Every finding on record at Medilodge of Sterling Heights

Based on observation, interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for six residents (R46, R56, R101, R116, R156, and R177) of six reviewed for food palatability. Findings include: R56 On 4/12/26 at 9:27 AM during initial tour R56 reported the food is always cold, over cooked, and tough. R56 explained they have reported the food concerns multiple times and nothing changes. R56 continued and stated, when staff are asked to reheat the food, the staff refuses. A review of R56's medical record noted, R56 was admitted to the facility on [DATE] with diagnosis of Fractures and Other Multiple Trauma. A review of R56's MDS assessment noted R56 with an intact cognition and required assistance with activities of daily living by staff. R46 On 4/12/26 at 11:13 AM, R46 reported cold water is not being passed on the weekend and the food is horrible. A review of R46's medical record noted, R46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Pulmonary Embolism. A review of R46's MDS assessment noted R46 with an intact cognition and required assistance with activities of daily living by staff. R101 On 04/13/26 at 11:58 AM, R101 reported the food is nasty. R101 was asked details regarding the food and reported it's just nasty. A review R101's medical record noted, R101 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of End Stage Renal Disease. A review of R101's MDS assessment noted R101 with an intact cognition and required assistance with activities of daily living by staff. R116 On 4/12/26 at 1:47 PM, R116 reported the food sucks, and that it's always cold. A review R116's medical record noted, R116 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of End Stage Renal Disease. A review of R116's MDS assessment noted R116 with an intact cognition and required assistance with activities of daily living by staff. A review of the facility's food committee meeting minute notes for the months of January 2026 to April 2026 revealed resident food concerns related to, palatability of the chicken salad, dryness of the meat and fish, grilled cheese sandwiches being greasy, soggy vegetables, and potatoes being hard. R177 On 4/12/26 at 12:31 PM, R177 was interviewed regarding food palatability at the facility. R177 stuck out their tongue and grimaced. A review of R177's electronic medical record (EMR) revealed that R177 was most recently admitted to the facility on [DATE] with diagnoses that included Schizoaffective disorder, Bipolar type and Dementia. R177's most recent minimum data set assessment (MDS) dated [DATE] revealed that R177 had a severely impaired cognition. R156 On 4/12/26 at 4:54 PM, R156 was interviewed regarding food palatability at the facility and stated, The food is terrible. R156 further indicated that their food was frequently cold. A review of R156's electronic medical record (EMR) revealed that R156 was most recently admitted to the facility on [DATE] with diagnoses that included End stage renal disease (Final stage of kidney disease) and Type 2 diabetes. R177's most recent MDS dated [DATE] revealed that R156 had an intact cognition. On 4/14/26 at 12:03 PM, a lunch tray was pulled from a food cart on the 400 unit and temperature checked by Dietary Manager (DM) B. The results were the following, Spaghetti with meat sauce: 106.9 Degrees Farenheit; Parmesan roasted cauliflower: 98.0 Degrees Farenheit. DM B was interviewed regarding the preferred temperature for the meal and stated, It's based on resident preference. DM B was further interviewed about food palatability issues at the facility and indicated that since beginning a food committee, resident complaints regarding food palatability have decreased. DM B tasted the spaghetti and meat sauce per the surveyor's request and indicated that it tasted good. On 4/14/26 at 12:07 PM, the surveyor taste tested the lunch tray and found the food to be lukewarm which negatively impacted the palatability. On 4/12/26 at 12:30 pm, the lunch meal food cart was delivered to the 400 unit. On 4/12/26 at 12:40 pm, a test tray was removed from the cart to check the food temperatures. The food temperatures were measured in the presence of Dietary Manager (DM) B. The following food temperatures were noted: Country fried steak 117 degrees Fahrenheit Diced potatoes 106 degrees Fahrenheit Cooked carrots 103 degrees Fahrenheit When queried about what the expected serving temperature of hot food items should be, DM B stated that in terms of serving temps, it's an individual preference. When asked if potatoes at 106 degrees Fahrenheit was acceptable, DM B stated it is for me.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include: 04/12/2026 at 8:40 AM, the Ice machine located in the ice machine room next to the conference room was observed with a leak behind the machine. The floor was damp with water, and there was a black mold-like substance on the surface of the floor tiles. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. On 04/12/2026 between 8:45 AM-9:30 AM, during an initial observation of the kitchen, the following items were observed: In the walk-in cooler, the floor was soiled and sticky. There was an undated pan of cut up pineapple chunks, an undated pan of mixed vegetables and an undated pan of chopped salad. When queried at that time, Manager-In-Training (MIT) T confirmed the items should have been dated and stated they would be discarded. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . In the dry storage room, there was a dented can of shredded sauerkraut and 2 dented cans of pumpkin on the rack of active stock of cans. When queried at that time, MIT T confirmed the dented cans should have been pulled out. There was food debris buildup on the top of several food containers and boxes. In addition, there was a black spotted mold-like substance on the surface of the over-head duct work, which was located directly above the rack of canned food goods. When queried about the black spotted substance on the over-head duct work on 04/12/2026 at 12:15 PM, Maintenance Director J was unsure what the substance was but stated they would clean it off right away. According to the 2022 FDA Food Code section 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Pf According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. At the cart washing area, there were cracked, broken floor tiles observed, and there was standing stagnant water pooled under the loose tiles and inside the wells of the missing tiles. There were several gnats observed flying about in the cart washing area. When queried about the broken tiles and standing water on 4/12/2026 at 11:50 AM, Dietary Manager B stated the broken tiles had been reported to Maintenance but provided no explanation for why the standing water had not been addressed. According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. 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 andsupplies;(B)Routinely inspecting the PREMISES for evidence of pests;(C)Using methods, if pests are found, such as trapping devicesor other means of pest control as specified under SS 7-202.12,7-206.12, and 7-206.13; and (D)Eliminating harborage conditions.

Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for one (R45) of four residents reviewed for sanitary environment. Findings include: On 04/12/2026 at 9:33 AM, R45 was interviewed in their room sitting up in their wheelchair. As the interview concluded R45 transferred from their wheelchair to their bed and laid down. During further observation of the resident's room, it was noted the resident's wheelchair had a folded bed sheet laying over the seat cushion and the sheet had a large stain of what appeared to be liquid brown stool residue. Review of R45's facility record revealed they were admitted into the facility 11/04/24 with diagnoses that included adjustment disorder with Depressed Mood and Other Specified Disorder of the Brain. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had intact cognition and required encouragement and assistance for completion of self-care activities. On 04/13/2026 at 8:54 AM, R45 was observed in bed sleeping. The resident's wheelchair still had the folded bed sheet with brown stool residue laying over the wheelchair seat cushion. A strong odor of urine was present in the room. R45 did not respond to verbal attempts to initiate an interview. At 1:53 PM, R45 was observed in bed and did not respond to verbal greetings. The soiled bed sheet remained in the wheelchair seat with the top layer of the sheet folded back covering a majority of the brown stool residue but leaving a portion still visible. The room continued to have a strong odor of urine. On 04/13/2026 at 3:26 PM, R45 was observed in bed. The resident did not respond to verbal greetings. The soiled bed sheet remained on the wheelchair seat cushion as before. The room continued to have strong odor of urine. Further observation of the room revealed a large puddle of dried urine on the far side of the bed between the bed and the wall. On 04/13/2026 at 3:55 PM, R45's room was observed along with the facility's Director of Nursing (DON). The soiled bed sheet remained in the wheelchair, and the presence of the urine/urine odor in the room since earlier that morning. The DON reported their expectation is the soiled wheelchair and the urine puddle should have been identified and removed/cleaned in a timelier manner. Review of the facility policy Safe and Homelike Environment dated 01/01/22 revealed the following entries: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living.Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department.

Based on observation, interview, and record review, the facility failed to ensure the dressing for a Peripherally Inserted Central Catheter (PICC) intravenous (IV) line was changed and dated timely for two residents (R169 and R171) of three residents whose IV sites were observed. Findings include: R169On 04/12/2026 at 11:11 AM, R169 was seated on their bed. R169 reported they had been receiving IV antibiotics daily through their right upper arm PICC line. The transparent dressing over the IV insertion site was soiled black around the edges and was peeling away from the skin at the lower inside edge. R169 was able to lift up the dressing with their fingers. The dressing was dated 03/23/26. A review of R169's record documented R169 had been admitted into the facility on [DATE]. R169 reported the PICC line had been inserted and dated at the hospital. On 04/14/2026 at 7:54 AM, the Director of Nursing (DON) reported PICC line dressings are to be assessed on admission and changed every 24 hours or 72 hours but would have to check the facility policy. R171On 04/14/2026 at 12:44 PM, R171 was observed wheeling themself backward down the hallway. A PICC line was observed in R171's left upper arm. The PICC line had a smaller (around three by three inches) transparent dressing over the insertion site. The dressing was not dated. Licensed Practical Nurse (LPN) A reported the dressings are dated when changed. A review of the facility policy titled, Dressing Change for Vascular Access Devices dated August 2021, revealed, Purpose: To prevent local and systemic infection related to the IV catheter . Central Venous access device and midline dressings changes will be done at established intervals and immediately if the if the dressing is compromised . transparent semi-permeable membrane dressings are changed every seven days and (as needed) PRN . A dressing is changed immediately if non-occlusive or soiled .

Based on observation, interview, and record review, the facility failed to ensure biologicals were dated when opened and expired medications were discarded in five of six medication carts. Findings include: On 04/13/2026 at 5:58 AM, the biologicals in the 400 hall front medication cart were reviewed with Registered Nurse (RN) C an over-the-counter bottle of meclizine (for motion sickness) with a date opened of 08/10/25 had an expiration date of 01/2026. On 04/13/2026 at 8:37 AM, the biologicals in the 100 hall medication cart were reviewed with RN G. An Anoro (umeclidinium and vilanterol inhalation powder) inhaler for R1 did not have a resident identifier on the inhaler. On 04/13/2026 at 9:05 AM, the biologicals in the 500 hall medication cart were reviewed with Licensed Practical Nurse (LPN) F, an Advair 250/50 9salmeterol/fluticasone inhaler for R213 was not labeled with the name and date opened on the inhaler and a Trelegy inhaler was not dated when opened on the inhalerOn 04/13/2026 at 9:25 AM, the biologicals in the 600 hall medication cart were reviewed with LPN E. A latanoprost eye drops vial for R137 was not dated when opened and two Humalog insulins for R37 were not dated when opened and the blood glucose test strips were not dated when opened.On 04/13/2026 at 10:11 AM, the biologicals in the 400 hall back cart were reviewed with RN D. Two opened glargine insulin pens for R58 were not dated when opened; An glargine insulin pen for R197 was not dated when opened; A glargine insulin pen for R168 was not dated when opened, and the blood glucose test strips were not dated when opened. On 04/14/2026 at 7:54 AM, the Director of Nursing (DON) reported medications carts are to be checked daily by the nurses, and unit managers once or twice a week, and would have to check with the pharmacy and facility policy about label and dating standards. A review of the facility policy titled Medication Storage with reviewed/revised date of 01/30/2024 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 and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.A review of the prescribing/consumer information for the Anoro (umeclidinium and vilanterol inhalation powder) inhaler revealed, .should be stored inside the unopened moisture-protective foil tray and only removed from the tray immediately before initial use. Discard 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. Write the date you open the tray on the label on the inhaler .A review of the prescribing/consumer information for the Advair (salmeterol/fluticasone powder) inhaler revealed, .Safely throw away in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first .A review of the prescribing/consumer information for the Trelegy (fluticasone furoate, umeclidinium, vilanterol inhalation powder) inhaler revealed, .Safely throw away in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler .A review of the glargine insulin pen consumer information on drugs.com revealed, .Store the injection pen at room temperature (do not refrigerate) and use within 28 days . A review of the latanoprost eye drops consumer information on drugs.com revealed, .In-use latanoprost ophthalmic is stable for only a certain number of days or weeks. Throw away any medicine not used within that time .

Based on observation, interview, and record review, the facility failed to maintain a sanitary tube feeding pole for one (R191) resident of three residents reviewed for environmental concerns. Findings include:On 04/12/2026 at 1:36 PM, R191 was observed in bed and was not responsive to verbal greetings. The resident's tube feeding pole and base of the pole was caked with a dried beige substance. A review of the facility record for R191 revealed they were admitted into the facility on [DATE] with diagnoses that included Gastrostomy Status (requiring nutrition via tube feeding). The Minimum Data Set (MDS) assessment dated [DATE] indicated R191 required total assistance for completion of self-care activities and the resident's cognition was severely impaired. On 04/14/2026 at 10:01 AM, R191 was observed in bed. They were alert and able to acknowledge the surveyor with head and eye movements but not able to answer interview questions. The tube feeding pole was observed to be in the same condition with a dried beige substance as observed the previous day. On 04/14/2026 at 12:34 PM, R191 was observed in bed with the facility Director of Nursing (DON) present. The DON observed the build-up of dried beige substance on the base of the tube feeding pole. The DON reported the expectation is the tube feeding pole would be kept clean and not be left in the currently observed condition and said any staff noticing the residue would be expected to clean it whether they are nursing or housekeeping staff.A review of the facility policy Safe and Homelike Environment dated 01/01/22 revealed the following entries: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living.

This citation pertains to Intake 2680407 Based on observation, interview, and record review, the facility failed to provide restorative therapy services (therapy to prevent or maintain range of motion - ROM) for one resident (R701) of two residents reviewed for ROM.Findings include:On 12/18/25 at 10:00 AM, R701 was observed lying in bed with their feet lying flat on the mattress. When queried, R701 confirmed they had not received consistent restorative therapy this week. A review of R701's medical record revealed they were admitted into the facility on 6/27/25 with diagnoses that included Spinal Stenosis, Multiple Sclerosis and Fibromyalgia. Further review of the medical record revealed the resident was alert and oriented x 4 (person, place, time, & situation) and required extensive assistance with bed mobility and transfers.A review of the physician orders dated 11/17/25 documented the following, Skilled restorative nursing three times a week for 12 weeks as tolerated. A review of the clinical record tasks revealed a 14 day look back for the following task: skilled restorative nursing: range of motion active to BUE (Bilateral Upper Extremity) and BLE (Bilateral Lower Extremity) three times a week for 12 weeks. 15-20 repetitions, three sets to include shoulder flexion/extension, elbow and wrist flexion/extension. flexion hip extension, abduction/adduction, knee and ankle flexion/ extension. The task record revealed the following dates were charted that restorative therapy was provided were on 12/6/25, 12/9/25, and 12/15/25 over a 14-day period (3 of 6 opportunities were provided). On 12/18/2025 at 5:00 PM, an interview was conducted with Certified Nursing Assistant (CNA) A who confirmed R701 received restorative therapy with them on 12/10/25, 12/11/25, and 12/12/25 and failed to document when once the task is complete. On 12/18/2025 at 2:30 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON was queried to why the restorative dates were not accurately documented as being completed and treatment not given as ordered. The ADON stated the restorative program was being reviewed for effectiveness. A review of a facility policy titled, Restorative Nursing Programs revealed the following: The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility. A restorative nursing program, when appropriate is based on the comprehensive assessment and resident .Restorative documentation requirements include documentation of implementation should be completed on the restorative delivery record or EMR (Electronic Medical Record) as applicable.

This citation pertains to Intake MI00153957. Based on observation, interview, and record review the facility failed to ensure a mattress was comfortable and changed timely upon resident request for one resident (R901) of three reviewed for a room furnishings. Findings include: On 07/01/25 at 8:17 AM, R901 was queried about a concern with uncomfortable mattresses. R901 reported the mattress feels like it has a hole in it and it feels like they are sitting on the frame of the bed. R901 further reported the mattress has been that way since they were admitted about six months ago. R901 also reported they had told different staff over the last six months and it had yet to be changed out. On 07/01/25 at 11:29 AM, Certified Nursing Assistant (CNA) D reported R901 had told them the mattress was uncomfortable at different times over the last four to five months and had reported it to the nurse because they were the ones who could put it in the maintenance needs reporting system (TELS). On07/01/25 at 12:11 PM, R901 was observed to be dressed and seated in a wheelchair dressed at the right side of the bed. The lunch tray was on the over bed table in front of R901. The sheets had been removed from the mattress and there was a visible wrinkle in the mattress cover in the center of the bed closer to the right side of the bed. The mattress had a firm bolster around the rim of the bed with a softer center which compressed easily. On 07/01/25 at 12:20 PM, Licensed Practical Nurse (LPN) E reported R901 had verbalized the mattress was a concern since they arrived around five months ago. LPN E further stated they thought they had told maintenance staff or put it into TELS. A review of the progress notes did not reveal any documentation by staff of R901's concerns with their mattress. On 07/01/25 at 12:52 PM, the identified concern was reviewed with the Assistant Administrator with a Corporate Representative present. The two staff reported they had reviewed the TELS reports for R901 and did not find a work order to change out the mattress. The administrative staff members further noted any staff can enter a work order into TELS and this is covered in orientation. A review of the TELS work orders for the last three months prior to the survey revealed mattresses were available and there were work orders which indicated other resident's mattresses had been changed out. On 07/01/25 at 2:25 PM, maintenance Staff F, was ask about any TELS work orders for a mattress replacement for R901 and reported that no one had entered any and further noted staff will tell maintenance about items but the work order still has to be entered when the work is done. A review of the Virtual Orientation Guide revealed, .55. Maintenance: a. All staff have the possibility of identifying equipment or items that are broken or in need of replacement. Anyone can complete a work order to notify the maintenance department so they can address the issue. The guide further noted the web site and that an application was also available to enter work orders.

