staff). The NHA indicated they have been doing drive-thru testing of staff with symptoms ever since and stated, We had two drive-thru testing's today for symptomatic staff. The staff that came through today were on the (dementia) unit prior to the residents being moved to Desk 3. I would say they were on (the dementia unit) around the time when the outbreak was starting there. A review of the facility's policy/procedure titled, Coronavirus Surveillance, reviewed/revised: 8/13/2020, revealed, Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents. Screening for visitors and staff: a. Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptoms of Coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell, fatigue, congestion or runny nose, nausea or vomiting, diarrhea) .Staff who have signs and symptoms of a respiratory infection shall not report to work . IJ Abatement Resident 510 was tested on ,[DATE] and 11-16 after possible exposure from an employee on 11-12 to which resident 510 was negative. Resident 510 was also tested on ,[DATE] as part of routine testing and resulted negative. However, three residents residing in the same unit as resident 510 tested positive for COVID at this time. Due to this we tested remaining residents on this unit for a second time of the week on 11-26. This is when Resident 510 tested positive for COVID. Resident 510 was not showing signs and symptoms of COVID at the time she tested positive. Upon testing positive, Resident 510 was moved to our F wing which is designated for COVID+ residents and placed in isolation. There was 6 COVID+ residents on F wing the day resident 510 was moved there. Upon testing positive, resident 510 had temperature, Spo2 sat%, and respirations checked every 4 hours. All residents are monitored for COVID signs and symptoms by licensed nurses. Residents are tested weekly. Residents who display symptoms or test positive, physicians will be notified immediately and physician's orders [REDACTED]. Staff who are symptomatic will call the facility in advance so they can participate in drive through testing in front of the building. All screener sheets will be viewed daily by the ICP/designee. All screener sheets will be reviewed weekly by DON/Designee.

This citation pertains to intake # 1. Based on observation, interview and record review, the facility failed to implement effective interventions to prevent exit seeking behaviors, adequately supervise one resident (Resident #701) with a known history of exit seeking behavior, of three residents reviewed for exit seeking behaviors, and respond to two alarming doors resulting in, Resident #701 displaying exit seeking behavior on 09/15/2020 at 2:16 AM. At 03:02 AM, the staff were alerted the resident was outside, whom was found by a pharmacy delivery person, laying on the ground next to the facility van. Resident #701 had kicked out the screen of their window, walked around the building, entered through an unlocked alarmed door (entering a hallway in between the hospital and facility), walked across the hallway and out another unlocked alarmed door, to the parking lot in front of the building. The temperature was around 49 degrees Fahrenheit (per accuweather.com). Findings include: The Immediate Jeopardy (IJ) started on 09/15/2020 and was identified on 10/01/2020. The Administrator was notified of the Immediate Jeopardy on 10/01/2020 at 01:42 PM and was asked for a plan to remove the immediacy. The IJ was removed on 10/02/2020, based on the facility's implementation of the removal plan as verified onsite on 10/02/2020. Although the immediacy was removed, the facility's deficient practice remained isolated with actual harm that is not immediate jeopardy. On 10/01/2020 at 08:15 AM, Resident #701 was observed in bed, dressed and groomed. Per Certified Educated Nurse Assistant (CENA/CNA) D, Resident #701 was not a one on one supervision (1:1) anymore but they try to tend to [Resident #701] often. CENA D did explain that Resident #701 does get combative with other residents and staff. Resident #701 was queried about exiting the building. Resident #701 was reluctant to answer any questions and denied exiting the building. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 had a Brief Interview for Mental Status (BIMS) score of 05, indicating a severe cognitive impairment. The MDS also revealed that Resident #701 was admitted to the facility on [DATE] with the diagnoses of Dementia with Behavior Disturbance and [CONDITION(S)]. Resident #701 needed supervision with transfers and ambulation and was noted to have wandering behavior. A record review of the Progress Notes for Resident #701 revealed the following: 2/29/2020 23:06 (11:06 PM) .Behavior Note .increased confusion and agitation tonight. resident repeatedly asking to go to (their) room. staff walk resident to room and resident becomes upset, states it is not (their) room. resident walks back to common area and repeatedly states 'why are you keeping me here' 'what are you getting out of this' 'let me go upstairs' 'why cant i go to my room' staff takes resident to room and shows (them) clothes and (their) name on the door. resident refuses to go in room and yells at staff to let (them) go. resident reminded (they) moved here last week and (their) sons come to visit (them). resident yells 'Bulls**t' unable to redirect or console resident. Precipitating factors/events: resident asking for (their)room Intervention(s) attempted: re orientate, re-direct Intervention results: unsuccessful Pharmacologic Intervention required: no PRNs (as needed medications) . 3/2/2020 00:06 (12:06 AM) .Behavior .Note .Resident very aggressive on 3/2. Resident presented with same behaviors from original report. Resident increased confusion and agitation at night. Resident repeatedly approaching staff aggressively and stating, 'why are you keeping me here.' Resident tried to hit staff several times. Staff stepped away from resident to diffuse situations. Resident was re-oriented, and distracted. Resident charged at staff members about 15 times from 2300 (11:00 PM) till resident went to bed at 230 am. Resident attempted to leave unit saying 'you cant force me to stay here.' Resident stated, 'im exhausted how much longer are you going to keep me here.' This nurse stated, 'would you like to lay down.' Resident responded, 'yes.' Resident walked aggressively behind staff as staff directed (them) to (their) room. After arriving in (their) room resident sat on bed. Resident was asked if (they) wanted the light turned off (they) responded 'your a bunch of a**holes.' Residents bathroom door was left open with light on and room door was closed. Resident had no behaviors following going to bed. 3/7/2020 00:03 (12:03 AM) .Behavior Note .Resident continuing to ask staff, 'when will you let me go.' Resident was aggressive and attempting to leave applewood unit. Resident re-oriented to situation and where (they were). Resident then asked finally asked to go to (their) bed. 3/10/2020 10:07 (AM) SOC (Standard Of Care) .Behavior displayed: Physical aggression towards staff when they attempted to provide care Attempted to elope History of behaviors: No Interventions attempted: Redirection Interventions successful/unsuccessful: Successful Intervention revision: None Pharmacologic intervention required: NA (not applicable) 3/12/2020 02:22 (AM) .Behavior Displayed: increased confusion. exit seeking behaviors. stating (Resident #701) needs to go home, (Resident #701) needs to leave. resident reminded (they) need to wait for sons and they are safe here for the night. yelling at staff to let (them) leave. unable to redirect resident. Precipitating factors/events: none. Intervention(s) attempted: attempted to redirect and reassure resident Intervention results: unsuccessful Pharmacologic Intervention required: n/a 3/14/2020 00:03 (12:03 AM) .Behavior Note .resident showing exit seeking behaviors. stating (Resident #701) needs to go. let me leave. let me out. asking repetitive questions. yelling at staff 3/15/2020 00:00 (12:00 AM) .Behavior Note .more confused at night. insists on going home or leaving. makes repetitive statements. unable to redirect 3/31/2020 04:31 (AM) .Behavior Displayed: Resident was exhibiting exiting behavior. Resident said (they) need to leave. Resident was re-directed several times. Resident was told (they) needed to wait till morning for (their) son and (they were) was safe. The resident then hit staff members . 3/31/2020 10:19 (AM) SOC .Behavior displayed: Resident is requesting to leave the facility. Continues to show aggression at times as well History of behaviors: Yes Interventions attempted: Redirection Interventions successful/unsuccessful: Successful overall, but behaviors continue at times 4/1/2020 00:31 (12:31 AM) .Behavior Note .Resident aggressive towards staff about going home. Resident was shown where (their) room was and (they) could call (their) son. Resident began yelling at staff 4/14/2020 10:19 (AM) SOC- .Behavior displayed: Wandering and some aggression Resident had some aggression ie pinching and scratching over the last few days . 7/6/2020 00:15 (12:15 AM) .Behavior Displayed: Resident is attempting to elope off the unit repeatedly. When staff is stopping the resident from wandering around the building the resident is grabbing the staff and punching and slapping them. Resident is name calling and pushing staff to get through them to every door on the unit Intervention(s) attempted: Distract resident from trying to leave with food and television and called for IM (Intramuscular Injection) [MEDICATION(S)] (antianxiety medication) . 7/9/2020 22:15 (10:15 PM) .Behavior Note .resident has been pacing the floors this shift and during HS (hour of sleep) .repeatedly asks to take (them) home, very confused, became violent with CENA grabbing her by the arms and scratching her, note in Dr (Doctor) book to address anxiety . 7/28/2020 18:23 (06:23 PM) .Behavior Displayed: Resident asking to leave and exiting through alarmed doors most of the day shift. Resident grabbed another resident's hand and attempted to pull them down the hallway with (them), CNA attempted to redirect resident and resident began grabbing and scratching her arms drawing blood. Resident attempted to enter another resident's where a different CNA was, CNA tried to redirect resident toward the front lounge area and resident grabbed her arms and began scratching and pinching her, again drawing blood. Precipitating factors/events: Resident is very confused and 'wants to go home with (their) mother and father'. Intervention(s) attempted: Redirection Intervention results: unsuccessful Pharmacologic Intervention required: Administered po (by mouth) [MEDICATION(S)] as ordered Comments: Resident still attempting to leave unit and asking repeatedly if (they) can go home with (their) parents. 7/29/2020 03:18 (AM) Pertinent Charting-Behavior Note .Resident has been pacing the floors this shift and during HS .repeatedly asks to go .home, very confused, repeatedly asking to call (their) mother and becoming angry about it 8/1/2020 16:00 (04:00 PM) .Behavior Note .Resident repeatedly asks to call (their) mother and asks if (they) can go home. Resident continues to be combative with staff and other residents. Resident redirected multiple times. Administered [MEDICATION(S)] 2 times this shift, very little change in behavior 8/2/2020 00:00 (12:00 AM) .Behavior Note .Resident aimlessly walked up and down the hall the first hour of the shift repeating, 'I would like to call my mother, what should I tell (them)?'. Resident attempted to elope once but did not walk through the second doors to exit outside. 8/17/2020 11:31 (AM) NP/PA (Nurse Practitioner/Physician Assistant) Progress Note .Nursing reports patient is restless patient frequently pacing unit and has tendency to be combative with staff and other residents . 8/20/2020 10:46 (AM) Nurses .Note .Resident still having wondering (sic) behavior. (Resident #701) wants to go home, (they are) constantly exit seeking, (they get) aggressive with staff. (Resident #701) sometimes rummages in rooms in others belongings. (Resident #701) believes (they own) the facility and will insist that the staff and people leave .Very difficult to redirect, resident is not interested in activities such as coloring, listening to music or watching a show. 8/21/2020 22:45 (10:45 PM) Nursing Evaluation .Resident anxiety was increased but resident still exit seeks, wants to call home, wants to go home, gets combative when staff try to keep resident from leaving. 9/1/2020 17:29 (5:29 PM) Nurses' Note .Resident frequently attempting to leave unit and becomes aggressive with staff with attempting to redirect. Resident very difficult to redirect. Routine [MEDICATION(S)] (antianxiety medication) given as ordered with no effect on residents exit seeking behavior or aggressive behavior with staff. Will monitor. 9/3/2020 14:29 (2:29 PM) Nurses' Note .Resident getting aggressive with staff when trying to redirect (them) when (they are) exit seeking. The 2 staff members are very calm with (Resident #701) and try to redirect (them) from leaving, but resident is trying to hit them so (Resident #701) can leave and go home. (Resident #701) receives schd (scheduled) anxiety medication. 9/10/2020 12:22 (PM) Transcribed Psychiatric Note . Complaint: behavioral distress, hard to direct when goal directed, becomes aggressive, exit seeking .Pt. (patient) mostly becoming physically aggressive once (they) wander and becomes goal directed, confused or disoriented, sometimes unable to redirect .often seeking to exit the unit, sometimes easily redirected but can become physically aggressive and unable to redirect other times. Pt. aggressive with another peer two days ago. These pattern of behavioral distress prompted referral for evaluation and behavior management consult . 9/13/2020 17:05 (5:05 PM) .Behavior Note .Resident roaming hallways, attempted to exit door to outside on a few occasions this shift. Resident scratched CNA (CENA), who was attempting to care for (them), on the arm. Will continue to monitor. 9/15/2020 02:16 (AM) .Behavior Displayed: aggressive towards staff, attempting to leave building Precipitating factors/events: unknown, possible from medication changed, intervention(s) attempted: re-direction, distraction, tv, food, drink intervention results: unsuccessful Pharmacologic Intervention required: IM [MEDICATION(S)] 1 mg (milligram) prn ordered [MEDICATION(S)] 1 mg q (every) 6 hour scheduled 9/15/2020 02:17 (AM) Nurses' Note .Resident was very aggressive and wanting to leave. when attempting to re-direct (Resident #701) to room. Resident has attempted leaving the exterior doors several times. Resident was re-directed by multiple staff members. Aggressive behaviors continued after redirection to room. This resident scratched this writer on both extremities. Then resident began slamming room door open and closed. 9/15/2020 02:20 (AM) Nurses' Note .This writer (Licensed Practical Nurse/LPN A) and another nurse [Registered Nurse (RN) B] were sitting in hallway watching for resident to come out of room 9/15/2020 03:02 (AM) .Behavior Note .This nurse (LPN A) was alerted that this resident was possibly outside. This resident was outside and brought back to the building . 9/15/2020 03:45 (AM) Nurses' Note .This writer (LPN A) was notified at 0302 (AM) that a possible resident was outside. This writer observed resident was missing from room and screen busted. Residents room was the last known location of resident at about 0230 (AM)when support staff had checked on (them) This writer then alerted support staff of situation. This is when the team proceeded to search property. Resident was found on property laying down by bus. Resident was assessed by this writer .redness on right calf, no signs or symptoms of injury, no complaints of pain . 9/15/2020 11:32 (AM) IDT (Interdisciplinary Team) .Note .resident discussed following increased aggression where resident became physically aggressive with staff and eloping out of the building. Resident has been placed on a 1:1 and SW (Social Worker) to contact psych services to have resident evaluated ASAP (as soon as possible) 9/18/2020 00:37 (12:37 AM) .Behavior Note .resident wondering (sic) up and down hallway. no 1:1 staffed for resident. staff redirecting resident away from doors 9/18/2020 01:02 (AM) Nurses' Note .resident wondering (sic) up and down halls, saying 'she told me she would take me home' repeatedly. staff attempted to redirect, unsuccessful. resident becoming irritated with staff. no 1:1 scheduled for resident this shift. 9/18/2020 12:23 (PM) Transcribed Psychiatric Note .Pt. with a history of physical aggressiveness, scratching staff when redirected from something (Resident #701) wants to do. Pt without a history of paranoid [CONDITION(S)], mostly exit seeking and missing home .--Pt. found to have eloped through the window of (their) room, found outside the building unharmed three days ago, and currently on 1:1 . Patient's Response to Interventions: Pt. without signs of increased anxiety or depression since .eloped the building. No increased exit seeking behaviors noted or reported by the team today. Pt. responding well (without physical aggressiveness) to supportive interventions, only guided and redirected when Pt. unsafe, otherwise, close monitoring and active anticipation of needs. If exit seeking from unit, Pt. guided to walk around the halls inside the facility, which helps (them) calm down. Continue supportive and operant interventions, with the goal of decreasing anxiety, confusion, and preventing aggression, including: 1. if Pt. already agitated, goal directed, please use de-escalating interventions -first meet Pt. where (they are) at emotionally and take time to help (them) feel safe before distracting or redirecting. 2. If Pt. insist on exiting the unit, take Pt. for a walk outside the unit, walk with (them) together and engage (them) in a casual/meaningful but easy to understand conversation. 3. Continue to explore possible triggers leading to increased wandering and anxiety, such as loneliness, boredom, increased confusion. 4. When Pt. asking for mom, even after (they) make calls, continue to help cope with loneliness and help Pt. engage socially. 5. Due to adjustment d/o (disorder); anxiety likely increased/triggered when coping skills overwhelmed by social, emotional, environmental stressors or difficulties understanding/processing information. Adjustment disorder with anxiety [F43.22] (unchanged)Plan: [MEDICATION(S)] as prescribed . 9/20/2020 05:34 (AM) .Behavior Note .Resident has not slept yet tonight. Resident wandering unit with 1:1 staff member . 9/20/2020 13:24 (1:24 PM) .Behavior Note .Resident not exhibiting any aggressive behavior, but .does seem to be wanting the 1:1 .Writer informed 1:1 to try not to take (Resident #701) for walks off the unit, writer concerned that resident will constantly exit seek since if we take (Resident #701) off the unit and walk. 9/23/2020 16:24 (04:24 PM) .Behavior Note .1:1 sitter discontinued. Resident up wandering halls asking if we have called (their) parents to pick (them) up. 9/25/2020 15:46 (03:46 PM) Nurses' Note .Resident attempting to exit unit multiple times this afternoon. Attacking CNA's and nurse. IM [MEDICATION(S)] administered without any effect. Resident still continues to leave unit and grab/scratch/hit staff. 9/25/2020 15:49 (03:49 PM) .Behavior Note .Resident repeatedly exiting unit from various different doors. Resident is unable to be redirected. Attempted a snack, a drink, a walk with staff, po scheduled [MEDICATION(S)] ([MEDICATION(S)]) and IM [MEDICATION(S)] have had no effect on resident. Resident continues to grab/hit/scratch staff. Resident's 1:1 sitter discontinued 9/23/20. 9/29/2020 14:14 (02:14 PM) SOC .Behavior displayed: Resident has a history of elopement and physical aggression History of behaviors: Yes Interventions attempted: Redirect and 1:1 Interventions successful/unsuccessful: Successful Intervention revision: 1:1 Pharmacologic intervention required: [MEDICATION(S)] .Referrals needed: Psych Comments: Remove 1:1, no behaviors in 2 weeks. Remove from SOC 9/29/2020 20:03 (08:03 PM) .Behavior Note: Exit seeking behavior, yelling at staff stating, 'I need to leave.' Precipitating factors/events: unknown Intervention(s) attempted: reassurance, distracted, attempted to give activity in room with wordsearchs Intervention results: unsuccessful . A record review of the Risk of Elopement/Wandering Review dated 09/15/2020 revealed that Resident #701 was at risk for eloping. There were no other elopement or wandering reviews located in the electronic medical record (EMR) for Resident #701. A review of the Care Plan for Resident #701 revealed the following: Focus: The resident has a history of elopement from the facility Date Initiated: 08/10/2020 Revision on: 09/15/2020 Goals: The resident's safety will be maintained through the review date. The resident will not exit the facility or enter an unsafe area unattended through the review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Reassure (them) that (their) Mother knows where (they are) (Initiated: 08/10/2020) Maintain consistent daily routine and consistent bedtime routine (Initiated: 08/10/2020) Observe for acute process which may increase wandering (Initiated: 08/10/2020) There were no other interventions listed. On 10/01/2020 at 10:23 AM, the Nursing Home Administrator (NHA) was interviewed and asked to walk this Surveyor through Resident #701's elopement from 09/15/2020. The NHA explained that she received a call from the facility around 03:30 AM on 09/15/2020 confirming that Resident #701 had eloped from the building. While in Resident #701's room, the NHA described that Resident #701 had opened their window, exposing the screen, and kicked the screen out. Resident #701 was then able to exit their room through the window. Resident #701 then walked around the back of the building, walked through an alarmed, unlocked door that entered into a hallway that was in between the hospital and nursing home. At this time, the NHA and this Surveyor traced Resident #701's steps and were now located in that hallway. Once entering the hallway, the door alarm had sounded, the NHA entered a code to silence the door alarm. The NHA was asked if the nursing facility staff were responsible for this doorway, and stated, Yes, this is ours (part of the building). The NHA then exited out an unlocked alarmed door that was across from the door that Resident #701 had entered. That door alarmed, the NHA punched in a code to silence the alarm. The NHA then pointed towards a parking lot in the front of the building and explained that the resident was found there. The NHA was asked if the facility staff had responded to the alarms that had sounded and stated that they had not done so appropriately. The NHA was asked who had found Resident #701 and had explained that pharmacy had come to deliver medications and had seen Resident #701 lying on the ground next to the facility van and reported it to the staff. On 10/01/2020 at 12:00 PM, Resident #701 was observed lying in bed in a different resident's room/bed. RN C was queried in regard to Resident #701's typical behavior. RN C explained that she had worked with Resident #701 regularly and was very familiar with their behavior patterns. RN C explained that Resident #701's behavior was tense but had improved during the day shift. RN C explained that Resident #701 frequently wanders the halls and will sleep in other resident's rooms. RN C, stated, That is just my shift (07:00AM-07:00PM). RN C explained that the other shift (07:00 PM-07:00 AM) had more issues with Resident #701. RN C stated, [Resident #701] used to walk a lot and misses going outside. When they (Resident #701) played that disappearing act (elopement on 09/15/2020), they weren't allowed to go outside. These guys (residents located on the locked unit) need a closed courtyard to go in. [Resident #701] told me when I asked them when the last time they were outside was, they said that it had been five years that they had been outside, it's sad. On 10/01/2020 at 12:46 PM, an interview was attempted via phone with LPN A. A voicemail message was left. There was no return phone call by the end of the survey. On 10/01/2020 at 12:47 PM, an interview was attempted via phone with RN B. A voicemail message was left. There was no return phone call by the end of the survey. On 10/02/2020 at 08:34 AM, Resident #701 was observed awake, lying in bed dressed and groomed. There was a 1:1 sitter placed in the Resident's room for supervision. On 10/02/2020 at 10:13 AM, an interview was completed with Social Worker (SW) E. SW E was questioned about the management of exit seeking behaviors of residents. SW E explained that she was not usually the SW to follow Resident #701 and that the SW who had been following the resident and running the behavior management meetings was no longer employed at the facility. SW E stated, I just took over the long term care, the other social worker's last day was Wednesday. Right now we have (Resident #701) on 1:1. We are trying to get a pattern and have noticed in the evening (Resident #701 had increased behaviors) they must have some sundowners (a syndrome involving a pattern of agitation, delusions, fear, sadness and hallucinations that occurs in dementia patients in the late afternoon, evening and at night). They want to talk to their family. I was just in there this morning and (Resident #701) said that they had a tummy ache and (Resident #701) said it is making them want to go out the window. SW E was asked what interventions were being utilized to calm Resident #701's exit seeking behavior and stated, Distraction, what we found is when staff redirect them, (Resident #701) gets aggressive and will swat or hit at them. (Resident #701) likes 1:1. On 10/02/2020 at 10:46 AM, the Director of Nursing (DON) was interviewed in regard to the exit seeking behaviors of Resident #701. The DON explained that she had recently taken over the DON position this week and was the interim. The DON was asked what interventions are being used to prevent Resident #701 from exiting the facility. The DON stated, (Resident #701) really wasn't a problem until recent days. We did a sitter. They seem good with a sitter. The DON was asked why the sitter had been discontinued if it was effective. The DON stated, They (the nurses) charted no behaviors (while on 1:1). They (Resident #701) seemed to calm down. So, we discontinued it. We try to have extra staff down there (the locked unit). (Resident #701) needs to be redirected, they get up with no warning and has a one track mind. They offer them snacks and stuff. The DON also stated, I know we were doing education and elopement training (with staff). We do elopement drills. On 10/02/2020 at 02:01 PM, the NHA was interviewed in regard to the exit seeking behaviors of Resident #701 and how the IDT handles those residents. The NHA stated, During the SOC, we review any interventions that are in place and add some if we need to. If for two weeks, if the interventions are not effective, we add some. I've only been here for three weeks, so I can't confirm if [Resident #701] was part of the meetings. The NHA was then asked about the elopement of Resident #701. The NHA was asked why the staff did not answer the alarming doors that Resident #701 had exited on 09/15/2020 and stated, Basically they (the staff) didn't follow the protocol thoroughly, when the alarms went off, they assumed that because the wing was empty, that no one got out. That is not what they were supposed to do. They were supposed to look around and check the residents to make sure no one was missing. A review of the facility policy titled, Unsafe Wandering & Elopement Prevention Protocol Missing Resident Protocol revised September 2016 revealed the following: Policy Statement-Every effort will be made to prevent unsafe wandering and elopement episodes .Nursing personnel must report and investigate all reports of missing residents. Policy Interpretation and Implementation-1. All residents who are at risk for harm because of unsafe wandering will be assessed by the interdisciplinary care planning team. 2. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan .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, per the missing person/s protocol. Reporting Practices-1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the licensed nurse in charge as soon as practical . IJ Abatement Plan - F689 Removal of Immediate Jeopardy Re: Resident Outside Unaccompanied. Immediate Facility Action: F689 Elopement Resident # 701 has been re-assessed for elopement risk and the care plan has been reviewed and revised by the DON on 10-2-20 * Purchased new safety locks were placed on all resident room windows in the facility * Resident #701 will have an activity plan formulated to meet resident's needs * Resident #701 will be placed on a 1:1 supervision for 7 days. IDT will assess the need for a 1:1 supervision after 7 days. 1:1 supervision will be removed if deemed appropriate by IDT team. * All door alarms were checked and are in working order * Staff will be educated on identifying behaviors that trigger elopement, need for immediate intervention and to notify the Administrator, Director of Nursing of the behaviors.