This citation pertains to Intake M100151122: Based on observation, interview, and record review, the facility failed to prevent the fall of one (R705) of four residents reviewed for falls. Findings include: Review of the facility record for R705 revealed an original admitted [DATE] and a most recent admission of 08/22/17 with diagnoses including Primary Generalized Osteoarthritis, Spinal Stenosis, and Muscle Weakness. The record indicated R705 is receiving hospice services. On 04/14/25 at 12:40 PM, R705 was interviewed in their room. During the conversation regarding care concerns the resident stated I wanted to tell you I fell off the bed last Monday. The hospice aide was changing me and I rolled off the bed. When it happened I had some pain in my neck so they tried to X-ray my neck but they weren't able to. R705 indicated the X-ray couldn't be completed properly due to positioning difficulties. The resident denied any residual pain and stated I'm just a little sore but I always feel that. When asked if they felt safe receiving care R705 stated, as long as there are two aides its ok.When I fell [hospice aide] was alone. Review of R705's progress note revealed a note dated 04/07/25 indicating the hospice aide notified the resident's nurse when they turned the resident in the bed the resident rolled off onto the floor. Review of the Incident/Accident report dated 04/07/25 pertaining to this fall included a statement from the hospice aide that indicated they were providing care to the resident without other staff assistance when the resident fell off the bed. Review of R705's care plan revealed a fall risk-related Focus area that included an intervention dated 10/21/24 documenting care requiring bed mobility to be provided by two staff members. On 04/14/25 at 01:42 PM, the facility Director of Nursing (DON) reported the facility was aware the hospice aide attempted to provide care to R705 without the assistance of a second person and said the expectation is the resident's care should only be provided with two-person assistance and that hospice as well as in-house personnel will review resident's plan of care prior to providing service. Review of the facility policy Falls-Clinical Protocol dated 11/02/23 includes the entry 2. Based on the [fall risk] assessment an initial plan of care will be developed and implemented to address identified risk.

Based on observation, interview, and record review, the facility failed to ensure food was served in a palatable manner and at the preferred temperature for nine residents (R6, R21, R22, R24, R60, R74, R108, R146, R188) and six confidential group residents, of sixteen residents reviewed for food palatability. Findings include: R188 On 3/10/25 at 10:44 AM, R188 was interviewed about the palatability of the food at the facility and indicated the food was, lousy and frequently cold. A review of R188's electronic medical record (EMR) revealed that R188 was admitted to the facility on [DATE] with diagnoses that included Partial amputation on left mid foot and COPD (Chronic obstructive pulmonary disease) (Lung disease). R188's most recent minimum data set assessment (MDS) dated [DATE] revealed R188 had an intact cognition. R108 On 3/10/25 at 10:56 AM, R108 was interviewed about the palatability of the food at the facility and stated, I don't like the food. A review of R108's EMR revealed R108 was admitted to the facility on [DATE] with diagnoses that included Osteomyelitis (Bone infection) and Protein-Calorie malnutrition. R108's most recent MDS dated [DATE] revealed that R108 had an intact cognition. R146 On 3/10/25 at 11:29 AM, R146 was interviewed about the palatability of the food at the facility and indicated the food did not taste good, was not prepared in a palatable manner, and the meat was hard to chew. A review of R146's EMR revealed R146 was admitted to the facility on [DATE] with diagnoses that included Respiratory failure and Heart failure. R146's most recent MDS revealed that R146 had an intact cognition. R6 On 3/10/25 at 2:26 PM, R6 was interviewed about the palatability of the food at the facility and stated, It's terrible and the portions are small. On 3/12/25 at 10:31 AM, R6 was further interviewed regarding the palatability of the food and indicated the food was not good saying, The food is better when you're (survey team) here. A record review of R6's EMR revealed R6 was admitted to the facility on [DATE] with diagnoses that included Sepsis (Infection) and Respiratory failure. R6's most recent MDS dated [DATE] revealed that R6 had an intact cognition. On 3/12/25 at 12:15 PM, a lunch tray was pulled off of a lunch cart in the facility and temperature checked by District Dietary Manager (DDM) M. The results were the following, Cranberry orange chicken: 119.8 Degrees Farenheight (F); Brussel sprouts: 121.3 F; Rice Pilaf: 122.1 F. DDM M was interviewed regarding their preferred temperatures for the food and indicated that it was based upon the resident preference. On 3/12/25 at 12:20 PM, the chicken and rice was taste tested by the survey team members and was noted to be luke warm and the brussel sprouts were mushy and lacked flavor. On 3/12/25 at 12:27 PM, the Administrator (NHA) was interviewed regarding their expectation for food palatability regarding food served to the residents at the facility. The NHA indicated food palatability was all related to resident preference. 34851 R21 On 3/10/25 at 11:48 AM, R21 reported the only concern they had was the food. R21 stated, the food is cold and sometimes burnt. A review of R21's medical record noted, R21 was admitted to the facility on [DATE] and readmitted [DATE], a review of R21's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted, R21 with a moderately impaired cognition. R22 On 3/10/25 at 10:05 AM, R22 explained, the food was nasty and cold. R22 requested for a temperature check of their lunch meal today. On 3/10/25 at 1:03 PM, R22's lunch meal temperature was as follows; 117.8 F pork slices, 115.8 F mashed potatoes, and 99.6 F sliced carrots. R22 explained the food was as hot as they liked their food. A review of R22's medical record noted R22 was admitted to the facility on [DATE] with a diagnosis of Incomplete at T11-12 level of Thoracic Spinal Cord. A review of R22's MDS assessment noted, R22 with an intact cognition. R24 On 3/10/25 at 10:27 AM, R24 reported the food is terrible and breakfast is really bad. R24 explained, they order out to restaurants. A review of R24's medical record revealed, R24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Myocardial Infarction. A review of R24's annual MDS, dated [DATE] noted R24 with an intact cognition. R60 On 3/10/25 at 9:56 AM, R60 was asked about the care at the facility and stated, Food, it sucks. R60 further explained the food doesn't taste good and they have spent a lot of money buying food from the outside. A review of R60's medical record revealed, R60 was admitted to the facility on [DATE] with diagnosis of Heart Disease. A review of R60's quarterly MDS dated [DATE] revealed R60 with an intact cognition. Seven confidential group participants. On 3/11/25 at 1:40 PM, during the group interview all seven participants reported the food was a hot button topic. They explained the food did not taste good and was served mostly warm not hot. On 3/12/25 at 2:05 PM, the Dietary Manager and the Corporate Manager were asked for the food temperature at the point of service. They both reported there is no set number, but what is palatable for the residents. The Dietary Manager explained she attends food committee meetings and it is usually the same residents that attend the meeting. A review of the food committee notes revealed, 2/24/25 . 3. Does the food taste good? 60% like the food saying its tasty, 20% not enough variety . 20% sometimes saying the food is hit or miss . 4. Are food served at the proper temperature: Last meeting we were about the same 65% saying it's hot . 35% say warm or not hot enough . A review of the facility's policy titled, Food: Quality and Palatability undated, noted, Policy statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature . Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature: Food should be at the appropriate temperatures as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns .

Based on observation, interview, and record review, the facility failed to maintain the dish machine area in the kitchen in a clean manner, resulting in the presence of gnats. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 03/10/25 at 9:15 AM, there were numerous gnats observed underneath the dish machine tank and drainboard. The flooring was wet with murky standing water, and the pipes underneath the drainboard were coated with a black slimy substance. When queried about the gnats, Dietary Manager S provided no explanation. Review of the pest control service reports noted: 8/20/24 Upon inspection of the kitchen it was found there was heavy gnat activity. The cause of the gnat activity is the cleanliness in the kitchen. Areas all around and underneath dish tank were so soiled with debris that they were creating harboring spaces for gnats. 9/20/24 Upon inspecting the kitchen, many gnats were present. Kitchen staff must do a better job of cleaning. 1/15/25 Upon inspection of the kitchen there was heavy gnat activity. This is mostly due to build up of grime and residue throughout the kitchen but mostly harboring underneath sinks, corners and drains. According to the 2017 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: .4. (D) Eliminating harborage conditions.

Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for five residents (R34, R86, R147, R612, and R613) of six residents reviewed for call light accessibility. Findings include: R612 On 3/10/25 at 1:10 PM, R612's call light was observed out of reach of R612 and on the floor. On 3/12/25 at 10:55 AM, [NAME] Clerk (WC) P was observed in R612's room and was interviewed regarding the preferred location of the call light for R612. WC P stated, It should be within hand reach. A review of R612's electronic medical record (EMR) revealed that R612 was admitted to the facility on [DATE] with diagnoses that included End stage renal disease (Damaged kidney) and Type 2 diabetes. R612's most recent minimum data set assessment (MDS) dated [DATE] revealed R612 had an intact cognition and required moderate assistance to supervision for all activities of daily living (ADLs). R613 On 3/10/25 at 2:32 PM, R613's call light was observed on the floor by the end of their bed. On 3/12/25 at 10:32 AM, R613's call light was observed on the floor by the end of their bed. At 10:41 AM, Licensed Practical Nurse (LPN) Q was observed to enter and exit R613's room. On 3/12/25 at 10:44 AM, upon LPN Q's exit from R612's room, an observation was made of R612's call light remaining on the floor. At 11:04 AM and 1:13 PM, R613's call light was observed to remain on the floor out of reach of the R613. A review of R613's EMR revealed that R612 was admitted to the facility on [DATE] with diagnoses that included Osteomyelitis (Bone infection) and Cerebral infraction (Stroke). R612's nursing admission evaluation dated 3/8/25 revealed that R612 had an impared cognition. On 3/12/25 at 1:18 PM, an interview was conducted with Unit Manger, Registered Nurse (RN) R regarding their expectations for placement of call lights in residents' rooms. RN R stated, They should be within reach of the resident when they are in their room. R86 On 3/11/25 at 1:34 PM, R86's call light was observed to be on the floor by the bed out of reach of R86. A review of R86's EMR revealed R86 was admitted to the facility on [DATE] with diagnoses that included, Sepsis (Infection) and Respiratory failure. R86's most recent MDS dated [DATE] revealed that R86 had an intact cognition and required partial to substantial assistance for all ADLs other than eating. 44750 R34 On 3/10/2025 at 9:28 AM, R34 was observed laying in bed. R34 stated that sometimes they call for help, and it takes a while for staff to come and answer their call light. R34 stated they were unable to locate their call light now. R34's call light was observed on the floor and out of reach of the resident. At 12:03 PM, R34 was observed sleeping. Their call light was still noted to be on the floor and out of reach. On 3/11/2025 at 10:13 AM, R34's call light was still noted to be out of reach and on the floor. R34 stated they did not have their call light all night. A review of the medical record revealed that R34 was admitted into the facility on [DATE] with the following diagnoses, Hemiplegia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 15/15 indicating an intact cognition. R34 also required staff assistance with bed mobility and transfers. R147 On 3/10/2025 at 9:28 AM, R147 was observed in the bed. R147 stated they often do not have their call light within reach. R147's call light was observed on the floor behind their curtain and out of reach. At 2:48 pm, R147 stated they never know where their call light is located and that they asked for their call light, and no one handed it to them. R147's call light was observed to still be located on the floor, behind their curtain and out of reach. On 3/11/2025 at 10:11 AM, R147's call light was noted to still be out of reach and on the floor, behind their curtain. R147 stated they did not have their call light all night and that they asked for it and no one gave it to them. At 10:31 AM and 11:59 AM, R147's call light was observed to still be out of reach and on the floor, behind the curtain. A review of the medical record revealed that R147 admitted into the facility on [DATE] with the following medical diagnoses, Muscle Weakness and Dysphagia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 6/15 indicating an impaired cognition. R147 also required staff assistance with bed mobility and transfers. On 3/12/2025 at 12:27 PM, the Administrator (NHA) was interviewed and asked about their expectations for placement of call lights in residents' rooms and confirmed staff should ensure the call light is placed where the resident wants it. On 3/12/2025 at 1:27 PM, an interview was conducted with the Director of Nursing (DON) and they stated the Unit Managers complete rounds each morning and have huddles with everyone in the morning, and they should be looking for call lights to be within reach. A review of a facility policy titled, Call Lights: Accessibility and Timely Response noted the following, .1. Staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access to the call light.

This citation pertains to Intake MI00150763. Based on interview and record review, the facility failed to timely complete an investigation for an allegation of abuse for one (R2) of two resident reviewed for abuse. Findings include: A review of the Intake reported to the State Agency noted an allegation that staff in the facility failed to treat the resident with dignity and respect (on 2/27/25). On 3/11/25, R2 was observed sitting in their room looking at their computer tablet. R2 did not recall the alleged incident or staff who cared for him on 2/27/25. A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dysphagia, delusional disorders, and mild intellectual disabilities. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental status score of 1 which indicated severely impaired cognition. On 3/12/25 at 9:00 AM, an interview was conducted with Maintenance Director (MD) I . When queried regarding the alleged incident MD I indicated they witnessed a female staff member (Registered Nurse (RN) L) mocking R2 (telling the resident they were misbehaving, and saying I'm going to tell on you) which led R2 to become visibly upset and crying. MD I indicated they immediately reported incident to the administrator. On 3/12/25 at 9:30 AM, an interview was held with the Nursing Home Administrator (NHA) regarding the alleged incident and said it was investigated inhouse but was unsubstantiated. A copy of the investigation was requested at 9:40 AM and provided at 10:15 AM. A review of the facility investigation folder revealed witness statements dated for 2/27/25 and signed by MD I and RN L on 3/12/25 (13 days after incident). The statement from MD I was not consistent the with interview conducted at 9:00 AM (on 3/12/25). Further review of incident lead to a second interview with MD I who stated he signed the incident statement today (3/12/25), but had not signed a witness statement on 2/27/25, the day of the incident. On 3/12/25 at 2:30 PM, RN L was queried regarding they're statement of the alleged incident and stated on 3/12/25 was the first time she was asked about the alleged incident and was asked to sign a 2/27/25 dated statement on 3/12/25. On 3/12/25 at 3:00PM, the NHA was queried to why the incident occurred on 2/27/25 and statements not obtained until 3/12/25, she stated due to their investigation they felt it was a customer service concern. A review of a facility policy titled, Abuse, Neglect and Exploitation Policy implemented on 07/28/2020 and revised on 01/10/2024, noted the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s).V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence). 3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator,witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

Based on interview and record review, the facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for two residents (R70 and R139) of 6 residents reviewed for PASARR screening. Findings include: R70 A review of R70's medical record revealed they were admitted into the facility on [DATE] with diagnoses including dysphagial, intellectual disabilities, functional quadriplegia. A Minimum Data Set (MDS) assessment dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Further review of R70 electronic medical record revealed a PASARR dated 11/27/24 and marked Preadmission screening and revealed no level II PASAAR request. R139 On 03/10/25 at 10:00 AM, R139 was observed lying in bed and watching television. R139 was finishing his breakfast meal. R139 verbalized concerns about wanting to meet with the social worker to discuss change in guardianship. A review of R139's medical record revealed they were admitted into the facility on [DATE] with diagnoses including adjustment disorder with anxiety and depressed mood, bipolar disorder, and chronic respiratory failure with hypoxia. A Minimum Data Set (MDS) assessment dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Further review of R70 medical record revealed a PASARR dated 7/08/24 indicating a hospital exemption for 30 days. A request for an updated PASARR was requested by social services. On 03/11/25 at 1:15 PM, during an interview occurred with Social Worker C regarding an updated PASARR for R139. Social Worker C confirmed there was not an updated PASARR completed nor available at this time. A review of the facility policy titled, PASARR - Pre-Admission Screen and Resident Review, noted the following: A facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and efforts. Specialized services are those services the State is required to provide or arrange for that raise the intensity of services to the level needed by the resident. That is, specialized services are an add-on to NF services - they are of a higher intensity and frequency than specialized rehabilitation services, which are provide by the NF. 1. The statute mandates preadmission screening for all individuals with mental illness (MI) or mental retardation (MR) who apply to the NFs, regardless of Policy (PASRR) the applicant ' s source of payment, except as provided below. Residents readmitted and individuals who initially apply to a nursing facility directly following a discharge from an acute care stay are exempt if: a. They are certified by a physician prior to admission to require a nursing facility stay of less than 30 days; and b. They require care at the nursing facility for the same condition for which they were hospitalized . 3. All residents are required to have a level I PASRR screen prior to or upon admission the facility. When indicated on the level I screen that a level II screen is required, the facility will complete notification to the State ' s PASRR program notice for the level II screen (in accordance with State specific laws. 4. If a resident is admitted with a level diagnosis as indicated above review is required upon change in the resident ' s condition. For example: a. A review and determination under clause (i) or (ii) must be conducted promptly after a nursing facility has notified the State mental health authority or State mental retardation or developmental disability authority, as applicable, under subsection (b)(3)(E) with respect to a mentally ill or mentally retarded resident, that there has been a significant change in the resident's physical or mental condition.

Based on observation, interview and record review, the facility failed to develop a care plan addressing Post-Traumatic Stress Disorder (PTSD) for one resident(R62) out of three reviewed for mood/behavior care plans. Findings include: A review of the medial record revealed R62 was admitted into the facility on [DATE] with the following medical diagnoses, Major Depressive Disorder and Post-Traumatic Stress Disorder (PTSD). A review of the most recent Minimum Data Assessment (MDS) set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. On 3/10/2025 at 10:00 AM, an interview was conducted with R62. R62 stated they do have PTSD due to things in their past. R62 stated they have triggers, but the medicine helps manage it. Further review of the medical record revealed a mood/behavior care plan. The mood/behavior care plan did not include the PTSD diagnosis or known triggers. On 3/12/2025 at 10:13 AM, an interview was conducted with Social Worker (SW) F. SW F stated when they assess the resident when they admit into the facility it should be added in the mood care plan. SW F stated that is where the PTSD diagnosis would go, as well as the known triggers. On 3/12/2025 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not have the PTSD diagnosis upon admission and it was later added and should have been communicated during the behavior meeting to ensure the care plan was developed. A review of a facility policy titled, Comprehensive Care Plans noted the following, .1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed.

Based on observation, interview, and record review, the facility failed to provide timely assistance for two residents (R24, R154) out of six reviewed for Activities of Daily Living (ADLs). Findings include: R24 On 3/10/25 at 10:27 AM, R24 reported over the past weekend Saturday (3/8/25) into Sunday (3/9/25) they requested ADL care around 6:15 AM, no one on the midnight shift came in to provide care. They explained they received care on the day shift at 9:45 AM. R24 explained on another (unknown) day they put the light on around 7:00 PM on a Friday, and did not receive care until 9:30 PM. A review of R24's medical record revealed, R24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Myocardial Infarction. A review of R24's annual Minimium Data Set (MDS), dated [DATE] noted, R24 with an intact cognition and required assistance from staff to complete activities of daily living (ADLs). Further review of R24's concern forms provided by the facility noted, multiple days of staff not providing care timely, not at all, or passing the care on to the next shift. A concern form revealed, Date: 3/27/24, assistance needed: care, Details: [R24] stated on MN (midnight) shift [R24] was placed on a bedpan around 3am and the CNA did not come back until about 5am . A review of R24's care plan revealed, [R24] has an ADL self-care performance deficit related to muscle weakness, limited mobility, and debility. Date initiated: 3/12/2024. Goal: [R24's] Activities of Daily Living (ADL) needs will be met through next review. Date initiated 1/5/2024, Interventions: Bed mobility: 2 person assist. Date initiated: 06/14/2024. Personal Hygiene: 1 person assist . On 3/12/25 at 1:36 PM, the Director of Nursing (DON) was asked about staff rendering timely care. The DON explained, the facility has identified a concern on the midnight shift and they have let a lot of people go. The DON further explained, that the residents should have someone checking on them every hour between the Nurses and the Certified Nursing Assistants. 44750 Resident #154 On 3/11/2025 at 12:00 PM, R154 was observed eating lunch in their room. R154 was observed to be shaking while picking up their fork. R154 stated they wanted to put some salt on their food, but was unable to pick up the package, open it, and shake the salt on the food. R154 was asked if they received assistance with eating and they stated the staff don't help them eat, but sometimes they could use it. On 3/12/2025 at 11:55 AM, R154 was observed eating lunch in their room with no assistance. R154's hands were noted to be shaking while they were raising their utensils to their mouth to eat. A review of the medical record revealed R154 was admitted into the facility on [DATE] with the following diagnoses, Bacteremia and Depression. A review of the recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R154 also required staff assistance with bed mobility, eating, and transfers. Further review of the physician's orders revealed the following order, Ordered: 2/7/2025 .1:1 feeding assistance with meals .Active . Further review of a nutrition note dated 3/11/2025 noted the following, .Benefits from supervision/assist with meals. On 3/1/2025 at 11:56 AM, an interview was conducted with Assistant Director of Nursing (ADON) K. ADON K was queried if R154 required 1:1 assistance with meals and stated the assistance is more for meal set up and cueing. ADON K stated someone should be in the room to help with cueing and see how much progress R154 is making. On 3/12/2025 at 1:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the floor nurse confirmed the feeding assistance order. A review of a facility policy titled, Activities of Daily Living (ADLs) noted the following, .3.A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure timely podiatry care was provided for one resident (R201) of one resident reviewed for foot care. Findings include: On 03/10/25 at 9:00 AM, R201 was observed sitting on the side of the bed. When asked about any concerns, R201 stated they are concerned about their toenails because they are too long and starting to hurt. R201 toenails were observed to be long extending past the tip of the toes. R201 could not recall the last podiatry visit. A review of R201's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Down's syndrome, Schizophrenia, and Chronic kidney disease. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental status (BIMS) score of 14 which indicated intact cognition. Further review of R201's elcetronic medical record did not reveal a current podiatry consultation. On 3/11/25 at 2:00 PM, an interview occured with the Social Service Director (SSD) O explained R201 is on the list to be seen by podiatry. SSD staff O further indicated the social services team is fairly new and they are working to connect with ancillary services. On 3/12//24 at 3:30 PM an interview occurred with the DON. The DON confirmed R201 had long toe nails and needed cutting. A review of a facility policy titled, Nail Care was implemented 10/20/2020 and revised 08/20/2024, noted the following: The purpose of this procedure is to provide guidelines for the care of a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 1. Assessments of resident nails will be conducted on admission and readmission to determine the resident ' s nail condition, needs, and preferences for nail care, if possible. a. Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.). b. Obtain history and preferences regarding podiatrist.

Based on observation, interview, and record review, the facility failed to label and date a tube feeding bottle for one resident (R75) out of two reviewed for tube feedings. Findings include: On 3/11/2025 at 10:24 AM, R75 was observed laying in bed. R75 was observed to have a tube feeding running. The bottle was noted to be unlabeled and undated. On 3/11/2025 at 10:24 AM, Licensed Practical Nurse (LPN) A was brought into the room and shown the tube feeding bottle. LPN A stated the tube feeding goes up on the evening shift, and that it should be labeled. A review of the medical record revealed that R75 was admitted into the facility on [DATE] with the following diagnoses, Quadriplegia and Gastrostomy. A review of the recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99 indicating they were unable to complete the assessment. R75 also required staff assistance with bed mobility and transfers. On 3/12/2025 at 1:24 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the tube feeding goes up at night and that the tube feeding should be labeled and dated as soon as it goes up. A review of a facility policy titled, Feeding Tubes did not address labeling and dating.

Based on observation and interview, the facility failed to ensure medications were discarded when expired from one medication cart (U100 low numbers) of three medication carts reviewed. Findings include: On 3/12/2025 at 02:07 PM, along with Licensed Practical Nurse (LPN) G, two expired stock medications were located in the top drawer of Unit 100's lower numbered medication cart. The medications were Glucosamine Chrondroitin with an open date of 10/1/24 and a stamped expiration date of 01/25 and Oyster Shell Calcium 500mg (milligrams) with an open date of 9/25/24 and a stamped expiration date of 08/24. On 3/12/2025 at 04:15 PM, the Director of Nursing (DON) indicated expired medications should be removed from use. A policy for Medication Storage was requested but not received by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure resident equipment (two beside dressers, one overbed table) was in good, clean, and safe condition for three residents (R20, R143, R167) of residents reviewed for homelike environment. Findings include: On 03/10/25 at 09:55 AM an observation of the bedside dresser for R20 revealed a two-inch gap between the first and second drawer. R20 was queried regarding the gap and responded, oh without further verbalization. On 03/12/25 a review of the record revealed R20 was admitted on [DATE] with a diagnosis of dementia. R26 has a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment. On 03/10/25 at 10:10 AM, an observation revealed the overbed table for R143 had many dark circular stains. R143 was asked if they found the condition of the overbed table bothersome. R143 provided a blank stare and did not respond at all. On 03/12/25 a review of the record revealed R143 was admitted [DATE] with a diagnosis of dementia. R143 has a BIMS score of 03 indicating severe cognitive impairment. On 03/10/25 at 09:38 AM, an observation revealed the resident bedside dresser for R167 had a top that was very stained, rough and with uneven edges. R167 was asked if the dresser top was bothersome. R167 was unable to answer. On 03/12/25 a review of the record revealed R167 was admitted to the facility on [DATE] with a diagnosis of dementia. R167 has a BIMS score of 00 indicating severe cognitive impairment. On 03/12/25 at 3:30 PM the Maintenance Director (MD) I reviewed bedside dressers, and overbed table. MD I reviewed the (name of) system used for maintenance requests and was unable to locate any submitted orders for bedside dressers or tables. MD I further indicated any staff member noting a concern can enter that concern into the maintenance system and concerns should report as soon as possible. A review of the policy, Preventative Maintenance Program dated reviewed/revised 02/12/22 states, The Maintenance Director is responsible for developing and maintain a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The policy further states, If preventative maintenance is required, the Maintenance Director may decide what tasks need to be completed . The policy further states, Documentation may be completed for all tasks and kept in the (name of) program.

This citation pertains to intake M100150293 Based on interview and record review, the facility failed to complete weekly skin checks for one (R704) of ten residents reviewed for skin checks, resulting in the development of gangrene of the right great toe, right foot pain and hospitalization . Findings include: Review of intake M100150293 revealed a concern that a family member visited R704 on 12/25/24 during which the resident reported right foot pain. The family member reportedly removed the resident's sock and found the right great toe to have what they believed to be gangrene. Review of the facility record for R704 revealed an admitted [DATE] with diagnoses including Osteoarthritis, Gout, Adult Failure to Thrive, and End Stage Renal Disease requiring Renal Dialysis. Review of R704's Care Plan dated 01/10/24 revealed the Focus statement [R704] is at risk for impaired skin integrity related to muscle weakness, incontinence and a diagnosis of failure to thrive. The Interventions associated with this Focus area included Complete skin inspection weekly and as needed. Review of R704's facility record of assessments revealed a skin assessment dated [DATE] that indicated no new abnormal skin areas. The next skin assessment was dated 12/25/24 and identified the concern of swelling in right foot and black skin on right great toe. On 02/18/25 at 1:45 PM, the facility Director of Nursing (DON) was interviewed and reported they were first made aware of R704's right foot condition on 12/25/24. The DON reported that family was visiting and had reported the concern to nursing staff. Staff contacted the DON by phone and they initiated response measures which led to the resident being transferred to the hospital that day. The DON expressed that they knew that the gangrenous condition of the toe would have taken time to develop and they recognized that there had been a deficient practice. The DON was asked about the nearly eight week gap between the 10/31/24 and 12/25/24 skin assessments and they acknowledged the assessments had not been completed. Review of R704's hospitalization records indicated the resident and was hospitalized from 12/25/24 until 01/10/25 at which time they returned to the facility. The hospital record verified the resident was diagnosed with Right Foot Gangrene, Dry as well as Sepsis, likely due to Gangrene and that the resident continued to report right foot pain during hospitalization . Additional review of R704's facility record revealed that following readmission on 01/10/25 the resident continued to report right foot pain as recently as 02/05/25 per the Physical Medicine and Rehab Nurse Practitioner's note dated 02/09/25. On 02/19/25 at 2:15 PM, the DON reported their expectation is that R704 should have had a head to toe skin assessment weekly as well as skin assessments during twice weekly baths/showers. The DON reiterated that they recognized a deficient practice had occurred and they began corrective measures on 12/25/24. Review of the facility policy Pressure Ulcer/Skin Breakdown-Clinical Protocol dated 10/30/22 revealed the section 7. Continued Assessment and Management which included the entry - Weekly skin evaluation/assessment by the licensed nurse on residents who have no current pressure ulcers/injuries. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: The facility identified an inconsistency with the documentation of the provision of potential identified treatment/wound care. 1. What corrective action(s) will be done for residents found to have been affected by the deficienct practice(s). (R704) sent to the hospital with skin discoloration noted to right foot with great toe included. No documentation of discoloration mentioned on weekly skin checks or nursing admission notes. We were out of compliance with treatment orders and was not assessed by the wound care team on date of admission. He was admitted prior to the PNC and we were out of compliance with his weekly skin assessments. 2. How will facility identify other residents having potential to be affected by practice and what corrective action will be taken. Skin assessments completed on all current residents by December 28, 2024. Residents with noted changes to skin integrity were evaluated by a licenced nurse and treatment in place if needed, appropriate, and in compliance with treatment order schedule. 3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur. The above action plan will be presented in QAPI (Quality Assurance Performance Improvment), January 23, 2025 meeting. Pressure Ulcer/Skin Breakdown - Clinical Protocol has been reviewed and deemed appropriate. The action plan and audits will be brought to QAPI monthly and will continue until discontinued by QAPI. The DON/Unit Managers will be responsible for the ongoing oversight of the provision of skin/wound assessments and documentation. Skin assessments will be monitored for completion during morning meetings, Monday thru Friday. 4. How the corrective actions will be monitored to ensure the deficient practices will not recur. The DON/designee will audit 10 residents weekly for timely and accurate completion of skin assessments and treatment orders in place if needed or extending as determined necessary, then monthly thereafter until substantial compliance is met and audits are discontinued by QAPI. The DON is responsible for sustained compliance. Signed by DON on 12/28/24. Supportive documentation/audits verified and available in survey folder. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to position a resident safely during care for two residents (Resident #102 and Resident #131) of four residents reviewed for falls, resulting in hospitalization , unnecessary prolonged pain and decreased range of motion resulting from injury. Findings include: Resident #102 On 10/18/2022 at 12:01 PM, Resident #102 was lying in bed in a hospital gown. Resident #102 was asked about getting out of bed and stated they had a broken hip and rubbed their left hip with their right hand. Resident #102 was further queried about their hip and explained that an unknown Certified Nurse Assistant/CNA had been changing them while in bed and had let go of them, causing the Resident to fall out of bed on the floor. Resident #102 further stated that their hip was indeed broke and had not been operated on but was unsure why. Resident #102 was asked about the pain experienced and stated, It hurts! They give me medication to help with the pain. A record review of the Minimum Data Set (MDS) assessments revealed the Resident was most recently admitted to the facility on [DATE] with the diagnoses of Displaced Intertrochanteric Fracture of Left Femur (hip fracture) and Diabetes Mellitus. Resident #102 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed extensive, two-person assistance with bed mobility and transfers. A record review of the progress notes for Resident #102 revealed the following: 9/25/2022 15:10 (03:10 PM) Progress Note-General Note Text: At approximately 1:55 PM CENA (Certified Educated Nurse Assistant) staff was assisting the resident with brief change and was rolling resident over to clean (their) backside up and (Resident #102) rolled out of bed .Resident has complaint of left hip pain of 10 at time of assessment. No changes in mental status fro (sic) baseline, unable to perform range of motion to left lower extremity related to pain. Received orders to send to ER (emergency room ) for eval (evaluation). Guardian .called and message left. 10/6/2022 15:13 (02:13 PM) Nurses' Notes Note Text .Refused .shower or bed bath stating .is in to (sic) much pain. Refused to have .skin assessed .states that the bed .is in is to small to move (Resident #102) to much due to fear of falling. Looking into larger mattress. 10/7/2022 09:15 (AM) Transcribed NP/PA Progress Note .Chief Complaint / Nature of Presenting Problem: Pain control History Of Present Illness: Resident is a [AGE] year old female that is being seen today for follow up on her pain control after sustaining (sic) a fall that resulted in a closed trochanteric fx (fracture) of .L femur. (Resident #102) saw ortho in hospital, (Resident #102) and guardian declined surgical repair .has received .abduction pillow to assist with turns as well. Upon exam .is lying in bed. States .is still having some pain but it has improved with increase of [MEDICATION(S)] to TID (three times a day). She also has Tylenol PRN (as needed) Q6H (every six hours) PRN . 10/10/2022 15:27 (03:27 PM) Transcribed NP/PA Progress Note Late Entry .Chief Complaint / Nature of Presenting Problem: pain. History Of Present Illness: Resident . is being seen for follow-up on .pain control after sustaining a fall that resulted in a closed trochanteric fracture of .left femur. Upon exam (Resident #102) is lying (on) back in bed tearful and anxious .states that .pain is better controlled on .current dose of [MEDICATION(S)] 50 mg 3 times daily. Psych consult ordered for increased tearfulness and anxious mood .new abrasions from fall to R (Right) elbow, R thigh, bruising to l arm and L hip . 10/14/2022 06:10 (AM) Transcribed NP/PA (Nurse Practitioner/Physician Assistant) Progress Note Late Entry: Note Text: PATIENT: Medications reviewed, please see MARS (Medication Administration Records). Resident is a [AGE] year-old female that is being seen for follow-up on .pain control, decreased appetite, and depressed mood. Resident was recently put on [MEDICATION(S)] 50 mg (milligrams) every 4 hours for pain. (Resident #102) states that .pain has improved significantly and that the current dose is adequate for .(pain) control. (Resident #102) also recently triggered for a weight loss and decreased appetite. Per facility charting resident is eating about 50% of .meals .states that .appetite is improving .Previously resident was having an increase in depressed mood anxiety and tearfulness. Psych services was consulted. (Resident #102) was put back on .[MEDICATION(S)] (an antidepressant) 30 mg once daily at bedtime .PHYSICAL EXAM .General: Chronically ill, debilitated, obese, and bedbound .patient laying back in bed resting wearing gown, abduction pillow (large foam device used to keep legs apart) between legs, appears in no acute distress .abduction pillow in place decreased ROM (range of motion) to LLE (left lower extremity), NWB (non-weight bearing) LLE, Hoyer lift (mechanical lift used to transfer resident) . 10/20/22 11:56 AM, Resident lying in bed awake. Explained that when (Resident #102) gets changed, the aid went to grab .left leg, she (the CNA) swung it around so that (Resident #102) could be held at the edge of the bed, (Resident 102's) body weight flung over and .fell to the ground and [NAME] .(left) hip. states that the aid was alone during the brief change. States .is in pain, usually between 7-10 (out of 1-10 pain scale, 10 being the worst pain). Explained that .cries out in pain when .is changed. Explained .takes [MEDICATION(S)] for pain which helps but is not strong enough. A review of the October 2022 MAR for Resident #102 revealed the Resident had pain rated from three to nine (1-10 pain scale) daily. A review of the Care Plan for Resident #102 revealed the following: Focus-[Resident #102] has an ADL (activity of daily living) self-care performance deficit r/T (related to) [CONDITION(S)] ([CONDITION(S)]/stroke) with LT (left) [CONDITION(S)] (paralysis). Date Initiated: 01/06/2017 . Goals-[Resident #102] will maintain current level of function in ADLs through the review date . Interventions . BED MOBILITY: [Resident #102] requires two assist with turning and repositioning in bed . ADLS . requires 2 person assistance with ADLS Date Initiated: 10/14/2020 . A record review of the incident report dated 09/25/2022 for Resident #102 revealed the following: .Nursing Description: Resident was being assisted with brief change and rolled out of bed while CENA staff was rolling .to clean .backside . CNA statement: I was rolling (Resident #102) over to clean (Resident #102) up and (they) rolled out of bed. On 10/21/2022 at 08:54 AM, Resident #18 was in bed awake. Resident #18 was asked about allowing staff to change their brief since 09/25/2022 and stated, I am not letting anyone get in their brief (to change them) again! On 10/21/2022 at 10:41 AM, the Director of Nursing (DON) was asked about Resident #102 rolling out of bed on 09/25/2022. The DON explained that he was new to the facility and referred this Surveyor to the Corporate Nurse (Corporate RN J). On 10/21/2022 at 11:12 AM, the Nursing Home Administrator (NHA) was queried about Resident #102 rolling out of bed on 09/25/2022. The NHA also referred this Surveyor to Corporate RN J. On 10/21/2022 at 12:12 PM, Corporate RN was interviewed in regard to Resident #102's incident on 09/25/2022. The Corporate RN J confirmed that on 09/25/2022, Resident #102 was assisted with a brief change with one CNA, the CNA attempted to grab the Resident's right leg and the leg along with the Resident's body weight flung over the bed on top of the CNA, causing her to be injured as well. According to Corporate RN J, the CNA ended up going to urgent care as a result of her injuries and was suspended from their current job duties. Corporate RN J further explained that because the CNA was hurt, she was involved in the investigation and the CNA would not be allowed to keep her job. Corporate RN J was asked if the CNA had mentioned why she had attempted to move the Resident without help and explained that the CNA had given a reason. On 10/21/2022 at 02:22 PM, the NHA was queried in regard to CNA's knowing how many persons should be helping with care for Residents and explained that the level of care needed for Resident care was in the Kardex (a computer system) and that the CNA's have access to and document on the computer program. The NHA was asked about the CNA performing bed mobility care to Resident #102 on 09/25/2022 without assistance from another staff member and explained that the CNA felt she could handle the Resident alone. Resident #131: On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and could not see very well. R131 was asked if they had sustained any injuries as they were observed with a sling on their right arm. R131 explained that they had fallen from their bed, causing injury to their shoulder which was in pain. A review of R131's medical record revealed that they were admitted into the facility on [DATE], with a readmission of 9/21/22 with diagnoses that included Dementia, [CONDITION(S)] and Diabetes. Further review of the resident's medical record revealed a Minimum Data Set assessment (MDS) dated for 9/27/22 revealing a Brief Interview for Mental Status score of 13/15 indicating an intake cognition, and revealed that the resident required extensive assistance of 2-persons for Activities of Daily Living including transfers and bed mobility. Further review of R131's medical record revealed the following progress notes: 9/19/2022 11:54 (11:54 am) Nurses' Notes. Around 11:30 am. Writer was called to the resident's room by the CNA (Certified Nurse Assistant), The CNA stated that the resident fell on the floor while providing care. Resident observed lying on the floor, on [their] back, parallel to [their] bed. Resident was crying and complaining of severe pain to [their] R (right) arm and shoulder. Resident unable to move R arm, Round, lump on the R outer humerus noted, C/O (complaint of) pain when palpated. Observed small bump on the back of [their] head .Resident is currently on blood thinner. Writer notified [physician], received order to send resident to the ER (emergency room ), 911 9/20/2022 10:29 (10:29 am) IDT-Interdisciplinary Progress Note. To prevent further falls. IDT advised to have 2 person assist while taking care of the resident. Further review of R131's medical record revealed that the resident was admitted to the local hospital on 9/19/22 with a final impression of, Other displaced fracture of upper end of right humerus, initial encounter for closed fracture. Further review of R131's medical record revealed the following care plan, Focus: [R131] is at risk for falls related to: impaired mobility, and weakness. Date Initiated: 04/23/2021. Revision on: 02/16/2022. Interventions: Be sure [R131's] call light is within reach and encourage [them] to use it for assistance as needed. Date Initiated: 04/23/2021. Revision on: 08/22/2022. Bed in low position when not providing care. Date Initiated: 04/23/2021. Revision on: 08/22/2022. Ensure [R131] is positioned in center of bed. Date Initiated: 08/06/2021. Revision on: 08/22/2022. Further review of R131's medical record revealed a Minimum Data Set assessment dated for 8/11/22, prior to R131's fall, that they required extensive assistance of 2-persons for bed mobility and transfers. On 10/21/22 at 9:05 AM, CNA P was interviewed regarding the fall of R131. CNA P explained that she was cleaning R131 by themselves. CNA P explained that R131 was lying in their right side, facing away from her. CNA P explained that she turned around to grab a towel, and at that time R131 rolled out of the bed onto the floor. CNA P explained that she went and obtained a nurse, and R131 was sent out to the hospital. CNA P explained that she was unaware that R131 was a 2-person assist, and later received training on how to check a resident's transfer/bed mobility status in the computer system. A review of the facility policy titled Fall Prevention Program dated 10/30/2022 revealed the following: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.