This citation pertains to intake # 3. Based on observation, interview and record review, the facility failed to effectively address and prevent repeated aggressive, physical behaviors for one resident (Resident #701) of three residents reviewed for behaviors resulting in Resident #701 being in a frequent state of anger and despair, causing physical aggression towards other residents and staff, and the likelihood of continued physical injury or harm to self and others. Findings include: The Immediate Jeopardy (IJ) started on 06/17/2020 and was identified on 10/01/2020. The Administrator was notified of the Immediate Jeopardy on 10/01/2020 at 01:42 PM and was asked for a plan to remove the immediacy. The IJ was removed on 10/02/2020, based on the facility's implementation of the removal plan as verified onsite on 10/02/2020. Although the immediacy was removed, the facility's deficient practice remained isolated with actual harm that is not immediate jeopardy. On 10/01/2020 at 08:15 AM, Resident #701 was observed in bed, dressed, and groomed. Per Certified Educated Nurse Assistant (CENA/CNA) D, Resident #701 was not a one on one supervision (1:1) anymore but they try to tend to [Resident #701] often. CENA D did explain that Resident #701 does get combative with other residents and staff. Resident #701 was queried about hitting other residents. Resident #701 was reluctant to answer any questions and denied being involved in any physical altercations. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 had a Brief Interview for Mental Status (BIMS) score of 05, indicating a severe cognitive impairment. The MDS also revealed that Resident #701 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #701 needed supervision with transfers and ambulation. A record review of the Progress Notes for Resident #701 revealed the following: 2/29/2020 23:06 (11:06 PM) .Behavior Displayed: increased confusion and agitation tonight. resident repeatedly asking to go to (their) room. staff walk resident to room and resident becomes upset, states it is not (their) room. resident walks back to common area and repeatedly states 'why are you keeping me here' 'what are you getting out of this' 'let me go upstairs' 'why cant i go to my room' staff takes resident to room and shows (them their) clothes and (their) name on the door. resident refuses to go in room and yells at staff to let (them) go. resident reminded (they) moved here last week and (their) sons come to visit (them). resident yells 'Bullsh*t' unable to redirect or console resident. Precipitating factors/events: resident asking for (their) room Intervention(s) attempted: re orientate, re-direct Intervention results: unsuccessful Pharmacologic Intervention required: no PRNs .(as needed medications) 3/2/2020 00:06 (12:06 AM) .Behavior Note .Resident very aggressive on 3/2. Resident presented with same behaviors from original report. Resident increased confusion and agitation at night. Resident repeatedly approaching staff aggressively and stating, 'why are you keeping me here.' Resident tried to hit staff several times. Staff stepped away from resident to diffuse situations. Resident was re-oriented, and distracted. Resident charged at staff members about 15 times from 2300 (11:00 PM) till resident went to bed at 230 am. Resident attempted to leave unit saying 'you cant force me to stay here.' Resident stated, 'im exhausted how much longer are you going to keep me here.' This nurse stated, 'would you like to lay down.' Resident responded, 'yes.' Resident walked aggressively behind staff as staff directed (them) to (their) room. After arriving in (their) room resident sat on bed. Resident was asked if (they) wanted the light turned off (Resident #701) responded 'your a bunch of a**holes.' Residents bathroom door was left open with light on and room door was closed. Resident had no behaviors following going to bed. 3/5/2020 10:27 (AM) IDT (Interdisciplinary Team) Progress Note .Reported that resident is verbally aggressive ie swearing, physically aggressive ie hitting, and threatening staff when they are attempting to provide care. No interventions noted. SW (Social Worker) updated target behaviors and care plan to include aggression and verbal threats. 3/6/2020 10:29 (AM) NP/PA (Nurse Practitioner/Physician Assistant) Progress Note . F/U (follow up) with PsychF/U with Neurology Monitor patient behaviors Redirect and reorient to environment as needed Medications reviewed . 3/7/2020 00:03 (12:03 AM) .Behavior Note .Resident continuing to ask staff, 'when will you let me go.' Resident was aggressive and attempting to leave applewood unit. Resident re-oriented to situation and where (Resident #701) was. Resident then asked finally asked to go to .bed. 3/10/2020 10:07 (AM) SOC (standard of care) Behavior Displayed .Physical aggression towards staff when they attempted to provide care Attempted to elope History of behaviors: No Interventions attempted: Redirection Interventions successful/unsuccessful: Successful Intervention revision: None 3/12/2020 02:22 (AM) .Behavior Displayed: increased confusion. exit seeking behavior .yelling at staff to let (them) leave. unable to redirect resident. Precipitating factors/events: none. Intervention(s) attempted: attempted to redirect and reassure resident Intervention results: unsuccessful Pharmacologic Intervention required: n/a 3/15/2020 00:00 (12:00 AM) .Behavior Note .more confused at night. insists on going home or leaving. makes repetitive statements. unable to redirect 3/19/2020 06:33 (AM) SOC .Behavior displayed: Resident continues to show both physical and verbal aggression towards staff when they provide care History of behaviors: Yes . 3/24/2020 10:28 (AM) SOC .Behavior displayed: Resident continues to show physical and verbal aggression History of behaviors: Yes . 3/31/2020 04:31 (AM) .Behavior Note .Resident was exhibiting exiting behavior. Resident said (Resident #701) needs to leave. Resident was re-directed several times The resident then hit staff members . 3/31/2020 10:19 (AM) SOC-Behavior Note .Resident is requesting to leave the facility. Continues to show aggression at times as well History of behaviors: Yes Interventions attempted: Redirection Interventions successful/unsuccessful: Successful overall, but behaviors continue at times 4/1/2020 00:31 (12:31 AM) .Behavior Note .Resident aggressive towards staff about going home yelling at staff 04/07/2020 NP/PA (Nurse Practitioner/Physician Assistant) .PLAN: Nursing reports no acute changes in patient condition,F/U with Psych F/U with Neurology Monitor patient behaviors Redirect and reorient to environment as needed Medications reviewed 4/14/2020 10:19 (AM) SOC .Behavior displayed: Wandering and some aggression Resident had some aggression ie pinching and scratching over the last few days . 4/20/2020 15:36 (3:36 PM) .Behavior Note .resident kicked other residents hand while laying on the couch 4/21/2020 12:10 (PM) SOC .Behavior displayed: Resident became aggressive with peers and began kicking them while (Resident #701) was lying on the couch on the unit . 05/14/2020 NP/PA Progress Note .Nursing reports no acute changes in patient condition, F/U with Psych F/U with Neurology Monitor patient behaviors Redirect and reorient to environment as needed Continue with supportive measures 06/10/2020 NP/PA Progress Note .Nursing reports patient at times becoming aggressive towards other residents, patient frequently wanders into other residents rooms. Patient sitting in room appropriate for exam, confused per baseline .PLAN: F/U with Psych F/U with Neurology Monitor patient behaviors Redirect and reorient to environment as needed. 06/16/2020 NP/PA Progress Note .Nursing reports patient is restless patient frequently wanders into other residents rooms .PLAN: F/U with Psych F/U with Neurology Monitor patient behaviors Redirect and reorient to environment as needed . 6/17/2020 14:35 (2:35 PM) .Behavior Note .Resident grabbed another resident by the arm causing bruising and scratches on her L (left) wrist & FA (forearm) . 07/01/2020 .NP/PA Progress Note .Nursing reports patient is restless patient frequently wanders into other residents room .PLAN: F/U with Psych F/U with NeurologyMonitor patient behaviors Redirect and reorient to environment as needed Continue with supportive measures . 7/6/2020 00:15 (12:15 AM) .Behavior Displayed: Resident is attempting to elope off the unit repeatedly. When staff is stopping the resident from wandering around the building the resident is grabbing the staff and punching and slapping them. Resident is name calling and pushing staff to get through them to every door on the unit Intervention(s) attempted: Distract resident from trying to leave with food and television and called for IM (intramuscular injection) [MEDICATION(S)] (an antianxiety medication) . 7/9/2020 22:15 (10:15 AM) .Behavior Note .resident has been pacing the floors this shift and during HS (hour of sleep) .very confused, became violent with CENA grabbing her by the arms and scratching her, note in Dr (doctor) book to address anxiety . 7/10/2020 11:27 AM psychiatric note- .wrote an order .to evaluate the patient for dementia and anxiety and to assess .current [CONDITION(S)] regimen for efficacy, necessity and side effects. The patient presents to this facility receiving [MEDICATION(S)] (medication used to slow the progression of Dementia) 10 mg (milligrams) daily and [MEDICATION(S)] 1 mg every 6 hours as needed. Patient is found to be sitting on a couch today .very pleasant during the day; however .can get somewhat upset at night and will hit out at staff .very combative and need redirecting .(Resident #701) is not necessarily sleeping well because at night (they get) up and wanders the facility, and when (they are) redirected that is when (they get) very angry and upset. It appears that (they are) obviously looking to go home as opposed to staying there all night. Patient is difficult to redirect secondary to .advanced dementia Plan: Continue [MEDICATION(S)] 1 mg every 6 hours as needed. Disposition: Patient is having some agitation in the evening. I advised the nursing staff to continue to use the as needed [MEDICATION(S)], as it is available, and it likely will help control this patient's anxiety 7/28/2020 18:23 (08:23 PM) .Behavior Note .Resident asking to leave and exiting through alarmed doors most of the day shift. Resident grabbed another resident's hand and attempted to pull (them) down the hallway .CNA attempted to redirect resident and resident began grabbing and scratching her arms drawing blood. Resident attempted to enter another resident's room where a different CNA was, CNA tried to redirect resident toward the front lounge area and resident grabbed her arms and began scratching and pinching her, again drawing blood. Precipitating factors/events: Resident is very confused and 'wants to go home with (their) mother and father'. Intervention(s) attempted: Redirection Intervention results: unsuccessful Pharmacologic Intervention required: Administered po (by mouth) [MEDICATION(S)] as ordered Comments: Resident still attempting to leave unit and asking repeatedly if (they)can go home. 7/28/2020 18:36 (06:36 PM) Nurses' Note .Resident has exhibited extremely volatile behavior throughout the shift. PO [MEDICATION(S)] given as ordered, without any improvement. Resident continues to grab staff and scratch and pinch. Resident told nurse that (Resident #701) would 'beat my *ss'. Resident followed staff into soiled utility room grabbing garbage bag while they attempted to dispose of it. 7/29/2020 03:18 (AM) .Behavior Note .Resident has been pacing the floors this shift and during HS, (they) repeatedly asks to go .home, very confused, repeatedly asking to call .mother and becoming angry about it 8/1/2020 16:00 (04:00 PM) .Behavior Note .Resident continues to be combative with staff and other residents. Resident redirected multiple times. Administered [MEDICATION(S)] 2 times this shift, very little change in behavior. 8/2/2020 00:00 (12:00 AM) Behavior Note .Resident aimlessly walked up and down the hall the first hour of the shift repeating, 'I would like to call my mother, what should I tell her?'. Resident attempted to elope once but did not walk through the second doors to exit outside. 08/07/2020 Psychiatry Doctor Note- .the patient currently receives the following [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #701) continues to respond well to these medications for control of (their) cognition and anxiety. 08/17/2020 NP/PA Progress Note-Nursing reports patient is restless patient frequently pacing unit and has tendency to combative with staff and other residents. PLAN: F/U with PsychF/U with Neurology Monitor Behaviors Redirect and reorient to environment as needed. No new orders were prescribed. 8/20/2020 10:46 (AM) Nurses' Note .Resident still having wondering (sic) behavior .gets aggressive with staff .sometimes rummages in rooms in others belongings .Very difficult to redirect, resident is not interested in activities such as coloring, listening to music or watching a show. 8/21/2020 22:45 (10:45 PM) Nursing Evaluation Summary Note .Resident anxiety was increased but resident still exit seeks, wants to call home, wants to go home, gets combative when staff try to keep resident from leaving. 9/1/2020 17:29 (05:29 PM) Nurses' Note .Resident frequently attempting to leave unit and becomes aggressive with staff with attempting to redirect. Resident very difficult to redirect. Routine [MEDICATION(S)] given as ordered with no effect on residents exit seeking behavior or aggressive behavior with staff. Will monitor. 9/3/2020 14:29 (02:29 PM) Nurses' Note .Resident getting aggressive with staff when trying to redirect (Resident #701) .The 2 staff members are very calm with (Resident #701) and try to redirect .from leaving, but resident is trying to hit them so (they) can leave and go home .receives schd (scheduled) anxiety medication. 9/8/2020 22:30 (10:30 PM) .Behavior Note .Resident was found in another females residents room down the hallway holding the residents arms. Resident left 2 cm sized laceration on residents inner elbow. Resident was redirected to (their) room. Precipitating factors/events: Unknown. Intervention(s) attempted: Redirecting resident to .own room. Resident is continuously wandering aimlessly. Intervention results: Unsuccessful. Pharmacologic Intervention required: Scheduled [MEDICATION(S)] given at 1600 (04:00 PM). Next dose due at midnight. There is no other medications that are ordered to calm resident . 9/10/2020 12:22 (PM) Transcribed Psychiatric Note . Complaint: behavioral distress, hard to direct when goal directed, becomes aggressive, exit seeking .psych evaluation and management of [MEDICATION(S)], [MEDICATION(S)] is noted, with good response to those interventions when Pt.(patient) last evaluated August 7,2020. Pt. mostly becoming physically aggressive once .wanders and becomes goal directed, confused or disoriented, sometimes unable to redirect; often wanting to call (their) mom but able to calm down once .attempts to dial the phone and hangs up; often seeking to exit the unit, sometimes easily redirected but can become physically aggressive and unable to redirect other times. Pt. aggressive with another peer two days ago. These pattern of behavioral distress prompted referral for evaluation and behavior management consult . 1. if Pt. already agitated, goal directed, please use de-escalating interventions -first meet Pt. where .at emotionally and take time to help (them) feel safe before distracting or redirecting. 2. If Pt. insist on exiting the unit, take Pt. for a walk outside the unit, walk with (them) together and engage (them) in a casual/meaningful but easy to understand conversation. 3. Continue to explore possible triggers leading to increased wandering and anxiety, such as loneliness, boredom, increased confusion. 4. When Pt. asking for mom, even after (they) make calls, continue to help cope with loneliness and help Pt. engage socially. 5. due to adjustment d/o (disorder); anxiety likely increased/triggered when coping skills overwhelmed by social, emotional, environmental stressors or difficulties understanding/processing information. Adjustment disorder with anxiety [F43.22] (unchanged) Plan: [MEDICATION(S)] as prescribed .Pt. tending to scratch caregivers and difficult to redirect when wandering and wanting to exit the unit. Pt. more easily consoled when asking about (their) mom and wanting to call her .has been relatively stable in the last couple of days. No [CONDITION(S)] has been noted. Pt. without suicidal or homicidal ideation. Pt. requires anticipation of needs even when able to clarify and make some of (their) needs and choices known. Pt. stable to mood and appetite. IDT (Interdicsiplinary team) to continue to monitor, document behaviors and interventions attempted, refer for follow up and further evaluation as needed . 9/10/2020 22:30 (10:30 PM) .Resident was scratching and slapping CNA when CNA asked resident to follow CNA out of another residents room. Self assisted CNA in removing resident from the room and resident scratched and hit self as well. 9/12/2020 22:30 (10:30 PM) .Behavior Note .Resident was walking through unit doors and CNA took resident for a walk. On the walk resident was getting aggressive and easily agitated. CNA redirected resident to a different hall and resident swung (their) hands at CNAS face. 9/13/2020 17:05 (05:05 PM) .Behavior Note .Resident roaming hallways, attempted to exit door to outside on a few occasions this shift. Resident scratched CNA, who was attempting to care for (them), on the arm. Will continue to monitor. 9/15/2020 02:16 (AM) .Behavior Note .aggressive towards staff, attempting to leave building Precipitating factors/events: unknown, possible from medication changed intervention(s) attempted: re-direction, distraction, tv (television), food, drink intervention results: unsuccessful Pharmacologic Intervention required: IM [MEDICATION(S)] 1 mg prn ordered [MEDICATION(S)] 1 mg q (every) 6 hour scheduled 9/15/2020 02:17 (AM) Nurses' Note .Resident was very aggressive and wanting to leave .Resident has attempted leaving the exterior doors several times. Resident was re-directed by multiple staff members. Aggressive behaviors continued after redirection to room. This resident scratched this writer on both extremities. Then resident began slamming room door open and closed. 9/15/2020 03:02 (AM) .This nurse was alerted that this resident was possibly outside. This resident was outside and brought back to the building . 9/15/2020 03:45 (AM) .Nurses' Notes .This writer was notified at 0302 that a possible resident was outside. This writer observed resident was missing from room and screen busted .Resident was found on property laying down by bus. Resident was assessed by this writer .redness on right calf, no signs or symptoms of injury, no complaints of pain . 9/15/2020 11:32 (AM) IDT-Interdisciplinary Progress Note .Resident discussed following increased aggression where resident became physically aggressive with staff and eloping out of the building. Resident has been placed on a 1:1 and SW (Social Worker) to contact psych services to have resident evaluated asap (as soon as possible) 9/18/2020 01:02 (AM) Nurses' Note .resident wondering (sic) up and down halls, saying 'she told me she would take me home' repeatedly. staff attempted to redirect, unsuccessful. resident becoming irritated with staff. no 1:1 scheduled for resident this shift. 9/18/2020 12:23 (PM) Transcribed Psychiatric Note .Pt. with a history of physical aggressiveness, scratching staff when redirected from something (Resident #701) wants to do. Pt. recently scratched a peer but aggressiveness towards others is not a typical behavior documented. Pt. without a history of paranoid [CONDITION(S)], mostly exit seeking and missing home .--Pt. found to have eloped through the window of (their) room, found outside the building unharmed three days ago, and currently on 1:1 . Patient's Response to Interventions: Pt. without signs of increased anxiety or depression since .eloped the building. No increased exit seeking behaviors noted or reported by the team today. Pt. responding well (without physical aggressiveness) to supportive interventions, only guided and redirected when Pt. unsafe, otherwise, close monitoring and active anticipation of needs. If exit seeking from unit, Pt. guided to walk around the halls inside the facility, which helps (them) calm down. Continue supportive and operant interventions, with the goal of decreasing anxiety, confusion, and preventing aggression, including: 1. if Pt. already agitated, goal directed, please use de-escalating interventions -first meet Pt. where (they are) at emotionally and take time to help .feel safe before distracting or redirecting. 2. If Pt. insist on exiting the unit, take Pt. for a walk outside the unit, walk .together and engage .in a casual/meaningful but easy to understand conversation. 3. Continue to explore possible triggers leading to increased wandering and anxiety, such as loneliness, boredom, increased confusion. 4. When Pt. asking for mom, even after (they) make calls, continue to help cope with loneliness and help Pt. engage socially. 5. Due to adjustment d/o (disorder); anxiety likely increased/triggered when coping skills overwhelmed by social, emotional, environmental stressors or difficulties understanding/processing information. Adjustment disorder with anxiety [F43.22] (unchanged) Plan: [MEDICATION(S)] as prescribed . 9/20/2020 05:34 (AM) .Behavior Note .Resident has not slept yet tonight. Resident wandering unit with 1:1 staff member . 9/21/2020 00:24 (12:24 AM) .Behavior Note .Resident currently sitting in applewood corridor working on a wordsearch. Resident hasn't slept since night of 9/18/20. Dayshift reported to this writer resident did not sleep during day shift. Resident asked if (they) wanted to go to bed; resident replied 'no.' Resident currently calm and cooperative. Left note in physicians book for follow-up about not sleeping. Resident started new medication Nudexta (medication used to treat mood disorders) within past 5 days, 9/23/2020 16:24 (04:24 PM) .Behavior Note .1:1 sitter discontinued. Resident up wandering halls asking if we have called (their) parents to pick (them) up. 9/25/2020 15:46 (03:46 PM) .Nurses' Notes .Resident attempting to exit unit multiple times this afternoon. Attacking CNA's and nurse. IM [MEDICATION(S)] administered without any effect. Resident still continues to leave unit and grab/scratch/hit staff. 9/25/2020 15:49 (03:49 PM) .Behavior Note .Resident repeatedly exiting unit from various different doors. Resident is unable to be redirected. Attempted a snack, a drink, a walk with staff, po scheduled [MEDICATION(S)] ([MEDICATION(S)]) and IM [MEDICATION(S)] have had no effect on resident. Resident continues to grab/hit/scratch staff. Resident's 1:1 sitter discontinued 9/23/20. 9/29/2020 14:14 (02:14 PM) SOC .Behavior displayed: Resident has a history of elopement and physical aggression History of behaviors: Yes Interventions attempted: Redirect and 1:1 Interventions successful/unsuccessful: Successful Intervention revision: 1:1 Pharmacologic intervention required: [MEDICATION(S)] .Referrals needed: Psych Comments: Remove 1:1, no behaviors in 2 weeks. Remove from SOC 9/29/2020 20:03 (08:03 PM) .Behavior Note .Exit seeking behavior, yelling at staff stating, 'I need to leave.' Precipitating factors/events: unknown Intervention(s) attempted: reassurance, distracted, attempted to give activity in room with wordsearchs Intervention results: unsuccessful Pharmacologic Intervention required: none Comments: Resident was re-directed. On 10/01/2020 at 12:00 PM, Resident #701 was observed lying in bed in a different resident's room/bed. RN C was queried in regard to Resident #701's typical behavior. RN C explained that she had worked with Resident #701 regularly and was very familiar with their behavior patterns. RN C explained that Resident #701's behavior was tense but had improved during the day shift. RN C explained that Resident #701 frequently wanders the halls and will sleep in other resident's rooms. RN C, stated, That is just my shift (07:00 AM-07:00 PM). RN C explained that the other shift (07:00 PM-07:00 AM) had more issues (behavior) with Resident #701. On 10/01/2020 at 12:46 PM, an interview was attempted via phone with LPN A to discuss Resident #701's behavior on the 07:00 PM-07:00 AM shift. A voicemail message was left. There was no return phone call by the end of the survey. On 10/01/2020 at 12:47 PM, an interview was attempted via phone with RN B to discuss the behaviors of Resident #701 during the afternoon/midnight shift. A voicemail message was left. There was no return phone call by the end of the survey. A review of the Care Plan for Resident #701 revealed the following: Focus-The resident is physically aggressive ie hitting, kicking, and grabbing at staff and residents r/t (related to) Dementia Date Initiated: 03/05/2020 Goals-The resident will demonstrate effective coping skills Date Initiated: 03/03/2020 The resident will not harm self or others through the review date. Date Initiated: 03/05/2020 Interventions-Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/05/2020 Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 03/05/2020 Assess and address for contributing sensory deficits Date Initiated: 03/05/2020 COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 03/05/2020 Frequent checks on resident while awake and monitor .interactions with other residents Date Initiated: 09/09/2020 Give the resident as many choices as possible about care and activities. Date Initiated: 03/05/2020 Modify environment: (Adjust room temperature to comfortable level, Reduce noise, dim lights, place familiar objects in room, keep door closed etc.) Date Initiated: 06/26/2020 Monitor every shift. Document observed behavior and attempted interventions. Date Initiated: 03/05/2020 Monitor/document/report PRN any s/sx (signs and symptoms) of resident posing danger to self and/or others. Date Initiated: 06/26/2020 Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 06/26/2020 When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 06/26/2020 Resident may enjoy painting .had a special talent for this. Date Initiated: 09/09/2020 Resident may enjoy talking about .childhood and siblings .had a good childhood and likes (their) siblings. Date Initiated: 09/09/2020 On 10/02/2020 at 08:34 AM, Resident #701 was observed with a 1:1 in their room. Resident #701 was dressed and groomed engaging in a conversation with the 1:1 sitter. On 10/02/2020 at 10:13 AM, SW E was interviewed in regard to the behavior management of Resident #701. SW E explained, I just took over the long term care, the other Social Worker's last day was Wednesday. Right now we have (Resident #701) on 1:1. We are trying to get a pattern and noticed in the evening (Resident #701) must have some sundowners (a syndrome involving a pattern of agitation, delusions, fear, sadness and hallucinations that occurs in dementia patients in the late afternoon, evening and at night). (Resident #701) wants to talk to their family. I was just in there this morning and (Resident #701) said that they had a tummy ache and they said it is making (Resident #701) want to go out the window. SW E was queried in regard to what interventions were to be utilized for Resident #701's aggressive behaviors and stated, Distraction, what we found is when staff redirect them, (Resident #701) gets aggressive and will swat or hit at them. SW E was asked what staff are supposed to do if the interventions are not effective and stated, If it's safe, they are supposed to back away when they get that way. (Resident #701) likes 1:1 . SW E was queried as to why Resident #701's sleep patterns had not been comprehensively assessed and stated, (Resident #701) is currently followed by [Psychiatry Group], we would have them see the resident. SW E was asked what the facility does if the psychiatry group does not change medications, or write new orders or address concerns. SW E stated, We are supposed to have a Zoom meeting today (with the psychiatry group regarding Resident #701). If we notice or have new cases we call the main office and discuss it with them. I haven't had to do that (ever) yet, but we could ask for a different provider to look at (Resident #701). I haven't had to do this before but am for this case. I am going to talk to the person in charge. SW E was queried on how the behavior management meeting was handled within the facility and stated, I have taken on coordination of the meeting. I was an administrator, so I know how these meetings are supposed to work. We need more communication. We create a list, email it ahead of time so they (psych group) can do the chart review. The IDT comes together and will identify new behaviors. We review the interventions every two weeks, we get input from the IDT. On 10/02/2020 at 10:46 AM, an interview was completed with the Director of Nursing (DON). The DON explained that she had just taken on the roll of DON this week and that the previous DON no longer works at the facility and was more involved with Resident #701. The DON stated, (Resident #701) really wasn't a problem until recent days. We did a sitter. They seem good with a sitter, they chart no behaviors and (Resident #701) seems to calm down. We discontinued it (1:1 after elopement, because no behaviors were reported). We try to have extra staff down there (on the locked unit). We try to keep (Resident #701) separated (from other residents). You can tell when (Resident #701) is in a mood, and try to keep them occupied. We put a psych consult in. The Doctor was in yesterday. I am not sure if he seen them or not. (Resident #701) definitely could use a med (medication) review. The DON was queried on how interventions are determined to be effective and stated, We are now monitoring the task (CNA can now chart in computer in Electronic Medical Record, they could not before). We started a log (anybody who is having behaviors we add to the log. We want to see what (Resident #701's) trends are to work with [Psychiatrist]. Sounds like sundowners. The DON was asked how staff were aware of new interventions put into place for Resident #701 and stated, (Resident #701) doesn't usually have many behaviors (on day shift), but that's their shift. We try to keep continuity of care (the same staff on the unit). The staff (afternoons and midnights) have not told me any concerns (behaviors regarding Resident #701). They all have my number. The DON was asked if she made attempts to reach staff on other shifts to discuss the concerns with Resident #701 and stated, I get feed back from [the day shift CENA], her son works afternoons. No one has come up to me to discuss (Resident # 701's behavior). On 10/02/2020 at 02:01 PM, the Nur [TRUNCATED]

This citation pertains to intake 0. Based on observation, interview, and record review, the facility failed to ensure adequate supervision of a known fall-risk resident for one sampled resident (R901) of three reviewed, resulting in the resident experiencing an unwitnessed fall with fracture, pain, and subsequent hospitalization . Findings include: On 7/23/20 at 7:37 AM, Confidential Witness Z was interviewed regarding R901's care in the facility. Witness Z stated that the resident fell in the facility on 7/18/20. Witness Z explained the fall and stated, [R901] was apparently unsupervised. The unit (locked dementia unit) normally has two aides and a hall monitor to observe residents but there was no hall monitor. [Licensed Practical Nurse (LPN) A] called me to tell me she heard [R901] call out Ow and found [R901] on the floor in the dementia unit dining room. I was called at 1:44 PM and told there was a red mark, that [R901] was probably going to be getting some X-Rays. They didn't know if [R901] hit their head but they were treating it like it was a head injury. I called the hospital to see if [R901] had been sent over there and they said [R901] was not. Two hours later I called the facility and [LPN A] said that EMS (emergency medical services) was not ready for the resident before but should be ready now (to take R901 to the hospital via ambulance). I talked with the EMTs (emergency medical technicians) at the hospital and they stated [R901] was calling out in pain just driving through the parking lot and said there was an obvious fracture. I don't know why it took so long to get [R901] over there. The surgeon at the hospital said [R901] was not a candidate for surgery. [R901] broke their right pelvic bone in two places. The facility said that [R901] fell after lunch. I think [R901] was probably trying to get up to go to the bathroom because that is their routine. But there was no one in the dining room supervising even though that area is supposed to be supervised. [R901] was admitted back to the facility last night for rehab (and put on a different unit). [R901] has fallen in the facility previously, most recently in May, so they know that [R901] is a fall risk. On 7/23/20 at 9:24 AM, R901 was observed lying in bed. The resident was in a room by themselves at the end of a hallway, away from the nurses' station. The resident's mattress was observed to be concave. Upon questioning, the resident was unable to verbalize anything relating to the fall. The resident was asked to show their right arm, which was underneath the blanket, however the resident was unable to follow the request. On 7/23/20 at 9:40 AM, a tour of the locked dementia unit was conducted. Unit Manager (UM) F was present in the dining room among a couple of residents sitting at tables. When queried if the dining room was always supposed to be supervised, UM F stated, Yes. When queried regarding number of staff on the unit currently, UM F stated, We have two aides right now. At 11 AM we will have three. We like to keep three staffed. If there are two, I like to be down here to monitor and help. When queried regarding staff presence if residents are in the dining room or common areas, UM F stated, Whenever there are residents in here, there should be a staff (member). Recently, an education was circulated. We had an issue with people leaving out to do tasks and leaving the room unsupervised. Staff should be waiting for someone to come cover them (if they need to go elsewhere). The education was just to remind them. Staffing for 7/23/20 was reviewed for the dementia unit and confirmed that two Certified Nursing Assistants (CNAs) and one nurse were scheduled on the unit and one Non-Licensed Aide (NLA) was scheduled to come in at 11 AM. Staffing for 7/18/20 was reviewed for the dementia unit and confirmed that one CNA (CNA C), one NLA (NLA B), and one nurse, LPN A were scheduled for day shift. A review of R901's progress notes and relevant fall documentation revealed the following: 7/18/2020 14:38 (2:38 PM) Pertinent Charting-Falls Note Text: Date of Fall: 07/18/2020, Situation Details: Heard resident yell out ouch from dining room and found lying on back on the floor., Assessment: VS (vital signs) wnl (within normal limits), neuro check wnl, resident c/o (complaining of) right hip pain. reddened area on right hip., Mitigating Factors: resident was in dining room with one other resident, Environmental Factors: [Blank], Interventions: Staff must be in dining room at all times when residents are in there. [Physician and Responsible Party Notified], Fall packet completed, bilateral hip xray ordered. Signed by LPN A. The incident/accident (I/A) report related to this fall was reviewed and had R901's time of the fall dated as 1330 (1:30 PM). Further review revealed, Fall Summary: Found on the floor (unwitnessed) .Fall location: Dining room/day room .What was the resident doing during or just prior to fall? Attempting to stand up unassisted .What type of assistance was resident receiving at time of fall? Alone and unattended .What did the resident say they were trying to do just before the fall? Resident unable to verbalize actions - confused .What appears to be the initial root cause(s) of the fall? Resident was unattended (and) fell upon attempting to stand and ambulate (without) assistance .Describe initial interventions to prevent future falls: Staff will remain in dining room at all times when residents are present . 7/18/2020 17:36 (5:36 PM) Nurses' Notes Note Text: While at the med cart by the front couch area on [dementia unit] I heard [R901] yell out ouch. Writer and CNA immediately went into the dining room and found resident lying on [their] back on the floor next to [their] wheelchair. The wheelchair brakes were on, but resident had pushed the table away from [themselves]. One CNA was feeding another resident on [another unit] and the other CNA was returning other residents to their rooms after lunch. Resident was in the dining room with one other resident at the time of [the] fall. Assessed resident, VS wnl, neuro check wnl, reddened area on right hip. Will continue VS and Neuro checks per protocol as fall was unwitnessed. Resident c/o pain in [their] right leg. [Physician] notified, bilateral hip xray ordered. [Responsible Party] notified, [LPN D] o/c (on-call) nurse notified, [Director of Nursing (DON)] notifed (sic), [Nursing Home Administrator (NHA)] notified. Resident transferred to [hospital] radiology via stretcher by EMS. Fall packet completed, as well as pain assessment, fall risk assessment, skin assessment, and pertinent charting for new fall. Signed by LPN A. 7/18/2020 17:45 (5:45 PM) Nurses' Notes Note Text: Per [ED physician], resident has r (right) sided pelvic fracture . 7/22/2020 18:53 (6:53 PM) Nursing Evaluation Summary Note Text: resident admitted .via gurney from [hospital]. primary dx (diagnosis): right pubic/sacrum fx (fracture). RESIDENT A&Ox1 (alert and oriented to person only), call light with in reach, resident reminded to use call light . 7/23/2020 11:03 (AM) New Fall/Follow-Up: New fall on 7/18/2020, Situation (where/when/what/who): Resident was in the dining room on [dementia] unit, around 1330 after eating lunch resident attempted to stand up out of wheelchair and fell to the floor. Injury/No injury: Resident yelled ouch and has redness on right hip area, Factors involved (acute condition/environment, etc.): Memory impaired, physically impaired, decision making impaired .Analysis of interventions to implement: Resident sent to [hospital] for xray of hip area. Ensure resident is monitored at all times while in common areas .Comments: Resident found to have fracture, readmitted to facility on 7/22/2020. Therapy screened and care plan updated. A review of R901's remaining I/A reports revealed the resident had an unwitnessed fall on 5/8/20 and was found on the floor alone and unattended in their room. The I/A included the following: What appears to be the initial root cause(s) of the fall? Tripped while using walker, lost balance .Describe initial interventions to prevent future falls: Bring out to common area to monitor . On 7/23/20 at 11:08 AM, CNA C was called for interview and left a message for call back, however no call was received prior to survey exit. On 7/23/20 at 11:42 AM, NLA B was interviewed and queried regarding R901's fall on 7/18/20. NLA B indicated she did not even know R901 fell until LPN A was trying to get EMS to come get the resident. NLA B continued and stated, I must have been giving a shower or something, I didn't even know it happened. [R901] was in the dining room by [themselves]. We kept popping in to check on them sitting at the table. [Residents on the dementia unit] walk all over the place and are trying to get out of the doors it's usually pretty crazy. There were only two aides and one nurse. We had the dementia unit and the C-wing. NLA B explained the C-wing was located in the hallway outside of the locked dementia unit doors. NLA B stated, We had 4-5 residents over there, call lights go off over there and we don't even know they are going off. We were covering those residents outside of [the dementia] unit so you have to go out and go over there. When queried regarding the length of time it took to get the resident to the hospital for evaluation, NLA B stated, The other aide was being told to wheelchair [R901] down to the hospital (attached to) the facility and she had an issue with that. We had no idea what was wrong with [R901]. The nurse was really stressed out, she wasn't okay with what she was being told to do (by the on-call nurse). There was no RN (Registered Nurse) in the building at the time. When queried further regarding R901's fall, NLA B stated, [R901] was saying their hip was hurting. They have dementia. If they are saying that that means something is probably wrong. When queried if staff is supposed to be present in the dining room on the dementia unit if residents are in there, NLA B stated, Yes, the next day we had to sign something to say [that]. There's no way with the way [the facility] is staffed that we can have someone in the dining room at all times. The dining room was completely closed off on Sunday (7/19) when I worked . We can't be everywhere at once. We were popping into the dining room because [R901] seemed happy there. On 7/23/20 at 1:36 PM, LPN A was contacted and interviewed regarding R901's fall on 7/18/20. LPN A stated, It was myself and two aides working that day. It happened shortly after lunch. We had been having trouble deciding where to put everyone at for lunch. Aides were removing people from the room. [R901] was in the dining room and an aide was down the hall feeding someone. I was at the medication cart parked under the TV. I heard a yell from the dining room, 'Ouch!' and I turned around and looked. [CNA C] was nearby and we found [R901] laying on [their] back. There was another resident in the room who said [R901] had attempted to stand from their wheelchair. We both went in and looked at [R901], got them back up and into the chair. [R901] said their leg was hurting. I did an assessment, fall packet, called everyone. Initially the resident seemed okay but complained of pain. Gave Tylenol then decided [R901] needed to be seen by someone. When queried if there was any confusion or discussion on how the resident was going to be taken to be evaluated, LPN A indicated, They (facility) had just told us (staff) that they were wanting us to take residents over to [the connecting hospital] ourselves. Initially, because [R901] was sitting up in the wheelchair, the on-call nurse (LPN D) told me to take [R901] over by wheelchair. I said [R901] needed to go by gurney not wheelchair and needed authorization to send by EMS. I said I can't have both aides taking the resident by gurney, I needed an OK from [LPN D] to use EMS (for the transfer). When queried regarding the resident's pain after the fall, LPN A stated, [The resident] wasn't yelling or anything, but when we got [them] up and into the chair, mostly what [R901] was saying was 'Ow,' and, My leg, and was touching their leg - kept touching the hip. We took and laid [R901] down and did neuro checks because we didn't see the fall. When we attempted to move [R901], [they were] calling out. LPN A was asked if that was the point when she called for transport by EMS. LPN A stated, I don't know for certain but believe that was the point I called the doctor, he wanted to go ahead and get an X-Ray done. There wasn't any discussion of ER just wanted to get an X-Ray. On a Saturday afternoon, it took a while to get someone on the phone at [the hospital], and we can't just walk someone over to the hospital without getting confirmation first. When asked if the dining room is supposed to be supervised on the dementia unit if residents are present, LPN A stated, Evidently, there is someone that needs to be in that dining room if there are residents in there. I hadn't heard that before. They gave education that someone needs to be in there at all times if residents are in there. At this point, I don't have an extra staff member. With what I had it was tough, we did not have the third person. I also had the whole locked [dementia] unit, the 'Little D' unit (first four rooms on other hallway, outside of locked doors to dementia unit), 15 residents on [the dementia] unit and there were four residents on the C-wing. That was part of the problem. My second aide was over on C-wing. So what happens when I'm over on 'Little D' and an aide is on C-wing? I closed the dining room on Sunday because we only had two aides, it was the same set-up for staffing (as Saturday). I didn't have the extra person on Sunday to do the dining room. We have several wanderers on the unit. The extra person makes a huge difference. When queried if R901 was a known fall risk, LPN A stated, Yes. [R901] used to walk around on [their] own with a walker, since then has been in their wheelchair more. I think [R901] forgets they can't get up and walk anymore. On 7/23/20 at 2:30 PM, the Assistant Director of Nursing (ADON) was interviewed regarding R901's fall on 7/18/20. The ADON indicated she was not fully involved with the fall but could answer some general questions. When queried if the dining room and common areas on the dementia unit should be supervised when residents are present, the ADON stated, Yes. When queried regarding the usual and ideal staffing assignment for the dementia unit, the ADON stated, Three CNAs and a nurse. The minimum is two CNAs. When queried regarding how the facility is able to provide adequate supervision of the unit when there are two CNAs, the ADON stated, The nurse needs to be involved, in the common area with [the residents] or in the dining room. If there are only the three staff, there has to be someone with them in the common area. The nurse would have to come out and switch if the two CNAs needed to go (complete a task). Or they can call the next unit and have someone come over and help. When queried how staff handles having to go between the locked unit and rooms outside of the locked unit, and how the facility ensures the residents on the dementia unit are being monitored when staff is on the other units, the ADON stated, I'm not sure the CNAs go to 'Little D', the nurse passes meds there. CNAs do go to the C-wing. When queried how the facility is ensuring adequate staff are present to supervise the dementia unit if they are going to other units, the ADON indicated there should be three aides on the dementia unit: two remaining on the locked unit and one helping on the C-wing. The ADON stated, Ideally there would be three aides. When queried regarding the fall intervention, Bring out to common area to monitor, for R901 that was written on the 5/8/20 I/A form, the ADON stated, Primarily the nurse is in the common area. On 7/23/20 at 2:51 PM, the Nursing Home Administrator (NHA), DON (via phone), and LPN D were interviewed regarding R901's fall on 7/18/20. When queried regarding the discussion that was had on how and when to send the resident for evaluation of their hip pain, LPN D stated, The nurse called the doctor and the doctor wanted to send the resident to be evaluated. Then the resident had to be assessed if they could be taken in the wheelchair or by EMS. It was discussed and decided better for the resident to be taken by EMS. It was decided the resident couldn't sit and tolerate the pain in the wheelchair so they were moved back into the bed from the wheelchair. The NHA, DON, and LPN D were queried regarding R901's fall at 1:30 PM and that the resident's medication administration record indicated the resident received Tylenol in the facility at 1602 (4:02 PM) on 7/18/20. They were queried as to why the doctor indicated he wanted the resident evaluated after the fall but at 4:00 PM had still not been taken for evaluation. LPN D stated, Initially, the resident was not having pain on the ground. Was moved to the wheelchair and moved to bed to rest and then presented with pain later in bed and had the redness. That's when [R901] was given the Tylenol and EMS was called after the nurse spoke with the doctor. I'm just not sure of the exact timing, I was on another cart at a rather busy hall. The NHA indicated the resident stating, Ouch, when they fell meant the resident felt pain when they landed on the ground. When queried regarding the fall intervention, Bring out to common area to monitor, for R901 that was written on the 5/8/20 I/A form, the NHA and LPN D indicated that intervention meant to monitor the resident in a common area with supervision from staff. LPN D stated, I started education of staff immediately in the building (after R901 fell on [DATE]). When queried regarding staffing on the dementia unit on 7/18/20, the NHA indicated he felt the unit was staffed appropriately. When queried if staffing with two aides and a hall monitor on the dementia unit is ideal, the DON stated, It depends, we have moved residents around recently. If we can we will put someone (staff) there. We had a hall monitor every day previously, we have alert and oriented people on that unit now. The NHA stated, The extra person is a bonus. When queried regarding the facility's strategy for maintaining supervision on the dementia unit when staff are assigned to work other units as well, the NHA stated, There's always a CNA that is to be on [dementia unit], only keep one CNA assigned to C-wing. So there is always someone on [the dementia unit]. When queried regarding R901 being left unsupervised in the dining room, the NHA stated, It is not our expectation to have the resident left alone in the dining room. That is why we started the education immediately. A review of R901's care plan revealed: The resident is at risk for falls related to: Balance deficits, Gait/balance problems, Resident has had fall, Date Initiated: 10/27/2019, Revision on: 07/20/2020. Goal: To reduce the risk of serious injury in the event of a fall through the review date. Date Initiated: 02/09/2018, Revision on: 05/12/2020, Target Date: 08/12/2020. Interventions: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Remove any potential causes if possible. Educate resident/family/caregivers as to causes. Date Initiated: 07/23/2020, The resident requires the following adaptive equipment/positioning devices while in bed [Concave Mattress] Date Initiated: 07/23/2020 Revision on: 07/23/2020, ([R901] should be monitored at all times when up and out of bed in common areas due to recent fall with hip fracture Date Initiated: 07/23/2020. A review of R901's hospital documentation dated 7/19/20 revealed: .8. Fall from wheelchair with right superior and inferior (upper and lower) pubic rami fractures (A group of bones that make up a portion of the pelvis. A pubic ramus fracture is a break in one of these bones) .Apparently, [R901] was ambulatory previously .was transferred to our hospital from [ER of hospital connected to the facility] for ortho(pedic) evaluation .sustained a fall out of [their] wheelchair onto [their] right hip, unclear exactly why [they were] in a wheelchair, as [R901] is reported to be ambulatory. The documentation indicated the resident was not a candidate for surgical repair and was also diagnosed with a urinary tract infection on admission. A review of R901's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] and readmitted on [DATE] with medical diagnoses of Unspecified Dementia Without Behavioral Disturbance, Anxiety Disorder, Alzheimer's Disease With Late Onset, Muscle Weakness, Urinary Tract Infection, Fracture Of Superior Rim Of Right Pubis, Subsequent Encounter For Fracture With Routine Healing, Unspecified Fracture Of Right Pubis, Subsequent Encounter For Fracture With Routine Healing, Unspecified Fracture Of Sacrum, Subsequent Encounter For Fracture With Routine Healing, and Fall. Further review revealed the resident was severely cognitively impaired and was assessed on the 5/17/20 assessment as A. Moving from seated to standing position: Not steady, only able to stabilize with staff assistance, and assessed to require extensive assistance from two+ staff for bed mobility, and transfers; extensive assistance from one staff for locomotion, dressing, eating, toileting, and hygiene. A review of the facility's policy titled, Falls - Clinical Protocol, reviewed/revised 6/2018, revealed, As part of an initial and ongoing assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling .Interventions should be developed and implemented per the assessed needs .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 .provide emergency care and assessment/s as indicated . A review of the facility policy titled, Staffing, reviewed 10/5/17, revealed, Our facility provides adequate staffing to meet needed care and services for our resident population .Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services .[CNAs] are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan .

This Citation Pertains to Intake Numbers: MI 552 and MI 025. Based on observation, interview and record review, the facility failed to document, assess and implement planned and meaningful interventions to prevent falls for two (#'s 701 and 703) of three Residents reviewed for falls, resulting in lack of documentation of falls, lack of implementation of planned interventions, lack of Resident centered interventions, unnecessary pain, and falls with injuries including rib fractures. Findings include: Resident #701 On 8/27/19 at 5:45 AM during a tour of the facility, Resident #701 was observed in their room in bed. A fall mat was not present on the floor next to the bed. On 8/27/19 at 6:24 AM, an interview was conducted with Nurse C. When queried regarding Resident #701 and falls within the facility, Nurse C replied, I don't think they have fell . They are alert and cognitive enough to use the call light. Record review on 8/27/19 revealed Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, had limitations in range of motion in both lower extremities, and required extensive assistance to perform Activities of Daily Living (ADLs). Review of Resident #701's care plans on 8/27/19 revealed a care plan titled, (Resident #701) is at risk for falls related to history of falls (Initiated: 7/25/19; Revised: 7/30/19). Care plan interventions included: Anticipate and meet the Resident's needs . (Initiated: 7/25/19) Be sure the Resident's call light is within reach and encourage the resident to use it for assistance as needed (Initiated: 7/25/19) Bed in lowest position when not providing care (Initiated: 7/25/19) Fall mat next to bed (Initiated: 7/25/19) An interview was conducted with Witness A on 8/27/19 at 9:41 AM. When queried regarding Resident #701's falling within the facility, Witness A stated, I went to visit (Resident #701) on the 19th (7/19/19) and I found (Resident #701) on the floor by the side of the bed and the bed was up really high. I ran to find a nurse for help. Witness A then stated, The second time (Resident #701) fell I don't know where (the Resident) fell . The aide slipped and told me (Resident #701) fell out of their wheelchair. They (facility) never even called me. When asked about the date of the second fall, Witness A replied, It was like a week after the first fall but I don't know the exact date. Witness A then stated, They (facility) brought in a floor mat to put by the bed but they never have it down, it is always behind the bed. On 8/27/19 at 11:25 AM, Resident #701 was observed sitting in their wheelchair in their room. The wheelchair had an extended arm rest on the right side. The Resident's right arm was positioned on the arm rest and appeared flaccid on the Resident's lap. The Resident's bed was positioned with the right side of the bed against the wall. A mat was noted between the wall and the bed. An interview was conducted with the Resident at this time. When queried regarding falls within the facility, Resident #701 replied, I fell twice. The first, I was in bed and reaching and I fell out. When asked what they were reaching for, Resident #701 pointed towards the over bed table in the room and stated, I was reaching for something on the table. With further inquiry, Resident #701 stated, The (over bed) table wasn't close to my bed. When asked what happened after they fell , Resident #701 replied, My (family member) found me. Resident #701 then stated, The pain in my shoulder started right away after the fall. My Therapist told me it was dislocated. When asked what their pain level was in their shoulder directly after the fall on a scale of zero to 10, Resident #701 replied, Nine. When asked about the mat observed between their bed and the wall, Resident #701 stated, They (facility staff) brought that in after I fell out of bed, but they don't put it down. It is always behind the bed. Resident #701 then stated, The other time, I fell out of my chair. I slid down to the floor. They (facility staff) didn't have the foot rests on. Review of Resident #701's progress note documentation on 8/27/19 revealed the following documentation related to falls: 7/30/19 at 3:00 PM: S[NAME]-Falls New Fall/Follow-Up: Initial note for fall on 07/19 at 14:40 (2:40 PM). Situation (where/when/what/who): Resident fell in bathroom when tried toileting themselves. (Resident) stated that they slid down to the floor. (Resident) was alert at time of fall. Injury/No injury: Resident hit his head; CT scan came back negative. Factors involved (acute condition/environment, etc.): (Resident) catheter had been last emptied at 1:00 PM . gripper socks on . left sided weakness .Notifications: (Doctor) and Unit Manager notified. Analysis of interventions to implement: Educated resident to use call light when need to use the restroom. Fall mat next to bed. (Resident) was sent to (hospital) for a CT scan . 8/6/19 at 3:11 PM: S[NAME]-Falls New Fall/Follow-Up: Follow up for fall on 07/19 . Review of Resident #701's Nursing Admission Evaluation, dated 7/19/19, revealed, Musculosketal . Left side weakness . Alterations in Musculosketal Care Plan . Focus: The Resident has an alteration in musculosketal status (related to) r/t stroke. Goal: The resident's mobility will be improved by working with Skilled Therapy by review date Intervention: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance . Intervention: Give [MEDICATION NAME] as ordered by the physician. Monitor and document for side effects and effectiveness . Record review on 8/27/19 of Resident #701's facility provided Incident and Accident Reports revealed one report dated 7/19/19. The Incident and Accident report specified, Date of incident: 7/19/19 . Time of Incident: 2:40 PM . Brief Description: Resident tried toileting themselves, said they slid down to floor . Resident slid down on floor, head was resting against bed foot break . Fall Summary: Found on floor (unwitnessed) . Location: Resident Room . (Resident) said they were trying to go to the bathroom to use the toilet . Time last toileted or Catheter empted: 1:00 PM - used urinal, emptied .(Nurse B) was in Resident's room at approx 1:00 and emptied Resident's urinal . Resident educated on using call light for assistance, fall mat placed next to bed . On 8/27/19 at 3:35 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding Resident #701's fall within the facility, the DON revealed they were new to the facility. When queried regarding observations of the fall mat not being in place beside the Resident's bed, the DON was unable to provide an explanation. When queried regarding statements indicating the Resident had two falls in the facility but only one incident report, the DON was unable to provide an explanation. When asked why there was no documentation of a fall in the Resident's medical record documentation until the note dated 7/30/19 and why the documentation indicated the Resident fell in the bathroom when the Incident and Accident Report indicated the Resident fell out of their bed on 7/19/19, the DON was unable to provide an explanation. An interview was conducted with Nurse B on 8/27/19 at 3:45 PM. When asked about Resident #701's fall in the facility on 7/19/19, Nurse B stated, (Resident #701's family member) came in to visit. They alerted us (Resident #701) was on the floor. With further inquiry, Nurse B revealed the Resident was taken to the hospital for a CT scan because of family concerns related to the Resident's medical history. When queried regarding the documented intervention of fall mat placement, and observation of the fall mat against the wall, behind the bed in the Resident's room, Nurse B replied, It (mat) should probably be there but it got in the way of (Resident #701's) wheelchair so we moved it. Resident #703 Record review on 8/27/19 revealed Resident #703 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision to limited assistance to perform Activities of Daily Living (ADLs). Review of Resident #703's care plans revealed a care plan entitled, (Resident #703) is at risk for falls related to dementia, lack of safety awareness, and history of falls (Initiated: 1/3/19; Revised: 7/1/19). Care plan interventions included: Assist (the Resident) in getting up when wakes up to prevent from self transferring (Initiated: 7/1/19) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Initiated: 1/10/19) Encourage rest periods as needed to avoid overtiring (Initiated: 8/26/19) Medication review (Initiated: 6/18/19) Offer me diversion activities so that I am occupied. Magazines, sorting, folding and social visits (Initiated: 7/9/19) Resident should wear gripper socks in bed so that if they ambulates upon waking, they can ambulate safely (Initiated: 1/10/19; Revised: 6/11/19) Use gait belt for transfers/walking (Initiated: 7/1/19) On 8/27/19 at 10:56 AM, Resident #703 was not present in their room. An interview was conducted with Nursing Assistant D and Nursing Assistant [NAME] on 8/27/19 at 11:02 AM. When queried regarding Resident #703's falls within the facility, Nursing Assistant D stated, (Resident #703) had a bruise on the back from a fall now. It is over the whole right side. When queried what happened when the Resident's back got bruised, Nursing Assistant D replied, I'm not sure. Nursing Assistant D then stated, It is hard. I can't give my patients the care they deserve when there isn't enough staff. With further inquiry, Nursing Assistant D indicated there are times when there is only one Nursing Assistant in the locked dementia unit of the facility. When asked about nursing staff assigned to the dementia unit, Nursing Assistant D stated, There is one, but the nurse covers three different halls so they have to leave (the locked dementia unit). It's a challenge especially if you need them. On 8/27/19 at 11:15 AM, Resident #703 was observed sitting on the couch in the main area of the dementia unit with their eyes closed. The Resident was not wearing shoes, had bright pastel colored socks on, and did not have a gait belt in place and/or near them. An interview was completed with Nursing Assistant [NAME] at this time. When asked about the Resident's footwear, Nursing Assistant [NAME] indicated the socks were the Resident's personal non-slid socks. Nursing Assistant [NAME] then raised the Resident's foot to reveal the socks had dots of non slid areas on the bottom. Multiple non-slid dots were missing from the socks. Nursing Assistant [NAME] was then observed assisting Resident #703 to stand and move without a gait belt. An interview was conducted with Nurse F on 8/27/19 at 11:22 AM. When queried regarding Resident #703's falls within the facility, Nurse F indicated the Resident has always been impulsive and unsteady. Record review of Resident #703's medical record documentation on 8/27/19 revealed the following documentation pertaining to falls: 6/10/19 at 4:24 AM: Pertinent Charting- Falls .Date of Fall: 06/10/19 .Resident was walking from bed to the bathroom in room lost balance and then fell on butt . Assessment: Witnessed. No head impact . Environmental Factors: Resident was in a dark room. Interventions: Have staff check on resident in room often . 6/11/19 at 2:17 PM: New Fall/Follow-Up: 6/10/19. Situation (where/when/what/who): Resident fell in the hallway after losing balance and falling on butt in the bedroom . No injury. Factors involved . Resident was confused as normally is, had normal socks on, it was 0100 (1:00 AM), was attempting to toilet self . Analysis of interventions to implement: resident is to wear gripper socks in bed so that they can safely ambulate if they wake up . 6/12/19 at 9:17 PM: Resident follow up fall charting. This nurse was notified by CNA at approx. 11:00 a.m. of bruise to residents right upper rib cage. Bruise measures 3 inches x 0.5 inches just below right breast. Resident notified CNA of pain to right side, this nurse and CNA assessed resident observing bruising . 6/15/19 at 5:43 PM: Pertinent Charting- Falls . Date of Fall: 06/15/19 .Fall resident on neuro checks . Mitigating Factors: Resident barefoot . Interventions: Resident to wear no slip grip socks at all times . 6/18/19 at 2:05 PM: S[NAME] Falls New Fall/Follow-Up: follow up regarding fall occurring on 6/10/2019 and initial regarding fall occurring on 6/15/2019. Situation (where/when/what/who): on 6/10/2019: resident fell in the hallway after losing balance and falling on butt. On 6/15/2019: resident observed laying on the floor in front of the reclining chair in the desk two common area . No apparent injury on 6/10/19. Incident occurring on 6/15/19 resident later showed bruising to R (right) side of abdomen and bruises on R breast, a bruise also on coccyx . Factors involved . resident is A Ox1-2 with waving bouts of confusion. Resident is very difficult to redirect and often combative with staff when they attempt to redirect . Analysis of interventions to implement: resident is to wear gripper socks (around the clock) ATC as tolerated, and is having PT/OT evaluation to improve strength for transfers and maintaining independence. Referrals: Resident was sent for a Chest X-ray. Comments: Results of X-ray revealed rib fracture . 6/29/19 at 6:30 PM: Pertinent Charting-Falls . Date of Fall: 6/29/19 .Observed sitting on the floor left side of the recliner with the foot of the chair still elevated. Previous shift toileted resident at 3 p.m. and put in the recliner to rest . 2 small skin tears. One to left elbow and left forearm .Interventions: When in recliner resident should be in a supervised area . 7/1/19 at 2:30 AM: Pertinent Charting- Falls . Date of Fall: 7/1/19 . Gait and balance slightly unsteady when walking around this shift . 7/1/19 at 3:50 PM: S[NAME] Falls New Fall/Follow-Up: Initial note for fall on 06/29 at 16:45 (4:45 PM). Follow-up for falls on 06/10 and 06/15. Situation (where/when/what/who): 06/29: Resident was observed sitting on the floor on L side with the foot of the chair still elevated. Previous shift toileted resident at 15:00 and put in the recliner to rest. Injury . 6/29: Two small skin tears to L (left) elbow and forearm. 6/15: Rib fracture. Factors involved: Fall was unobserved. It appeared that (Resident) tried to get up from the chair without assistance . confused and disoriented at time of fall, consistent with baseline Analysis of interventions to implement: Med review completed on 06/19. Assist resident in getting up when wakes up to prevent from trying to get up on own . 7/9/19 at 1:35 PM: S[NAME] Falls New Fall/Follow-Up: Initial fall: 7-8-19. Follow up for fall dated 6-28-19 . Resident was rolling slowly at the end of hallway in a wheelchair. Resident attempted to stand and ambulate alone without assistance. Resident lost grip and slowly fell to floor on left side of body . No apparent injury . Resident with one gripper sock on and one off .Analysis of interventions to implement: Diversional activities in common area . 7/12/19 at 8:23 PM: Pertinent Charting-Falls . Date of Fall: 7/12/19 .Resident's fall unobserved. Resident was laying in bed. CNA left room after helping resident lay in bed, tech student was across the hall assisting care for another resident, tech student over heard loud noise across the hall and went into residents room across the hall, observed resident lying on the floor . Resident sent to hospital for possible head injury. Dime sized purple bruise center of the back of residents head. Resident stated having back pain. Resident stated having a headache, and back injury . Interventions: Supervise resident when ambulating, assist resident when transferring . 7/13/19 at 12:23 PM: Pertinent Charting- Falls . Ambulating about ad lib . 8/22/19 at 1:16 PM: Pertinent Charting- Falls .Date of Fall: 8/22/19 . Roommate came out of the room stating (Resident #703) fell on the floor. Entered the room and (Resident) was up ambulating. When asked . stated 'Yes I fell on the floor' . Extremity small abrasion left mid back and left knee . Comments: Monitor closely. Past HX (history) of Rib FX (fracture) during a fall . 8/25/19 at 3:16 AM: Pertinent Charting- Falls .Date of Fall: 8/25/19 . 8/26/19 at 7:16 AM: Pertinent Charting- Falls .Date of Fall: 8/22/19 . Resident has large bruise on trunk on left side, tenderness when touched . Review of Resident #703's X-Ray report, dated 6/13/19 at 2:21 PM, at this time revealed, History: Right rib pain and injury . Impression: Nondisplaced anterolateral rib fractures of ribs 7 and 8 on the right. Review of Resident #703's Incident and Accident Reports on 8/27/19 revealed documentation of Resident #703 having falls on 6/12/19, 6/15/19, 6/29/19, 7/8/19, 7/12/19, 7/19/19 and 8/22/19. An interview was conducted with the Director of Nursing (DON) on 8/27/19 at 3:35 PM. When queried regarding Resident #703's fall on 6/10/19 resulting in rib fractures and the Resident not wearing non-skid socks when they fell , the DON indicated they were new to the facility and not aware of the situation. When asked about the documentation in the medical record and the dates on the incident reports, the DON did not provide an explanation. Review of facility policy entitled, Falls-Clinical Protocol (Reviewed/Revised (MONTH) (YEAR)) revealed, Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include Resident abilities and deficits For and individual who has fell , staff should attempt to define possible causes within 24 hours of the fall .Staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .

This Citation pertains to intake #MI 622 and #MI 680. Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement care plan interventions to prevent falls for 1 ( # 501) of 3 residents reviewed for falls, from a total sample of four, resulting in multiple falls with injuries that included right [MEDICAL CONDITION], skin tears, and head injury/hematoma (raised area resulting from trauma). Findings include: On 5/23/18 at 10:30 a.m., Resident #501 was observed in the hallway against the wall and handrail seated in a geri chair (reclining cushion chair with wheels), sleeping, with a lap tray (locked tray attached to recliner to prevent forward motion) attached to chair. On 5/23/18 at 12:29 p.m., Resident #501 was observed alone in the bedroom, sitting in a geri chair with a lap tray attached. The lap tray was observed to be away from the resident's lap area, closer to the knee and lower leg area away the waist. During this observation Resident #501 was observed to slide toward the end of the chair, attempted to get something off the floor. Resident #501 was also observed shaking the table and attempting to pull the handles of the table. On 5/23/18 at 12:32 p.m., during an interview, Certified Nursing Assistant (CNA A) was asked if the lap tray was in the closet position for Resident #501. CNA A stated, I'm not sure. This is not my assigned resident. CNA B would know better. CNA A was then observed trying to move the tray closer to Resident #501. CNA A was able to move it closer. CNA B entered the room and was asked if the lap tray was in the closet position. CNA B stated, I don't put it at the closet position because he may hurt his knees under it. The lap tray was observed to remained with a gap and not at the closet locked positron for Resident #501. On 5/23/18 at 2:50 p.m., Resident #501 was observed hanging out of the geri chair with feet touching the floor. The lap tray was observed to not be in the closet locked position. Resident #501 was observed yelling for help and banging on the lap tray. A Staff member was observed to look into the room and continue to walk pass without assistance. On 5/23/18 at 2:55 p.m., CNA A was observed going into Resident #501's room. At that time CNA A was asked if Resident #501 had a non slide pad/grippie in the geri chair. CNA A stated, I'm not sure. CNA B came into Resident #501's room and looked for the non slide pad/grippie and was unable to locate it in the room. CNA B stated, I'm not sure where it is. I'm not his normal CNA, I'm usually on another unit. On 5/23/18 at 2:55 p.m., during an interview, the Director of Nursing (DON) was asked if Resident #501 has a non slide pad/grippie. The DON was observed looking in the seat of Resident #501's chair and stated, No I don't see one. The DON verified that Resident #501 is care planned to have a non slide pad/grippie while in a geri chair. The DON continued and stated, It has to come from therapy. We will get one for him. The DON was asked who is responsible for ensuring the non slide pad/grippie is in the chair, the DON stated, The CNA's. The DON was asked about the staff member that walked by Resident #501 while he was hanging out of the geri chair. The DON stated, That staff member should have helped. On 5/23/18 at 2:56 p.m., Resident #501 was observed being placed in the hallway by CNA A. CNA A placed Resident #501 against the wall next to the handrails. Resident #501 was observed pulling the handrails and moving the geri chair. Resident #501 was observed yelling in the hallway and making inappropriate comments to staff. Resident #501 stated, See those camera's. I'm going to take them out. Pow! Resident #501 was observed in a motion of shooting the cameras down and repeated the motion three times. Staff were not observed offering interventions that were care planned. On 05/23/18 at 9:30 a.m., the clinical record for Resident #501 was reviewed and revealed the resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated cognitive impairment and Resident #501 required extensive assistance of two persons for all activities of daily living (ADL). Continued review revealed the following documents: Physical Restraint Consent Restraint Intervention Recommended: Restraint Type, Frequency. Lap Tray. Specific Target Behaviors: to maintain safety and body alignment while up in recliner/broda chair). Care Plan: Focus. The resident has an ADL (activities of daily living) self care performance deficit r/t (related to) confusion . Interventions: Anticipate and meet res (resident) needs. Observe for no verbal signs of unmet needs offer food, fluids and toileting if I become restless. Date Initiated 10/24/17 Revision on 12/14/17. Do not leave me alone while in the dining room as I may attempt to self transfer. Date Initiated: 10/23/17. Focus: The resident has had a fall. Date initiated: 6/09/17. Revision on: 09/21/17. Goal: The resident will be free of major injury through the review day. Date Initiated: 6/09/17. Revision on: 9/21/17. Interventions: Alarming seat belt while up in w/c (wheelchair). Date Initiated: 10/30/17. Appropriate, grippie socks or shoes. Date Initiated: 6/9/27. Revision on: 6/21/17. Attempt to play movies or music for this resident as diversion approach to help keep him safe from falling. Date Initiated 10/3/17. Ensure grippe is in place on top of my wheelchair cushion. Date Initiated: 6/12/17. Revision on: 1/21/18. Involve resident in diversion activities. Resident likes to keep his hands busy. Date Initiated: 9/30/17. Keep in sight at all times when up, resident is very fast and is able to stand up quickly out of w/c and attempt to transfer out of recliner as soon as he wakes up. Date Initiated: 11/28/17. Offer me hand held activities that may capture my interest, a tote of things I may enjoy is kept in the linen room at desk one. Date Initiated: 10/17/17. Resident is not to be left alone in DR (dining room) for any length of time. If staff member needs to leave DR, another staff member must be present in DR to supervise resident. Date Initiated: 10/25/17. Focus: The resident has had a fall, and is at high risk for further falls. Resident on hospice and has terminal restlessness at night in bed. Date Initiated: 1/30/18. Revision on: 1/31/18. Goal: The resident will be free of major injury through the review day. Date Initiated: 6/09/17. Revision on: 9/21/17. Interventions: assure alarming seatbelt is working before placing (resident) in recliner chair. Date Initiated: 2/15/18 When resident is up in recliner, do not place chair near hallway hand rails. Resident will grab them and try to get out of chair. Date Initiated: 2/15/18. Incident and Accident Reports 1. Date of incident: 11/13/17, Time of incident: 1:30 p.m. Brief Description: Resident was observed lying on floor in front of the recliner chair. Injury type: No apparent injury. Fall Scene Investigation Report: 1. Factors observed at time of fall: Resident lost their balance . 3. Fall Summary: Found on the floor (unwitnessed) . 5. What was resident doing during or just prior to fall? Other (specify): in Dining room for dinner. 6. What type of assistance was resident receiving at time of fall? Alone and unattended. 2. Date of incident: 11/27/17, Time of incident: 9:00 a.m. Brief Description: Resident was sitting in recliner then observed lying on floor in the TV sitting area - previous shift had put him in the recliner and was sleeping. Equipment: Was mobility device used? Yes. Alarm. Was bed/personal alarm in use? Yes. Did alarm sound? No. Fall Scene Investigation Report: 1. Factors observed at time of fall: Resident lost their balance . 3. Fall Summary: Found on the floor (unwitnessed) . 13. Alarm being used at the time of fall? Yes. Not sounding previous shift left the alarm on the w/c (wheelchair) - was not put on him in the chair . 3. Date of incident: 12/4/17, Time of incident: 8:00 p.m. Brief Description: Another resident yelled help when CENA (Certified Nursing Assistant) came to help she observed resident lying on floor on R side Desk 1 sitting area. Equipment: Was bed/personal alarm in use? Yes. Did alarm sound? No. Resident took sweater off. Fall Scene Investigation Report: 1. Factors observed at time of fall: Resident lost their balance . 3. Fall Summary: Found on the floor (unwitnessed) . 5. What was the resident doing during or just prior to fall? Attempting to self-transfer. 6. What type of assistance was resident receiving at time of fall? Assisted per care plan: Alone and unattended. 13. Alarm being used at the time of fall? Yes. Was hooked on sweater Resident took sweater off . 4. Date of incident: 1/18/18, Time of incident: 3:00 a.m. Brief Description: CENA found resident lying on floor next to bed. Equipment: Was bed/personal alarm in use? No. Fall Scene Investigation Report: 1. Factors observed at time of fall: Resident lost their balance . 3. Fall Summary: Found on the floor (unwitnessed) . Statement of witness continued. CENA approached me and told me (resident) had falling out of bed. Saw patient did not noticed any internal or external rotation, pt had no c/o (complaint of) pain, took patient to bathroom with no c/o of pain. Performed ROM (range of motion) - no issues/pain noted . Progress note: Notified this a.m. that resident was on Neuro checks due to fall last night. Resident was up in wheel chair propelling himself around . assist staff stood him up from the wheelchair to toilet, this writer noted facial grimace and grabbing his right hip. (Physician) was notified and sent to (hospital) x-ray for stat right hip x-ray at approx. 3:30 (Hospital) called with results of right Troch. FX (fracture). Unit manager and DON (Director of Nursing) notified . Radiology Report Exam date and time 1/19/18 at 16:38 (4:38 p.m.) Reason for exam: Pain, Fall. Findings: There is an impacted basicervical right proximal femoral fracture . Fracture fragment extends cranially to the level of the superior acceptable . Impression: . [MEDICAL CONDITION]. 5. Date of incident: 2/15/18, Time of incident: 10:30 a.m. Brief Description: Resident was sitting in his reclining/Lounge wheelchair slid himself forward going down to the foot rest then sitting on the floor. Equipment: Was bed/personal alarm in use? Yes. Did alarm sound? No. Fall Scene Investigation Report: 1. Factors observed at time of fall: Resident slide, down foot rest. Equipment malfunction seat belt alarm . 3. Fall Summary: Found on the floor (unwitnessed) . 5. What was the resident doing during or just prior to fall? Attempting to self-transfer. 6. What type of assistance was resident receiving at time of fall? Assisted per care plan: Alone and unattended. 6. Date of incident: 2/15/18, Time of incident: 6:30 p.m. Brief Description: Resident had just been toileting by CENA - wheelchair recliner was parked on C - wing hall and resident used hand rail to pull himself out of the chair. Equipment: Was bed/personal alarm in use? Yes. Did alarm sound? No. Fall Scene Investigation Report: 1. Equipment malfunction (specify) CENA Did not turn seatbelt alarm on after toileting . 3. Fall Summary: Found on the floor (unwitnessed) . 5. What was the resident doing during or just prior to fall? Attempting to self-transfer . 7. Date of incident: 3/9/18, Time of incident: 8:30 a.m. Brief Description: Another Nurse notified writer that resident had fallen from wheelchair in dining room after attempting to stand. Resident has skin tear to L (left) side of forehead assessment done. Injury Type: Skin Tear. Equipment: Was mobility device used? Yes. Type: Wheelchair. Was a restraint in use? Yes. Was bed/personal alarm in use? Yes. Did alarm sound? No. Action taken: Care plan Update. Intervention make sure chair lock set at table. Fall Scene Investigation Report: 1. Wheelchair/bed brakes unlocked . 3. Fall Summary: Found on the floor (unwitnessed) . 5. What was the resident doing during or just prior to fall? Other: Attempting to stand . Statement of witness continued. Resident was in DR 1 at table for breakfast. Resident pushed himself away from table and stood up, when he stood up he fell to the right and onto the floor. I assessed patient, notified his nurse had small amount of blood on left temporal. small skin tear noted. ROM done by this RN (Registered Nurse), assisted back to chair . small hematoma forming, cold pack applied to area. Seat alarm attached. Progress notes: 3/9/18, 9:35 a.m., Situation: . pushed himself away from table and stood up out of chair and fell to floor, hit head on floor, small skin tear noted to left temporal area . Neuro checks completed . Interventions: lock chair when in dining room. 8. Date of incident: 3/10/18, Time of incident: 10:00 a.m. Brief Description: Resident was sleeping in his specialty chair by the TV climbed out and was sitting on his buttocks next to the chair. Equipment: Was mobility device used? Yes. Type: (not noted). Was bed/personal alarm in use? Yes. Did alarm sound? No. Fall Scene Investigation Report: 1. Factors observed at time of fall: Lost strength/appeared to get weak . 3. Fall Summary: Found on the floor (unwitnessed) . 5. What was the resident doing during or just prior to fall? Other: Attempting to self transfer. 6. What type of assistance was resident receiving at time of fall? Assisted per care plan: . Pertinent Charting Initial -Falls dated 3/10/18 . B. Event Details: 1. Situation Details: Per previous shift resident was up most of the night had just went to sleep in his specialty chair by the TV. At 10 a.m. resident was observed sitting on the floor next to his chair. Alarm was not sounding because was not turned on. Neuro checks in place. (Physician) notified and his wife notified . Skin Assessment: dated: 3/10/18 A. Skin evaluation. Are there any new abnormal skin areas? a. Yes. Site Other (specify) Description: dime size bruises/swelling on the L (left) eye brow. Nurse Practitioner /Physician Assistant Note: 3/13/18 Nurse Practitioner /Physician Assistant. ROS (reason of service). Patient had just completed breakfast when he tumbled out of his chair - patient hit his left forehead - staff reports he had a headache immediately following the fall . Exam: . patient has the beginnings of a contusion on his left forehead - the area slightly raised - approximately 2 inches in diameter - discoloration/bruising is just beginning . P[NAME] (plan of care) . maintain safety at all times . 9. Date of incident: 3/22/18, Time of incident: 1:00 p.m. Brief Description: Resident was sitting in his chair by TV area and observed lying on his right side with chair tilted forward. Was bed/personal alarm in use? Yes. Did alarm sound? No. Action taken: Staff re-education Checking alarm. Fall Scene Investigation Report: (page one not available) . 10. Footwear at the time of fall: Bare feet . 13. Alarm being used at the time of the fall? Yes. Not on . 10. Date of incident: 3/30/18, Time of incident: 9:30 p.m. Brief Description: Patient slide from his chair on to the floor . Resident was sitting in his chair by TV area and observed lying on his right side with chair tilted forward. Was bed/personal alarm in use? Yes. Did alarm sound? Yes. Fall Scene Investigation Report: 1. Factors observed at time of fall: Resident slide . 3. Fall Found on the floor (unwitnessed) . 6. What type of assistance was resident receiving at time of fall? Alone and unattended . 11. Date of incident: 4/4/18, Time of incident: 6:20 p.m. Brief Description: Resident was in his reclining wheelchair on wing B awaiting CNA assistance when he removed the seatbelt chair alarm sounded and was found on the floor . Assigned nurse on C wing assisting another CNA with patient care. Injury Type: Swelling Right elbow and hip pain . Action Taken: Staff re-education. Other Resident sent to Emergency . Radiology Report Date: 4/4/18. Reason For Exam Pain. Findings There is a large spur on the olecranon (elbow) process of the ulna (thinner and longer of the two bones in the human forearm) . Conclusion: [DIAGNOSES REDACTED] spurring . 12. Date of incident: 4/19/18, Time of incident: 9:00 p.m. Brief Description: Resident had broken out side of his geri chair then resident then climbed out the side of his geri chair and staff observed him lying on floor. was in his reclining wheelchair on wing B awaiting CNA assistance when he removed the seatbelt chair alarm sounded and was found on the floor. Fall Scene Investigation Report: 1. Factors observed at time of fall: Equipment malfunction . 3. Fall Summary. Found on the floor (unwitnessed). 4. Fall location. Hallway . 13. Date of incident: 4/7/18, Time of incident: 8:30 p.m. Brief Description: Alarm was sounding (CNA) was told to watch him. Resident was found on floor next to chair by sitting area. Action: Care plan update. Staff re-education. Fall Scene Investigation Report: (no page one) 10. Footwear at time of fall Bare feet . 14. Date of incident: 4/22/18, Time of incident: 2:02 p.m. Brief Description: Resident was found sitting on floor in lobby apparently sliding out of his chair. 15. Date of incident: 5/16/18, Time of incident: 12:38 p.m. Brief Description: Resident was found on his butt in front of his w/c slid right out under tray; no injuries noted resident stated he did not hit his head Fall investigation tool: What appears to be the initial root causes of the fall? Tray wasn't at closest setting. Describe initial interventions to prevent future falls: Ensure tray is at closest locked position when in chair unattended. Progress Note: 5/22/18 . What will the restraint assist the resident to do: Alarming seatbelt removed and lap trap brought in by hospice, to be in place while up in chair for meals and activities . Other interventions/Least restrictive devices attempted: Wedge cushion, dropped w/c back down, non-skid mat under resident and under w/c cushion, pommel . On 5/23/18 at 3:53 p.m. during an interview, the DON was interviewed about the facility's expectations of implementing preventive devices and interventions for a resident that is high risk and has had a lot falls. The DON stated, You expect staff to implement the interventions. We have weekly meetings on falls to trouble shoot for the root cause. The DON verified that interventions were not always in place for Resident #501 and that the falls have lead to major and minor injury. On 5/23/18 at 4:30 p.m., the facility's policy and procedure dated 2/2017 titled Falls - Clinical Protocol noted . 4. Interventions should be developed and implemented per the assessed needs . policy dated 7/26/17, titled Care Plans - Resident and Objectives Care plans shall incorporate goals, objectives, and interventions that lead to the resident's highest obtainable level of independence and are driven by the resident as the center of decision-making. Policy Interpretation and Implementation . 2. Resident care plan interventions are actions taken by the facility, resident, and/or resident representative to achieve the desired goal and objectives .