This citation pertains to intakes: MI 329, MI 313, MI 516, and MI 727. Based on observation, interview and record review the facility failed to protect three sampled residents and one unsampled resident (Unsampled R724 from perpetrator R701, R722 from perpetrator R712, R714 from perpetrator R723 and R717 from perpetrator R716) of 16 residents reviewed for verbal and physical abuse resulting in, mental anguish, distress, frustration, a laceration, and a hematoma resulting hospitalization . Findings include: Resident #717 (R717) On [DATE] at 10:30 AM, the following progress note was reviewed in R717's electronic medical record (EMR), [DATE] 18:30 (6:30 PM): Note Text: Date of Fall: [DATE] Situation Details: Around 4:15 pm, writer heard a yell Get out, NURSE from room [ROOM NUMBER], Writer was called by the CNA (Certified Nursing Assistant) to the room and observed [R717] lying on the floor on their left side. Writer asked The resident who reside(s) in room [ROOM NUMBER] [R716] what happened and they stated that 'I told [R717] to get out and they started laughing, so 'I kicked them.' Assessment: Observed lacerated wound, on [R717's] left temple about 2 inches length, bleeding profusely. Writer applied pressure using towel with ice for at least 10 minutes. Bleeding stopped, wound was cleansed, steri strip applied and wrapped head with gauze. Pupils equal, normal and reactive to light. No lethargy noted. No decline in neuro checks. Vital signs stable. No change in mentation, ROM (range of motion) gait or mobility. Laceration to [R717's] temple and Bruising and swelling to [R717's] index knuckle noted, No decrease in mobility to fingers noted. Mitigating Factors: Environmental Factors: Interventions: MD Notification: Notified [Health Care Provider] Received order to send resident to ER for possible stitches to [R717] lacerated wound, on her left temple. Responsible Party Notification: RP [Responsible Party] was notified as well. Comments: [R717] is non verbal and unable to explain what happened due to advance Dementia. Administrator and DON [Director of Nursing] were notified and came to the unit to see the resident. Ambulance came in and picked up resident to go to [Hospital], around 5:30 PM, report and paper works given to the EMT. Note Text: Event Date: [DATE] Behavior Displayed: Around 4:15 pm, writer heard [R716] yell Get out, NURSE. Writer went to [R716] room and observed another resident [R717] lying on the floor on their left side, with lacerated wound on their left temple, bleeding profusely. Precipitating factors/events: writer asked [R716] what happened and they stated that 'I told [R717] to get out of my room and they started laughing so I kicked [R717].' [R716] was laying in bed visibly upset and verbally abusive. Intervention(s) attempted: Intervention results: Pharmacological Intervention required: Resident had been refusing medications Comments: [R716] refused skin assessment, or Vital sign taking. Notified NP (Nurse Practitioner). Left voicemail for [R716's] legal Guardian. Administrator and DON (Director of Nursing) were notified and came to the unit. [R716] was transferred to unit 409 per administrator, Report and meds given to the 400 unit nurse. On [DATE] at 10:35 AM, further documentation review revealed that R716 was sent to the hospital and discharged from the facility on [DATE]. On [DATE] at 11:45 AM, R717 was interviewed about the incident involving themself and R716 on [DATE]. R717 was unable to respond to any questions regarding the incident. On [DATE] at 12:45 PM, Nurse A was interviewed regarding the incident involving R717 and R716 on [DATE] and stated, [R716] was yelling, I went to their room and [R716] indicated that [R717] had come into their room and was smiling and laughing at them so they kicked [R717]. Nurse A further indicated that they observed [R717] on the floor with a laceration to their temple, Bleeding profusely. Nurse A indicated that [R717] was sent to the hospital emergency room (ER) for evaluation and treatment and [R716] was moved to another room on another unit in the facility. On [DATE] at 12:52 PM, Nurse A was further interviewed about R717 wandering into resident's rooms and indicated that R717 frequently wanders around the unit and into resident's rooms. Nurse A stated, We try and redirect [R717] and engage them in activities. Nurse A indicated that on the day of the incident, R717 was in the, Common area and wandered away unobserved into [R716's] room. On [DATE] at 1:45 PM, CNA B was interviewed regarding the incident involving R717 and R716 on [DATE] and indicated that they heard R716 scream and when they entered the resident's room, they observed [R717] In a pool of blood, face down. CNA B indicated that they notified their nurse and then asked [R716] what happened and they indicated that they had kicked [R717]. CNA B was further interviewed about R717's wandering and indicated that [R717] wanders All the time. [R717] had wandered into [R716's] room before. That night was [R717's] unlucky night. On [DATE] at 2:07 PM, the Administrator (NHA) was interviewed about the incident involving R717 and R716 on [DATE] and indicated that [R717] should have been redirected out of [R716's] room. The NHA stated, No it's not okay .staff should redirect wandering residents. On [DATE] at 2:15 PM, R717's EMR was reviewed and revealed that R717 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R717's most recent minimum data set assessment (MDS) dated [DATE] revealed that R717 had a severely impaired cognition. On [DATE] at 2:30 PM, a facility policy titled Abuse, Neglect, and Exploitation Date Reviewed/Revised [DATE] was reviewed and stated the following, Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing .policies that prohibit and prevent abuse .Definitions: 'Abuse' means the willful infliction of injury .with resulting physical harm .It includes physical abuse .'Willful' means the individual must have acted deliberately .'Physical Abuse' includes but is not limited to hitting, slapping, punching, biting, kicking . Resident #701 On [DATE] at 08:44 AM, Resident #701 was observed awake in their bed reading a book. Their door was open and the room was easily accessible (there was no stop sign at the door). An interview was attempted to be completed with the Resident, however they were reluctant to talk and became annoyed with conversation. Resident #701 did not recall any physical incidents involving other residents. On [DATE] at 08:49 AM, Certified Nurse Aide (CNA) J was interviewed in regard to how they typically care for Resident #701. CNA J explained that the Resident often refuses showers and care and stated, They pretty much do their own thing. (Resident #701) can get nasty (usually verbal, but sometimes physical) to other residents and staff. CNA J also stated, Usually (Resident #701) will just call them out their name, and then stomp down the hall and go back to their room. On [DATE] at 09:47 AM, Resident #701 was observed to be in their room in bed reading a book. There was no stop sign on the door. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #701 had a moderately impaired cognition and needed limited assistance with bed mobility and transfers. Resident #701 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ½ tab, twice per day. A review of the Progress Notes for Resident #701 revealed the following: [DATE] 13:12 (01:12 PM) Pertinent Charting-Behavior Late Entry: Note Text: Event date: [DATE] Resident attempted to hit another resident today, but was redirected by a staff member. Resident will continue to be monitored. [DATE] 17:30 (05:30 PM) Pertinent Charting-Behavior Note Text: Event Date: [DATE] Behavior Displayed: It was witnessed by staff that resident pushed another resident in the hallway, which resulted to the other resident falling and hitting (their) head to the wall. Precipitating factors/events: Intervention(s) attempted: Redirected back to .room to avoid further altercation. Intervention results: No, resident still paces the hallway making faces to other residents and verbally abusive to staff .Comments: When resident was asked by the writer what happened, resident became agitated and told writer to get out of .room. Refused skin assessment or pain assessment .DON (Director of Nursing) and Administrator (Nursing Home Administrator (NHA) was made aware of the incident. A review of the Facility Reported Incident (FRI) revealed the following: Event: On [DATE]th at 3:16 pm there was an incident involving [Resident #701] and [Unsampled Resident #724]. Staff reports they heard yelling in [Resident #701's] room and when they rushed to see the problem, saw [Resident #701] push [Unsampled Resident #724] from the doorway of (Resident #701's) room across hallway where [Unsampled Resident #724] fell to the floor bumping .head on the wall. [Unsampled Resident #724] sustained injury including a red bump on the right side of .head, bruising to the right elbow, and swelling of the right facial cheek. It was also noted a subconjunctival hematoma to the right eye .Administer/Abuse Coordinator was notified. I-DON was notified . Interviews: Both residents, [Resident #701] and [Unsampled Resident #724] were not able to contribute to the investigation due to cognitive status .2 CNA who were in the area at the time state they were in hallway and saw [Resident #701] push [Unsampled Resident #724], when (Unsampled Resident #724) lost (their) balance and fell hitting the right side of .head on the wall as (Unsampled Resident #724) fell . Additional witness statement from .RN (Registered Nurse), states that she heard [Resident #701] screaming, as staff were running to room to discover the problem .saw [Resident #701] push [Unsampled Resident #724] from room into hallway .Conclusion: After a thorough investigation, the facility cannot substantiate that the incident that occurred was intentional, based on [Resident #701's] limited ability to form intent to cause harm related to .cognitive deficits/disease process. The facility can substantiate that [Resident #701] did make contact with [Unsampled Resident #724]. [Unsampled Resident #724] did sustain pain, redness, and injuries as a results of the incident. Care plans were reviewed and remain appropriate .Action Plans: Notification of of Physician. Notification of Responsible Party. Pain and Skin Assessments Completed, a Picture of [Unsampled Resident #724] was placed outside of .doorway to better able (Unsampled Resident #724) to locate the appropriate room. Care Plans reviewed Medical Workup for [Unsampled Resident #724] Stop/Closed sign ordered for [Resident #701's] room door. Social services Continue to Follow Residents . Written Statements- CNA B-While walking down the hall, I saw [Resident #701] push [Unsampled Resident #724]. [Unsampled Resident #724] fell on .right side and hit .head on the wall. CNA K-I was walking down the hallway when I saw [Resident #701] push [Unsampled Resident #724] and [Unsampled Resident #724] fell sideways and hit the right side of .head. RN A-[Registered Nurse states she and 2 CNA were at desk/common area when they heard [Resident #701] yell 'Get out of here!' As they rounded corner to view hallway to go to [Resident #701's] room saw [Resident #701] push [Unsampled Resident #724] when (they) fell to the ground. A review of the Unsampled Resident's #724 medical record revealed they expired in the facility on [DATE] (due to unrelated issue). A review of the care plan for Resident #701 revealed no care plan specific to the Resident's behaviors. A review of the Incident Report (dated [DATE]) for Resident #701 revealed the following: Per staff, [Resident #701] was witnessed in the hallway pushing (Unsampled Resident #724) on .R (right) side, (Unsampled Resident #724) hit the wall on .R side of head and fell to the lfoor (sic) on .R side. [Resident #701] then went back to .room, slamming the door. When writer asked [Resident #701] what happened (they) yelled to get out of (their) room. On [DATE] at 12:01 PM, the Social Worker (SW) D was attempted to be interviewed but explained that she was new to the position (day 6 of employment) and was not familiar with Resident #701. On [DATE] at 03:08 PM, the DON and NHA were interviewed in regard to Resident #701's behavior. The DON stated, (Resident #701) is sweet but stubborn. (Resident #701) refuses to do a lot. It is their right to refuse. (Resident #701) will sometimes get aggravated if you push them too hard. The DON was asked how the facility manages Resident #701's behaviors and explained that it was a day to day process with the Resident. The NHA was asked about the stop sign that was to be applied to Resident #701's door to prevent other Residents from wandering in their room. The NHA stated, (Unsampled Resident #724) did wander, and we did put up a stop sign (on Resident #701's door), but (Resident #701) took it off and wouldn't keep it on there. The NHA further stated, We have activities going on back there (on the locked dementia unit). We have (Resident #701) going to the beautician. (Resident #701) likes word searches or puzzles. Resident 714 (R714) and Resident 723 (R723) A review of Intake: MI 516 revealed the following,Complainant states when [they] arrived at the facility [they were] harassed by resident [R723]. Complainant states on [DATE] and [DATE] [R723] 'sucker punched' [them] in front of staff at the front desk. The complainant states [they] filed a complaint with the facility and was told that the facility couldn't reprimand [R723], but they could move the complainant to another room. Complainant states [R723] continues to verbally assault [them], stalk and harass [them]. The complainant states [they] continue to report the incidents, but nothing happens to correct the issues. Complainant states last week, [R714] and [R723] got into a heated argument because [R723] started cussing at [them] as [they] walked by [them] in the hallway. The complainant states [R723] began tossing things around the room. The complainant states staff told [them] to 'walk away' from [R723], and states that staff won't do anything else to control [R723] . On [DATE] at 8:43 AM, R714 was interviewed about their experience with R723, and they explained that they were admitted into the facility in [DATE] after having a stroke, and noticed [R723] would follow them around. R714 explained that they were coming back from an activity when [R723] crashed their wheelchair in front of them, and on [DATE], R723 punched them twice on the shoulder. R714 explained that again on [DATE], R723 punched them again, twice. R714 explained that after the second incident, the facility offered to move their room for their safety however, a month later, R723 started coming around their new unit and following them around, refusing to move out of their path of walking, and would appear out of nowhere. R714 further explained that they have been told that R723 has Autism, and the punches don't hurt however, R723 stated, It's getting to me because it keeps going on and on. R714 further explained that last month, R723 punched them again in the shoulder twice while they were walking past one another in the hallway resulting in R714 contacting the police. R714 explained that they have made complaints countless times, and I don't believe it has been properly investigated. R714 explained that they have spoken to the Director of Nursing (DON) about their concerns, and was told there isn't much they can do. R714 stated, [R723] is interrupting my peace and serenity. I'm trying to adjust to having a stroke, living a different life, and getting better. A review of R714's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS) assessment revealed a moderately impaired cognition, and required independent to limited assistance for Activities of Daily Living (ADLs). Further review of R714's medical record revealed the following progress notes: [DATE] 16:30 (4:30pm) Pertinent Charting-Behavior Note Text: Event Date: [DATE] Behavior Displayed: Resident to Resident Precipitating factors/events: Intervention(s) attempted: Separating residents. Intervention results: Successful Pharmacologic Intervention required: N/A Comments: Resident was passing by resident in room ,d+[DATE]. Resident in ,d+[DATE] began calling negative names using profanity. Resident cont (continue) to wheel pass when resident in ,d+[DATE] punch resident in left arm. MD (medical doctor), DON and EC (abuse coordinator) notified. Resident denies pain. Resident currently separated. [DATE] 08:27 (8:27am) Social Services Progress Notes Note Text: Spoke with resident in [their] room. [They have] continued with [their] normal routines, [R714] is not fearful of co-res (co-resident), [R714] said [they] would just be giving [them] a wide birth (sic) when [R714] see's (sees) [them]. [R714] does not want to change rooms, [they said they] like [their] room and [their] room mate. [DATE] 15:43 (3:43pm) Social Services Progress Notes Note Text: Nurse on unit spoke with resident about changing rooms. [R714] was agreeable and room move slip out. [DATE] 16:37 (4:37pm) Nurses' Notes Note Text: Resident agreed to transfer to room ,d+[DATE]. Resident and all belong (belongings) transferred. Report given to receiving nurse. [DATE] 18:44 (6:44pm) Nurses' Notes Note Text: resident is complaining of being attacked and abused by [R723], i called don and she stated that she will call the abuse coordinator. [DATE] 15:19 (3:19pm) Social Services Progress Notes Note Text: SW (social work) visited with resident in [their] room. [They said they are] upset that this co-resident continues to bother [them]. [R714] talked for a bit about [their] feelings regarding [their] stay here. Will continue to assess and monitor. [DATE] 14:30 (2:30pm) Nurses' Notes Note Text: At 2:05pm writer heard [R714] on phone stating that [R714] would like to report an assault. [R714] was on phone with 911. After getting off of phone [R714] stated that [they were] near 400 unit going to see social services and another resident struck [them] in the back of [their] left shoulder. Denies pain. States that [they were] not hurt. Police arrived and spoke with [R714]. R723 On [DATE] at 1:49 PM, an attempt to interview R723 was attempted to no avail due to their cognition. A review of R723's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of their most recent MDS revealed that they have a severe cognitive impairment and require supervision to limited assistance for ADLs. Further review of R723's medical record revealed the following: [DATE] 16:30 (4:30pm) Pertinent Charting-Behavior Note Text: Event Date: [DATE] Behavior Displayed: Resident to Resident Precipitating factors/events: Seeing resident in room ,d+[DATE] Intervention(s) attempted: Keeping resident separated and redirecting resident. Intervention results: Successful Pharmacologic Intervention required: N/A (not applicable) Comments: Resident was sitting in 500 hallway when resident in room ,d+[DATE] past by . Resident began calling resident in room ,d+[DATE] negative names and using profanity. Resident in ,d+[DATE] cont. to wheel pass when resident in ,d+[DATE] punch resident in left arm. MD, DON and EC notified. Resident denies pain. Residents currently separated. [DATE] 09:08 (9:08am) Social Services Progress Notes Note Text: SW (social work) met with resident in their room. [R723] does not want to move rooms. [R723] acknowledged [their] understanding that [they] can not hit others or call them names. [R723] could not give this writer any reasons for why [they] did. Will continue to monitor. [DATE] 23:00 (12:00pm) Pertinent Charting-Behavior Note Text: Event Date: [DATE] Behavior Displayed: Witness reported resident hit (punch) resident [R714] in the back in the front lobby. Resident was heard by witness calling [R714] a punk loudly before hitting [them]. Residents immediately separated, redirected to units. R723 placed on q15 min checks (every 15 minute checks) until further notice. Precipitating factors/events: None Intervention(s) attempted: Redirection to units, immediate separation, R723 placed on q15 min checks. Intervention results: Successful Pharmacologic Intervention required: None Comments: [blank] A review of R723's care plan revealed the following: Focus: [R723] has the potential to be verbally and physical aggressive r/t (related to) Poor impulse control towards males and mostly with males with white to gray hair. Date Initiated: [DATE]. Revision on: [DATE]. Interventions: Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: [DATE] Revision on: [DATE]. Give [R723] as many choices as possible about care and activities. Date Initiated: [DATE] Revision on: [DATE]. Monitor behaviors around other males during the common area. Document observed behavior and attempted interventions. Date Initiated: [DATE]. Revision on: [DATE] On [DATE] at 3:20 PM, an interview was completed with the Nursing Home Administrator (NHA) and DON regarding R723's aggression toward R714. They explained that R714 looks like a man that used to terrorize R723 in the past, so anytime R723 would see R714, they would call R714 a punk. They explained that staff intervenes, R723's family is involved, they've separated them by placing them on different units, they tried to educate R714 on R723's diagnoses, and put interventions in place. They also explained that they tried to put a 1:1 staff member with R723, but it only irritated them. They further explained that they are considering finding another facility that may be more diverse in regard to culture, and has also talked to R714 about seeking another facility if they are unhappy. Resident 712 (R712) and Resident 722 (R722) A review of the Facility Reported Incident (FRI) MI 313 revealed the following, On [DATE], at around 8:00 PM, there was an incident involving [R712] and [R722]. [R722] was heading to the front lobby to sign [themselves] out on a LOA (Leave of Absence) and [R712] started yelling at [R722]. [R722] ignored [R712] yelling and as [R722] was passing [R712], [R712] hit [R722] in the chin. Residents were separated and pain and skin assessments completed for both residents with no redness or pain noted. A room move happened for [R722]. Administrator/Abuse Coordinator was notified . Conclusion: After a thorough investigation, the facility cannot substantiate that the incident that occurred was intentional, based on [R712] ability to form intent to cause harm based on his cognitive deficits/disease process. The facility can substantiate that [R712] did make contact with [R722]. No pain, redness, or injuries were sustained because of the incident. A review of the statement made by R722 revealed the following, I came out of my room, and I came down the hall. I get to the double doors and [R712] was sitting in [their] wheelchair and was pointing at me. I asked [R712] what they were pointing at and said you stop. I just thought to myself, I am not dealing with this, and I went to go around [R712] and I was starting to go around [R712] and [R712] reached out and hit me .[R712] hit me right on the chin. R712 was unable to be interviewed due to cognition status. A review of R712's progress notes revealed the following, [DATE] 20:01 (8:01 PM) Behavior Note Text: Event Date: [DATE] Behavior Displayed: Writer observed resident punch resident [R722] in the left chin as [they] attempted to pass by. Resident continued to yell and attempt to attack as writer intervened and separated them away from each other. Precipitating factors/events: None. Intervention(s) attempted: Separated residents away from one another. Intervention results: Yes. Pharmacologic Intervention required: Resident took medication prior to incident. Comments: DON, Administrator, and doctor notified. Resident sent to (name of local hospital) for increased agitation, aggressive. A review of the medical record revealed that R712 readmitted into the facility on [DATE] with the following diagnoses, Dysphagia, Dementia, and Generalized Anxiety Disorder. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 99, indicating that R712 was unable to complete the assessment. R712 also required extensive one person assist with bed mobility and transfers. Further review of the MDS revealed a behavioral symptom occurring within the period of the MDS assessment. A review of R712's care plan revealed the following, Focus: [R712] has a history of physically aggressive with other residents and staff, swearing at times, with no triggers related to Dementia and Alcohol Abuse with Mood Disorder .Goal: [R712] will not harm self or others through the review date .Interventions: o Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. o Assess and anticipate [R712] needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. o 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. o Psychiatric consult as indicated. See therapist and NP/psychiatrist o When [R712] 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. On [DATE] at 3:18, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding R712 hitting R722. The NHA replied that R712 and R722 were on the same unit and R722 liked to go out and smoke. As R722 was going around the corner R712 did not like the way R722 looked and hit R722 in the chin. The NHA said that R712 has had behaviors in the past and that one-to-one supervision makes R712's behaviors worse. The DON stated, We have noticed that [R712's behaviors are worse in the afternoon. But we are checking [R712's] [MEDICATION(S)] levels regularly and that has been helping with [R712's] behaviors.

This citation pertains to intake MI 382, MI 775, MI 733 and MI 377. Based on observation, interview, and record review the facility failed to complete weekly skin assessments on two sampled Residents (703 and 719) and prevent the development and/or worsening of pressure ulcers on two sampled residents (702 and 719) out of three reviewed for skin management, resulting in an facility acquired unstageable pressure ulcer and the potential for missed wound development, deterioration, pain, delay in treatment, and wound complications. Findings include: Resident #719 (R719) A review of intake MI 775 noted the following, [R719] developed bed sores from sitting in urine and feces for days at a time. A review of the medical record revealed that R719 readmitted into the facility on [DATE] with the following diagnoses, Dysphagia, Acute Kidney Failure, and [CONDITION(S)]. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7/15, indicating a severely impaired cognition. R719 also required two-person dependent assist with bed mobility and transfers. A review of the Electronic Medical Record (EMR) revealed skin assessments were completed for R719 on the following days: 2/24/2022, 3/15/2022 and 3/27/2022. Further review of the skin assessment dated [DATE] revealed the following, 1. Are there any abnormal skin areas? -Yes. Site-Left trochanter (hip) Description-Stage 2 pressure. Site-Right Gluteal Fold Description-Stage 2 pressure. A review of wound care notes revealed the following: Date: 3/21/2022. Wound Location: Right Buttock. Etiology: Pressure injury/ulcer-Wound Stage 2 -Pressure Injury. Date:4/18/2022. Wound Location: Sacrum. Etiology: Pressure injury/ulcer-Wound Stage 2-Pressure Injury. A review of progress notes revealed the following, Date: 4/14/2022 13:41(1:41 PM) SOC-Skin Explain area(s) (new/existing/size/description/etc.): [NAME] (In- House Acquired) Sacrum stage 3 PI (Pressure Injury)- 1.5 x 1 x 0.2 [NAME] L buttock stage 2 PI- 1 x 2 x 0.1 . On 6/2/2022 at 12:21 PM, an interview was conducted with Wound Care Nurse (WCN) E and Wound Care Nurse F regarding R719's wounds. WCN E stated, [R719] developed a stage two on their right buttock while in the facility, I believe they developed it because [R719] spent a lot of time in bed. WCN E was queried regarding skin assessments being completed and stated, Nurses on the floor should do skin assessments twice a week. Some are on paper, and some are in the computer. On 6/2/2022 at 3:02 PM, an interview was conducted with the Director of Nursing (DON) regarding skin in the facility. The DON stated, If someone develops a wound while in the facility, we do a meeting and try to figure out why they developed the wound, so it does not happen again. For the skin assessments we do weekly audits to make sure that the skin assessments are completed. These audits are completed by the interdisciplinary team. Resident #702 (R702) On 06/02/22 at 8:53 AM, a complainant for R702 reported they felt the bedsore R702 had on their sacrum was neglected and they were never told how bad it had become. It was reported that a picture was taken two days after arrival at the hospital. The picture revealed a wound covered in black (necrotic [dead, non-viable] appearing) tissue that extended from the sacral area onto the lower back. The family described the sacral wound as bigger than the size of a softball and the worse the doctor had seen. The family further noted that the death certificate indicated the sacral wound contributed to R702's death. On 06/02/22 at 10:04 AM, the care needs of R702 while on the 300 unit were reviewed with Certified Nursing Assistant (CNA) G. CNA G reported that R702 was alert to self but confused, ate well, would get moody and try to fight staff and other residents, but could walk and got up every day. CNA G did not recall any wounds on R702. CNA G confirmed they had cared for R702 since admission and R702 appeared to decline after the resident left their unit. On 06/02/22 at 10:12 AM, Nurse H was queried about R702's care needs while on their unit and reported R702 was very confused, really aggressive and a sundowner (nice in the morning, more aggressive in evening). Nurse H reported R702 had no wounds other than some bruising to the arms while on their unit. Nurse H recalled R702 liked their snacks and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the progress notes for R702 documented R702 was transferred to the 800 unit on 12/22/21. On 06/02/22 at 11:14 PM, Wound Nurse E and F were asked about R702. They reported that they were called to see R702 about a coccyx/sacral wound. On review of the electronic medical record they also reported R702 had been discharged on [DATE] due to a worsening and infected sacral wound. Wound Nurse E noted an initial observation of the wound on 02/07/22. The nurses indicated R702 was bed bound at the time and may not have recovered from a urinary tract infection. A review of the first facility picture on 02/07/22 recorded the wound to the sacral area as unstageable and measured 10.3 centimeters (cm) long by 15.3 cm wide. The picture was not an actual photo, but only outlined the wound area. The consult physician notes were reviewed and revealed: On 02/07/22 the coccyx wound was unstageable (could not determine depth of wound) had 10 percent necrosis (dead tissue), 10 percent slough (non-viable tissue) and no signs of infection. The tissue around the wound was macerated (wet, moist, white). The physician documented will have to see how it evolves. The note dated 02/14/22 revealed the coccyx wound was 8.2 cm by 10.8 cm, was unstageable and had 30% slough. The physician documented, overall prognosis for the patient is fair. The note dated 02/21/22 revealed the coccyx wound was 8.4 cm by 14.6 cm, was unstageable, 50 percent necrotic, 10 percent slough. The skin around the wound was documented as unhealthy. The physician documented, The overall prognosis for this patient is poor. The note dated 02/28/22 revealed the coccyx wound was 10.6 cm by 13.5 cm, was unstageable, 60 percent necrotic, 20 percent slough. Wounds were also documented: the right heel was 2.5 cm by 1.5 cm and 100 percent necrotic and the left heel was 2.7 cm by 2.9 cm and 100 percent necrotic. The note documented R702 was sent out to the hospital for possible [CONDITION(S)] (wound infection). The physician notes did not indicate an attempt to call family until 02/28/22. The wound team documented contact of responsible party on 2/10/22. Further contact of the responsible was not recorded in the progress notes. On 06/02/22 at 12:31 PM, CNA I was asked about the care of R702. CNA I reported R702 had come to them from another unit and was initially walking. CNA I reported they really don't know what happened, but at some point something happened as one day they had tried to get R702 up and R702 would not get up and did not get out of bed since. CNA I indicated R702's medication changed and then R702 never walked again. CNA I further commented they did not know what they used to mellow R702 out, but would find R702 loopy and with all their clothes off. CNA I was also asked about R702's ability at that time and reported R702 could still move their upper body a little but did not move their lower half without assistance. On 06/02/22 at 2:35 PM, the Director of Nursing (DON) was asked about the care of pressure ulcers and reported they had reviewed with the nursing staff the need to check the air mattresses are at the right pressure setting. They also noted on review of the record for R702 that no additional psych note after 01/14/22 was found. A review of the Nurse Practitioner notes dated 02/15/22 and 02/22/22 documented the recommendation to replace the low air loss (LAL) mattress as it was not working properly. On 06/02/22 at 3:01 PM and 3:55 PM, the Maintenance Director was asked if any maintenance had been completed for the LAL and reported they had the initial installation of the mattress, but no documentation that the mattress had been re-inspected or in need of repair. A review of the facility records for R702 revealed R702 was admitted into the facility on [DATE] and 05/26/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] indicated moderate to severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 5/15 and the need for limited assistance of one person for bed mobility and transfer; the need for the extensive assistance of one person for dressing, personal hygiene and bathing; and supervision with locomotion/walking and eating. The MDS further indicated no mobility devices such as a walker or wheelchair were used. A review of the MDS dated [DATE] indicated severely impaired cognition and the need for extensive assistance of one person for bed mobility, transfer, locomotion, dressing, toilet needs and personal hygiene. Bathing required the total assistance of one person. Mobility devices were documented as a wheelchair. A review of the 01/18/22 physical therapy discharge note indicated stand by or contact guard assist for walking. The occupational therapy discharge note dated 02/08/22 indicated R702 was moderate to max assist for transfers. A restorative program was recommended. Restorative program documentation was requested but not received prior to survey exit. A nurse practitioner note dated 02/09/22 documented R702 was able to shift weight and turn and reposition independently. The notes also documented a low air loss (LAL) was received on 02/09/22. A review of the nursing care plan focus initiated 02/23/22 documented, (R702) medical condition is declining. (R702) is spending a majority of (their) time in bed watching television. (R702) needs 1:1 house calls from (activity) act staff for added stimulation. The nursing care plan focus initiated 01/10/18 and revised 02/08/22 documented, Resident has pressure ulcer development to coccyx related to impaired mobility and [CONDITION(S)] .risk for complications related to impaired skin will be minimized .pressure ulcer will progress through the healing process and remain free from infection .administer treatments as ordered and evaluate for effectiveness .Resident requires (low air loss) LAL mattress (initiated 02/08/22). A review of the February 2022 Treatment Administration Record (TAR) for the coccyx wound indicated 02/25/22 was left blank and not documented as done. A review of the January TAR documented a treatment to the buttocks twice a day. An observation of an anonymous resident on the 800 unit, unable to turn themselves was made on 06/02/22 at 11:00 AM, 11:36 AM, and 12:05 AM. The resident had a contracture to the left hand and wrist area. The resident was observed to be in bed on their back with the head of the bed around 30 degrees and no positioning devices or pillows under the heel or at the sides. At 12:21 PM, the resident was in bed with the head of the bed around 45 degrees and continued in bed on their back at 12:55 PM, 1:02 PM (when the lunch tray was taken out), 1:09 PM and at 1:50 PM. Staff were observed to enter the room for the lunch tray A review of a facility policy titled, Pressure Injury Prevention and Management dated 1/1/2022 revealed the following, .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate 3. Assessment of pressure Injury Risk b. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Resident #703 On 06/01/2022 at 11:00 AM, Confidential Witness L was interviewed via phone in regard to Resident #703's skin condition. Confidential Witness L explained that in March (2022), Resident #703 had been at [CONDITION(S)] and had complaints of skin problems. Confidential Witness L stated, [Resident #703]'s skin is breaking down because [Facility] staff are not changing (Resident #703). (Resident #703) has sat in a dirty brief for 6-9 hours at a time .[Resident #703] is now bleeding in (their) groin area from sitting in soiled briefs for too long that caused skin breakdown . A record review of the Skin Care Plan for Resident #703, created 12/30/2021, revealed the Resident had a surgical wound. A record review of the skin assessments for Resident #703 revealed no pressure wound areas during the months of January 2022-February 2022. There were no skin assessments in the medical record for the month of March (2022). Skin assessments were requested from the Nursing Home Administrator (NHA) on 06/02/2022 at 11:57 AM, as none for the month of March or after could be located. However, the requested documentation was not provided by the facility prior to the end of the survey. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #703 was most recently admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