This citation pertains to MI Based on observation, interview and record review, the facility failed to prevent the further development of 2 unstageable pressure ulcers, update the care plan with interventions, and prevent the worsening of pressure ulcers for 1 (#701) of 2 sampled residents reviewed for pressure ulcers from a total sample of 3, resulting in the development of 2 facility acquired pressure ulcers and the worsening of 2 community acquired pressure ulcers. Findings include: On 11/28/17 at 9:55 a.m., a record review of the face sheet and Minimum Data Set (MDS) assessment for Resident #701 was completed. According to the face sheet, Resident #701 was newly admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #701 was a full code (not opposed to receiving tube feedings and intravenous fluids for nutrition or hydration).The MDS dated [DATE] indicated that Resident #701 was severely cognitively impaired, had an unstageable pressure ulcer (a wound on the skin caused by pressure which cannot be staged because the wound depth cannot be seen related to dead tissue covering the wound bed), was incontinent of stool and was completely dependent for bed mobility. On 11/28/17 at 1:50 p.m., a record review of the physician's orders revealed that all 4 wounds were to be cleansed, and collangenase ointment was to be utilized to the wound beds, and then covered with dry gauze. On 11/28/17 at 2:00 p.m., a record review was completed of the wound measurements and the initial nursing evaluation. According to the initial nursing evaluation completed upon Resident #701's admission, there was 1 stage 4 wound present on her coccyx (wounds are staged 1-4, 4 being the worse) that was present upon admission. Measurements were reviewed and revealed the following: Coccyx wound (stage 4) 9/20/17 (initial measurement) 4.5 x 2.5 x 1.5 centimeters (cm) 11/22/17 (most current measurement in the medical record) 4.8 x 5.4 x 2.8 cm Left ischium (stage 4) 9/20/17 (initial measurement) 3.5 x 4.2 cm 11/22/17 (most current measurement in medical record) 8 x 4.6 x 5.8 cm Spine (unstageable) 11/22/17 3.2 x 1 cm Right buttocks (unstageable) 11/22/17 2.5 x 0.6 cm On 11/28/17 at 2:15 p.m., the skin care plan (created 9/20/17) was reviewed for Resident #701 and revealed the following interventions: Encourage good nutrition Float heels while in bed Keep skin clean and dry . Monitor size and location of wounds . Pressure relieving mattress .wheelchair cushion . Yellow dot system On 11/28/17 from 10:05 p.m.-2:25 p.m., the following observations were made: 10:05 a.m.-Resident #701 is nonverbal, but responds to speech via eye contact and was lying slightly on her left side in bed. 10:50 a.m.-Resident #701 lying on her right side in bed. 1:10 p.m.-Resident #701 lying on her right side in bed. 2:25 p.m.-Laying on right side in bed. On 11/28/17 at 2:35 p.m., Certified Nursing Assistant (CNA) A was queried in regards to the repositioning of Resident #701. CNA A stated, I put her (Resident #701) on her right side after breakfast, then I went to help with lunch and I am getting help now to reposition her. On 11/28/17 at 3:35 p.m., an observation and interview was made of wound care for Resident #701 with the Wound Care Nurse (RN B). The following was observed: Coccyx and ischium wound-deep red and moist. No odor. Large amount of clear, watery drainage. Buttocks wound-soft, pale yellow slough tissue (dead tissue). Spine wound-Smooth, black dead tissue. No drainage was observed. During the observation, RN B was interviewed. RN B was queried in regards to what interventions are being done for Resident #701 to prevent the further development of wounds and heal the wounds that are present. RN B stated, Well, I would like to have her repositioned every hour, but the Doctor and the Director of Nursing (DON) think it would be best to just leave it at every 2 hours because that way the staff would be able to do it. Right now, the plan is to reposition her every 2 hours, get her up for meals only. Staff are to position her from side to side only. She (Resident #701) cannot reposition herself. RN B was asked about the care plan not having specific interventions regarding the positioning of Resident #701. RN B stated, Well, I think I am supposed to be creating and updating them (the care plans), I just haven't got to them yet. To tell you the truth, I am not sure I even know how to do it (create and update care plans), I have just been overwhelmed. I should just ask (DON) to show me how to do it. When asked if Resident #701 ever gets out of bed, RN B stated, The Doctor wants her in bed because if she gets up in her chair then she will just sit in it all day without getting repositioned. RN B also stated, She (Resident #701) was admitted with the ischium and coccyx wound. I hate to say it, but she developed the wound on her spine and buttocks here. I never looked at her back and I am not sure why no one noticed the wound on her spine before while doing care. I feel real bad about it. RN B was asked how the wound on the spine had developed. RN B stated, I think from sitting up in the wheelchair, you can see that it (the wound) is right over her spine, which is a pressure point, and she is quite thin. On 11/28/17 at 4:15 p.m., an interview was completed with the DON and the Administrator in regards to the wounds present on Resident #701. The DON stated, She (Resident #701) is challenging. She is not eating well and does not stay positioned in bed. The DON was queried in regards to the care plan interventions for the wounds for Resident #701. The DON stated, I have showed her (RNB) how to do that before. The Administrator did not provide and explanation in regards to Resident #701's skin care. During the interview, a copy of the wound notes from the wound care doctor were requested, however no progress notes were received by the end of the survey. On 11/28/17 at 4:30 p.m., a record review of the facility policy and procedure titled, Wound Care, revised on 03/23/2011 was completed. The policy did not state specific guidelines for management of residents with wounds or interventions for skin care.

This citation has 2 Deficient Practice Statements ( DPS) DPS #1 Based on observation, interview and record review, the facility failed to provide effective interventions and monitor residents to maintain safety and prevent falls and serious injuries for 7 (#'s 703, 705, 707, 708, 713, 718, 720) of 13 residents reviewed for safety and falls from a total sample of 24, resulting in residents experiencing multiple falls leading to injuries, including Resident #718 sustaining a hip fracture after falling repeatedly, and Resident #720 sustaining two skin tears and bruises. Findings include: On 9/19/17 at 2:00 PM, a review of the facilities staffing assignment sheets for Nurses and Certified Nursing Assistants (CNA's) on the D & E (Unit 2) Halls, (the E Hall is the locked Dementia unit), revealed the following: Facility Census = 123 residents, D and E Hall census = 52 residents 7 am-3:30 PM - 3 CNA's assigned to the D and E Hall combined, along with 1 trainee. PM- 11:30 PM - 3 CNA's, with 1 trainee. 11pm-7:30 am - 1.5 CNA's. 7:00 am-7:30 PM- 1 Nurse, 7:00 PM- 7:30 am- 1 Nurse (shared between the locked Dementia unit and another unit). On 9/19/17 at 4:50 PM an interview with Confidential Person AA revealed, There are not enough staff to take care of the residents. They are falling. They can't watch them. How can they watch them? They are falling and breaking bones. A record review on 9/20/17 at 9:30 am revealed, Resident #718 was originally admitted into the facility on [DATE] and readmitted on [DATE] (after hospitalization related to falling at the facility and breaking a hip on 9/2/17), with additional Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment, dated 7/9/17, indicated the resident needed 2 person assistance with bed mobility, transfers and toileting, 1 person assistance with walking, dressing, hygiene and bathing and was able to feed themselves with set up assistance. Resident #718 had severe cognitive impairment. A review of the Care Plans for Resident #718, on 9/20/17 at 9:45 am, revealed the following: I like to walk on my unit .I am often awake and alert at night .I will continue to ambulate safely on my unit .Initiated: 11/13/16 with 1 updated intervention on 8/29/17, Redirect other residents away from resident, as she gets upset . I have had a fall .My risk for fall with serious injury will be minimized .(Revised 8/6/17) . The Fall Care Plan was initiated on 11/13/16 and updated 2/16/17- Wheelchair with /unsteadiness/weakness . 8/16/17- Monitor me closely .I have fallen attempting to transfer and ambulate . and after the fall with hip fracture added 9/6/17- Bed in lowest position .adequate pain control .mat on floor beside bed, 9/7/17-Monitor me frequently while in bed or on couch in TV area . 9/7/17- Physical Therapy (PT) and Occupational Therapy (OT) were added with recommendations related to the resident's inability to bear weight on the left leg or walk after the fall with fracture on 9/2/17. The Care Plans were not updated to reflect the residents current condition and inability to walk. On 9/20/17 at 10:08 am, Resident #718 was observed lying in bed. The bed was in a low position and the resident's legs were placed on a positioning cushion. The resident was awake and looking around, but did not answer any questions. The call light was not in reach. On 9/20/17 the following interviews occurred: 10:10 am- Certified Nursing Assistant (CNA) EE was queried, if Resident #718 always stayed in bed, because the resident was not observed in the dining room for dinner on 9/19/17 at 5:25 PM either? CNA EE responded that they usually assisted Resident #718 out of bed for lunch and returned the resident to bed after therapy worked with the resident in the early afternoon. The CNA indicated the resident was no longer able to walk. CNA EE was further queried on how many CNA's were assigned to the locked Dementia unit that day and responded, There are 2; 1 in the dining room and 1 on the hall. 10:13 am- Nurse B was queried on what measures were in place to prevent resident's from falling multiple times, and stated, .Beds in the correct position, CNA's rounding, frequent checks, I try to round . Nurse B was asked how 1 CNA on the hall could frequently check the residents if they were in a room, with the door closed, caring for another resident and stated, That is true correct. They can't. Nurse B was asked if the measures in place were effective for residents who had fallen multiple times and with serious injury and stated, We keep trying. Nurse B was queried if 1 CNA on the floor and 1 in the dining room on dayshift and 1 alone at night was enough to adequately care for the residents needs and stated, 3-4 CNA's would be proper. Nurse B was queried if there was written documentation that frequent checks were being completed on the residents and stated, No. On 9/20/17 at 2:30 PM, a review of the Incident and Accident (I&A) reports for Resident #718, revealed the resident had fallen 10 times since January 2017: 3/February, 2/March, 1/May, 2/August and 2/September- Including once (9/9/17) after Resident #718 had fallen and broke their left hip at the facility. The resident fell 3 times from the couch, 3 times from the wheelchair, 3 times from bed, 1 unexplained event with injury and the resident stated, I fell at my grandma's house last week. The Care Plan was not updated with new interventions after each fall. Some interventions such as, Monitor the resident . were mentioned several times. An interview with the Director of Nursing (DON) related to fall prevention, on 9/20/17 at 3:15 PM provided, We try new interventions. We always try something new after each fall. When the DON was queried on whether those interventions were effective for those residents who continued to fall and sustain a serious injury, the DON stated, Obviously the previous ones aren't working. Resident #720 On 9/20/17 at 9:55 a.m., Resident #720 was observed sitting in a wheelchair with a sensor pad alarm attached playing bingo, while in the dining room. Resident #720 answered short simple questions appropriately. On 9/20/17 at 11:50 a.m., review of an incident report provided by the facility, dated 12/3/16 at 7:55 p.m., revealed the following documentation: Called to room by CNA/Nurse. Res. (Resident) observed sitting on floor in front of toilet. Chair sensor not sounding. Body check done - two small skin tears size of dime on RFA (right forearm) - purple bruising noted to RFA .Fall summary: found on the floor (unwitnessed). Root cause of this fall: Alarm. Footwear at time of fall: Bare feet. Alarm being used at time of fall? Yes. Chair sensor not on. The incident report included the intervention to prevent future falls was to Ensure resident's alarm is functioning properly. The incident report concluded the following: Resident put on call light. Asked to toilet, another resident was in the BR (bathroom). CNA went to help another resident. Resident #720 went into BR when it was free and attempted too toilet self. Review of the nurse's note, dated 12/3/16 at 10:41 p.m., revealed the following documentation: Called to room by CNA/nurse. Resident observed sitting on floor in front of toilet. Chair sensor not sounding .Two dime sized skin tears noted to RFA-and purplish bruise noted above skin tears . On 9/20/17 at 12:40 p.m., review of Resident #720 clinical record revealed the following: The face sheet indicated an admission into the facility on [DATE] and a re-admission on 8/3/15 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 10/24/16, indicated the requirement of limited assistance with activities of daily living (ADL's) and a moderately impaired cognition. The fall prevention care plan, initiated 11/5/16, included the interventions appropriate footwear and I have a sensor in bed and w/c (wheelchair). On 9/20/17 at 3:33 p.m., the Director of Nurses (DON) was queried regarding the fall on 12/3/16. The DON stated, I was not here at that time. I have only been here a couple of months. Resident #703 On 9/18/17 at 11:30 a.m., a review of the Minimum Data Set ((MDS) dated [DATE] revealed, Resident #703 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated that Resident #703 was severely impaired in cognition and required supervision and one person assistant for all activity of daily living (ADL's). On 9/18/17 at 9:40 a.m., Resident #703 was observed in their room, walking to the bathroom alone. The resident was unsteady on their feet, dressed in a shirt with a heavy soiled brief. The resident's roommate (#702) held his hand to assist him. No aide was present in the room or in the area of the hallway at that time. On 9/19/17 at 12:58 p.m., Resident #703 was observed in room sitting in wheelchair, sipping on a liquid from the cup. The Resident was attempting to come out of door in wheelchair and was attempting to stand up. The resident's roommate (#702) assisted the resident back in the room. No Certified Nursing Assistant (CNA) or nurse was visible on that end of the hall. On 9/19/17 at 2:20 p.m., incident reports for Resident #703 were reviewed. Resident #703 had falls as indicated below: 11/30/16 (5:00 p.m.): Resident observed on one knee in front of wheelchair attempting to pick up a paper from floor and fell . No injury noted. Intervention: Neurochecks initiated. 11/30/16 (7:00 p.m.): Resident observed laying on his right side next to wheelchair on b-wing hall. Resident stated they slid out of the chair. No apparent injury. Interventions: updated to reflect frequent checks of supply and reminders to keep in place. 12/22/16: Resident was observed lying on left side on floor holding his neck after attempting to get himself into bed from wheelchair. Neck pain. Intervention: Neurochecks and neck x-ray. 3/15/17: Resident reaching down and slipped on floor. No apparent injury. Intervention: Monitor resident for self-directed behaviors. 3/28/17: CNA heard resident yell and Resident was on the floor in the bathroom. No apparent injury. Interventions: Neuro checks, 15 minutes safety checks, remind resident about use of call light. 4/14/17: Resident observed on the floor outside the bathroom door. No apparent injury. Interventions: Neurochecks, encourage resident to use call light, have walker or wheelchair. 5/16/17: Resident observed on the floor outside room, after attempting to put pants on. No apparent injury. Intervention: Neurochecks, 15 minutes safety checks. 5/31/17: Resident states, fell in his bathroom. No injury noted. Interventions: Reminded to use call lights, have help to transfer/ambulate, ensure hipsters are worn for proactive safety measures, Neurochecks and 15 minutes safety checks initiated. 7/11/17: Resident observed sitting on floor in bathroom. No apparent injury. Interventions: Call light in reach; offer toileting upon rising, between meals, bedtime and as needed. 8/14/17: Resident observed lying on hallway floor in front of room. No apparent injury. Intervention: grippy socks, Neurochecks, 15 minute checks. An interview was conducted with the Director of Nursing (DON) on 9/20/17 at 3:00 p.m., who indicated that Resident #703 tries to self ambulate instead of using the call light and that they encouraged him to use the call light. When queried about new interventions, the DON stated, we do the 15 minute checks. When asked how do they audit the checks, the DON stated, I would hope they are honest and do them. Resident #707 On 9/19/17 at 10:10 a.m., a review of the Minimum Data Set ((MDS) dated [DATE] revealed, Resident #707 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] indicated that Resident #707 was cognitively impaired and required limited assistance with one person for transfers, dressing, and hygiene; extensive assistance with toileting. On 9/19/17 at 2:35 p.m., incident reports for Resident #707 were reviewed. Resident #707 had falls as indicated below: 2/6/17 - Resident reported that she fell in the bathroom and got herself up, and that her left knee was hurt. Interventions: Neurochecks, 15 minutes checks. 2/19/17 - Resident observed sitting on floor on buttocks indicating she fell out of bed. Small scrapes to the right elbow. Intervention: 15 minutes checks and Neurochecks. 3/15/17 - Resident fell face first to the floor. Resident receive a bump on her forehead and red spot on the nose. Intervention: Neurochecks, ask for help. 4/12/17 - Resident observed sitting on the floor next to bed on bottom. Abrasion/skin intact. Intervention: room change, Neurochecks, bed at functional level. 4/27/17 - Resident loss her balance and fell to sitting position on the floor. No injury noted. Resident educated. 6/1/17 - Resident fell out of bed while sleeping. No apparent injury. Intervention: Concave mattress, floor mat. 6/13/17 - Resident was observed laying on her left side next to her bed. No apparent injury. Interventions: Bed check for appropriate height, Neurochecks, 15 minutes safety checks while in bed. 6/26/17 - Resident observed lying face down on floor in front of toilet and brief around her ankles. Bruise noted to right eye, unable to open eye. Intervention: Night light, longer call light cord to reach commode, Neurochecks. Encourage resident to use call light, have toileting assistance. 7/7/17 - Resident was observed lying on her back on floor in front of toilet in room. No apparent injury. Interventions: Neurochecks, 15 minutes safety checks. 7/17/17 - Resident was observed lying on back on floor where the rolling walker tipped away from resident. Resident lost her balance and fell while self transferring from bed. No apparent injury. Intervention: Remind resident to use call light, keep bathroom light on/crack the door and Neurochecks. 7/24/17 - Resident was observed lying on the floor in front of bed with walker between her leg. No apparent injury. Intervention: Keep wheelchair within reach near the bed and encourage use when she is unsteady. 8/1/17 - Resident observed sitting on the floor in front of her bedside table crying. Resident stated she was trying to get to her wheelchair. Bruise above right eye and a small red area at the base of hairline on neck. Intervention: Neurochecks and 15 minute checks. 8/5/17 - Resident was observed on the floor attempting to go to bathroom. No apparent injury. Interventions: Keep wheelchair within reach, neuro checks and 15 minute checks, pharmacy review of med's. 8/18/17 - Resident observed lying in her room on the floor in front of her wheelchair. No apparent injury. Intervention: appropriate footwear and clothes. 8/21/17 - Resident observed lying next to her bed on the floor mat on her left side. No apparent injury. Intervention: Neurochecks. 9/10/17 - Resident was observed on buttock on the floor in front of toilet. No apparent injury. Intervention: Ensure proper footwear is on prior to transferring. An interview was conducted with CNA M on 9/19/17 at 9:20 a.m. CNA M stated, We have residents that we keep check on every 15 minutes. We try, but we get busy and we just can't do it. I have 19 residents now, and one more on the way. It is impossible for us to give the resident the care that they need. These residents need help. An interview was conducted with the Director of Nursing (DON) on 9/20/17 at 3:00 p.m., who indicated that Resident #707 takes herself to the bathroom and we use different interventions such as doing safety checks every 15 minutes. The DON also stated that they have a meeting every day and discuss falls and try to come up with interventions and if the intervention don't work, they try something else. According to the facility policy titled Falls - Clinical Protocol dated February 2017, 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 .If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. Resident #705 On 9/19/17 at 8:55 AM, a review was completed of Resident #705's electronic medical records and it revealed the following: Resident #705 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) assessment dated 8//20/17 the Resident was one person assist for most Activities of Daily Living (ADL') and is cognitively intact. On 9/20/17 at 9:50 AM, an interview was conducted with Resident #705 and they stated there is not enough staff to assist the Resident's in meeting their daily needs. The Resident denied having any current falls and seemed comfortable in their environment. On 9/21/17 at 9:00 AM, a review was completed of the five falls the resident sustained [REDACTED]. 11/22/16 at 6:15 AM: Resident observed sitting on the floor stating they fell out of their wheelchair and hit their head on the bedside table. Resident sent to emergency room for evaluation. There were no interventions added. 11/27/16 at 11:15 PM: Resident was observed by CNA sitting in front of wheelchair on floor in room. No new interventions were added. 12/10/16 at 11:15 AM: Resident was hanging robe in closet and lost balance and fell to their bottom. No new interventions were added. 1/18/17 at 12:11 PM: Resident was observed laying on their right side in front of the recliner. Resident was trying to pick up crumbs off of the floor. Interventions: Neuro checks for 72 hours. 1/7/17 at 1:30 PM: Resident leaned in the recliner slide to the floor. Interventions: Follow current care plan. Resident #708 On 9/18/17 at 2:00 PM, a review was completed of Resident 708's electronic medical records and it revealed the following: The Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 9/19/17 at 9:40 AM, Resident #708 was observed sitting in the dining room eating breakfast. The Resident was using profanity toward many of the Residents and the staff had to constantly redirect the Resident. CNA U reported the Resident has not had any recent falls but is on fall precautions for just in case purposes. The CAN reported there are three CNA's working the dementia unit which is not normal. The CNA reported it is normally two CNA's. On 9/19/17 at 4:30 PM, a record review was completed of Resident #705's fall care plan. It provided the following interventions: anti-lock brakes, non-skid footwear, and floor mat and grippy on wheelchair. On 9/21/17 at 11:00 AM, a review of completed of the five falls the Resident had while at the facility and it revealed the following: 1/24/17 at 10:00 PM: Resident was observed sitting on the floor next to their bed. Interventions: Neuro checks for 72 hours and frequent safety checks. 4/3/17 at 4:50 PM: Resident was observed sitting on their bottom in the doorway of the room and hallway. Interventions: 15 minutes checks while on hall. 4/6/17 T 4:00 PM: Resident was observed sitting at the dining room table and the Resident pushed themselves away from the table and the wheelchair came out from under the Resident and they fell on to their buttocks. Interventions: Attempt to engage in activities. 4/8/17 at 2:15 PM: Resident slide out of wheelchair to the floor. No new interventions were added. 8/1/17 at 11:00 PM: Resident was observed sleeping on mat next to bed. No new interventions added. Resident #713 On 9/18/17 at 1:00 PM, a review was completed of Resident #713's electronic medical records and it revealed the following: Resident #713 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicates the Resident being severely cognitively impaired. On 9/18/17 at 1:45 PM, Resident #713 was observed in the activity room sitting in the wheelchair and was speaking to a Certified Nursing Assistant (CNA). Nurse U explained Resident #713 previously had a lap buddy that the Resident was able to release but this intervention is no longer in place. On 9/19/17 at 9:55 AM, an interview was conducted with CNA V who reported Resident #713 falls all of the time and had some falls after the lap buddy was taken away. The CNA explained the Resident is very unsteady on their feet and does know their limitations. On 9/19/17 at 5:00 PM, a review was completed of 18 falls that Resident #713 has had at the facility. 14 falls occurred in the dining room and four falls occurred in the Resident's dining room. They are as follows: 11/27/16 at 2:25 PM: Resident fell attempting to self-transfer and sustained a left forehead abrasion and left forearm elbow abrasion. No new interventions added. 11/28/16 at 10:15 AM: Resident fell while standing up from wheelchair, no injury noted. Fall occurred in the dining room. No new interventions added. 11/29/17 at 2:10 PM: Resident fell in room and his head hit the wall causing an indentation in the wall. No new interventions added. 12/24/ 16 at 3:10 PM: Resident was attempting to self-transfer from wheelchair and was guided to floor by staff. Interventions: monitor for attempts to self-transfer. 12/29/16 at 8:30 AM: Resident attempting to stand from his wheelchair unassisted and fell to the floor. Fall occurred in the dining room. Intervention: Staff to ambulate. 12/31/17 at 5:00 AM: Resident observed on the floor in the dining room next to exit door. No new interventions added. 2/4/17 at 5:30 PM: Resident was self-transferring in the dining room and fell to the floor. No new interventions added. Interventions: Monitor resident frequently. 3/22/16 at 10:00 AM: Resident was lowered to the floor after standing in front of the wheelchair. Fall occurred in the dining room. No new interventions added. 3/26/17 at 3:20 PM: Resident attempting to self-transfer and slowly fell to his knees, then onto the left side. Fall occurred in the dining room. No new interventions added. 4/12/17 at 7:45 AM: Resident was in the living room area and leaned too far forward and fell out of wheelchair. Had abrasion to the center of forehead. No new interventions added. 4/23/17 at 5:00 PM: Resident learned too far forward and fell out of wheelchair while in the dining room. Interventions: Activity lap tray. 5/3/17 at 8:50 AM: Resident observed standing and falling slowly into sitting position, in the dining room. No new interventions added. 6/17/17 at 4:45 AM: Resident was walking out of bedroom and Resident lost balance in hallway and was lowered to the ground. Interventions: Fifteen minute checks. 8/11/17 at 1:30 PM: Resident attempted to self-transfer and was observed laying on the floor mat in bedroom. Interventions: Continue 15 minute checks. 8/12/17 at 6:15 AM: Resident was sitting on floor at foot of bed and was complaining of back hurting. No new interventions added. 8/27/17 at 9:00 AM: Resident was attempting to self-transfer from his wheelchair and fell , which caused abrasion on his forehead. Interventions: No new interventions added. 9/9/17 at 4:00 PM: Resident was sitting in wheelchair and fell on his left side in the dining room. No new interventions were added. 9/12/17 at 9:00 AM: Resident stood up from wheelchair and tried to sit back down and the wheelchair rolled from behind them and Resident landed on his buttocks. Anti-rollbacks were not working properly. On 9/20/17 at 8:10 AM, a review was completed of Resident #713's fall care plan. It revealed the following interventions: grippy socks, mattress next to low bed, anti-rollbacks on wheelchair, diversional activities, monitor frequently. On 9/19/17 at 3:20 PM, an interview was conducted with the Director of Nursing (DON) in regards to the 15 minutes checks that were implemented for Resident #713. The DON reported 15 minutes checks are completed but they are not documented. The DON reported this is a Standard of Practice at the facility. The DON was queried as to how they know if staff are completing the checks and the DON responded, I don't know, and Hoping I can take them at their word. On 9/20/17 at 10:05 AM, Resident #713 was observed in the dining room sitting on the couch, watching television. The Resident did not have on their grippy socks (as indicated in the fall care plan) but regular white socks. Nurse W was queried as to where Resident #713's grippy socks were and Nurse W reported they did not know and summoned a CNA to place grippy socks on the Resident. At 10:20 AM on 9/20/17, Nurse W was queried about the current interventions that are in place for Resident #713 as it relates to his falls. Nurse W reported the Resident has a mattress on the floor, auto-lock brakes, pommel cushion, low bed, creative redirection and ambulation the Resident. Nurse W was queried about the 15 minutes checks for Resident #713 and if they are completed and documented. Nurse W reported there is usually a paper the staff document on but it's hard to keep up with it on this unit. Nurse W reported the staff, Make a good attempt at doing them but get busy. On 9/20/17 at 3:53 PM, an interview was conducted with the DON in regards to Resident #713's falls. The DON explained Resident #713 does not know their own limits and has been in restorative therapy and diversional activities to curtail the Residents falls. The DON reported the Resident has a very short attention span. On 9/21/17 at 11:45 AM, a review was completed of the facility policy entitled, Fall-Clinical Protocol, revised February 2017. It revealed the following: .If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. Deficient Practice Statement #2 Based on interview and record review the facility failed to prevent an avoidable fall for one (Resident #713) of 13 reviewed for falls and preventative wheelchair maintenance from a total sample of 24, resulting in the potential for serious physical harm and unwanted feeling of embarrassment. On 9/18/17 at 1:00 PM, a review was completed of Resident #713's electronic medical records and it revealed the following: Resident #713 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicates the Resident being severely cognitively impaired. On 9/18/17 at 1:45 PM, Resident #713 was observed in the activity room sitting in the wheelchair and was speaking to a Certified Nursing Assistant (CNA). Nurse U was questioned if there were preventive maintenance check on the Resident's wheelchairs by maintenance and the Nurse responded, No. The Nurse U explained if something is broken they complete a form for maintenance and they will fix it. Nurse U explained Resident #713 previously had a lap buddy that the Resident was able to release but this intervention is no longer in place. On 9/19/17 at 9:55 AM, an interview was conducted with CNA V who reported Resident #713 falls all of the time and had some falls after the lap buddy was taken away. The CNA explained the Resident is very unsteady on their feet and does know their limitations. CNA V was asked if preventative maintenance checks are completed on the wheelchairs for Residents and the CNA responded, No. On 9/19/17 at 12:01 PM, a record review was completed and it was revealed that on 9/12/17, Resident #713 stood up from their wheelchair and went to sit back down, when the chair rolled from underneath them because the auto-lock brakes were not working properly. On 9/19/17 at 12:35 PM, an interview was conducted with the facility Maintenance Director in regards to preventive maintenance on Resident's wheelchairs. The Maintenance Director explained the wheelchairs are checked quarterly and they are alerted by their system that these checks need to be completed. The Director was queried as if there is documentation of preventive maintenance completed on Resident #713's wheelchair. The director explained the checks are not individualized to the Resident and there would be no documentation that the checks for Resident #713 were completed. It was added his team is alerted in morning meeting if any falls occurred involving malfunctions with wheelchair and they immediately rectify the issue. On 9/19/17 at 2:00 PM, a review was completed of a document entitled Maintenance Request that was completed on 9/12/17 for Resident #713. The request states, Roll backs on chair aren't working properly. The request was completed on 9/12/17.