This citation pertains to intake MI 910 Based on observation, interview, and record review, the facility 1) failed to monitor, supervise, and provide an environment free from physical sexual abuse for sampled Resident (R706), 2) failed to provide an environment free from verbal sexual inappropriateness for sampled Residents (R718, R719 and R720), resulting in R706 being digitally penetrated by R705 while sleeping, R717 being verbally intimidating, and those affected avoidance and isolation. This deficient practice resulted in an Immediate Jeopardy (IJ) and the likelihood for serious sexual and /or psychosocial harm (based on the reasonable person), injury, impairment or death. Findings include: R705 and R706 A review of a Facility Reported Incident (FRI) dated 03/01/2022 revealed the following, On Saturday February 19th [Nurse B] states as she went to go give [R706's] roommate medication [Nurse B] witnessed [R705] on [their] knees touching [R705] inappropriately . The facility can determine what was witnessed by the nurse did occur. The facility conclusion is inconclusive on the allegation of abuse based on the fact [R706] did not cry/yell for help and was observed prone and relaxed during the activity that was observed by the nurse .The facility has an equal number of facts that this was consenting adults and the same number that support nonconsenting and cannot determine that abuse occurred . On 03/15/2022 at 10:12 AM, an interview was conducted with Certified Nursing Assistant (CNA) C. CNA C stated, I'm doing a 1:1 with [R705]. They have been on a 1:1 since the sexual incident. [R705] really doesn't do much and they don't like to talk about what happened. On 03/15/2022 at 10:14 AM, an interview was conducted with R705. R705 was queried about what happened with R706. R705 stated, I don't want to talk about it, it's all water under the bridge. I'm happy [R706] isn't here anymore. It happened and [R706] is gone. R705 was queried, if they were given permission to touch R706 sexually and they responded, No, [R706] was sleep and I did not have permission to do it, but [R706] did not tell me to stop either. R705 was queried about how R706 would tell them to stop if they were sleep to which R705 stated, I don't want to talk about it anymore. A review of R705 medical record revealed that they were admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. Further review revealed R705 was independent with bed mobility and transfers. A review of R706's written witness statement dated 02/19/2022 reflected the following, We were both talking by the front door and my stomach was hurting. I went to my room and got in bed. Then [R705] came into my room and started rubbing my back, then I fell asleep. Next thing I remember is both of you standing here and telling me to sit up. A review of an additional written witness statement dated 02/21/2022 by R706 revealed the following, Feeling so-so, I'm having a really hard time sleeping. I really don't know what happened. A review of R706 medical record revealed that they were admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE] revealed a BIMS score of 6/15 indicating severely impaired cognition. R706 was also independent with bed mobility and transfers. On 03/15/2022 at 10:48 AM, an interview was conducted with Nurse B regarding the incident with R705 and R706. Nurse B stated, [R706's] door was closed, and I knocked to give [R706] roommate their 2:00 PM medication. [R706] was sleep laying on their left side with their left arm across their face. I saw [R705] on their knees fingering (digitally penetrating the vaginal area with finger(s)) [R706]. I said [R705] what are you doing, and [R705] got up and left to their room. I then went and got another nurse and called [R706] name three times before they woke up. I told [R706] what I saw and [R706] said the last thing they remember is [R705] rubbing their back. I then called the [Nursing home Administrator (NHA)] and the police. In between that time, I asked [R705] what happened, and [R705] admitted that [R706] did not give permission for them to touch them sexually, but [R705] knew [R706] liked it. I also called [R705's] daughter and she stated, F*ck I knew [R705] would mess this up. They were both put on 15-minute checks and [R705] did not leave their room. When [R706] did see [R705], [R706] ran to another room and started crying because [R706] had seen [R705]. [R706] said they were embarrassed and scared. [R706] wanted to press charges after seeing [R705]. I also called [R706's] son who came and picked them up and took [R706] on a LOA for a couple of hours. Also, two other residents heard about it and asked [R706] about it, which really upset [R706] and made [R706] feel embarrassed. A review of the police report revealed the following, INVESTIGATION 02/21/22: I reviewed the responding officer's report. I spoke with the [NAME](Victim), [R706]. [NAME] stated they were followed back to the room by the DEF(Defendant), [R705]. Once in [R706] room the DEF offered [R706] a back rub as the [NAME] had been complaining of back/shoulder pain. The [NAME] stated they agreed and laid in their bed on their left side, fully clothed. [NAME] stated they fell asleep during while the [R705] was rubbing their shoulders. [NAME] stated the next thing they remembers is hearing a staff members voice, later identified as Nurse B yelling at the DEF. [NAME] stated they had no knowledge of the incident until Nurse B advised [R706] of the incident. [NAME] stated at no point did they give the DEF permission to digitally penetrate their vagina. [NAME] advised that they are interested in pursuing criminal charges. I then spoke with Nurse B -on duty nurse. Nurse B stated they entered the [NAME]'s room and observed the [NAME] laying on their back with an arm over her face. WIT stated the [NAME]'s pants and briefs were pulled down to their knees and observed the [R705] on their knees on the right side of the [NAME]'s bed with at least one finger inserted into the [NAME]'s vagina. Nurse B stated they confronted [R705] by asking [R705] what they were doing. Nurse B stated [R705] stood up and left the room, walked to their room and closed their door 02/24/22: [Detectives] made . to attempt to speak to the [R705]. [R705] was read their [NAME] Rights, rights were understood, [R705] initialed and sign form.[R706] again stated they did not give the [R705] permission to do anything other than rub their back/shoulders. [R706] stated they then noticed their pants and briefs were around their knees. On 03/15/2022 at 11:48 AM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding the incident between R705 and R706. The NHA stated, We did pain and skin assessments for everyone with a Brief Mental Status (BIMS) assessment score below 10. Everyone with a BIMS above 10 we asked them about their safety. The NHA was queried regarding if they asked the residents specifically about sexual abuse and the NHA stated, We did not ask specifically about sexual abuse because we wanted to catch any and all abuse concerns. The NHA and DON was queried about what R705 said happened between them and R706. The NHA stated, [R705] would not speak with me about it. We have been talking to [R705's] daughter and discussing discharge planning. The NHA was asked about the cameras in the hallway and if they watched them. The NHA stated, We watched them and determined that [R705] was in [R706] room for approximately 22 minutes. On 03/15/2022 at 1:01 PM, an interview was conducted with Family Member E. Family Member E stated, I was told about the incident from [R706's] nurse who said they went in to give [R706's] roommate medication and found R706 asleep. The nurse told me that [R706's] pants and underwear were pulled down and [R705] was touching [R706]. I was told by the nurse if they had not gone in to give medication to the roommate, they would have never known. I called the facility multiple times and was told the resident that did this was moved to the other side of the building, but they were allowed in the lobby and food area still with a sitter. [R706] still has extreme anxiety about being in the facility to the point I signed [R706] out for a visit and they refused to come back. [R706] would see [R705] and had to be consoled because of the incident, one time [R706] was inconsolable and I had to come pick them up. [R706] is still having issues with it and it has really affected [R706]. On 03/18/2022 at 11:42 AM, an interview was conducted with Social Worker (SW) A who stated, I spoke with both R705 and R706 regarding the incident. R705 would not speak to me about it and R706 always said that they were fine after I spoke to them. SW A was asked if they were ever told about R706's increased anxiety and crying when they saw R705. SW A stated, I was never told about that, I would have interviewed [R706] and ordered an emergent visit. R717, R718, R719 and 720 On 03/15/2022 at 10:25 AM, R717 was observed in the common area speaking with R718 and R719 in a sexual manner. R718 and R719 were observed telling R717 to stop and that they did not want to hear that type of talk. R717 was observed telling R718 and R719, I can talk about sex if I want, and I can have sex in here if I want. On 03/15/2022 at 10:35 AM, an interview was conducted with R718 and R719 regarding R717 and the earlier conversation. R718 stated, [R717] needs to get in trouble. [R717] is always talking about sex and no one wants to hear that. R719 stated, [R717] can make me uncomfortable sometimes. One time [R717] offered to put some powder on me and I told [R717] to get away from me. There are a couple of ladies that won't even come out of the room when [R717] is around, [R720] is one of them. On 03/15/2022 at 10:45 AM, an interview was conducted with R720 regarding R717. R720 stated, I leave when [R717] comes out their room, I don't want to be anywhere near [R717]. [R717] talks to me about porn, playboy, and other things that I don't want to talk about. Since [R717] is always out, I have just been staying in my room. R720 was asked if they had ever told anybody about R717 and they stated, I told the Social Worker (SW) about it. A review of R720 progress note dated 02/03/2022 revealed the following, 2/3/2022 10:30 Social Services Progress Notes Note Text: spoke with resident in SS (Social Serves) office. [R720] was upset and tearful that [R717] keeps stopping to talk to [them]. [R720] said that [R717] says [R720] is [R717] friend but [R720] says [they] are not. Educated resident that [R720] needs to tell [R717] to move on that they don't want to talk, however [R720] needs to do this every time [R717] stops, because talking to [R717] sometimes, is confusing and [R717] won't get the point that [R720] doesn't want them to stop and talk. Referral made to psy(psychiatry) for added support with this matter. A review of R717 progress note dated 02/03/2022 revealed the following, 2/3/2022 10:34 Social Services Progress Notes Note Text: Spoke with resident in [their] room. Explained to [R717] that co-res does not want [them] to stop and talk with [R620]. [R717] said that [R720] is [their] friend. Explained again that R720 does not want to be [their] friend, [they] needs to find a different friend. [R717] also needs to not touch others without permission from that person first. [R717] acknowledged [their] understanding. Referral made to psy for added support on this matter as well. On 03/15/2022 at around 12:00 PM, an interview was conducted with the NHA regarding R717. The NHA revealed that R717 has a history of speaking in a vulgar manner and it is care planned. The NHA was queried, if sexual inappropriateness was care planned and the NHA stated, No. The NHA was queried if they heard about R720 self-isolating due to R717. The NHA stated, Yes, I heard about that, and we educated them both. But around that time R720 was being flirty, so we just told them to stay away from each other. On 03/17/2022 at 11:42 AM, an interview was conducted with SW A regarding R717 and R720. SW A stated, I just talked to them both and went from there. I have never heard of anyone else complaining about R717. On 03/17/2022 at 11:00 AM, R718 and R719 were seen in the hallway. R718 and R719 stopped this surveyor and stated, Thank you so much for your help, it has been so pleasant with R717 having someone with them. [R717] hasn't been talking like they usually do, and we hope it stays that way. A review of the facility policy titled, Abuse noted the following, The facility will develop and implement written policies and procedure that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The Nursing Home Administrator was notified of the Immediate Jeopardy on 03/15/2022 at 3:40 PM and a plan of correction was requested to remove immediacy that began on 02/19/2022. Immediate Jeopardy was removed on 03/15/2022 and validated by the team on 03/16/2022. The facility provided the following removal plan. Removal Plan Resident 706 no longer resides in the facility Resident 705 remains on 1:1 supervision. Care plan has been revised related to sexual behaviors and inappropriate language Resident 717 has been placed on 1:1 supervision. Care plan has been revised related to sexual behaviors and inappropriate language. Resident will be assessed by Psych (Psychiatry) services for additional interventions as needed. Resident 718 has been assessed for psychosocial distress by the Social Service Worker (SSW). Their care plan had been revised to include Social service visits for potential psychosocial distress. Resident 719 has been assessed for psychosocial distress by the SSW care plan revised to include social service visits for potential psychosocial distress. Resident 720 has been assessed for psychosocial distress by the SSW care plan revised to include social service visits for potential psychosocial distress. Residents with BIMS score of 10 or above will be assessed for psychosocial concerns related to sexual abuse by the SSW. Residents with BIMS score of 9 or below will have a complete skin assessment completed by licensed nursing staff to rule out sexual abuse. The facility will re-educate staff on the abuse policy and procedure, specifically related to perpetrators. No staff will work past 3/15/22 if not re-educated. The social services will develop target behaviors related to inappropriate language or physical actions for identified residents to alert the clinical team for follow up. Although the immediacy was removed on 03/15/2022, the facility remained out of compliance at isolated with actual harm that is not Immediate Jeopardy, as sustained compliance could not be verified by the state agency.

This citation pertains to intake 6 and 2. Based on interview and record review, the facility failed to properly secure a seatbelt during a medical appointment and failed to transfer per care plan, for two sampled Residents #305 and #310 (R305 and R310) of three residents reviewed for accidents, resulting in two broken legs and an unsafe transfer. Findings include: Resident #305 (R305) A review of the intake summary noted, [R305] was taken to [local] hospital and the X-ray determined both legs are broken in multiple places. [Facility] is stating they don't know what happened and [R305] is denying [they] fell . On 12/01/21 at 10:35AM, R305's Responsible Party was called and asked about R305's injuries and stated, I'm not sure what happened, [R305] is still in the hospital. A Nurse called me around 11:00 PM, on the 19th [November 19, 2021] and said they are sending [R305] to the hospital because [R305] said [R305's] legs hurt. She also said that they (legs) were black/blue with abrasions on the knees and top of feet. That's all she told me. The Responsible Party was asked if they had communicated with the hospital and stated, Yes [R305] had surgery and the legs are broken in two spots. A review of R305's medical record revealed that they were admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included, Abnormalities of gait, Difficulty in walking, [CONDITION(S)], Lack of coordination, and [CONDITION(S)] disorder. R305's Minimum Data Set assessment dated [DATE] revealed that R305 had an impaired cognition and was dependent with Activities of Daily living. A review of R305's Care plan revealed, Patient requires a Hoyer lift for transfers. Date Initiated: 07/17/2020. Patient requires a Hoyer lift for transfers Date Initiated: 07/17/2020. Patient will be a 2 person transfer with Hoyer lift, utilizing Medium/beige sling Date Initiated: 07/17/2020 Revision on: 11/26/2021. A review of R305's unit assignment sheet noted Certified Nursing Assistant (CNA A) assigned on 11/19/21. On 12/2/21 at 11:22 AM, CNA A was interviewed and asked if she cared for R305 on 11/19/21 and did R503 report pain during the shift and stated, Yes, I had [R305]. I don't recall of any pain. CNA A was asked were there any reports of R305 having a fall during that week. CNA A stated no, but I heard [R305] was in an accident during transportation. CNA A was asked if it was an outside company or the facility's transportation. CNA A stated, I am not sure. CNA A was asked how long ago the accident was and explained, that it was in the month of November. CNA A was asked the status for R305 for transfers and stated, Hoyer lift two to three people. Therapy would also do the transfers sometimes for us. On 12/2/21 at 12:01 PM, the Nursing Home Administrator (NHA) and the Assistant Nursing Home Administrator (ANHA), provided the facility's investigation and explained that R305 slid out of the wheelchair on 11/16/21, two times during the trip back to the facility. ANHA explained, it was reported by CNA G (driver) that [R305] slid out of the wheelchair the first time and hit the floor. The driver pulled over and picked [R305] up off the floor and placed [R305] back in the chair. The second time R305 slid out of the chair but did not hit the floor. CNA G explained that he told a Nurse about the falls when he returned to the facility with R305. A review of R305's unit assignment sheet noted CNA F was assigned to them on 11/13/21. On 12/2/21 at 12:53 PM, CNA F was interviewed via phone and asked about R305 and the last time they worked with the resident. CNA F stated, I haven't worked with [R305] recently. CNA F was asked if the facility reported that R305 had fallen. CNA F stated that, I was told [R503] got dropped, not for sure if it was [outside transportation company] or our transportation. A review of R305's unit assignment sheet noted CNA E was assigned to them on 11/16/21. On 12/2/21 at 3:25 PM, CNA E was interviewed via phone and asked about R305 return from the medical appointment on 11/16/21. CNA E stated, [R305] was back around 6:30 PM, around the same time unit 800 got [food] trays. [R305] complained of pain during care and about [R305's] left foot hurting. I just thought it was because the footrest was gone and [R305] had been holding up [their] leg. So, I propped it up. After dinner I put [R305] in bed and noticed [R305's] right knee scarred up and pants bloody. I asked [R305] what happened and [R305] told me 'They dropped me'. I asked who, [R305] said 'The driver.' I went and told Nurse M she was doing med pass at the cart. I told her [R305] has wounds and blood in pants. She didn't say much, I went back in the room. I didn't chart what I saw, because I did it before I got [R305] in the bed. CNA E was asked if they observed Nurse M go into R305's room, CNA E explained Nurse M never went in to do a skin check. CNA E was asked if they were assigned to R305 after 11/16/21 and stated, Thursday night they called me into the room to look at [R305]. They showed me [R305's] feet. [R305's] left foot was really red and I didn't see that on Tuesday. A. of the facility's investigation noted, CNA E Witness statement, Dated 11/23/21 via phone. That it was my mistake that I charted that I was rushing thru charting and I did tell the nurse that [R305] had scrapes on [R305] knees. After I charted nothing. After I was getting [R305] in bed I noticed the blood on [R305] knees and told the nurse. The nurse was Nurse M and she did not say anything. [R305] got back around 630pm. I did not see the driver I just saw [R305] on the unit when I came out to the hallway. I then pushed [R305] to [R305's] room and passed [R305's] tray before I gave [R305] tray I propped [R305's] foot up because [R305] said it was hurting and I told the Nurse M about [R305's] foot pain. [Another CNA] and I changed [R305] and [R305] was complaining of pain and we told the Nurse M, [Nurse M] did not go into the room on Tuesday. On 11/17/21 I didn't have [R305]. But didn't have [R305] on Thursday 11/19/21 I had [R305] on the 16th. On 12/2/21 at 1:06 PM, Nurse M was interviewed and asked about the report that R305 had blood on pants and new wounds. Nurse M stated, I don't remember. I do know I had to turn on [R305's] feeding tube. On 12/2/21 at 9:07 AM, CNA G was interviewed and asked about R305 falling out of the wheelchair during the ride back to the facility. CNA G explained, I was on the freeway driving and heard [R305] say 'O'. I looked back and [R305] was on the floor. CNA G was asked, how did R305 look on the floor, CNA G was observed to show R305's position on the floor during the interview. CNA G position was, knees on the floor, feet under the chair, arms hanging on the arm rest, and their back touching the wheelchair seat. CNA G was asked how long was R305 on the floor. CNA G stated, A good five minutes on the ground. I got off the freeway and pulled over, then put [R305] back in the chair and strapped [R305] back in. CNA G was asked how it was putting [R305] back in the chair, did R305 make any noise. CNA G stated, [R305] made some noise when I put [R305] back in the chair, but I thought [R305] was ok. The second time [R305] did not come all the way out the chair but was kind of hanging out of the chair. [R305] didn't hit the floor all the way. CNA G was asked about the training before transporting residents and explained that the Maintenance staff N and Activities Staff O trained him on how to use the truck and how to lock wheelchairs in the van. CNA G continued and stated, The wheelchair was locked down, that didn't move. [R305] went under the seatbelt. That wasn't tight. CNA G was asked what happened once back at the facility, and stated I told the Nurse, I can't remember her name. We did a check while [R305] was in the wheelchair, and she said that she would do a full check when they get [R305] in the bed. I was suspended and when I came back, I was trained again. They showed me how to do the seatbelt and taught me a different technique and how to adjust the seat. That's when I saw how to tighten the seat belt. I didn't know how to tighten it, and no one showed me how to do that before the second training. A review of R305's medical record noted the following progress notes: 11/16/2021 17:57 (5:57 PM) Nurses' Notes Text: Resident just came back from [Local hospital] for [R305's] [MEDICATION(S)] pump. VS (vital signs) is stable. On hold medications is given and no paper works received from the resident. 11/16/2021 18:33 (6:33 PM) Nurses' Notes Text: Paper works was received for the resident. [R305]. [R305] next appointment for [R305's] [MEDICATION(S)] pump would be on January 4, 2021 1:30 PM at [local hospital]. 11/16/2021 23:21 (11:21 PM) Orders Administration Note Text: [MEDICATION(S)] HCI Tablet 50 mg (mailgrams) Give 1 tablet via (by) PEG-Tube (Percutaneous endoscopic gastrostomy) every 8 hours as needed for pain related to CRAMP AND SPASM. PRN (as needed) Administration was: Effective Follow-up Pain Scale was: 1. 11/17/21 15:35 (3:35 PM) Orders Administration Note Text: [MEDICATION(S)] HCI Tablet 50 mg Give 1 tablet via PEG-Tube every 8 hours as needed for pain related to CRAMP AND SPASM. PRN Administration was: Effective Follow-up Pain Scale was: 2. 11/17/21 23:01 (11:01 PM) Orders Administration Note Text: [MEDICATION(S)] HCI Tablet 50 mg Give 1 tablet via PEG-Tube every 8 hours as needed for pain related to CRAMP AND SPASM. PRN Administration was: Effective Follow-up Pain Scale was: 0. 11/18/21 20:54 (8:54 PM) Orders Administration Note Text: Acetaminophen Tablet 325 mg. Give 2 tablet via PEG-Tube every 6 hours as needed for pain/fever. 11/18/21 23:22 Orders Administration Note Text: Acetaminophen Tablet 325 mg. Give 2 tablet via PEG-Tube every 6 hours as needed for pain/fever. PRN Administration was: Unknown. 11/18/21 23:22 Orders Administration Note Text: [MEDICATION(S)] HCI Tablet 50 mg Give 1 tablet via PEG-Tube every 8 hours as needed for pain related to CRAMP AND SPASM. PRN Administration was: Unknown. 11/19/21 00:58 Nurses' Notes Text: approximately 2030 CNA notified nurse that resident was refusing ADL care r/t leg pain and that S/P catheter had hematuria with scant amount of urine noted. Nurse entered room approximately 20 minutes later to assess catheter and administer PRN pain meds. Vitals obtain BP (blood pressure) 101/65, HR (heart rate) 79, RR (respirations) 16, T (temperature) 98.9 talking with resident about [R503's] report of leg pain while assessing S/P catheter site was ensuring catheter is functioning properly, drainage bag change with foley anchor in place, amber urine return. Upon discussing leg pain with resident [R305] states I was crushed by a van. When asked resident about a possible fall [R305] again states I was crushed by a van. Linen remove from BLE (bilateral lower extremities) and writer called 700 unit nurse to room to assist with assessment. Upon assessment of resident legs large fluid filled blisters were noted on RLE (Right lower extremities) with bruising with large abrasions to R (right) knee and abrasions on toes and top of foot with open area, draining blood and swelling to extremity. LLE (lower left extremity with discoloration, abrasion to knee and bruising to ankle and foot, noted swelling with visual deformities to foot. Bilateral extremities warm to touch with pain noted upon writer's touch. Writer exited resident room and immediately notified resident physician and receive order for a STAT xray. Administrator notified immediately and reported findings and DR doctor order. Administrator would like residents sent to ER (emergency room ) for assessment due to unknown injury. [local transportation] notified and in to transport resident to [local hospital] at 2300. Exited facility alert and oriented to baseline. All belongs remain in room. 11/19/21 06:56 (6:56 AM) Nurses' Notes Text: Spoke with guardian . this morning via phone conversation. Further review of R305's documentation noted, incident and accident reported revealed, 11/18/21. Time of incident: 20:20 (10:20 PM). Brief Description: Resident complaining of leg pain upon assessment bruising, blisters, discoloration, swelling and abrasions noted to BLE. Administrator notified immediately and resident sent to [local hospital]. Nurse P's witness statement noted, Date 11/19/21 via phone. I was [R305's] Nurse (on 11/16/21). I don't know about it. I checked [R305's] vitals, everything was fine. [R305] complained of pain the next day said it was arm, never mentioned it to me. I don't know anything about it. Nurse M's witness statement noted, Date 11/23/21 via phone. Did you have [R305] as a resident on the 17th (11/17/21)? Yes was [R305] in any pain or did notice anything unusual. Did [R305] ask for pain meds. I don't recall. [R305] doesn't usually complain about anything. I didn't do any skin checks. Just turned tube feeds off (at) 8, [R305] slept through night. On 12/6/21 at 2:40 PM the NHA was asked if CNA G was trained and stated, Yes. This was not their first-time driving residents. On 12/6/21 at 3:00 PM, Maintenance director N was asked about training the driver for resident transportation and stated, I'm not a CNA, I never drive residents. I only drive equipment or other staff members. I trained CNA G to drive the van, not sure who trained him to drive residents. On 12/6/21 at 3:00 PM, the Director of Nursing (DON) was asked the process if a accident or an incident occurs during transportation. The DON stated, He should have called back here, and we would have given direction. Or he could have called 911. The DON was asked if CNA G should have picked the resident back up off the floor, and stated, No. On 12/6/21 at 3:07 PM, the Activities Assistant Director O was asked if they trained CNA G on transporting residents and explained, [CNA G] asked me to show him how to lock a resident in the van, because he had an appointment that day. I showed him how to lock the chair in and how to strap the resident in the van. Resident #310 (R310) On 12/2/21 at 10:20 AM, Certified Nursing Assistant (CNA) H was observed finishing morning care for R310. CNA H was caring for the resident with no other staff member present in the room. CNA H pulled R310's wheelchair up to the resident's bed and locked the brakes. CNA H helped R310 sit up on the edge of the bed. CNA H then directed R310 to put their arms around her (CNA's) neck and hug her, while she bent down towards the resident. CNA H then wrapped her arms around R310, lifted the resident into the air, and placed R310 into the wheelchair. No lift, additional staff member, nor gait belt was used by CNA H to help transfer R310 from bed to wheelchair. A review of R310's care plan at this time revealed: TRANSFER: The resident requires 2 person with hoyer lift beige sling. Date Initiated: 11/11/2019, Revision on: 11/12/2021. A review of R310's medical record revealed that the resident was initially admitted into the facility on [DATE] and most recently readmitted on [DATE] with medical diagnoses of [CONDITION(S)], Dementia Without Behavioral Disturbance, Hypertension, Chronic Heart Failure, [CONDITION(S)] Disorder, [CONDITION(S)], Cognitive Communication Deficit, [CONDITION(S)], [CONDITION(S)] Disorder, [CONDITION(S)] Type, Alzheimer's Disease With Late Onset, Pressure Ulcer Of Sacral Region, Chronic Kidney Disease, Other Abnormalities Of Gait And Mobility. A review of R310's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has moderately impaired cognition and required extensive assistance from two or more staff members for transfers. A policy/procedure regarding transfers (bed to wheelchair, etc.) had been requested from the facility, however, the Assistant Nursing Home Administrator (ANHA) indicated on 12/6/21 at 11:06 AM that the facility used Standard practice of care. On 12/6/21 at 3:25 PM, the Director of Nursing (DON) was interviewed. The DON was asked if staff is were to follow the care plan when it came to transferring residents, since the facility did not have a policy/procedure. The DON stated, Yes. If [a resident is] a hoyer it's always two person assist. But follow the care plan. The DON was queried if she would expect one staff member to transfer a resident, who was care planned as needing a hoyer lift for transfers, by holding the resident under their arms and picking them up to put them into a wheelchair. The DON replied, I would not expect that. I am assuming it happened since you're asking about it. All staff have been educated, we just did education regarding two-person assists, hoyers, etc. I think they (staff) just think they're being efficient, and it's not .[They] could hurt somebody. A review of the facility's policy titled Fall-Clinical Protocol dated, 1/1/2021, noted .8. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in a fall for example a balanced problem caused by an old or recent stroke. Once a fall occurs it is important to gather as much information as possible; Observe for evident trauma, Observe to determine what the resident was attempting to do if possible, Observe for environmental hazards which may have contributed, If the resident is able what does he/she state happen, Staff present and responders what did they see or hear Provide emergency care and assessment as indicated. Residents who have fallen and have been witnessed to hit their head, suspected to have hit their head, and all unwitnessed falls regardless of the residents cognitive status should have neurochecks per MD orders or protocol. The physician and responsible party should be notified as soon as the resident is stabilized. Document findings and the residence medical record or EHR per standard protocol. Document falls on the 24 hour shift report. An incident accident report will be completed and forwarded to the Don as part of the facilities internal quality assessment and assurance program .