This Citation pertains to Intake #MI 891 Based on observation, interview and record review, the facility failed to prevent development of multiple wounds including unstageable and stage 3 pressure ulcers for 2 (#'s 701, 704) of 2 residents reviewed for pressure ulcers from a total sample of 4 residents, resulting in unnecessary pain and suffering, the potential for wound infection, decreased mobility and quality of life. Findings include: Resident #701 On 5/24/17 at 11:40 am, Resident #701 was observed in a family member's room. The resident stated, I don't always get the care that is needed. It should be better. The resident grimaced and stated, Ow, when shifting weight in the wheel chair. The resident's family member stated, Sometimes it takes 1, 2 or 3 hours to answer the call light. There are usually 2 CNA's (Certified Nursing Assistants) for this hall and they go to the other hall also. Resident #701 indicated they were not assisted out of bed in time, that morning to eat breakfast in the dining room. The resident's family member added, I usually have to help (the resident) eat. An interview with Confidential Person J, on 5/24/17 at 12:05 PM, provided, the resident fell in October, at home, and broke (their) hip and had hip surgery. Resident #701 was admitted into the facility on [DATE]. Confidential Person J felt the resident received good care in the rehab unit, but then moved to the long term care unit. The resident was hospitalized from [DATE] - 4/1/17 with dehydration and bed sores (pressure ulcers) on their heels and buttocks. Confidential Person J further stated the resident, lost 20 pounds in the last 2 weeks. We've had several meetings (with the facility), with Awesome Plans, but they don't follow through. (Resident #701) has 2 cal and Ensure Plus (nutritional supplements), but they are not helping (the resident) with eating .(the resident) is seeing a wound care doctor. I know (the resident) is at the end of life, but I don't think (the resident) deserves to have this happen. On 5/24/17 at 12:35 PM, an interview with Confidential Person I, revealed, (The resident) was admitted into the facility in October 2016 for rehab and moved to another room about March 6, 2017. I assumed (the resident) was getting good care. I came in and (the resident) was moaning and was transferred to the hospital, they found pressure ulcers on the buttocks and right heel, a soaking wet brief that smelled terrible. (The resident) used a urinal before, but now because of the bed sores has a catheter. I've been up here for several hours, 3-4 and (the resident) hasn't been moved (The resident) has lost 20 pounds in the last 2 weeks. Staff refused to provide resident care in front of the family. Last Saturday (May 20, 2017), I came in at 10:00 PM, (the resident) had a shower at 3:30 pm, and went to bed at 4:00 pm and was still in bed and hadn't eaten dinner. They brought a sandwich and Ensure and (the resident) was satisfied. (The resident) needs to be up for every meal. This past Monday, May 22, 2017, breakfast was sitting in the room, close to noon, it was still untouched. No one helped (the resident) and should be in the dining room to eat. A record review on 5/24/17 at 12:40 PM, indicated Resident #701 was admitted into the facility on [DATE], discharged on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had confusion and required extensive 2 person assistance with bed mobility, 2 person assistance with dressing and transfers and extensive 1 person assistance with eating, hygiene and bathing. The resident did not walk and had a [MEDICAL CONDITION] and urinary catheter that needed 1 person to assist with care. Resident #701 was observed in the dining room with family providing assistance with lunch, at 1:30 PM on 5/24/17. On 5/24/17 at 1:50 PM, a review of the Care Plans for Resident #701 revealed the following: Skin Care Plan, initiated on 11/13/16 and stated revised on 1/7/17 with no updated interventions: I currently have skin breakdown on my right heel, coccyx and right posterior lateral calf. I have MASD (moisture associated skin damage) on my bil (bilateral) buttocks-There is 1 intervention on the Care Plan and it is dated 11/13/16-Monitor for s/sx (signs and symptoms) of complications. Measure wound weekly. Complete Drsg (dressing) changes per D.O. (doctor's order), Call Dr. (doctor) prn (as needed). There were no preventive measures indicated on the Skin Care Plan provided and dated 11/13/16. ADL (activities of daily living) Care Plan, initiated on 4/14/17 with the following interventions dated 4/14/17: Resident requires staff assistance with all ADL's-I require extensive assist x 1 with bed mobility, Encourage fluids and snacks, I am at high risk for skin breakdown related to decreased mobility, Meals-I require supervision with assist as needed following set-up of my meals and I need to be eating in DR (dining room) 1. This contradicted the MDS dated [DATE], that indicated extensive 2 person assistance with bed mobility. The ADL Care Plan was updated on 5/25/17 with, Offer resident food and fluids every 2 hours. On 5/24/17 at 2:00 pm, a review of a Nurse Practitioner's progress note, dated 5/3/17, Patient just had dressings changed on the decubitus ulcers on (the resident's) buttocks and is very uncomfortable .exam: patient is currently laying in bed and is crying out due to the pain from receiving the dressing changes on the ulcerations, patient is to receive a dose of pain medication stat (right now) .the patient has large ulcerations on the left and right buttocks. An interview with Wound Care Nurse H, on 5/24/17 at 2:50 PM revealed the skin breakdown on the resident's buttocks began as MASD (moisture associated skin damage) related to prior urinary incontinence and progressed with pressure ulcers. The resident now has an indwelling urinary catheter due to the continued worsening of the residents wounds. On 5/24/17 at 3:50 PM, wound care for Resident #701, was observed performed by Nurse H. The resident's seat cushion was wet upon transfer to bed and the resident's clothes were wet and foul smelling. The dressings on the resident's buttocks wounds were soaked wet and foul smelling. Nurse H stated there was, Drainage from the buttocks wounds. CNA D, was assisting Nurse H and stated the resident's clothes were soaked. Nurse H removed dressings from 16 wounds, including a new unstageable wound with slough, to the Left Trochanter, identified, Tuesday or Wednesday of last week, per Nurse H. The following wounds were identified: Left heel with eschar, left ankle scabbed, left lateral foot scabbed, right buttocks with one unstageable and 1- stage 3 pressure ulcer, Left foot-2nd and 3rd toes blackened scabbed, right outer calf-stage 3, right foot toes-1, 2, 3 & 5 with blackened areas, right heel- red, right ankle scabbed, left knee- stage 3 with eschar (deadened tissue) and reddened peri-wound, right knee- scab lifted and now open. Nurse H was observed removing soiled wet dressings from the resident's wounds, removing her gloves, performing hand hygiene, reapplying gloves and then cleansing the wounds and applying Santyl ointment( an ointment to disolve dead skin) to a gauze pad that was larger than the width of the wound, with her fingers to the new dressings, without changing her gloves or performing hand hygiene after cleansing the wounds. Nurse H then applied barrier cream with her fingers to the peri-wounds with the same gloves. Per manufactures recommendations for Santyl it should only be applied to the area of the wound with dead tissue. It should not be applied to healthy tissue. On 5/25/17 at 10:50 am, a review of the Bathtime Skin Anatomy Diagrams, revealed the following: 3/2/17: Sacral/Coccygeal-sore, has bandages, Ischial Tuberosity-intact groin, red (scrotum), Tibia/fibula-scratch on scabbed right leg. (3 areas) 3/8/17: Sacral/Coccygeal-clear, Ischial Tuberosity-patches, open sore, Tibia/fibula-clear. (1 area) 4/15/17: Sacral/Coccygeal-clear, Ischial Tuberosity-open sores, Heel-sores, Knees-sores, Greater Trochanter-clear. (3 areas) 4/20/17: Sacral/Coccygeal-open sores, Ischial Tuberosity-open sores, Heel-pressure sore (boots put on), Greater Trochanter-clear. (3 areas) 4/29/17: Sacral/Coccygeal-open sores, Ischial Tuberosity- open sores, Heel-both heels wrapped, Knees-small skin tear right knee, Greater Trochanter-clear, intact. (5 areas) 5/3/17: Sacral/Coccygeal-clear, Ischial Tuberosity-open sores and redness, Heel-sores, Knees-right knee scab, Tibia/fibula-right leg scab, Toes-two middle toe scabs, Greater Trochanter-clear. (6 areas) 5/7/17: Staff documented Bed bath due to sores and smell, Sacral/Coccygeal-open wound, Ischial Tuberosity-open wound, Heel-open wound, Knees-clear, intact, Tibia/fibula-right leg open area, Metatarsal heads-right toes scabbed over, Greater Trochanter- clear, intact. (5 areas) 5/10/17: Sacral/Coccygeal-open areas, Heel-open areas, Knees-open areas, Tibia/fibula-clear, intact, Greater Trochanter and Ischial Tuberosity have an arrow drawn through from the Sacral/Coccygeal documentation, open areas. (4 areas) 5/13/17: Sacral /Coccygeal-clear, Ischial Tuberosity-sores, Heel-sore on left, Knees-left sore, right scrape, Tibia/fibula-right leg sore, Toes-scabs on toes, Greater Trochanter-clear. (6 areas) 5/20/17: Sacral/Coccygeal-open wound, Ischial Tuberosity-open wounds, Heel-sores on both heels, Knees-red areas, Tibia/fibula-discoloration, Toes-old scabs, Greater Trochanter-Intact. (6 areas) On 5/25/17 at 11:20 am a review of the Wound Care, note written by PA S on 5/3/17, indicated Resident #701 had 8 documented wounds with 1 resolved wound (4R, toe): Left lateral leg, 2R, 3R, Right heel, left heel, right buttocks, left buttocks and left knee. Further documentation on 5/3/17 indicated, Left lateral leg- macerated, 40% slough (wet stringy discolored tissue), 3R-100% eschar, Right heel-discolored, left heel- 100% eschar (black deadened tissue), Right buttocks- 100% slough, too wet, green drainage, odor present, Left buttocks-80% slough, too wet, moderate green drainage, odor present. On 5/5/17 a urine culture and sensitivity result, revealed Resident #701 had a urinary tract infection with the bacteria pseudomonas aeruginosa, which is known to produce green foul smelling drainage. There was no wound culture performed to determine if this bacteria was also causing the green foul smelling drainage from the resident's buttock wounds. The resident was treated with antibiotic therapy for the urinary tract infection. Copious, foul smelling drainage was still present from the buttocks wounds on 5/24/17. 5/10/17: 10 documented wounds: Right lateral leg, right 2nd toe, 3R(toe), right heel, left knee, left heel, right buttocks, left buttocks, peri-skin, right forearm. There was further documentation on 5/10/17 that indicated, Left knee-Post debridement (removal of skin with a sharp blade), 80% slough, Left heel-100% eschar, Right buttocks-60% slough. A review of the 15 Minute Check documents from 5/1-5/24 indicated, the staff should document the following interventions: Check [MEDICAL CONDITION] every 2 hours, Offer fluids every 2 hours, Report Change in Condition, Every 2 hour turns. The items were not documented at all on 7 days and partially on each of the other days. There were no days that the items were documented as specified. Resident #704 On 5/24/17 at 12:40 pm, a record review revealed Resident #704 was initially admitted to the facility on [DATE], discharged to the hospital on [DATE] after sustaining a fall with right [MEDICAL CONDITION], returned on 4/20/17. The resident has returned to the hospital multiple times since the fall and was discharged again on 5/9/17 and readmitted on [DATE], discharged on [DATE] and readmitted on [DATE], with Diagnoses: [REDACTED]. The MDS assessment dated [DATE], indicated the resident had no cognitive decline and required extensive 1 person assistance with transfers, bed mobility, bathing and toileting. An interview with Nurse H on 5/24/17 at 3:05 pm revealed, Resident # 704 developed a pressure ulcer-Stage 3 on the left buttock. The area was observed by Nurse H on 5/23/17, after the resident returned from the hospital on [DATE]. The resident also had an unstageable pressure ulcer on the right heel and a Stage 1 pressure ulcer on the left heel. The resident had a history of [REDACTED]. Nurse H documented the left buttock wound as follows: 3.5 centimeters (cm) width by 3.7 cm height by 0.3 cm depth, on 5/23/17. An interview with Resident #704 on 5/25/17 at 10:25 am revealed, I told them it was hurting and they told me what it was. It looked like a boil from sitting in my wheelchair all day. I don't walk anymore, since my hip surgery. I just sit in this chair all the time. When the resident was asked if the wound was present prior to the most recent discharge to the hospital on [DATE], the resident responded, Yes, it was. I told them about it here. A review of the twice weekly skin assessments on 5/25/17 at 2:10 pm indicated, there was 1 skin assessment completed between 5/2/17 and 5/23/17, on 5/6/17. The resident was hospitalized ,[DATE]-[DATE] and 5/13-5/22/17. On 5/25/17 at 2:20 pm, a review of the resident's Care Plans provided the following: Skin Care Plan: The resident has potential impairment to skin integrity related to limited mobility, date initiated 4/21/17 and cancelled on 5/10/17, Monitor/document location, size and treatment of [REDACTED].and any other notable changes or observations. A new Skin Care Plan was started on 5/23/17 to indicate identification of the Stage 3 pressure ulcer on the left buttock and provided, Air mattress and a cushion in wheelchair, Heels up, quilted heel boots, Yellow Dot Program, Encourage resident to turn and reposition every 2 hours and as needed, Encourage resident to eat and drink well to keep skin healthy, look at skin during care, report redness and open areas to nurse. On 5/25/17 at 8:47 am, Nurse E was queried on Pressure Ulcer Prevention and stated, To my understanding, interventions include, turns every 2 hours-especially those that are High Risk, foods/fluids, change every 2 hours, Skin Assessments on shower days twice weekly, the CNA completes and the nurse signs off. On 5/25/17 at 3:05 pm, the Administrator was queried on Pressure Ulcer Prevention and stated, You'll have to talk to the wound care nurse. On 5/25/17 at 4:30 pm, a review of the facility policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 3/23/11 provided, The nursing staff and Attending Physician will assess and document an individuals significant risk factor for developing pressure sores.

This Citation pertains to Intake # MI 187 Based on observation, interview and record review, the facility failed to provide interventions and monitor residents to prevent falls and serious injuries for 3 (#'s 702, 703, 704) of 4 residents reviewed for safety and falls, resulting in Resident #702 not being able to walk, after falling and sustaining right arm, right femur and left pelvic fractures; Resident #703 with multiple falls resulting in face and head injuries and Resident #704 with decreased mobility after falling and sustaining a right hip fracture. Findings include: Resident #702 An observation on 5/24/17 at 9:25 am revealed, Resident #702 was sitting in a wheelchair in the dining room on the 200 unit. Certified Nursing Assistant (CNA) A was assisting the resident with breakfast. A record review on 5/24/17 at 11:00 am revealed, Resident #702 was originally admitted into the facility on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a significant change in abilities, after falling on 3/23/17 and required extensive 2 person assistance with transfers and toileting and no longer ambulated. The resident's memory was not assessed due to confusion. The resident received the following medications: [REDACTED]. A review of the Incident and Accident reports indicated Resident #702 had fallen twice: On 1/2/17 the resident fell , after being left alone and developed a right elbow skin tear. The Certified Nursing Assistant (CNA) P, indicated Resident #702, .was standing. I went to ask (the resident) to sit . (the resident) said to get the f*** away from, so I gave (the resident) some space, went to get napkin for other CNA and then Resident fell on the right side . On 3/23/17 the resident was standing in the day room folding a blanket and fell . CNA P indicated, Resident was behind couch in lounge area .was folding a lap blanket started to lose balance and tipped sideways falling on (the residents) buttock. There was no documentation that the resident was supervised or received assistance with ambulation prior to the fall. On 5/24/17 at 12:00 PM, a review of the resident's care plans indicated: an ADL Care Plan, dated 12/15/16, stated, I can ambulate with a RW (rolling walker) and SBA (stand by assist), the resident requires supervision by 1 staff to move between surfaces. The ADL care plan was not updated to indicate the resident was no longer able to walk or needed extensive 2 person assistance with transfers. The Fall Care Plan initiated on 12/15/16 indicated, Assist with mobility. There were no updated interventions after the resident's fall on 1/2/17 or 3/23/17. The care plan had a revision date of 1/3/17, but all interventions were dated 12/15/16. An observation on 5/24/17 at 12:30 PM indicated Resident #702 was sitting in a wheelchair in the dining room with supervision for lunch. An interview with Certified Nursing Assistant A provided, (The resident) used to walk all over, before (the resident) fell and broke (their) hip. (The resident) doesn't walk now. On 5/25/17 at 10:45 am, a review of the Fall Risk Evaluation, revealed the following: 1/3/17 - Ambulates with problems and with devices, Balance unsteady. 3/14/17- Ambulates without problem and without devices, Balance not steady. 4/13/17-Confined to chair, Balance-not able to attempt without physical help. Resident #703 On 5/24/17 at 9:30 am, the resident was observed sitting in the dining room eating breakfast. The resident had purple bruises under the right eye, forehead, left eye, left cheek and left jaw line. There were abrasions on the left forehead and under the left eye. A record review, on 5/24/17 at 10:15 am, indicated Resident #703 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated the resident had severe cognitive impairment and required 1 person assistance with transfers, ambulation and toileting. On 5/24/17 at 11:25 am, an interview with CNA A, indicated Resident #703 had 2 falls recently. CNA A was queried on what measures were in place to assist in preventing further falls for Resident #703 and responded, 15 minute checks when in bed and a bed alarm for prevention. We have the checks and bed alarm because (the resident) only falls when in bed. When queried if the 15 minute checks were documented, CNA A stated, I believe so. It's on paper. I don't know where it is. An observation on 5/24/17 at 12:45 pm, revealed the resident was sitting on the couch in the dining room. CNA A assisted with the transfer and Resident #703 began walking alone around the dining room, without a walker or other assistive device. On 5/24/17 at 1:15 pm, a review of the Incident and Accident reports indicated Resident #703 fell 5 times from 12/28/16 - 5/20/17. Each time the resident fell on their face or head. Three falls were in the resident's room, one in the hallway and one in the dining room. On 1/4/17 the resident was transferred to the hospital after being found on floor on belly, Resident was lethargic, difficult to arouse ., on 1/3/17. A review of the Nurse practitioner's progress note dated 1/7/17, indicated Resident #703 complained of head and face pain and was grimacing, grabbing their head and complaining of a headache related to the recent fall. The Nurse Practitioner further noted, .patient needs supervision if ambulating or if in wheelchair, patient has multiple bruises on hips, knees, lower extremities, bilateral orbits and skull related to multiple falls. An interview with CNA F on 5/24/17 at 7:50 pm provided, I don't usually work down here. I'm not sure, when queried on what interventions were in place to aid in preventing Resident #703 from falling again. CNAG replied, No, not now, when asked if the resident had 15 minute checks. On 5/25/17 at 9:15 am, Nurse N was queried on what measures were in place to prevent falls and stated, A Care Plan for individual measures, dedicated staff (staff who consistently work in that area), specific staffing to resident ratio (none specified) and being observant. Bringing up the fall in the morning meeting: cause, time, trends, what was going on at the time; 15 minute checks, the CNA keeps it with them and it is scanned into the record. On 5/25/17 at 11:15 am, a review of the Fall Risk Evaluations, for Resident #703, revealed the following inconsistencies: 1/3/17-Ambulates without problem and without devices, Balance, Steady, maintains position as required. 1/4/17-Ambulates with problems and with devices, Balance, not steady, only able to stabilize with physical assistance. 1/31/17- Ambulates without problem and without devices, Balance, not steady, but able to stabilize without physical assistance. 3/21/17-Ambulates without problem and without devices, Balance, steady maintains position as required. 5/17/17-Ambulates with problems and with devices, Balance, not steady, only able to stabilize with physical assistance. 5/20/17-Ambulates without problems and without devices, Balance, steady, maintains position as required. A review of the Fall Risk Assessments, dated 6/13/16-9/16/16, indicated the resident had a Fall Risk- Total Score of 13-19. The assessment further provided, Upon admission and quarterly (at a minimum) thereafter, assess the resident status in the eight clinical condition parameters .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential FALLS. A prevention protocol should be initiated immediately and documented on the care plan. A review of the Care Plans for Resident #703 revealed an ADL (activities of daily living) care plan initiated on 11/13/16, Ambulation (revised 1/31/17), Encourage and assist with use of RW (rolling walker) and verbal cues to /from bathroom/dining room, Transfer- limited 1 assist (revised on 1/10/17). The Fall Care Plan dated 11/13/16 indicated, 2 updated interventions, since the resident's last fall on 5/20/17: 5/22/17-Resident will wear grippy socks, and 5/23/17-I have a sensor alarm pad on my bed for safety. An intervention on 11/13/16 provided-Offer w/c (wheelchair) if I seem to be tired or my gait appears unsteady. There were no additional updates or preventive measures added to the Care Plan after Resident #703 fell on [DATE], 1/3/17, 1/31/17 or 5/17/17. Resident #704 On 5/24/17 at 12:40 pm, a record review revealed Resident #704 was initially admitted to the facility on [DATE], discharged to the hospital on [DATE], after sustaining a fall with right hip fracture and returned on 4/20/17. The resident has returned to the hospital multiple times since the fall and was discharged again on 5/9/17 and readmitted on [DATE], discharged on [DATE] and readmitted on [DATE], with Diagnoses: [REDACTED]. The MDS assessment dated [DATE], indicated the resident had no cognitive decline and required extensive 1 person assistance with transfers, bed mobility, bathing and toileting. A record review, on 5/24/17 at 2:15 pm revealed the following: A review of the progress notes indicated, Resident #704 fell 3 times at the facility: 3/27/17-while standing from the wheel chair, the resident fell and landed on the foot pedal, 4/7/17-the resident fell while walking in the room and hit their head on the TV, 4/14/17-the resident fell while showering self and was transferred to the hospital with a hip fracture requiring surgical repair. A review of the Fall Risk Evaluations indicated the following: 2/11/17-Ambulates with problems and with devices; Balance, not steady, only able to stabilize with assistance. 3/3/17-Ambulates without problem and with devices; Balance, not steady, but able to stabilize without physical assistance. 3/29/17-Ambulates without problem and with devices; Balance, steady, maintains position as required. 4/14/17-Ambulates without problem and with devices; Balance, steady, maintains position as required. 5/22/17- Confined to chair; Balance, not able to attempt without physical help. A review of the Standards of Care (SOC)-Falls meeting notes on 5/24/17 at 2:25 pm revealed the following: 3/30/17-Resident had a fall brought to I&A (incident and accident), will review next meeting. 4/5/17-Resident had a fall on 3/27/17, Foot pedals were on, may have been a factor in the fall, Remind resident to adjust pedals to the upright position or have staff remove for transfers from wheel chair. The Care Plan was not updated to show this. 4/13/17-Resident has had no further falls. The resident fell on [DATE]. 4/20/17-Resident had a fall on 4/14/17; Resident slipped and fell in the shower while showering self. On 4/24/17 at 2:45 PM, a review of the Care Plans for Resident #704 indicated the following: An ADL Care Plan dated 2/11/17: The resident has an ADL self- performance deficit related to impaired balance, limited mobility and pain: Resident can ambulate independently with 4 wheeled seated walker. (dated 3/16/17 and cancelled on 4/18/17) There was no entry on the ADL care plan for showering ability until 4/14/17: I need supervision with bathing. (discontinued on 4/18/17) The MDS dated [DATE], indicated the resident needed extensive assistance with 1 person for bathing. This was not indicated on the Care Plan. A Fall Care Plan dated 2/13/17 indicated,The resident is at risk for falls related to deconditioning, gait/balance problems and pain: All interventions were initiated on 2/13/17 including, Follow facility fall protocol. After the readmission, from the hospital, of Resident #704 on 4/20/17, new Care Plans, dated 4/21/17 were initiated: ADL Care Plan- I require extensive assistance while bathing/showering at all times and Non-ambulatory at this time. An interview with Resident #704, on 5/25/17 at 10:25 am provided, I was using the shower chair and the chair slid backwards. (The CNA) told me they would do a skin assessment and never came back. (They) left me on my own. I don't walk anymore. I just sit in this chair all the time, when queried on how the resident had fallen in the shower. On 5/25/17 at 10:45 am, Nurse R was queried on the showering procedure for Resident #704 prior to the fall on 4/14/17 and stated, We helped (the resident) into the shower and (the resident) washed (themselves). The staff stood in the doorway. When asked if the CNA stood in the doorway, while the resident showered on 4/14/17, Nurse R responded, No, (CNA) was in the hall. On 5/25/17 at 2:35 pm, an interview with, CNA Q revealed, It was (the resident's) shower and another resident's (shower). I asked if (Resident #704) wanted to do the shower. The Care Plan for CNA's said Independent-showers Independent, transfers Independent, I asked another CNA and they said Yeah, (the resident) was independent, I was across the hall filling out the skin assessment. An interview with the facility Administrator on 5/25/17 at 3:05 pm provided, I'll have to check on that, when queried on what measures were in place to prevent Resident #704 from falling prior to the fall on 4/14/17. When queried on the resident's need for assistance with showers, as indicated in the 2/17/17 MDS, the Administrator stated, (The resident) was independent. On 5/25/17 at 4:15 PM, a review of the facility policy titled, Falls-Clinical Protocol, dated 2/2013 provided, The Minimum Data set .will be utilized to develop the comprehensive plan of care to minimize falls and injuries with falls, the interventions should be developed and implemented per the assessed needs, the care plan and CNA care card should be updated as interventions change, the staff will monitor and document the individual's response to interventions intended to reduce falling .If the resident continues to fall .re-evaluate the continued relevance of current interventions, Residents will be reviewed through Standards of Care .after new interventions are implemented to determine if effective or revision is necessary.

This citation pertains to Intake # Based on interview and record review, the facility failed to recognize, evaluate, and intervene to prevent an avoidable weight loss for one (#701) of two sampled Residents reviewed for weight loss, of a total sample of three, resulting in severe weight loss and the potential contribution for a decline in overall medical condition. Findings include: Resident #701 Record review on 3/20/17 at 9:20 AM revealed that Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review also indicated the Resident was discharged from the facility on 3/9/17. Review of Resident #701's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the Resident required extensive assistance to complete Activities of Daily Living (ADL's) and indicated that the Resident was rarely/never understood in regards to cognitive status. Resident #701's facesheet indicated that the Resident had a guardian/responsible party. On 3/20/17 at 9:25 AM, Resident #701's weights were reviewed. On 5/16/16, the first weight documented in the medical record for the Resident was 193.4 Lbs (pounds). Record review of additional weights revealed the following measurements: -10/5/2016 - 187.0 Lbs -12/6/2016 - 180.6 Lbs -2/6/2017 - 175.6 Lbs -3/8/2017 - 157.2 Lbs Record review on 3/20/17 at 11:00 AM of Resident #701's Dietary Care Plan (Date Initiated: 11/5/16, Revised Date: 2/24/17) revealed the following Focus Area My weight has trended upward. My weight has stabilized in the 180's-low 190's. Resident has had a decreased po (oral) intake. Care Plan interventions included: -High cal (calorie) mashed potato BID (twice a day) with meals (Date initiated: 3/9/17) -Ice cream BID with meals (Date initiated: 3/9/17) -Mechanical soft with ground meat with thin liquids, allergy to fish and shellfish. strict aspiration precautions, meals in DR3 (dining room) for supervision, 90 degree positioning for all PO (oral) intake (Date initiated: 3/9/17) -Two cal 60 cc TID (three times a day) with med pass (Date initiated: 3/9/17) -Weigh weekly (Date initiated: 2/24/17) An interview was conducted with Dietitian Staff A and Dietary Manager Staff B on 3/20/17 at 1:20 PM. When queried regarding Resident #701's weight loss, Staff A stated, (Resident #701) was on our radar for weight loss. When asked what Staff A and Staff B utilize for Resident #701's usual weight measurement, Staff A replied, I am using the 170's now. When queried further regarding what interventions had been implemented related to the Resident's weight loss, Staff A stated, We started (Resident #701) on ensure clean twice a day on 2/24/17. Staff B added, We also changed (Resident #701) from monthly weights to weekly weights on 2/24/17. Staff A then stated, We changed the ensure to high calorie mashed potatoes and 60 milliliters (mL) of two calorie (dietary supplement) twice a day. When queried when updated interventions were implemented, Staff B replied, March 9th. When queried regarding Resident #701's discharge date , Staff B replied, (Resident #701) was sent out to the hospital on [DATE]. When asked if the Resident received the modified dietary interventions, Staff B replied, No. When questioned regarding why interventions were not implemented prior to 2/24/17 and 3/9/17 for Resident #701, Staff A replied, We didn't change any interventions until after we had our Dietary Care meeting which was on the (March) 9th. When queried if the concern regarding Resident #701's weight was identified prior to the 3/9/17 and why interventions were not implemented prior to 3/9/17, Staff A replied, We did update the interventions on 2/24/17. I see what you are saying. We could have changed the interventions sooner. When queried regarding Resident #701's food intake, Staff B replied, (Resident #701) has never been a big eater but lately, (the Resident) hadn't been eating much. (Resident #701) told me their mouth hurt. When asked when the Resident said that, Staff A replied, I think it was the day (Resident #701) left so March 9th. When queried why the Resident's mouth hurt, both Staff A and Staff B were unable to provide an explanation. When queried if there was a medical or personal reason that the Resident wanted to lose weight, Staff B replied, No, (Resident #701) did have some issues with retaining fluid because of their heart in the past but that hasn't been a problem in a long time. Upon request of a policy pertaining to weight loss, monitoring, and interventions at this time, Staff A stated, We really don't have a specific policy. I use general dietary guidelines, not a policy. Based upon a usual weight of 175 lbs., weight measurements indicate Resident #701 experienced the following severe weight loss amounts while at the facility: -A 17 percent weight loss from October 2016 to March 2017 (6 month timeframe). -A 13.3 percent weight loss from December 2016 until March 2017 (3 month timeframe). -A 10.5 percent weight loss from February 2017 to March 2017 (1 month timeframe). During a confidential interview on 3/20/17 at 2:20 PM, when queried regarding Resident #701, Confidential interview participant C stated, I went to the facility on [DATE] to visit (Resident #701). When I saw (the Resident), they looked so skinny. I have never seen (the Resident) look like that before. They (the Resident) told me that they hadn't really ate in a week. It was awful. Record review of Resident #701's food intake records dated 3/1/17 to 3/9/17 on 3/20/17 at 3:30 PM revealed documentation for 25 meals. Of the 25 total meals, Resident Refused is documented for 11 meals and Resident #701 ate 50 percent or less of seven meals during this timeframe. No documentation was found in Resident #701's medical record regarding mouth pain or abnormalities during review at this time. An interview was conducted with the Director of Nursing (DON) on 3/20/17 at 2:50 PM. When queried regarding Resident #701's weight loss, the DON stated, I believe that the Dietitian and Dietary Manager were working on that. When asked what the facility considers significant weight loss, the DON replied, Greater than 10 percent in a month is significant. When queried what is considered severe weight loss, the DON replied, It's the same. When queried regarding documentation of mouth pain for Resident #701, the DON stated, I saw the Resident and I didn't see anything wrong with her mouth the day that she went to the hospital. The (Resident) family wanted the transfer so we had (the Resident) transferred. When queried regarding a policy pertaining to weight loss, monitoring, and interventions, the DON stated, Not sure what we have, I will see what I can find. When queried if Resident #701 not eating well, refusing meals, and severe weight loss is considered a significant change in condition, the DON did not provide a response. Record review of facility policy entitled Guidelines for Standards of Care (SOC) Meeting (No Date) on 3/20/17 at 3:15 PM revealed that The facility will meet routinely to monitor and evaluate the individual quality of Resident care . and The weekly meeting reviews: . Nutrition/Hydration Risk . Weight Loss/Gain. Record review of facility policy entitled Change in Resident's Condition or Status (Revised date 10/7/10) on 3/20/17 at 3:20 PM revealed that the facility shall promptly notify the Resident, his or her Attending Physician, and representative (sponsor) or changes in the Resident's medical/mental condition and/or status. The policy additionally revealed a significant change of condition is a decline or improvement in the Resident's status that: will not normally resolve itself without intervention by staff . , impacts more than one area of the Resident's health status, and requires interdisciplinary review and/or revision to the care plan.

Based on observation, interview and record review, the facility failed to prevent development of a stage 4 pressure ulcer for 1 (# 503) of 4 sampled residents reviewed for pressure ulcers from a total of 24 residents, resulting in unnecessary pain and suffering and the potential for wound infection, decreased mobility and quality of life. Findings include: On 11/15/16 at 1345 record review revealed that Resident (#503) was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the The Minimum Data Set (MDS) quarterly assessment dated [DATE] indicates Resident( #503) has a Brief Interview for Mental Status (BIMS) score of 7 indicating cognitive impairment. The MDS also indicates Resident (#503) requires extensive assistance with transfers, dressing, toileting and bathing, limited one person assistance in motoring her wheelchair and supervision with eating. An unstageable wound to the left sacral/lower back area was also noted. A significant change MDS was completed on 9/14/16 and identified a stage 4 pressure ulcer to the left sacral area. The admission MDS did not indicate presence of a pressure ulcer. On 11/15/16 at 0900 during the initial tour with the Director of Nursing (DON), resident # 503 was observed sleeping in bed positioned on the left side. The DON stated, The resident has a stage 3 pressure ulcer when asked if it was facility acquired she stated, yes. On 11/15/16 at 1115 Wound Care Nurse L was asked to observe the dressing change, she stated, The dressing was changed last night, but we can look at the dressing, she has a wound vac. Wound Care Nurse L removed the residents brief, Wound Care Nurse L stated, The wound vac is disconnected. A border foam dressing dated 11/15/16 was observed on the left sacral/lower back wound. Wound Care Nurse L was asked why it was applied instead of the wound vac, she stated, The wound vac must have come off and someone put this dressing on. When asked if she was aware that the ordered dressing was not in place she stated, No. The wound was measured by Wound Care Nurse L, at 2.7 centimeters (cm) height by (x) 2.2 cm width x 1.3 depth, with 1 cm undermining. The wound vac dressing was applied. On 11/15/16 at 1445, a review of Resident (#503's) weight history revealed that the first admission weight of 170 pounds (lbs), on 4/30/16 to 119.2 lbs; on 11/7/2016. indicated a 50.8 pound unplanned weight loss. Resident (#503) lost 36.2 pounds between the time of admission on 4/29/16 and 8/5/16. On 11/16/16 at 1100 review of the completed skin assessments-Bathtime Skin Anatomy Diagram for Resident (#503) Showed: 6/7/16 documented redness for Sacral/coccygeal, Greater Trochanter and Ischial Tuberosity the assessment was not signed by a nurse aide or nurse. The June 2016 treatment administration records did not indicate a treatment was ordered for the reddened area. 7/5/16 documented very red/irritated, applied barrier cream. The document was signed by a nurse aide and a nurse. 7/8/16 documented Red-barrier cream applied for the Sacral/Coccygeal area. A nurse aide and nurse signed the document. 7/22/16 documented Red for the Sacral/Coccygeal area: signed by a nurse aide and nurse. No intervention documented. 7/26/16 documented still a little red, Applied antifungal cream. Signed by a nurse aide and nurse. The treatment administration records did not indicate a treatment was ordered in July 2016. 8/2/16 documented wound care referral made and barrier cream applied, Left butt cheek red mark not opened. Signed by a nurse aide and a nurse. 8/5/16 documented Bad Bruise/sore cleaned and applied barrier cream sacral/left buttock area highlighted, signed by a nurse aide and nurse. 8/9/16 documented, treatment in place for Sacral/coccygeal area. On 11/16/16 at 1120, review of the treatment records and orders dated 8/3/16 revealed an order for [REDACTED]. A review on 11/16/16 at 1500 did not indicate the physician was notified of the reddened area prior to 8/2/16. A record review on 11/17/16 at 1000 indicated the Wound Care physician saw Resident (#503) on 8/17/16 for the first time. On 11/17/16 at 1015 record reviewed shows that Resident (#503) has had sharp surgical debridement of the stage 4 sacral wound 4 times: 8/17/16, 8/24/16, 9/1/16, and 10/7/16. On 11/15/16 at 1545, review of the Activities of Daily Living (ADL) Care Plans documentation program for Resident (#503) were not updated to include a new intervention for prevention of skin breakdown after the redness was identified on 6/7/16. The Care plan was not updated until after the identified wound on 8/2/16. A significant change MDS was completed on 9/14/16. On 11/16/16 at 1340, the Registered Dietitian (RD) H was interviewed and asked if she was monitoring the food acceptance of Resident (#503), as the Resident had lost 50 lbs. since admission. The RD H stated, Honestly no, I don't look at the food acceptance. I ask theCertified Nurse Assistant (CNA)'s. Review of RD H's progress note dated 5/5/16 indicates Resident (#503's) diet was downgraded to mechanical soft on 5/4/16, Mightyshake was added at lunch. Current diet remains appropriate to meet estimated needs. The next RD progress note was dated 6/24/16 and noted the resident had allergies [REDACTED]. She avoids nuts, seeds, rice, hard vegetables and fruits. An interview on 11/16/16 at 1340 with Dietary Director J provided, I order gluten free pasta and bread for the resident. When asked if Resident (#503) eats the products, Dietary Director J states, She does not like the gluten free products and will not eat them. When asked what is provided instead, both RD H and Dietary Director J said the resident receives Mightshakes and supplements. When asked if she likes those they responded, No. When asked if they have tried to find foods that the resident might like to eat, RDH responded, I called the daughter, but she didn't really say what she liked to eat. When asked if the RD had reviewed the food acceptance records to determine what the resident does eat more of , RDH stated, No. The DON was interviewed on 11/17/16 at 1315 and stated, The resident has a history of wandering around the facility in her wheelchair. She puts things in her chair and the day the pressure ulcer was discovered she had a magazine and a mirror in her chair. We think she was sitting on it. The Administrator was interviewed on 11/17/16 at 1345. She also said the resident had a history of [REDACTED]. On 11/17/16 at 1500, review of the facility's policy, titled, Prevention of Pressure Ulcers, dated 3/21/11, reads, The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family and addressed, General Preventive Measures: Immediately report any signs of a developing pressure ulcer to the supervisor. ( )

Based on observation, interview and record review, the facility failed to weigh 1 (#518) of 1 sampled resident weekly and failed to assess the benefits and risks of restricting and downgrading the diet and obtain the food preferences for 1 (#503) of 11 sampled residents reviewed for weight loss from a total sample of 24 residents, resulting in significant unplanned weight loss for each resident. Findings include: On 11/15/16 at 1345 record review revealed that Resident #503 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicates Resident #503 has a Brief Interview for Mental Status (BIMS) score of 7 indicating cognitive impairment. The MDS also indicates Resident (#503) requires extensive assistance with transfers, dressing, toileting and bathing, limited one person assistance in motoring her wheelchair and supervision with eating. An unstageable wound to the left sacral/lower back area was also noted. A significant change MDS was completed on 9/14/16 and identified a stage 4 pressure ulcer to the left sacral area on 8/2/16. The admission MDS did not indicate presence of a pressure ulcer. On 11/15/16 at 1100 , a review of the residents weights revealed: 4/30/16 170 pounds (lbs) 5/2/16 167.4 lbs 7/5/16 145.8 lbs 8/5/16 133.8 lbs 8/11/16 130.6 lbs 9/22/16 122.2 lbs 9/26/16 122.8 lbs 10/4/16 124.6 lbs 10/6/16 127.6 lbs 10/10/16 124.2 lbs 10/17/16 121.4 lbs 11/7/16 119 lbs 11/17/16 117.2 lbs This represent a weight loss of 48.6 lb significant weight loss/28.58 percent (% ) from admission through the first 6 months of stay at the facility. The Nutrition/Hydration progress notes written by Registered Dietitian H and reviewed on 11/16/16 at 1030 indicate the following: 5/5/16 Diet was downgraded to mechanical soft, ground meat on 5/4/16. Mighty shake added at lunch.Current diet remains appropriate to meet estimated needs. Will continue to monitor and make further dietary interventions 6/24/16 allergies [REDACTED]. Resident avoids nuts, seeds, rice, hard vegetables and fruits. She consumes meals in dining room [ROOM NUMBER]. Will increase Mighty shake to TID (three times a day). 7/21/16 Will add a magic cup at lunch in addition to aid with prevention of further weight loss. 7/28/16 . fortified mashed added to aid with prevention of further weight loss. 11 of 18 Nutrition/Hydration progress notes stated, Current diet remains appropriate to meet estimated needs, as Resident #503 continued to lose weight. On 11/15/16 at 0900, Resident #503 was observed lying in bed sleeping. The meal tray was on the bedside table and untouched. On 11/16/16 at 0845 the resident was observed in dining room [ROOM NUMBER] (the dining room for those residents needing assistance with eating) wheeling herself towards the doorway. The staff called out to the resident and encouraged her to come back to the table to eat. The resident had eaten less than 50% of her breakfast and stated, It doesn't taste good. 11/17/16 at 0900 the resident was observed sleeping in bed. The breakfast tray was covered and untouched. On 11/16/16 at 1340, the Registered Dietitian H was interviewed and asked if the food acceptance documentation was reviewed for Resident #503. RD H stated, Honestly no, I don't look at the food acceptance, I ask the Certified Nurse Assistants (CNA)'s. When asked if the residents food preferences by intake on the food acceptance were reviewed, the response from RD H stated, I ask the CNA's how the residents are eating. RD H was asked how she was informed of a residents weight loss, she said she reviews the weight report collected by the Certified Dietary Manager (CDM I) and Cena's usually let someone know. When queried if she was aware that Resident #503 has had a severe weight loss, RD H stated, The weight loss continues, the resident eats about 50%. The resident is hit or miss with the supplements and doesn't really take anything. The daughter was contacted for food preferences and isn't really sure why she has a gluten free diet. The Dietary Director J was interviewed and stated, I order gluten free pastas and breads for the resident. She does not like the gluten free products and won't eat them. When asked if the resident was able to eat foods that she liked, or fresh fruits and vegetables, the RD and Dietary Director stated, She is on a mechanical soft diet. When asked if the fruits and vegetables could be softened to accommodate the diet, the dietary director stated, To be honest I haven't watched what she eats the best. I have 130 residents at this facility to monitor. A review of the Dietary Care Plan dated 11/12/16 for Resident #503 indicates the items the resident can't have and the supplements ordered, but does not include the residents preferences and likes. A peanut butter and jelly with gluten free bread sandwich is added, but when RDH was asked if the resident would eat the gluten free bread the response was, No. The Care Plan also includes, Resident consumes meals in dining room one. She requires set-up assistance with meals and cues for continued intake. Encourage small bites/sips and a slow rate of intake. Review of the facility's policy, titled, Weight assessment and Intervention, dated 3/21/11 indicates: Significant weight changes are defined as: a., more or less than 5% within 30 days, and b., more or less than 10% within 6 months. Care Plan interventions will include, Resident preferences Interventions for undesirable weight loss should focus first on food. Liquid nutritional supplements, per facility formulary, may be considered if resident caloric intake remains inadequate to stabilize or increase weight. The physician may order tests, appetite stimulants or medications as appropriate. On 11/17/16 at 1315, the Director of Nursing (DON) was interviewed and asked about the significant weight loss for Resident #503. The DON stated, I'm not sure if the weight loss is 5 or 10% when we notify the responsible party and physician. ON 11/17/16 at 1345, the Administrator was interviewed on and was asked about the residents significant weight loss. The administrator said, the resident had a history of [REDACTED]. ( ) On 11/17/16 at 8:30 a.m., the facility provided a list of residents who had weight loss. Resident #518 was on the list and revealed that she had lost 11.1 percent (% ) of her weight within the past 30 days and 15.1% within the last 90 days. On 11/17/16 at 9:05 a.m. review of Resident #518's face sheet indicated an admission into the facility on [DATE] and a re-admission on 10/21/16 with [DIAGNOSES REDACTED]. Resident #518's most recent quarterly Minimum Data Set (MDS) assessment, dated 11/3/16, indicated an intact cognition, extensive assistance required with activities of daily living (ADLs), and weight loss. On 11/17/16 at 12:50 p.m., Resident #518 was observed sitting in her wheelchair at the bedside with her lunch meal in front of her. 95% of her pureed meal was untouched. Resident #518 stated, Would you eat that? Resident #518 was asked if she normally ate her meals. She responded by stating, It doesn't look appetizing. On 11/17/16 at 2:40 p.m., the facility's Registered Dietician (RD H) was queried regarding Resident #518's weights. RD H was unable to retrieve Resident #518's weights at the time and reported that she would have to obtain them from the Dietary Manager. RD H reported that Resident #518 was on weekly weights. On 11/17/16 at 4 p.m., RD H presented weights for Resident #518. Resident #518 was weighed on re-admission on 10/21/16 at 219.2 pounds. The most recent weight was on 10/25/16 at 219.6 pounds. There were no further weights, although Resident #518 should have been on weekly weights since she was a re-admission into the facility and she had triggered for significant weight loss. On 11/17/16 at 4:10 p.m., review of Resident #518's care plan titled The resident has had a weight loss with a history of weight fluctuations, last revised 11/8/16, revealed the intervention to perform weekly weights (weigh weekly). Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. On 11/17/16 at 4:25 p.m., review of the facility's policy entitled Weight Assessment and Interventions, revised 3/21/16, revealed the following documentation: The nursing staff will measure resident weights on admission and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter or as ordered. ( )

This citation has 3 Deficient practices Deficient practices #1 This citation pertains to M 5839 Based on interview and record review the facility failed to ensure one Resident (#601), of six residents reviewed for falls, out of a total sample of 24, was provided adequate monitoring with supervision and failed to provide proper functioning assistive devices (chair alarms) to prevent falls, resulting in Resident #601 falling multiple times with injury, culminating in a fall in which the resident sustained [REDACTED]. On 10/26/15 at 12:00 p.m., Resident #601's clinical record was reviewed. The Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] noted that the resident had severe cognition impairment and required extensive one person assist for transferring and tolieting. Further review of the clinical record on revealed the following progress notes: 10/15/15 (18:36): Resident was sitting in her wheelchair attempted to stand and turn reached back tipping wheelchair on its side mobility alarm attached not sounding resident was lying on left side. Hipsters were on resident. Neuro checks initiated. Family and M.D. (medical doctor) notified .Will notify oncoming shift. 10/16/15 (14:39): During AROM (active range of motion) and PROM (passive range of motion) resident is having some moaning sounds stated, that hurts having difficulty, resident would not stand for transfer. M.D. notified and new orders for bilateral hip x-ray 10/18/15 (00:46): The nurse was called by Dr. at approximately 9:40 PM that resident has a L (left) femur fracture from s/p Resident was transferred to hospital . On 10/27/15 at 9:41 a.m., a phone interview was conducted with the Resident's family member, who stated, My mom has had at least five falls since May 2015. The last one she had resulted in a fracture and surgery. We have had so many discussions with the facility regarding her falling. You should check her records. This is her second fall with an injury. She fractured her thumb in June and then her femur a few weeks ago. I think they are so short on staff. If you look at the dementia unit you will see that most of the Resident's are placed in the dining/common are all day until bedtime. They tell me that one person stays in the room to watch the residents, but I'm not even sure that happens all the time or who the one person is. I believe Dementia Unit Coordinator (DUC) I was there the night she broke her hip. However, I've been in there when nobody is there, because they have to go help the other aide who is working in the hall. There are usually like 10-15 resident's in that common area, I'm not sure how one person can watch everyone. All those residents have dementia. My mom was supposed to have an alarm that would alert the staff. At one point they decided to take away the Resident's alarms. We asked that she continue having one, they did agree, but I don't think they even turn it on. On Saturday 10/24/15, when I came to visit her alarm was not connected. I did tell a nurse and asked her document our conversation. The last fall with the fracture her alarm did not even sound and that is not the first time. I believe when she fell and broke her thumb, her alarm was not on. On 10/27/15 at 10:00 a.m., the Facility was asked to produce all Incident and Accident (I/A) reports for Resident #601 since May 2015. The following reports were provided and revealed, in part, the following: Date of Incident: 5/8/15: 8:00 p.m. Location: Dining Room - Unobserved Brief Description: Resident observed lying on back in DR2 (dining room 2). Resident had no alarm on chair due to family leaving her in chair and not placing an alarm on chair after they left. List staff witness that was present at the time of the incident: BLANK Progress note dated 5/11/15 revealed: Incident day #3 for episode where observed on floor. Facial grimacing with movement continues. When asked where pain was located, resident pointed to lower back. T-shaped bruising noted to coccyx approx. 3 cm (centimeters) x 3 cm and blue/purple color. Date of Incident: 5/17/15: 7:00 p.m. Location: Dining Room- Unobserved Brief Description: Resident observed on floor in DR2 beside her chair she was sitting in. Resident alarm was in place. ROM within normal limits. Skin assessment with no apparent injury. Assisted back into wheelchair. Assist x2. List staff witness that was present at the time of the incident: BLANK Date of Incident: 5/31/15: 10:20 a.m. Location: Dining room-Observed Brief Description: Resident stood up from her w/c (wheel chair). Her R (right) foot got caught on the foot pedal and she fell . Resident did hit the R side of her forehead, quarter sized lifted area List staff witness that was present at the time of the incident: CENA in DR (No name provided) It should be noted that the Resident's progress note dated 6/5/15 revealed, in part, the following: Resident had a fall on 6-1 in DR 2 when she stood from her w/c and tripped on her foot pedals. Her nurse witnessed the fall, but could not reach her in time to stop her. She received a small raised area on right side of forehead Sensor alarm was in place, but not activated CENA was educated on proper use of alarms. Resident was care planned for sensor in bed and wheel chair and anti-thrust wc cushion. Resident was observed to have some bruising to left thumb on 6/1 and she was sent for an x-ray that revealed an oblique fracture involving the distal phalanx of the left thumb . Date of Incident: 9/27/15: 3:10 p.m. Location: Dining room - Unobserved Brief Description: While changing shifts the CENA was seating one resident when she turned and observed the resident had just fallen Res stood while in w/c and has unsteady gait. List Staff Witness: first name provided Comments: resident is now to wear hipsters, she jumps up and has unsteady gait. May have been too much stimulation with CENA shift and report going on. Family brought this w/c when mentioned having it ok'd by therapy, DUC I said, I will handle that I don't know if the w/c is appropriate or if therapy ever checked for it. Date of Incident: 10/15/15: 6:30 p.m. Location: Dining room- Observed Brief Description: Resident attempted to stand turning wheelchair -tripping on its left side. Mobility Alarm still attached/Not sounding. Resident lying on left side. List Staff Witness: Dementia Unit Coordinator (DUC) I 10/23/15: Physician Note: Reason for Admission: Left hip fracture status [REDACTED]. On 10/27/14 at 3:50 p.m an interview was conducted with DUC I regarding the incident that occurred on 10/15/15. DUC I stated, I was the only staff member present in the Dining room. 11 other Residents, including Resident #601 were present in the room. When queried as to what happened on 10/15/15, DUC I stated, I was in the room the day that she fell . I was busy getting items out of the closet for an activity. I am the Dementia Unit Coordinator and part of my job is to coordinate activities for the Residents. While I am a licensed CNA, my job description is different. You can ask to see my job description, I am not really a CNA. With respect to Resident #601 she is very confused and tries to get out of her wheelchair. I really didn't see what happened, but when I was finished getting out my stuff, I turned around and noticed she was on the floor. Her alarm did not go off, I am not sure why. DUC I was further queried as to whether there were any other staff members in the room that evening, DUC I stated, No, I was the only one. Most of the time I am the only person in this room from 2-10:30 p.m., it can be hard to monitor all the residents, especially if I am trying to get things organized. It would be nice to have a CNA in the room that can help me. It's hard to keep your eyes on everybody. Also, they did do away with the fall alarm system for most of the residents in the building, not that it always prevents a fall, but it can help at times. On 10/28/15 at 10:00 a.m., an interview and record review was conducted with the Director of Nursing (DON) regarding Resident #601's fall. The Resident's care plan dated last updated (6/12/15), was reviewed and revealed the following: Problems: I have a hx (history) of fall. Resident has generalized weakness, poor safety awareness, is at risk for falls. Approaches: · keep my bed in low position · monitor me for attempts to self transfer/ambulate, I require assistance with the use of RW and gaitbelt · I have sensor alarms on my bed and w/c · I have a mobility alarm on ATC · I have an antithrust cushion in my w/c · I will not have foot pedals on my w/c when I am ambulating Following review of the careplan dated 6/12/15, the DON was queried to how monitoring was defined and whether Resident #601 was actually being monitored per her care plan interventions. The DON stated, monitoring means 24/7 monitoring. As far as the dining room is concerned we always have one person in the room watching. It was noted that in the I/A reports referenced above, no staff were noted to be present at the time of the incidents on 5/8/15 and 5/17/15. Additionally, no names were provided for the incident that occurred on 5/31/15. When further queried as to the lack of the fall alarm system working on 5/31/15 and 10/15/15, the dates Resident #601 sustained a serious injury, the DON responded, I believe on 10/15/15, the alarm just didn't disconnect so that is why it did not alarm. She now has a sensor pad on the wheelchair and hipsters. We discontinued our fall alarm system, but the family wanted her to keep it. The DON did not provide information pertaining to the disconnected alarm on 5/31/15. At the end of the interview, the DON was asked if there was any additional documentation, including, but not limited to, interview reports etc. pertaining to the I/A's listed above. The DON stated, I believe that is all we have, if we have anything else, I will get it for you. No additional documentation pertaining to the I/A's was provided by the time of exit. On 10/28/15 at 11:30 a.m., an interview with Resident #601's daughter and son-in-law was conducted. The family member's reported, last night (10/27/15) we went to visit mom, she was sitting in the dining room and we noticed that the alarm was not hooked up again. On 10/28/15 at 3:00 p.m., a review of the Facility's Falls-Clinical Protocol revised 2/2013 revealed, in part, the following: Cause Identification/Response: For an individual who has fallen, staff should attempt to define possible causes within 24 hours of fall c. Once a fall occurs it is important to gather as much information as possible; i. Observe the evident trauma ii. Observe to determine what the resident was attempting to do if possible iii. Observe for environmental hazards which may have contributed iiii. If the resident is able, what does he/she state happened v. Staff present and responders, what did they see/hear Monitoring and Follow-up: 1. The staff will monitor and document the individual's response to interventions to reduce falling or the consequences of falling. 4. If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling (beside those that have already been identified) and will re-evaluate the continued relevance of current interventions. ( ) Deficient practice #2. The facility failed to ensure safe storage of sanitizing chemicals, razor blades and oxygen cylinder on two resident living areas resulting in the potential for accidents and/or harm to residents entering these areas. Findings include: During tour of Unit F, 300 hall shower room on 10/26/15 at 6:35 am, the following observations were made: 1. The entry/exit doors to the shower room were propped open allowing unimpeded access into the room. There were no physical locking mechanisms on the shower room entry/exit doors. 2. Inside the shower room was an unlocked wooden storage cabinet containing: A. Three sanitizing chemical containers (Clorox urine removal spray, Clorox disinfectant spray, and Clorox Four in One disinfectant/sanitizer aerosol). These chemicals were clearly labeled as being known irritants and having the potential to cause harm to humans. The label on the aerosol spray indicated to be stored in a locked area. B. 25 triple bladed razors (unused). 3. Gurney having a large oxygen cylinder stored underneath. The oxygen cylinder was stored in a horizontal position (sideways). There was no resident on the gurney and no clinical evidence that a resident needed to be transported on the gurney or use the oxygen underneath at the time the observations were made. During an interview with certified nurse aide (CNA) 'C' on 10/26/15 at 6:40 am, CNA 'C' said the wooden cabinet in the shower room could not be locked and the razor blades had always been stored there. CNA 'C' said the sanitizing chemicals in the wooden cabinet should not have been stored there. CNA 'C' said the oxygen cylinder was usually stored underneath the gurney in a horizontal position. During an interview with CNA 'D' on 10/26/15 at 6:50 am, CNA 'D' said due to construction, room 321 was being used as a temporary shower room for all residents on the unit. During tour of Unit H, room 321 (temporary shower room) on 10/26/15 at 6:55 am, the following observations were made: 1. The entry/exit doors to room 321 (temporary shower room) had no physical locking mechanisms; this allowed unimpeded access into the room. 2. Small storage shelf above bathroom sink contained 20 triple bladed razors (unused). During second observation of Unit F, 300 hall shower room on 10/27/15 at 3:40 pm, the following observations were made: 1. Gurney still contained a large oxygen cylinder stored horizontally underneath. Again, there was no resident on the gurney and no clinical evidence that a resident needed to be transported on the gurney or use the oxygen underneath. During separate interviews with housekeeping staff (HSK) 'E' and HSK 'F' on 10/28/15 at 10:50 am and 10/28/15 at 11:00 am, both HSK 'E' and HSK 'F' said they had been trained to keep sanitizing chemicals locked at all times for safety reasons when not in use, and there were specific areas in the facility to safely store the chemicals, including locked boxes on portable housekeeping carts and locked chemical storage room. During an interview with housekeeping supervisor (HSK) 'G' on 10/28/15 at 11:20 am, HSK 'G' said it was facility policy/procedure to store chemicals in locked areas when not in use. During an interview with the maintenance manager (MNT) on 10/28/15 11:30 am, the MNT said oxygen cylinders are supposed to be stored upright (vertically) in specified holders. The MNT said oxygen cylinders may be stored sideways (horizontally) when a resident is being transported on the gurney and needed use of the oxygen. Review of facility policy/procedure on 10/28/15 at 11:45 am revealed the following documents: Policy and procedure entitled, Storage Areas revised April 2006 that indicated, under policy statement, Housekeeping and laundry department storage areas shall be maintained in a clean and safe manner. and, under policy interpretation and implementation, 3. Cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products. Policy and procedure entitled, Oxygen Administration reviewed/revised July 2013 that indicated, under equipment and supplies, .Keep oxygen concentrators, containers, and cylinders upright and placed so they cannot be hit, tipped, or knocked over . and Oxygen Cylinders shall be stored away from any heat source in a room that shall remain locked . The surveyor requested a policy for sharps storage but as of the exit time of the survey the facility only provided a policy for sharps disposal that did not address concerns of razor blade storage. ( ) Deficient practice #3. Based on observation, the facility failed to ensure that unlabled medications or ointments were not left unattended at bedside for one of 21 sampled residents (#67), resulting in the potential for misapplication. On 10/26/15 at 2:45 p.m., a medication cup with whitish cream was observed at the bedside table of resident #67. The medication cup was not labelled for whom and what was the content. Resident #67 was observed in a wheelchair, alert and verbal. Resident #67 stated that the medication was for her skin but did not like it applied. Resident #67 stated that (pointing to the medication cup with the cream) was placed by the nurse two nights ago. Nurse Bdid not offer any explanation. The Administrator was present and was presented the unlabelled medication cup. The administrator offered no explanation. Per record review on 10/27/15 at 11;30 a.m., Resident #67 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's policy on medication storage in the facility revised 1/2015 documented that medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. The facility's policy on self administration of medication indicated that, any medication found at the bedside not authorized for bedside storage are to be reported to the charge nurse . ( )

Based on observation, interview and record review the facility failed to provide cardiac and respiratory medications to one (#508) of one resident reviewed with cardiac and respiratory deficiencies from a total of 24 residents, resulting in a re-hospitalization for shortness of breath and rapid ventricular response. Findings include: On 12/2/14 at 2:15 p.m., during an interview with resident #508, he indicated that he had been at the facility prior to the current admission. He stated that it was "For just a short time. They didn't give me any of my medication. I was here for about 12 hours. I take a heart pill, inhalers and a blood thinner, they didn't give me any of that. I just got one breathing treatment. My heart started racing. I really need my heart pill, I take it every six hours. I started getting anxiety. They didn't do anything for me, so I wanted to go back to the hospital." Resident #508 was observed wearing oxygen tubing which was attached to an oxygen concentrator. The resident appeared short of breath during the interview. On 12/3/14 at 12:30 p.m., record review revealed that resident #508 was originally admitted into the facility on [DATE] at 2:45 p.m., discharged on [DATE] (no documented time in nurses notes) and readmitted on [DATE]. The Admission face sheet documented that resident #508 had [DIAGNOSES REDACTED]. Resident #508's Admission Nursing assessment dated [DATE] indicated that the resident was alert and oriented to person, place and time. Resident #508 required continuous oxygen at 2 liters/minute via nasal cannula. Review of the hospital discharge physician's medication orders dated 11/21/14 documented the following; [MEDICATION NAME] (High Blood Pressure) 60 mg one every 6 hours, last dose given 11/21/14 @1:04 p.m. [MEDICATION NAME] 3 mg one and one-half tablet once per day, last dose given 11/20/14. Review of the facility's admission physician's medication orders dated 11/21/14 documented the following; [MEDICATION NAME] (blood pressure) 25 mg one tablet per day. [MEDICATION NAME] Inhaler one inhalation four time a day. [MEDICATION NAME] (for [MEDICAL CONDITION] Fibrillation) 250 microgram (mcg) one tablet per day. [MEDICATION NAME] 60 mg one tablet every six hours. [MEDICATION NAME] (respiratory treatment) 0.5 mg-3 mg/3 milliliter (ml) one [MEDICATION NAME] three time a day. [MEDICATION NAME] (diuretic) 40 mg two times a day. [MEDICATION NAME] (high blood pressure) 40 mg one every 12 hours. [MEDICATION NAME] 90 mcg [MEDICATION NAME] one inhalation every 12 hours. [MEDICATION NAME] (decongestant) 10 mg one every day. [MEDICATION NAME] 3 mg one and one-half tablet every evening. On 12/3/14 at 1:30 p.m., Review of the facility's Medication Administration sheets dated 11/21/14-11/22/14 revealed that resident #508 only received one [MEDICATION NAME] 0.5 mg breathing treatment on 11/21/14 at 10:00 p.m., and no other medications were signed out as given. On 12/3/14 at 3:00 p.m., Review of the facility's list of back up medication revealed that the following medications were available for administration on the evening of 11/21/14; [MEDICATION NAME] (which was due at 6 p.m.), [MEDICATION NAME], and [MEDICATION NAME] (which was due at 7 p.m.). On 12/4/14 at 10:00 a.m., during further review of the medical record, a document titled "Patient Transfer Form" dated 11/22/14 revealed that resident #508's vital signs and discharge summary were as follows; "Pulse-92 (normal range 60-80), respiration rate-24 (normal range 18-20), and blood pressure 144/68 (normal 120/80). Difficulty breathing, wheezing, updraft (breathing treatment) given-no relax, pulse oxygen (ox) 78-84%, High Anxiety." There was no discharge time on the hospital transfer form or correlating discharge nurses note. The admission facesheet from the hospital emergency room documented an admission into the hospital on [DATE] at 5:18 a.m. with complaints of shortness of breath and rapid heart rate. The History and Physical report dated 11/22/14 documented, "The patient was discharged from (Long Term care facility's name). It seems like they did not give him his breathing treatment. They did not reconcile any medication for him including his [MEDICATION NAME], including his [MEDICATION NAME] and he kept having increasing shortness of breath. This morning, he was very anxious. He was short of breath. All of a sudden they started giving him a breathing treatment. He did not improve. They (the resident) asked them (the facility) to bring him back to the hospital and he was very upset and very mad at the fact that they did not give any medication throughout the whole, almost 12 hours that he was there....He has a chronic wheezing, but it seems like his wheezing was worse today on exam. According to the patient, he did not get his medications till midnight. The patient become more short of breath. He was given an updraft. His oxygen saturation had gone down to 78-82% and the patient was brought to the emergency room . In the emergency room , the patient was noticed to have [MEDICAL CONDITION], severe [MEDICAL CONDITION], chronic Cor Pulmonale and swelling in the legs...". On 12/5/14 at 9:10 a.m., the Director of Nurses (DON) was interviewed regarding the incident with resident #508. The DON said that the pharmacy makes they're medication delivery around 12 midnight, and the nurses can get medications from the back up box during the interim time. The DON stated, "(Staff Nurse A) was the nurse on that evening. I don't know if she just forgot to sign out the medication or just didn't give it. I will have to call her." On 12/5/14 at 9:30 a.m., the Director of Pharmacy Services, Staff "B" was interviewed over the phone regarding the delivery time of the medications for resident #508. Staff "B" stated "The medication left the pharmacy at 8:15 p.m. (11/21/14) and was delivered to the facility at 2:21 a.m. (11/22/14) and signed for by (Nurse "A")." On 12/5/14 at 1:05 p.m., Nurse "A" was interviewed over the phone. Nurse "A" stated that (resident #508) "was very anxious and he couldn't breathe. I checked his lung sound and noted rhales (lung congestion) and gave him an updraft. I think that was around 9-10 p.m. on 11/21/14. The resident said 'I really can't breath', so I tried calling the doctor. I didn't get any response, so I just sent him out. I really don't know what time that was. It was early in the morning on 11/22/14." Nurse "A" was asked if earlier in the shift she attempted to get any of the resident's medications from backup medication box and stated, "I know I headed there (to the backup medication box), but I had so many call lights and alarms going off, I never got to the back up." On 12/5/14 at 1:45 p.m., review of the facility's undated policy titled, "Prescriber Medication Orders" documented; "...C. The prescriber is contacted to verify or clarify an order. D. The prescriber is contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available. F. Non-Emergency Medication Order: The first dose of medication is scheduled to be given after the next regularly scheduled pharmacy delivery to the facility." ( )

Based on observation, interview and record review, the facility failed to consistantly implement and preform pressure ulcer (localized injuries to the skin and/or underlying tissue as a result of pressure) treatments, for two (#501 and #503) of nine sampled residents reviewed for pressure ulcers from a total sample of 24, resulting in the risk of infection, delayed wound healing, and actual deterioration and worsening of a current wound. Findings Include: During the initial tour of the facility on 12/2/14 at 9:15 a.m., with Licensed Practical Nurse (LPN) Staff "E", Resident #503 was observed lying on his back on an alternating pressure mattress with heels elevated on a pillow. Per Staff "E" Resident #503 was admitted to the facility with a community acquired Coccyx/sacral pressure ulcer. At 2:15 p.m. Resident #503 was observed in his room in bed asleep on his back. On 12/3/14 at 9:40 a.m., Resident #503 was observed in his room in bed on his back. The wound care team had just assessed and provided treatment to the wound. Resident #503 was complaining of pain. The wound care Physician "AA" gave an order for [REDACTED]. The wound care Physician, "AA", stated "Resident (#503) has had an ongoing wound on his Coccyx for sometime. He was admitted with an infection in the wound which was treated with intervenous (IV) antibiotics. Physician "AA" stated "I did a debridement (medical removal of dead, damaged, or infected tissue or bone to improve the healing potential of the remaining tissue) of the wound and removed fragile, flaky bone today. The Resident (#503) has a catheter (tube inserted through the urethra to drain urine) and will have a [MEDICAL CONDITION] (surgical procedure in which an opening is formed and the intestine is brought through an incision in the abdomen to excrete stool) placed on Monday, to aid in wound healing. Physician "AA" stated that Resident (#503) is confused and refuses to stay off his back." On 12/2/14 at 1:00 a.m., review of the electronic medical record (EMR) for Resident #503, revealed an original admission into the facility on [DATE], and readmission on 9/15/14, with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #503 was severely cognitively impaired and required extensive assistance of two persons for bed mobility, transfer, hygiene, bathing and toileting. He was able to make himself understood and to understand others. The MDS documented a Stage IV pressure ulcer measuring 1.6 cm (centimeter) x 1.2 cm x 1.2 cm to the sacrum (buttock at tail bone). The 9/4/14 admission Braden Scale assessment (assessment of risk factors for pressure ulcers) documented Resident #503 was a 13 (moderately at risk). The EMR had a Physician order [REDACTED].#503 being non-complaint with turning and repositioning was found in the EMR. A care plan dated 9/15/14 titled "Pressure: at risk for alteration in skin integrity related to: I was admitted with a stage IV pressure ulcer on my sacrum. I don't always understand my care needs. Interventions included "Treatments as ordered--see TAR (treatment Administration record) for specific instructions. . . Ulcer care as ordered-see TAR for specific instructions. . .implement turning and repositioning program per individual needs, notify nurse and document refusals of repositioning." On 12/4/14 at 8:30 a.m., a review of Nursing notes for wound care team visits revealed the following: 9/17/14 "Resident seen by wound care team. Residents stage 4 pressure ulcer on sacrum (buttock at tail bone) measures 2.5 cm x 1.3 cm x 2 cm with circumferential undermining (separation of tissue from the surface under the edge of the wound) to max depth of 5.2 cm at 5-6 o'clock (describe by clock face with patients head at 12). Wound bed has bone and tendon visible and remainder red and granular (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process). Large amount of serous (thin clear watery) purulent drainage. Slight foul odor. Resident complaint of pain when area is slightly palpated. Resident currently on intervenous (IV) antibiotic for treatment of [REDACTED]. Continue current treatment plan. Preventative measures in place and remains appropriate. . ." 9/25/14 ". . . measures 2.8 cm x 1.4 cm x 1.5 cm. . .undermining to max depth 5 cm at 6-7 o'clock. Continues to have bone and tendon exposed, with remainder beefy red and grandular. Clean moist wound edges. Large amount of serosanguinous (thin red) and purulent drainage. Slight foul odor is present, however not as prevalent from prior week. . .IV antibiotic continues. Resident complaint of pain. Continue current treatment. . ." 10/2/14 " . . .measures 2.6 cm x 1.8 cm x 1.2 cm. . .undermining to max depth of 4 cm at 5-6 o'clock. . . continues with bone and tendon exposed, with remainder beefy red and granular. Clean edges. . . Large amount of serous drainage. Zero odor. . ." 10/8/14 . . .measures 2.5 cm x 1.7 cm x 1 cm . . .undermining . . .3 cm at 7 o'clock . . ." 10/15/14 " . . .measures 3 cm x 2 cm x 1 cm . . . undermining . . .3.2 cm at 7 o'clock . . ." 10/22/14 " . . .measures 3 cm x 1.8 cm x 0.9 cm . . .undermining . . .5 cm at 5-7 o'clock. . . No pain . . ." 10/30/14 ". . .measures 2 cm x 1.4 cm x 1 cm . . .undermining . . .6 cm at 5-7 o'clock . . .no pain. . .no pain. . ." 11/5/14 ". . .measures 4.8 cm x 2.0 cm x 2.0 cm with skin bridge of 1.3 cm . . .undermining 6 cm 5-7 o'clock . . .Wound edges are macerated from 5-2 o'clock to depth of 0.2 cm . . .no pain. . ." 11/12/14 ". . .measures 5.5 cm x 2.0 cm x 3 cm . . .undermining . . .6 cm . . .5-7 o'clock. Wound bed continues to have bone and tendon exposed, with remainder covered with 60 % thick yellow slough (a layer or mass of dead tissue separated from surrounding living tissue). . . Slight foul odor noted. Resident complaint of pain when wound is palpated. . . Resident's daughter has concerns with loose stools going into wound . . .to be evaluated for . . .[MEDICAL CONDITION]." 11/19/14 " . . .measures 4.5 cm x 2.5 cm x 2 .cm . . .undermining of 6 cm at 5-7 o'clock . . 60 % thick yellow slough and remainder beefy red and grandular. Wound edges excoriated with slough present. . . complaint of pain. . ." 11/24/14 " . . .measures 6 cm x 2.6 cm x 2 cm . . .undermining of 3 cm. . . 60 % slough and remainder beefy red and grandular. Wound edges are excoriated with slough present. . ." 12/3/14 ". . .4.6 cm x 2.5 cm x 2 cm. . . . undermining 3 cm. . . 60 % slough . . .Slight foul odor noted. Resident complaint of pain when wound is palpated near the exposed bone. (Physician "AA") obtained biopsy of the exposed . . .bone . . ." A review of the treatment administration records (TAR) on 12/3/14 at 8:45 a.m. revealed the following: A physician ordered treatment dated 9/15/14 to 10/15/14 for "Irrigate wound with 30 cc (cubic centimeter) syringe using Dakins (solution used to kill germs and prevent germ growth in wounds) , flush until clear, apply Dakins 0.125 % moist guaze filled into wound opening and cover with dry dressing , twice daily." The 9/15/14 to 9/30/14 TAR had no documentation (blank spaces with no Nursing initials) that treatments were done 10 times (eight (8) on day shift and two (2) on night shift). The 10/1/14 to 10/15/14 TAR had no documentation that treatments were done nine (9) times, (five (5) on day shift and four (4) on night shift), (30 treatments should have been done in September and 30 in October). A physician ordered treatment dated 10/15/14 to 10/22/14 for the same treatment as above to be done only once daily. Treatments were not documented as done two (2) times on day shift, (seven (7) treatments should have been done). A physician ordered treatment dated 10/22/14 to 10/29/14 for "Irrigate wound with 30 cc syringe using Dakins, flush until clear. Apply [MEDICATION NAME] (Matrix Collagen Wound Dressing) into tunnel, covering bone, cover with dry 4 x 4 s, and comfort foam dressing every day." The 10/22/14 to 10/29/14 TAR had no documentation treatments were done six (6) times, (eight treatments should have been done). A physician ordered treatment dated 10/29/14 to 11/22/14 for "Irrigate wound with 30 cc syringe using Dakins, flush until clear. Apply Dakins 0.125 % moist packing guaze into tunnel, cover with dry 4 x 4 guaze and cover with comfort foam dressing every day. The 10/29/14 to 11/22/14 TAR had no documentation treatments were done 14 times, (24 treatments should have been done). A physician ordered treatment dated 11/24/14 to 1/1/15 for "Cleanse wound with NS (normal saline) apply Dakins 0.125 % moist guaze into wound bed, cover with dry 4 x 4 and abdominal pad twice daily. The 11/24/14 to 12/3/14 TAR's had no documentation treatments were done 10 times (six (6) times on day shift and four (4) times on night shift, (20 treatments should have been done). On 12/3/14 at 1:50 p.m. the facility Director of Nursing (DON) reviewed the 9/2014 to 12/3/2014 TAR's for Resident #503. The DON stated she "Was not aware that the TAR's showed treatments were not done as ordered. It may be in the Nurse's notes or wound team notes. I will review and see what I can find." On 12/4/14 at 9:50 a.m., the DON stated "I can't find any documentation that (Resident #503)'s treatments were done on the days that it was not documented on the TAR's. I looked at notes for Nurses and wound care. I have no doubt it was done." The DON stated she would look again. On 12/5/14 at 9:35 a.m., the DON stated "I did not find documentation for missing treatments for Resident #503, I can triple check. I see what you are saying." When questioned about the treatments not being done and the wound worsening, the DON stated "It worsened because of the wound care treatment done prior (not in facility)." No additional documentation was provided by survey exit related to treatments or non-compliant care plans. On 12/5/14 at 1:00 p.m. the facility protocol titled "Pressure Ulcers/Skin Breakdown- Clinical Protocol" dated March 2014 was reviewed and revealed the following: "Residents will have a head to toe skin assessment completed. . .When necessary, the physician will be consulted to authorize pertinent orders to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings. . .and application of topical agents . . .Physician orders [REDACTED]. . .As needed, the physician will help identify medical and ethical issues influencing wound healing. . .The physician may be consulted to help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. . ." ( ) This citation pertains to Intakes # MI 254 Intake # MI 536 Resident #501 On 12/3/14 at 9:45 A.M., Resident #501 was observed lying in bed with eyes closed, and unresponsive to stimuli. Family members present stated that the resident was on Hospice, and was actively dying, so "family are here to be with her at the end." On 12/4/14 at 3:35 P.M., Resident #501's clinical record and facility Incident and Accident reports (I&A) were reviewed with the Director of Nursing (DON) and the Safety Coordinator/Restorative Nurse "O" and revealed the following: A face sheet documented that Resident #501 was admitted into the facility on [DATE], with a readmission after hospitalization on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set Assessment ((MDS) dated [DATE], documented that Resident #518 had moderately impaired cognition (dementia) , did not walk, and needed extensive physical assistance for transfers to the wheelchair, dressing, toileting, hygiene and mobility in bed. An Admission skin assessment dated [DATE] at 12:05 P.M., documented that Resident #501 was readmitted into the facility after a hospitalization , with three pressure ulcers, documented as a suspected deep tissue injury (pressure damage that has not yet opened up into an ulcer) on the left heel, a right leg wound (no depth or staging noted), and an unstageable (depth could not be determined due to covering of dead tissue) wound on the sacrum. Review of Physician's wound care treatment orders for Resident #501, Nursing and wound care progress notes, the facility Treatment Administration Record (TAR) and TAR nursing documentation for the period 11/3/14 through 12/3/14 (after readmission with community acquired pressure sores), revealed Resident #501's wound treatments were not documented as performed multiple times. The following omissions were noted; 1. Order, dated 11/5/14, discontinued (d/c) 11/22/14 at 6:59 P.M.: "Apply dressing to sacral spine twice daily; cleanse wound with normal saline (n.s.) apply (brand name) moist gauze to wound bed and cover with dry 4 x 4 (size of gauze dressing) and comfort foam dressing (drsg) twice daily (bid) " There was no documentation to indicate that this was done on 11/5/14, 11/6/14, 11/8/14, 11/10/14, 11/17, and 11/19 on the evening shift (eve), both day and eve shifts on 11/7/14, and 11/21/14, and on the day shift on 11/9/14, 11/14/14 and 11/18/14, a total of 13 missed treatments. 2. Order, dated 11/22/14 at 7:00 A.M., discontinue 12/30/14 (current treatment order): "Apply dressing; sacral spine twice daily: cleanse sacral wound with n.s. apply (brand name) moist gauze to wound bed and cover with dry 4 x 4 and comfort foam dressing bid. There was no documentation to indicate that this was done on 11/22/14, 11/24/14, 11/27,and 11.29/14 eve shift, both day and eve shift on 11/28/14, and day shift on 11/25/14, 11/26/14, 11/30/14 and 12/2/14, a total of 10 missed treatments. Review of Treatment records, physician's orders [REDACTED].#501's heel, antifungal skin tream to treat fungal [MEDICAL CONDITION], antifungal powder to treat fungal [MEDICAL CONDITION], and treatments (santyl ointment and dressing) for Resident #501's right medial leg wound. On 11/5/14 at 9:40 A.M., the Director of Nursing (DON), and the Treatment Nurse "C" were requested to provide any additional information to indicate that missing treatments were performed. this was not received by survey exit. When queried about this, the DON and Treatment Nurse "C" did not provide a comment. ( )

This citation has four deficient practices. Deficient Practice Statement #1: Based on observation, interview and record review, the facility failed to ensure personal safety devices (alarms) and transfer assistance safety devices (gaitbelt) were consistently utilized, applied and functioning, for two (#512, #513) of nine residents reviewed for falls from a total sample of 24, resulting in preventable falls with injury, including a fall with Subarachnoid Hemorrhage (bleeding into the brain), a fractured knee, a fractured wrist, and a fractured femur (broken leg). Findings include: Resident #512 During the initial tour of the facility on 12/2/14 at approximately 9:15 a.m., with Licensed Practical Nurse (LPN) Staff "V", Resident #512 was observed in a low bed against the wall, with a floor mat and bolster on the open side of the bed and sensor alarm in place on the bed, a mobility alarm attached to the Resident's clothing. Resident #512 was observed to have yellowish/green discoloration to right forehead, temple and cheek with darker blue discoloration to right eye and cheek bone. Staff "V" stated Resident #512 had sustained a subarachnoid hemorrhage from a recent fall. Resident #512 was not able to answer questions. On 12/3/14 at 1:30 p.m., a review of the electronic medical record revealed (EMR) Resident #512 a [AGE] year old was originally admitted into the facility on [DATE] with a readmission on 11/13/14. [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #512 was severely cognitively impaired, usually able to make her self understood and sometimes able to understand others. Resident #512 required extensive assistance of two persons for bed mobility, toileting, and bathing. A review of the EMR section for assessments revealed only one fall assessment dated [DATE], with a score of 11 (10 or higher equals high risk). A review of fall care plans revealed the following: A fall care plan initiated 1/3/14 and discontinued 3/24/14 for "poor safety awareness." Intervention's, "every 15 minute cheeks thru 1/6/14 to establish sleep pattern." A fall care plan dated initiated 4/2/14 and discontinued 8/19/14 for "generalized weakness at times I may need assistance, I can become upset with staff assisting me as I prefer to be independent." Interventions which included, Neuro checks thru 4/4/14, limited assist of one with gait belt for ambulation and transfers. (In place at the time of the 8/8/14 and 8/18/14 falls). A fall care plan initiated 8/19/14 and discontinued 11/17/14, for "generalized weakness and poor safety awareness at times, I am at risk for falls." Interventions included, neuro checks until 8/19/14, every 15 minute checks, sensor alarm on bed and chair and other areas I choose to sit, call light available and within reach. (In place at the time of the 11/8/14 fall). A review on 12/4/14 at 9:30 a.m., of the facility provided incident and accident (I & A) reports for Resident #512, revealed falls on 4/2/14, 8/8/14 with no apparent injuries. An unwitnessed fall in the hall on 8/18/14 at 8:45 p.m., resulting in a skin tear, hematoma and fracture. Per the 8/18/14- I &A, Resident #512 had no care planned safety interventions at the time of the fall. Post fall interventions included every 15 minute checks around the clock and therapy evaluation. A Nurse's note dated 8/19/14 documented "resident (#512) observed sitting on the floor. . . She (Resident #512) remarked "I want to go home, where is (name of husband). There was no witness to the incident. Vital signs taken and stable, neuro checks negative. She (Resident #512) received a skin tear to left arm and complaint of pain. . . returned from (name of hospital) with [DIAGNOSES REDACTED]. She is wearing a splint. . ." The x-ray report dated 8/18/14, documents fractures to the distal radius and ulnar (right wrist bones). An I & A dated 11/8/14 at 9:00 p.m., revealed a Certified Nursing assistant (CNA) observed Resident #512 on the floor next to the bed. Upon assessment Resident was noted with a large hematoma above the right eye, bleeding actively and a small abrasion to the left shin. The Resident stated "I don't know what happened." The I & A documented "Resident fell from bed to floor. . . Resident's bed was not lowered to ground, bed at half height. . . Sensor alarm was not on. . . Mobility alarm (clip alarm) attached to bed ( clip not attached to the Resident)." Post fall interventions included every fifteen minute checks and landing strip (floor mat) to be placed along bed. The Nurse's note dated 11/8/14 documented, "At 2100 (9:00 p.m.), CNA observed resident (#512) lying face down on floor, next to bed. . . Resident stated I don't know what happened but it hurt. . . .large hematoma observed above right eye, bleeding. . .Resident also had a small abrasion present to lift shin. Resident stated her head hurt near her right eye, but was unable to rate pain. VS (vital signs) blood pressure 138/94 (normal 120/80), pulse 113, (Normal 60-100) respirations 19. Resident A& O x 1(alert and oriented times one-person only) ROM (range of motion) wnl (within normal limits). Bed sensor alarm was off. Clip alarm on and attached to bed (not clipped to Resident). . .Resident transported to (emergency room ). A review on 12/4/14 at 11:00 a.m., of the emergency transfer sheet dated 11/13/14, noted Resident #512 was transferred VIA ambulance with "contusions on lateral right face spanning superior to eyebrows and inferior to chin." Review of the hospital records provided by the facility revealed Resident #512 was admitted to the hospital with [REDACTED]. On 12/4/14 at 2:29 p.m., CNA staff "F" was interviewed by phone regarding Resident #512's fall on 11/8/14. Staff "F" stated, that she was assigned to Resident #512 and had put her to bed approximately one hour prior (to the fall) and placed her alarm on. Staff "F" said she was on break at the time of the fall. "I thought that I turned the alarm on, but it wasn't working when she fell . . .I usually pull it to see if it works. I am guessing I was busy and maybe didn't turn it on all the way. . . I have seen her (Resident #512) sit up at the edge of the bed, but never get up. She (Resident #512) didn't have a bolster or landing strip (floor mat) at the time. . . No alarms were sounding, the Nurse said. . ." When queried as to having been in-serviced, staff "F" said she did have an in-service after the fall, and was told to make sure alarms were in place and turned on." On 12/4/14 at 6:10 p.m., CNA staff "G" was interviewed per phone. Staff "G" stated she found (Resident #512) after the fall during her rounds. "She (Resident #512) was on the floor, head was slightly under the foot of the bed, her body was beyond the foot of the bed. She had a safety alarm she sat on and one that attached to her shirt. The alarm was not attached to her shirt when she fell and neither alarm was sounding. I went right away to get the nurse and went back with her. When we turned on the light. . .her head was in a puddle of blood, the top of her head and right eye. She was alert and asking about the blood on her shirt. She had a rug burn between her foot and knee and complaints of pain. I touched her under her eyebrow and she said it hurt and hurt to open her eye. Her bed was (raised) up to my knees and should have been in the lowest position." On 12/5/14 at 9:35 a.m., the Director of Nursing (DON) was interviewed related Resident #512's fall. The DON stated, all staff are responsible for checking alarms placement and function. The DON stated fall assessments are done on admission following a fall and any change in condition. A request for any fall assessments for Resident #512 were made at that time. None were provided prior to exit. The DON stated the CNA assigned to Resident #512 at the time of her fall said she had turned on the sensor alarm. The DON stated "It didn't sound and the clip came off (was not attached to Resident #512) and didn't sound. . . Resident #512 had alarms related to attempts to self transfer." On 12/5/14 at 2:10 p.m. the Licensed Practical Nurse, Unit Manager Staff "E" stated "Resident #512 had been in bed for the night. The bed was suppose to be low and the alarms on and working. The CNA's are suppose to check safety equipment on change of shift rounds with the new CNA. Staff "E" was asked if the CNA's should be checking all safety devices for placement and function when putting resident's to bed, and she responded "Yes". Resident #513 During the initial tour of the facility on 12/2/14 at approximately 9:15 a.m., with Licensed Practical Nurse (LPN) staff "V", Resident #513 was observed in a low bed against the wall, with a floor mat and bolster on the open side of the bed, a sensor alarm in place on the bed, and a mobility alarm attached to the Resident's clothing. Resident #513 had a brace in place on her left leg. Staff "V" stated Resident #513 had multiple falls. On 12/3/14 at 3:30 p.m., a review of the electronic medical record (EMR) for Resident #513 revealed an original admission into the facility on [DATE] and a readmission on 10/6/14 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #513 was moderately cognitively impaired, able to make her self understood and understand others. Resident #513 required extensive assistance of one person for bed mobility, toileting, and bathing. The MDS documented a history of falls. According to the Significant change MDS dated [DATE] Resident #514 was severely cognitively impaired and required extensive assistance of two persons for bed mobility, transfer, toileting and bathing. A review on 12/4/14 at 10:30 a.m., of the facility provided incident and accident (I & A) reports for Resident #513, revealed 19 falls between 3/25/14 and 11/3/14. All except two falls were noted as "unobserved." The I & A's for the above noted falls revealed the following: Resident #513 had four falls between 3/25/14 and 5/10/14 with no apparent injury noted. A fall on 5/14/14, with no apparent injury which noted "One alarm not not function properly. . . alarm went with Resident (not properly placed on bed rail, clip and alarm box went with Resident during fall, and did not sound)." Two falls on 5/17/14, one at 4:15 a.m. with no apparent injury and a fall at 3:40 p.m. with a skin tear. A fall on 5/23/14 with complaint of pain in shoulder x-ray negative for fracture. A fall on 5/26/14 with no apparent injury. Two falls on 5/28/14 one at 8:30 a.m. and one at 6:00 p.m. with no apparent injuries. It was documented the "alarm did not sound" at the time of the 6:00 p.m. fall. Resident #513 had two falls without injury on 5/31/14 and 6/5/14. A fall on 6/6/14 noted hematoma/bruise to right arm. The Nurse's note related to the fall dated 6/7/14 documented "No alarms sounding." Resident #513 had three falls with no apparent injuries on 6/15/14, 7/9/14, and 9/10/14. The fall I&A dated 9/26/14 at 4:00 p.m., documented Resident #513 had a witnessed fall when she was lowered to the floor by Certified Nursing Assistant (CNA Staff "F"). Per the I & A, the interventions to be in place at the time of the fall were documented as extensive assistance of one person with rolling walker and gait belt. The I & A included an in-service with CNA Staff "F" which documented "On 9/26/14 (Staff "F") was transferring resident (#513) and Resident was lowered to the floor. A gait belt was not utilized during the fall." A review of the Nurse's note date 9/26/14 documented Resident (#513) complained of left lower extremity pain. . .facial grimacing noted. . . x-ray ordered. A Nurse's note dated 9/27/14 documented a CNA reported to the Nurse Resident (#513) was not gotten up (from bed) related to severe pain. "Nurse assessed resident. Resident was shaking and asking for pain (medication) as soon as I (Nurse) walked into her room. Resident stated the pain was in her left knee. Facial grimacing noted. Left knee swollen and warm to touch. Resident x-ray pending. N.O. (New order) received for x-ray of hip, femur and knee. . . At approximately 10:00 a.m. Resident sent to (hospital) x-ray. . . CNA with Resident called Nurse stating . . ."she (Resident #513) was in so much pain she was puking and x-ray (technician) told CNA left knee was broken. . .Resident sent to (hospital) emergency room ." The x-ray report dated 9/26/14 at 7:04 p.m., noted "A fracture of the distal femur (thigh bone) is suspected only partially visualized." The x-ray report dated 9/27/14 at 10:58 p.m., noted "There is a comminuted fracture of the distal femur (Thigh bone)." Resident #513 had an unobserved fall with no apparent injury on 11/3/14. "Resident observed laying on bedside mat next to bed. Bed locked and in low position, alarm sounding. Immobilizer on left leg. Resident stated 'I don't know how I got here." The I & A and a Nurse's note dated 11/3/14 documented Bed Sensor-not working, was on, but not sounding. The Nurse's noted documented Resident alert and oriented to person only. Further review of the EMR on 12/4/14 at 1:00 p.m., revealed the following: A review of Resident #513's care plans revealed a safety care plan dated initiated 3/11/14 and discontinued 3/27/14 for altered safety awareness related to dementia, which documented interventions including therapy as needed, place in higher visibility area at desk if needed, assess need for safety equipment, landing strips (floor mat) on all open sides of bed. (In place for fall on 3/25/14). A fall care plan dated initiated 3/27/14 and discontinued 10/6/14 for generalized weakness and poor safety awareness, with interventions that included low bed, landing strip, sensor alarm on bed and wheelchair, mobility (clip alarm), added on 4/18/14, every 15 minute checks for safety thru 4/30/14, added on 5/12/14, neuro checks thru 6/8/14, added on 6/2/14, ensure that all of my safety equipment is properly attached and working, added on 6/16/14, bolster to side of bed. ( In place for 17 falls from 4/18/14 to 9/26/14). A care plan for falls dated 10/6/14 for generalized weakness and poor safety awareness, with interventions that included, low bed, landing strip, sensor alarm to bed and wheelchair, mobility alarm, every 15 minute checks, ensure all of my safety equipment is properly attached and working as directed. I have a bolster to one side of my bed. (In place for fall on 11/3/14). On 12/4/14 at 2:29 p.m., CNA staff "F" was interviewed per phone regarding Resident #513's fall. Staff "F" stated "(Resident #513) was a one person transfer at the time and was taken to the shower room for toileting. Her legs wouldn't hold her up, I called for the Nurse. . .when we were lowering her to the ground her left leg was bent back under her. . . and she was in pain. We lifted her back up and straightened her left leg. . . The Resident (#513) went to the hospital because she broke her femur." Staff "F" was queried as to whether she used a gait belt for the transfer and stated "No, I wasn't aware that if a Resident could stand up that I needed to use a gait belt. I was in-serviced after the fall by. . .the Unit Manager and told all Residents with a transfer need used a gait belt. . . .I did not use a gait belt." Staff "F" added Resident #513 had many falls and rolled out of bed." On 12/5/14 at 9:35 a.m., the Director of Nursing (DON) was interviewed related Resident #513's fall. The DON stated, all staff are responsible for checking alarms placement and function. The DON stated fall assessments are done on admission, following a fall, and/or any change in condition. A request for any fall assessments for Resident #513 were made at that time. None were provided prior to exit. The DON stated that Resident #513 had a lot of falls in 2012 but that her falls had decreased when she was moved to the dementia unit. Date of move to Dementia unit requested, but not provided prior to exit. The I & A's for Resident #513's falls with documented injuries and the falls with documentation of safety interventions not functioning properly, or not being in place at the the time of the falls were reviewed with the DON. The DON sated the following: Related to the 5/24/14 fall when the motion alarm did not sound, "It was not attached to the (bed) rail properly." Related to the bolster added on 5/17/14 following a fall, "It was added for boundary awareness. Later that day she (Resident #513) fell in the dining room not her room." Related to the 5/23/14 fall with shoulder injury, "Resident did self propel at the time and took herself to the room." Related to the 9/26/14 fall, "All Resident's are transferred with a gait belt unless it is contraindicated." When the DON was queried regarding the multiple incidents involving safety interventions that were not properly in place, and functional, and the gait belt not being used. The DON nodded her head and made no comment. On 12/5/14 at 2:10 p.m., the Unit Manager Staff "E" was interviewed regarding Resident #513's fall on 9/26/14, and stated "The Resident (#513) was to have a gait belt on according to her care plan at the time of the fall." A review of the facility policy titled "Falls Protocol" dated August 2013, and the policy titled "Usage of Gait Belt" undated, revealed the following: To identify resident with a history of falls or potential risk for falls. To implement safety measures and monitoring to prevent serious injury. 1. A fall risk assessment is completed upon admission. All residents entering the facility are considered at risk for falls. 2. Individual fall risk factors are identified through a multifaceted interdisciplinary process. 3. Interventions are put into place based on the intimal assessment. 4. Nursing will complete an assessment following a fall and assess for changes in condition. . ." "A gait belt will be used for all residents who need "hands on" assistance to transfer or ambulate unless contraindicated by a medical condition. To minimize risk of injury to staff and residents during transfers and ambulation." A request for a policy for monitoring of safety interventions was requested by not provided prior to exit from the facility. ( ) Deficient practice #2. Based on observation, interview and record review, the facility failed to ensure that residents were adequately secured for wheelchair transport and that planned toileting supervision was provided in a timely manner, for four (#501, #509, #510 and #518) of nine residents reviewed for falls out of a total sample of 24, resulting in preventable falls and the potential for injury. Findings include: On 12/2/14 at 9:30 a.m., during the initial tour, Resident #510 was observed lying in bed awake resting. The Unit Manager (Nurse "E") reported that he had a history of [REDACTED]. A padded mat, the length of the bed, was noted on the floor next to his bed (left side), as the right side of the bed was pushed against the wall. Two safety alarms were noted attached to Resident #510's bed. Nurse "E" was queried regarding what type of alarms they were. Nurse "E" identified one as a sensor pad alarm, but was unable to identify or explain the other alarm. Again, on 12/3/14 at 9:15 a.m., Resident #510 was observed lying in bed. Two alarms, including the sensor pad alarm was attached to his bed. The padded mat, the length of the bed was noted to the left of the bed on the floor, and the bed was pushed against the wall. On 12/3/14 at 2:25 p.m., review of an incident report, dated 11/16/14 at 10:00 a.m., regarding Resident #510, revealed the following documentation: "Res (Resident) was placed on the toilet by staff and asked to pull the light when read (ready). Resident stated he tried to pull the light and slipped off the toilet. No c/o (complaint of) pain." The incident form indicated that Resident #510 had a mobility alarm (a tab/clip alarm attached to the Resident) as a fall prevention intervention. The form indicated "staff member placed Resident on toilet and left alarm on w/c (wheelchair)." The results of the investigation were documented: "CNA (Certified Nursing Assistant) was re-educated on no leaving residents who require safety alarms alone in the bathroom." On 12/3/14 at 2:40 p.m., Review of Resident #510's face sheet indicated an initial admission into the facility on [DATE] and a re-admission on 11/11/14 with [DIAGNOSES REDACTED]. Review of Resident #510's admission Minimum Data Set (MDS) assessment, dated 11/3/14, indicated an intact cognition, and required extensive assistance with all activities of daily living (ADLs), including use of the toilet. The MDS further indicated that Resident #510 had impairment on one side of his lower extremity, was not steady and was only able to stabilize with staff assistance moving on and off the toilet. On 12/5/14 at 2:30 p.m., the facility's Restorative Nurse (Nurse "O") was queried regarding the fall on 11/16/14 for Resident #510. Nurse "O" reported that the CNA assisted Resident #510 to the bathroom and after he had the fall, the assigned CNA was re-educated and/or instructed to not leave residents alone in the bathroom who require safety alarms. On 12/5/14 at 3:10 p.m., the Director of Nursing (DON) was queried regarding the fall on 11/16/14 for Resident #510. The DON provided no explanation. On 12/5/14 at 3:30 p.m., review of the facility's policy entitled "Falls Protocol," revised 8/2013, revealed the following documentation: "Interventions are put into place based on the initial assessment." A policy was requested regarding safety alarms, but was not provided by the survey's exit. ( ) Resident # 509 On 12/02/14 at 2 p.m., a group meeting with 14 alert and oriented residents at the facility was conducted. The group was queried about concerns at the facility. The residents indicated Staffing was an issue. There was not enough staff to take care of them. Nine of the fourteen spoke out about staffing. Two residents stated they " have been left on the toilet so long that their legs began to hurt and went numb, about 20 or 30 minutes. " On 12/04/14 at 3:25 p.m., Resident #521 was queried about the incident related to being left on the toilet too long and stated, " It was on the afternoon shift about three weeks ago. I had to bang on the wall even with the call light on. The back of my legs went numb and it hurt so bad. It happened to my neighbor (resident #72) too. " ( ) On 12/3/14 at 8:10 A.M., and on 12/4/14 at 9:15 A.M., 11:00 A.M., and 2:00 P.M., Resident #509 was observed in bed, fully dressed, with a personal alarm attached. The Resident did not respond to questioning, and appeared asleep. On 12/4/14 at 2:00 P.M., Resident #509's roommate, Resident #39 stated, "She (Resident #509) sleeps a lot. There were no staff noted providing supervision. On 12/4/14 at 2:15 P.M., Social Worker "X" was queried regarding Resident #509, and stated, "She does sleep a lot, but does get up for meals. She has some confusion and memory problems, but can answer questions." On 12/4/13 at 2:17 P.M., Resident #509 was interviewed. The Resident was able to answer simple questions with some confusion and memory impairment. On 12/4/14 at 3:45 A.M., Resident #509's clinical record and facility Incident and Accident reports (I&A) were reviewed with the Director of Nursing (DON) and the facility Safety Coordinator, Restorative Nurse ""O", and revealed the following: A face sheet documented that Resident #509 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set Assessment (MDS), dated [DATE], and the previous annual MDS assessment dated [DATE], documented that Resident #509 had severe cognitive impairment (dementia), needed physical assistance from staff for transfer to the wheelchair, toileting, and mobility once in the wheelchair, and had balance impairments. A Psychiatry Services Assessment, dated 11/11/14 documented Resident #509 had a [DIAGNOSES REDACTED]. There was no fall risk assessment noted. The DON was unable to provide a fall risk assessment fro Resident #509 when asked, but stated that Resident #509 was at risk for falling. Review of Resident #509's Nursing Care Plans revealed a care plan for Activities of Daily Living (ADLs), dated 6/30/13 with an intervention (staff instructions) dated 9/17/14, "I need extensive assistance x 1 (of one person) with 2 wheeled walker platform on right and gait belt for safety in transfers," and dated 7/15/13, "I have a sensor alarm on my bed and wheelchair." A care plan entitled, "Safety", dated 7/15/13, noted the following interventions for Resident #509, "I have a sensor alarm on my bed (started 7/15/13)", and, (added 9/23/13), " I have a sensor alarm on my wheelchair (w/c), monitor me for attempts to remove it. I have poor safety awareness with impulsive attempts to transfer independently", and "please check my sensor pad alarm to ensure that it is working effectively as I tend to put items on it to prevent it from sounding (10/6/14)". There was no careplan to address Resident #509's noncompliance with the care planned safety alarms, or documentation of any interventions attempted to prevent Resident #509 from removing or tampering with the alarms. Review of I&A for Resident #509 revealed documentation that Resident #509's personal alarm did not sound on two occasions resulting in falls. An I&A documented that Resident #509 was found on the restroom floor on 7/11/14 at 8:00 A.M. The I&A noted, "Resident turned her alarm off". A Nursing Progress note for the incident, dated 7/11/14 at 1:25 P.M., documented, "Alarm did not sound. Resident has history of turning her alarms off." When asked why no interventions to prevent Resident #509 from removing the alarm had been implemented if it was known that the resident removed the alarms, or why no new interventions were added after this fall, the DON and Restorative Nurse stated that all safety alarms were checked for functioning and placement once a week. An I&A dated 7/14/14 at 3:15 P.M., documented that Resident #509's personal safety alarm sounded, alerting staff in time to prevent the resident from falling. An I&A dated 10/3/14 at 4:00 P.M., documented that resident #509 was found on the floor next to the bed. The I&A documented, "I was going to make toast and tea (resident statement). Sensor pad alarm did not sound. It became unplugged under the sheet and she had her purse and shoes sitting on it. Was self transferring." When asked about this, the DON stated, "She (Resident #509) takes her alarms off." When asked what was done to prevent Resident #509 from removing or disconnecting the alarms, or to monitor the alarms for function and placement, The DON stated, "Staff are supposed to be checking the alarms. We also do daily safety rounds, and then check the alarms." When queried, the DON was unable to provide any documentation of this, other than a one time per week alarm audit. When asked what was done to prevent Resident #509 from falling, if the careplan documented that the resident either removed or tampered with the alarms, and did not include guidelines for checking the alarms or any instructions to minimize tampering, the DON stated that staff provided supervision for Resident #509 by, "rounds and 15 minute checks (frequent supervision)." When queried, the DON was unable to explain how this was implemented if the Certified Nursing Assistants (CNA) and the Staff Nurse were busy providing care to other residents. The DON was unable to provide documentation to indicate that staff were advised that Resident #509 required frequent (every 15 minute) checking, on either the CNA care guide or the Nursing Care Plans. Resident #518 On 12/4/14 at 2:10 P.M., Resident #518 was interviewed. The resident was alert and oriented to time, place and person, and responded appropriately to interview. The resident was in a wheelchair, and had ankle foot orthotic devices (AFO, foot splints to correct joint contractures) on both feet. Resident #509 stated that there were, "not enough staff" resulting in long waits for the nursing "call bell" (nurse call system) to be answered. Resident #509 stated that she had had "embarrassing accidents, I wet myself twice, because it took so long for someone to come after I rang the bell." Resident #509 then stated, "I often have to wait for a long time on the toilet after I'm done. I ring the bell, and it takes a long time for some one to come and get me off. I fell on ce because I got tired of waiting for some one to come, and I tried to get up by myself. It was my own fault that I fell . I shouldn't have tried to get up by myself. On 12/5/14 at 9:50 A.M., Resident #518's clinical record was reviewed with the Director of Nursing (DON) and the Safety Coordinator, Restorative Nurse "O", and revealed the following: A face sheet documented that Resident #518 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE], documented that Resident #518 had intact cognition (no dementia) and needed extensive physical assistance from staff to walk and for transfers to the wheelchair and toileting. The MDS documented that Resident #518 had impaired balance, and had a fall prior to admission. The Nursing Admission Assessment fall risk assessment for Resident #518 was blank (not completed). The DON was requested to provide documentation of a fall risk assessment for Resident #518, but was unable to do so prior to survey exit. A Nursing Care Plan for Activities of Daily Living (ADLs) for Resident #518, dated 11/13/14, noted the following instructions to staff (interventions) dated 11/26/14, "Transfers: I require supervision for toileting transfers", and "I require supervision for toileting tasks." A Nursing Note for Resident #518, dated 12/1/14 at 4:15 P.M., titled, "Fall without injury", documented the following, "Resident observed on the bathroom floor on her bottom. Resident states, "When I transferred from the toilet to the wheelchair (w/c), my knees buckled and I lowered myself slowly. I am not hurt, just embarrassed." When asked about this, the DON and the Restorative Nurse "O" stated that they could not provide any additional information, or comment on Resident #518's fall, because, "We haven't seen the I&A yet." On 12/5/14 at 11:45 A.M., the Administrator was asked if the facility had identified a concern with residents being left on the toilets for long waits after ringing the call light for assistance to get off the toilet. The Administrator stated, "The concern was brought to the Resident Council. Everything (concerns) from the Resident Council has been addressed and is taken care of." On 12/5/14 at 2:45 P.M., Certified Nursing Assistant (CNA) "N", Resident #518's assigned CNA on 12/1/14 at the time of the fall, was interviewed about Resident #518's fall, and stated, "I came back and seen she had her flashing light on." When queried, CNA stated that the flashing light indicated that the Resident has activated the nurse call system in the restroom. CNA "N" stated, "I found her on the floor." When asked if Resident #518 required supervision during toileting, CNA "N" did not answer the question, but stated, "I didn't put her on the toilet." When asked if Resident #518 's room call light had been on earlier (to request assistance), CNA "N" stated, "I don't know." When asked if another staff member assisted Resident #518 to the toilet, CNA "N" stated, "I don't know. I was b

This citation pertains to MI 122 Based on observation, interview and record review, the facility failed to ensure that one (#501) of two residents reviewed for injuries out of a total sample of four, was transferred to the wheelchair using the required assistive equipment, resulting in a laceration (deep cut) which required transfer to the hospital emergency room (ER) for sutures (stitches), skin glue, and butterfly sutures (adhesive strips used to hold wound edges together). Findings include: On 9/17/14 at 1:25 P.M., Resident #501 was interviewed in the room. Resident #501 was alert and oriented, and responded appropriately to questions. The resident was in bed on an air mattress, and reported that before Certified Nursing Assistant (CNA) "A", "dropped her", she transferred to the wheelchair using a sliding board (assistive equipment) with two staff assisting. Resident #501 reported that CNA "A" did not use the correct procedure to transfer her on the date of the incident, and stated, "(CNA "A") was acting the fool and dropped me on to something sharp on the wheelchair, I don't know what. All the nurses came running into the room, and they used every washcloth in the place to try and stop the bleeding. I had to go to the hospital for stitches. There was a lot of blood. I had a smaller wheelchair then. It had footrests. I don't remember exactly, but there were a lot of stitches, and it still hasn't healed. " On 9/17/14 at 1:30 P.M., Resident #501 pulled the sheet off her left leg to reveal a 15 centimeter (cm) irregularly shaped, puckered area on the right medial (inner) area of the left calf, which had areas of indented white scar tissue surrounding jagged, irregularly shaped, thick brown scabs of varying thickness and width . On 9/17/14 at 1:35 P.M., CNA "B" reported that she had not been present at the time Resident #501 received the left leg laceration, and stated, "(Resident #501) was doing really good with the sliding board at that time. After the incident, they changed her to a maxi lift transfer (mechanical full body lift machine). When queried about Resident #501's cognition, CNA "B" stated, "She's pretty with it." On 9/17/14 at 2:14 P.M., CNA "A", (the CNA who did Resident #501's transfer at the time of the incident) was interviewed by telephone and stated, "We were transferring (Resident #501) from her wheelchair (w/c) to her bed. It was a pivot transfer. The charge nurse was helping me do the transfer. We didn't notice anything wrong until we seen blood. I found out afterwards that she was a slide board transfer. (Unit Manager "C") told me afterwards, that she was a slide board transfer because her skin was fragile. I didn't get a chance to look at the care plans." When asked, CNA "A" was unable to say if the w/c leg rests were removed or folded back out of the way during the transfer, stating, " I don't remember where the (w/c) leg rests were. You're the first person who's asked me that question." On 9/17/14 at 2:25 P.M.,Resident #501's clinical record and facility incident report forms (I&A) were reviewed with the Minimum Data Set Assessment (MDS) Coordinator "D" , who was also interviewed at that time. The following were revealed: A face sheet documented that Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] documented that Resident #501 had moderately impaired cognition, impaired balance, did not walk, needed extensive staff assistance for movement in bed, and needed extensive assistance from two staff for transfers to and from the wheelchair. The most recent MDS, dated [DATE] documented that Resident #501's cognition was intact, and that the Resident was only transferred out of bed one time during the seven day look back period (was mostly bedfast). A Physical Therapy Progress Report for Resident #501, dated 6/6/14 - 6/11/14, noted, "balance deficits, decreased range of motion, muscle tone limitations, strength impairment, and a left leg external rotation (joint deformity). A Nursing Care Plan for Activities of Daily Living (ADLs), dated 5/6/14, contained the following intervention, dated 6/9/14, "Transfers: I require two person extensive assist with a slideboard to/from bed and w/c." An I&A for Resident #501 documented an incident on 6/13/14 at 8:30 P.M., noting, "While transferring resident with two assist (two staff), after resident was in bed, CNA and nurse noted that resident had a laceration to the left lower extremity (LLE - left leg). Area freely bleeding. Pressure to area. area wrapped with gauze abdominal pad and four by four (gauze squares)." A "Patient Transfer form" (ambulance record), dated 6/13/14 (no time indicated) documented that Resident #501 was transferred to the hospital for "LLE laceration." An ER (ED) Triage Report for Resident #501, dated 6/13/14 at 8:00 P.M., noted, "Left leg laceration. Left shin. Length 20 centimeters (cm)." A Nursing Note for Resident #501, dated 6/14/14 at 12:44 A.M., documented, "At approximately 8:30 P.M., this nurse and (CNA "A") were transferring resident from her w/c to her bed. Resident was transferred to the bed with two assist, and when resident was sitting on bed, the CNA noticed that her LLE was bleeding. Upon inspection, resident's LLE had a large deep skin tear, and was bleeding freely. Pressure and gauze was applied to area and resident was transferred to emergency room (ER). At 10:00 P.M., the resident returned from ER and resident had sutures, ( and), ( brand name of butterfly sutures) and skin glue to area. (Wrap dressing) was on LLE with slight oozing of blood." A Nursing Note for Resident #501, dated 6/25/14 at 10:28 A.M., documented, "Resident's trauma wound on left calf; Doctor removed sutures. Resident developed a hematoma (bleeding into the tissues) on medial (inside) aspect of suture line. Doctor debrided (surgical removal of) the nonviable (dead) tissue." A Wound Care Services note for Resident #501, dated 7/16/14 at 9:52 A.M., documented, "left medical calf: Debridement was performed down to and including the subcutaneous (underneath the skin) tissues with a #15 blade." On 9/17/14 at 2:40 P.M., MDS Coordinator "D" stated, "There wasn't an investigation because we know how this fall happened. The nurse did document on the I&A that she re-inserviced (counseled) (CNA "A") because he didn't check the care plan before doing the transfer. I'm on the Safety Committee (reviews falls). (CNA "A") went in, he needed help transferring, the nurse helped. (CNA "A") told the nurse that (Resident #501) was a two person pivot transfer, but (Resident #501) was care planned for a slide board. It seemed a pretty cut and dried thing. (CNA "A") forgot to check the care plans. There was blood on the w/c foot rest. The nurse told the Director of Nursing (DON) that it was the foot rest, but with (Resident #501)'s skin, it might have been anything." When queried, MDS Nurse "D" stated, "I don't know if the foot pedals were flipped back out of the way or not. We didn't check." When asked why the charge nurse didn't check Resident #501's nursing care plan for transfer needs prior to assisting CNA "A", MDS Coordinator "D" stated, "(the charge nurse) relied on what (CNA "A") told her." When queried, the MDS coordinator was unable to explain how the charge nurse could provide oversight of the resident's care if she was unfamiliar with the resident's care plan. On 9/20/14 at 9:00 A.M., review of the facility policy entitled, "Therapy", (no date indicated), revealed the following statements, "Every Resident has a care plan! It is very important to understand and read the care plans provided. In the care plan, every aspect of care you need to know to provide safe and quality care are listed. Therapy provides information in the care plan addressing the following: Transfer status." On 9/20/14 at 9:10 A.M., review of the facility policy entitled, "Care Plans", revised 7/2014, revealed the following statement, "CNA's will confirm that care plans were reviewed and followed every shift via ADL charting for CNA's or on the care plan confirm section of the 24 hour CNA report." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY PLACE A THERAPEUTIC CHAIR CUSHION IN IT'S PROPER POSITION (DEVICE USED FOR THE PREVENTION OF PRESSURE ULCERS) FOR ONE (#507) OF FIVE RESIDENTS REVIEWED FOR PRESSURE ULCERS, OUT OF A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN A STAGE IV FACILITY ACQUIRED PRESSURE ULCER. FINDINGS INCLUDE: ON 11/29/11 AT 2 P.M., RESIDENT #507 WAS OBSERVED IN BED LYING ON HER BACK ASLEEP ON AN AIR MATTRESS. HER FOLEY CATHETER INTACT AND DRAINING CLEAR YELLOW URINE. ON 11/29/11 AT 2:30 P.M., RECORD REVIEW OF RESIDENT #507'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT'S ANNUAL MINIMUM DATA SET (MDS), dated [DATE], INDICATED RESIDENT #507 HAD A SEVERELY IMPAIRED COGNITION, WAS DEPENDENT UPON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S), AND HAD A STAGE IV PRESSURE ULCER ( FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION, TISSUE NECROSIS, OR DAMAGE TO MUSCLE, BONE OR SUPPORTIVE STRUCTURES). ON 11/29/11 AT 2:45 P.M., THE UNIT MANAGER (NURSE "D") WAS QUERIED REGARDING RESIDENT #507'S PRESSURE ULCER DEVELOPMENT. NURSE "D" REPORTED THE PRESSURE ULCER ON RESIDENT #507'S SACRAL AREA DEVELOPED ON 8/15/11 DUE TO AN IMPROPER PLACEMENT OF THE CUSHION TO RESIDENT #507'S WHEELCHAIR. NURSE "D" STATED, "HER WHEELCHAIR CUSHION WAS PUT ON BACKWARDS THE DAY AFTER HER WHEELCHAIR WAS POWER WASHED. THE SEAT CUSHION WAS ACTUALLY PUT ON BACKWARDS. WITHIN A MATTER OF ONE DAY, SHE BEGAN TO BREAKDOWN. THE WHEELCHAIR CUSHION WAS ASSESSED TO BE APPROPRIATE (WHEN PLACE PROPERLY). AN AIR MATTRESS WAS ADDED TO HER BED ON 8/15/11. WHEN WE NOTED IT, IT WAS DARK, UNBLANCHABLE AND MEASURED 4.5 CENTIMETERS (CM) X 6.8 CM. AT THAT TIME, WE APPLIED ALLEVYN DRESSINGS." NURSE "D" DENIED ANY OTHER POSSIBILITIES FOR THE CAUSE OF RESIDENT #507'S SKIN BREAKDOWN SUCH AS WEIGHT LOSS, POOR APPETITE, OR LACK OF REPOSITIONING. ON 11/29/11 AT 3 P.M., NURSE "D" PRESENTED A FACILITY FORM TITLED "PRESSURE SORE INVESTIGATION DATA COLLECTION TOOL." THE FORM WAS LABELED WITH RESIDENT #507'S NAME AND ROOM NUMBER. THE FORM INDICATED RESIDENT #507'S PRESSURE ULCER TO HER COCCYX WAS DISCOVERED ON 8/14/11 DURING PERINEAL CARE. THE FORM DESCRIBED THE WOUND AS AN UNSTAGABLE WOUND. THE FORM ALSO REVEALED DOCUMENTATION FOR THE CAUSE OF THE WOUND THAT READ, "RESIDENT WITH GEL CUSHION INCORRECTLY PLACED IN WHEELCHAIR LEADING TO DEVELOPMENT OF WOUND." REVIEW OF THE WOUND NOTES FOR RESIDENT #507, DATED 8/18/11, REVEALED DOCUMENTATION THAT READ, "RESIDENT DEVELOPED AN UNSTAGABLE WOUND ON COCCYX MEASURING 4.5 CM X 6.8 CM, DARK PURPLE UNBLANCHABLE, NO DRAINAGE, NO COMPLAINTS OF PAIN WITH TREATMENT. CENTER OF WOUND WITH SMALL OPEN AREA IN MIDDLE MEASURING 1.5 CM X 1.0 CM., WOUND EDGES CLEAN. RESIDENT RECEIVED AIR MATTRESS AND ASSESSED WHEELCHAIR CUSHION WHICH REMAINS APPROPRIATE WITH PROPER PLACEMENT..." ON 11/29/11 AT 3:05 P.M., REVIEW OF RESIDENT #507'S WHEELCHAIR REVEALED A DEEP CONTOUR CHAIR CUSHION. THE RESIDENT WAS LAYING IN BED ASLEEP ON HER BACK. ON 11/30/11 AT 9:55 A.M., RESIDENT #507 WAS OBSERVED LYING ON HER LEFT SIDE IN BED RESTING ON AN AIR MATTRESS. HER FOLEY CATHETER WAS INTACT AND DRAINING YELLOW CLEAR URINE. ON 11/30/11 AT 10:10 A.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING RESIDENT #507'S WOUND DEVELOPMENT. THE DON STATED, "SHE HAS A WEDGE CHAIR CUSHION. SHE WAS MOVED FROM A DIFFERENT UNIT. THEY PLACED THE CHAIR CUSHION ON THE WRONG WAY. THIS WAS TAKEN TO QA (QUALITY ASSURANCE)." ON 11/30/11 AT 12:10 P.M., A WOUND OBSERVATION OF RESIDENT #507'S WOUND REVEALED A 3.2 CM X 1.3 CM WITH 0.5 CM DEPTH. MINIMAL YELLOWISH/BROWNISH SLOUGH WAS NOTED. THE WOUND DOCTOR CLEANSED THE WOUND WITH NORMAL SALINE, CLEANSED THE EDGES WITH [MEDICATION NAME], AND APPLIED SANTYL TO THE CENTER OF THE WOUND BEFORE A DRESSING WAS THEN APPLIED. THE WOUND WAS STAGED AS A STAGE IV PRESSURE ULCER. ON 12/1/11 AT 9:30 A.M., RESIDENT #507 WAS OBSERVED AGAIN IN BED LYING ON HER BACK RESTING ON AN AIR MATTRESS. SHE ANSWERED SOME SIMPLE QUESTIONS REVIEW OF THE FACILITY'S POLICY ENTITLED, "PREVENTATIVE MEASURES FOR ALTERED SKIN INTEGRITY," UNDATED, REVEALED INTERVENTIONS THAT INCLUDED "USE PRESSURE REDUCING PRODUCTS SUCH AS A SPECIALTY BED, AIR MATTRESS OR OTHER PRESSURE RELIEVING DEVICES AND CHECK FOR PROPER FUNCTIONING. GEL CUSHION OR OTHER PRESSURE RELIEVING CUSHION FOR WHEELCHAIR SEAT AND/OR BACK." THE FACILITY PROVIDED NO FURTHER EXPLANATION FOR THE DEVELOPMENT OF THE STAGE IV PRESSURE ULCER FOR RESIDENT #507, NOR WAS THERE ANY OTHER DOCUMENTATION PROVIDED AND/OR OFFERED REGARDING THE DEVELOPMENT OF THE PRESSURE ULCER ( )