This citation pertains to intake #MI 850, MI 8385, MI 389 and MI 966. Based on observation, interview, and record review, the facility failed to prevent verbal and mental abuse by not identifying and thoroughly investigating abuse complaints from multiple cognitively intact residents and staff members, and neglected to provide physician ordered medications timely, for seven residents (Resident #49, #93, #100, #104, #140, #152, and #159) of ten reviewed for abuse, on the 500 and 600 Unit, resulting in Immediate Jeopardy due to psychosocial harm, emotional distress, fear, unnecessary prolonged pain, humiliation, anger, and mental anguish. Findings include: Resident #49 On 07/19/2021 at 8:44 AM, during an initial tour, Resident #49 was observed to be awake, dressed and groomed. Resident #49 had clear speech and was alert and oriented to person, place, time and situation. During the interview, Resident #49 had expressed that their biggest concern with the facility was not receiving their [CONDITION(S)] medication. When asked to elaborate, Resident #49 explained that they either got their pill late or didn't get it at all. Resident #49 stated, My doctor always told me that my [CONDITION(S)] pill was supposed to be given to me a half hour before I eat in the morning A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #49 was most recently admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #49 had a Brief Interview for Mental Status score (BIMS) of 15 out of 15, indicating an intact cognition, and was independent with transfers and bed mobility. The MDS also indicated the Resident had no behavioral issues. A record review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .START DATE 10/19/2019 0600 (AM). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/21/2021 at 01:49 PM, Resident #49 was interviewed regarding their [CONDITION(S)] medication not being given. Resident #49 brought out a notebook with mostly illegible handwriting, and stated, I keep a notebook, it is the nurse [Licensed Practical Nurse/LPN A]. She hates me! I am not sure why, but for some reason she hates me! I was keeping track of different times of her giving me my [CONDITION(S)] pills. The following dates were legible in the notebook: May 26-no meds .5/27 0 (zero meds given)-go to bed .5/28 720 am (late) .5/30 Sun (Sunday) did not wake up (was not woken up by LPN A) .Tue 7/20 no pill. The notebook contained at least 10 pages with various dates and times written on it. Resident #49 was asked what made them start the notebook and explained that they were concerned with not getting their medication but cannot see and felt the need to record when they were not getting their medication. Resident #49 explained that they would tap a button on a device on their bedside table that would indicate the time out loud and utilized that time and would write it down on the paper. Resident #49 was asked if they ever asked LPN A where their pill was and stated, I ask where my medication is, she just tells me to go to my room and I would wait and wait, and she never came. Resident #49 further stated, There has been a lot of difficulty between her and me, she has just been nasty. One day, [Certified Nurse Assistant/CNA DD] came in and cleaned up my roommate, a different one (a different roommate than current one) than this one. She threw the dirty diaper and linens on the floor in the middle of the room so I could not get around it to go to the bathroom. I had to yell out five times for help because no one was answering my call light. She [LPN A] came in and was mad at me, screaming and yelling at me because I broke up her conversation with her friend (CNA DD). I couldn't even understand her, but I know it was not nice, it (the yelling) was not good. She asked me what my problem was. I explained to her that I needed to use the bathroom but could not get around the dirty items to go to the bathroom. She picked up the mess and I came to the bathroom door and that's when she [LPN A] picked up the (roommate's) dirty diaper and put it about an inch from my face and told me that she would like to 'Shove it in my face'. I said to her, 'Go ahead, I would love to [NAME] you.' She threw it in the basket and let me go to the bathroom. When I was done using the bathroom, I went out and went to my bed, my bed was full of water. My big cups that were full of water on my table were laying emptied out on my bed. After that, (CNA DD) changed my sheet, the mattress was damp and wet. I am not lying! I would swear to God! She (LPN A) is nuts! I reported her that night. I went to the main desk and asked who was in charge here. Someone took all the info and wrote it down. After that, [Previous Director of Nursing] spoke to me. When [CNA DD is with [LPN A], all the bad comes out. Resident #49 was asked what happened after they reported the incident and stated, [Previous DON] came back a few days later, takes charge, talks to [LPN A], I guess. She (Previous DON) brings [LPN A] in my room for the [CONDITION(S)] pill and made sure I got it every day. Once [Previous DON] stopped coming with her (LPN A), it started all over again. She (LPN A) hated me, she absolutely hated me. I felt terrible, the [CONDITION(S)] is a very important part of my body. It is supposed to be given before seven (AM), I don't know what it (the [CONDITION(S)]) is doing to my body, but I feel tired and have no energy. Other times I would ask for the pill, she (LPN A) was standing at the med cart, she could have easily reached in and grabbed it and gave it to me at that time, but told me that she could not give it to me in the hall, she told me to go in the room and then never would come or would come late. Another time she was screaming at me in the middle of section 6 (600 hallway), which is across the hall. It was four or five in the morning. She followed me all the way down here to the middle of section 5 (500 unit where Resident #49 resides) until one of the aides came out, got me and put me back in my room and shut the door to get me away from her. Resident #49 was asked if they reported that incident and stated, I talked to [DON], that is the head nurse here. She said she would talk to her (LPN A) to see what is wrong, but they can't fire her because they can't find someone to take over the 5 and 6 (500 and 600) unit. I even spoke to [Nursing Home Administrator/NHA] who is in charge of the whole building, it was like she (NHA) was defending her (LPN A) and made me feel like an idiot. So, I left her office. That was less than a month ago, I don't remember the exact date. Resident #49 further stated, She (LPN A) is too busy taking care of section 6 (600 Unit) to bother with me here. She would report (to the oncoming nurse) that she had given me all my medications and she never gave me one. I would ask the (oncoming) nurse for my pills and they would say I got them already, even when I know I didn't. One time I was on a pill because I had terrible itching, she (LPN A) would not give it to me (the medication to help with itching), I told her I have not had anything for pain or itching, she didn't care. I get up early to go to the bathroom and I will go out and see if I can find someone to help me, if she (LPN A) was on, they will ignore me for hours then. Three times this past week I have not gotten my pills. I figure if I die, she is going to be responsible for it, and it is going to happen shortly. A record review of the progress notes for Resident #49 revealed the following: 3/9/2021 12:58 (PM) Nurses' Note .This morning patient said, 'I did not get my morning medication I want to know if the nurse (LPN A) charted she gave them to me so I can report her again.' I explained to (Resident #49) that the nurse gave me report that (Resident #49) was sleeping and was unable to wake up and explained that I can give .the medication, she said, 'No, I do not want it, I just want to see if .she charted that she gave me the medication so I can report her, I do not like her' . 3/9/2021 07:25 (AM) Nurses' Note (Authored by LPN A) resident come at 3 am to retrieve 6 am meds resident notified it was too early. during 6 am med pass nurse and cna attempted to wake resident 3 x resident remained sleep. reported to on coming nurse as well. 3/15/2021 12:22 (PM) NP/PA (Nurse Practitioner/Physician Assistant) Progress Note .Resident expressed concern that .is not getting .[MEDICATION(S)] early enough in the morning. Discussed possibility of taking HS (at night) instead .She is alert and oriented x 3 .[CONDITION(S)] - Continue [MEDICATION(S)] in AM. Evening dose is not possible with current medication regimen. A request was made for the most recent [CONDITION(S)] Stimulating Hormone (TSH) lab draw on 07/22/2021 at 10:57 AM for Resident #49's [CONDITION(S)] but was not provided prior to exit of the survey. Resident #93 On 07/19/2021 at 11:37 AM, during the initial tour, Resident #93 was observed lying in bed awake, dressed and groomed. Resident #93 had clear speech and was alert and oriented to person, place, time and situation. Resident #93 was asked about the care received at the facility and stated that they were not pleased. When asked to elaborate, Resident #93 stated, I haven't gotten my pain medication yet, my legs hurt so bad. Resident #93 explained that they were at the facility for short term rehabilitation and that they had severe [CONDITION(S)] in their legs. Resident #93 stated, I was supposed to get my pain medicine at midnight and at 06:00 AM, my legs are the reason why I am here! I ask for my medicine but, I don't get it! Resident #93 had explained that they were in so much pain. Resident #93 stated, I asked for it (from current day shift nurse) at 11 (AM), and she said that I had to wait for an hour. Then I told her I had not received them on 6:00 AM or at midnight, so she is getting it for me now. On 07/20/2021 at 08:28 AM, Resident #93 was observed dressed and groomed in their wheelchair. Resident #93 was interviewed about LPN A and stated, We don't get along, the nurse and I don't see eye to eye. Resident #93 was asked to elaborate and explained that their medications was supposed to be scheduled but LPN A does not give it, so they feel compelled to ask. If I do get it, then I get it late. One day, I asked for my medication and fell asleep because it was taking so long, she finally came in and told me that she was going to report me to my doctor because I was nodding off! It was 1:00 AM! I was tired, she was insinuating that I was on too many drugs. Then, a few hours later, I heard a noise in the corner of my room and seen someone in there. It was an aide; I could not see very good because it was dark in my room. I asked what she was doing in my room, and she told me that [LPN A] sent her in my room to watch me because I was being disruptive. I felt so humiliated! Resident #93 was asked if they had reported any of the incidents and explained that they had to the head nurse but felt if fell on deaf ears. Resident was unable to remember when they reported it and the name of the staff member, they reported it to. A record review of the July 2021 MAR for Resident #93 revealed the following medication order: [MEDICATION(S)] Tablet Give 100 mcg by mouth one time a day for [CONDITION(S)]-Start Date-06/09/2021 0600. [MEDICATION(S)] Capsule 300 MG Give 1 capsule by mouth four times a day for Peripheral [CONDITION(S)] -Start Date-06/15/2021 1800. [MEDICATION(S)] Tablet 10-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 6 hours for Pain related to SPINAL STENOSIS, CERVICAL REGION (M48.02)-Start Date-06/08/2021. Upon further review of the MAR, the above medications were not given on July 11, 13, 16 and 19th. A record review of the care plan for Resident #93 revealed the following: Focus-The resident is at risk for pain. Date Initiated: 06/27/2021 Goal-The resident will adequate pain control as evidenced by such things as decreased behaviors, irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying .Date Initiated: 06/05/2021. Interventions-Administer pain medications as ordered. Give 1/2 hour before treatments or care. Date Initiated: 06/05/2021 . A review of the MDS dated [DATE] for Resident #93 revealed an admission to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #93 had no behavior issues, needed assistance with most ADL and had a BIMS score of 15 out of 15, indicating an intact cognition. Resident #100 On 07/22/2021 at 09:57 AM, Resident #100 was awake in their room lying in bed, dressed and groomed, they had clear speech and was alert and oriented to person, place, time and situation. Resident #100 was interviewed regarding LPN A and stated, She is just nasty. She never gave me my pills, or they would be two hours late. That was common. She talks bad all the time. I don't even want to remember her. The first time I met her, I said, 'Oh, you are new here, what is your name?' Right away she said, I don't go like that, I am just here to give you your pills, and that is it.' I guess, she thought I was trying to tell her what to do. One time she wasn't even on the floor the whole night. She took off, she was hiding from me. I was starting to get angry and when she finally did appear, I would ask for my medication and she said, 'Your [MEDICATION(S)] is coming up, we will see how fast I move to give you it.' I would get mad; she would do that because we were arguing (about getting my medication). She is just nuts! She is crazy! She hated me! I kept telling her, 'You gotta go!' Resident #100 was asked if they ever reported LPN A's behavior and stated, I reported her. That is why I got in this room (off of the 500 and 600 Unit). I used to tell people, I told the head nurse, I told [Nurse Manager HH], I told [Social Worker/(SW GG)]. [SW GG] said the State didn't want to do anything about it. So, I just quit talking to her (LPN A). If you didn't speak to her, then you were fine depending on what mood she was in. I didn't trust her either. I used to taste my medicine to make sure she was giving the same things. I wanted to kill her, I was so mad at her! I wanted to beat the s#@t out of her! I have been in pain for over [AGE] years. It's (pain) in my back, knees, legs, it's every day! On a daily basis, my pain is a 7, 8 or 9 (out of a pain scale of 10: being the worst pain) at all times. It is constant pain, it hurts, I never sleep because of it. I am up all night. I moved up here (to this unit) weeks ago. She was really making me hostile; I already have high blood pressure and have had three stents put in. I do not need any more of this garbage! A record review of the progress notes for Resident #100 revealed the following: 6/3/2021 19:11 (07:11 PM) Nurses' Notes (authored by LPN A) resident became upset with nurse due to nurse bringing pain medication within the one hour grace period, resident assumped (sic) nurse didn't like them, nurse explained she had came in early to help and wasn't use to passing (their) meds at this time, however she indeed do apologize if this has cause any problems, resident remained agitated, and begame (sic) to verbal threaten nurse stating, 'i'll have your ass hung tomorrow if you keep this s#@t up.' nurse explained the hour before hour after, and anytime other would require permission from the prescribing MD (Medical Doctor), Resident went on calling nurse annoying b*tches. Nurse and witness exited room, notified administrator. Later while Nurse and aide went in to render care to roommate resident begun to yell aggressively, at nurse and aide making threats towards staff, stating how he could hang them, and how nurse better get my medication on time, or he would dig a hole for her. nurse and aide quietly rendered care to roommate left. A record review of the MDS assessment dated [DATE] revealed that Resident #100 had a BIMS score of 15 out of 15 and was most recently admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #100 was independent with most Activities of Daily Living (ADL) and did not have any behavioral issues. Resident #104 On 07/19/2021 at 06:49 AM, Resident #104 was observed dressed and groomed in the hallway. Resident #104 was visibly upset and stated, I never got my pills this morning. Resident #104 had clear speech and was alert and oriented to person, place and time. Resident #104 stated, This happens all the time! I am sick of it! A record review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Give 1 tablet by mouth three times a day related to [CONDITION(S)] .Start Date-05/18/2021. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the MDS assessment dated [DATE] revealed that Resident #104 was most recently admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #104 was independent with most ADL and had a BIMS of 12 out of 15, indicating a moderate cognition impairment. On 07/22/2021 at 10:12 AM, Resident #104 was interviewed regarding LPN A and not getting their medications. Resident #104 stated, She needs to be fired! I don't remember specific dates, but she tells me she is going to call the cops on me if I walk over to the other side (the 600 Unit). She either does not give me my pills, or she gives them to me late. She is always saying and yelling at me to get away from here. One time, I walked out to the hallway, and I asked for a snack, she got upset and she threw all the snacks in a room and locked them up so that I could not get one. I had to walk all the way to other side of the building to get a snack! I was so hungry! Resident #104 was asked if they had ever reported LPN A's behavior to anyone and stated, I reported her to [NHA] and [DON]. All of them! They say it is hard for one nurse to pass out medications for the whole floor! Well, they should have two nurses then! I want her terminated! I keep telling my Guardian that I want out of here! Resident #140 On 07/22/2021 at 10:30 AM, Resident #140 was observed up in their wheelchair in their room, and was alert and oriented to person, place, time and situation. Resident #140 was interviewed on how it was going with LPN A as their midnight nurse. Resident #140 stated, She is always slamming the door in my face because she doesn't want to give me my pills. My pain pills. I have to ask for them. I guess they figure if they shut the door, they won't have to deal with us. She is pretty mean. While conversing, Resident #140 would become short of breath from just talking and needed to pause in between sentences to catch their breath. Resident #140 stated, I remember when I was in isolation with C-diff (Clostridium Difficile, an infection of the intestines causing diarrhea), she (LPN A) didn't want to give me my medicine then, she wouldn't even come in my room because I was on isolation. She didn't want to do anything for us. Resident #140 stated, There was another incident when I couldn't breathe. I put on my call light, and no one came. I asked my roommate (Roommate JJ) to call for help. During this time, Roommate JJ began to speak. Roommate JJ stated, I put my button on. We were waiting one, then two, then three hours. No one came in to answer the light. Finally, a nurse aide came in and asked if they could help. I explained that my roommate (Resident #140) was having a hard time breathing and was asking me to call 911 (because no one would come in and help). The nurse aide went to go find the nurse but couldn't find her. We waited and waited. Then another nurse aide came in and asked if they could help me. I said, 'She needs the nurse! Or oxygen, or something, I don't know!' The nurse aide went to find a nurse for 5-10 minutes, but still could not find her. She came back to my room and explained that her sister was a nurse and that she would call her and ask what to do. She put her (nurse sister) on speaker phone and explained that my roommate was having a hard time breathing and was on oxygen. The nurse on the phone asked if someone told the nurse. The nurse aide explained that they could not find the nurse. Just then the original nurse aide (Roommate could not remember either of the nurse aide's names) came back in to check on (Resident #140) and explained that they were still looking for the nurse. The whole time I kept my light on and no one had shut it off. Finally, another nurse aide (a third one) came in the room and said (to Resident #140), 'You don't look right, there is something wrong.' I started freaking out and yelling for help because I don't want my roommate to die because they can't get no help. The nurse that was on the phone finally said, 'I think we should call 911.' I ended up calling 911, (Resident #140) couldn't breathe. Then, [LPN A] walked in my room and immediately began yelling at me asking me, 'Who do you think you are calling 911?' .I was so scared! I said, 'Miss, (Resident #140) can't breathe!' Suddenly, 911 walked in (they still came even though I hung up on them) and took (Resident #140) to the hospital. [LPN A] was waiting for 911 to leave and came back in my room and was yelling at me saying, 'Who do you think you are? These are my patients!' I explained again, that (Resident #140) could not breathe, and she was getting worse. [LPN A] stated, 'What is it your business? My patients are not your business!' I told her that we had three nurse aides looking at her and that she didn't see what I saw, (Resident #140) was getting bad and couldn't breathe!' She then left and slammed the door in my face! I mean I was crying and everything. Just then, Roommate JJ starting crying. We try to get help and all we get is attitude, if I yell for help, I get yelled at to quit yelling for help because I am waking the whole unit up. Resident #140 added, She (Roommate JJ) was just trying to help me! I was scared! I needed to go to the hospital! A record review of the MDS dated [DATE] revealed that Resident #140 was most recently admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #140 had a modified independent cognition status (needed help with decision making in new situations only), needed extensive assistance with ADL (Activity of Daily Living) and had no behavioral concerns. A record review of the care plan for Resident #140 revealed the following: Focus-The resident has the potential for shortness of breath (SOB) r/t (related to) dx (diagnosis) of [CONDITION(S)]. Date Initiated: 11/17/2018. Goal-The resident will have no complications related to SOB though the review date. Interventions .Monitor/document breathing patterns. Report to MD abnormalities: Nasal flaring, Respiratory depth changes, Altered chest excursion, Use of accessory muscles, Pursed-lip breathing or prolonged expiratory phase, Increased anteroposterior chest diameter. Date Initiated: 11/17/2018. A record review of the July 2021 MAR for Resident #140 revealed the following midnight medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] Acetaminophen-[MEDICATION(S)] Tablet 300-30 MG Give 1 tablet by mouth every 6 hours for Pain-Start Date-07/09/2021. 0600. [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth every 6 hours related to PAIN, UNSPECIFIED . -Start Date-07/09/2021 0600. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes for Resident #140 revealed the following: 06/23/3021 08:21 AM (authored by LPN A) resident called EMS (Emergency Medical Services) due to feeling like .could not breath, nurse assessed vitals VSS (vital signs stable) SPO2 (pulse ox) at 99% on oxygen, resident roommate called EMS due to resident request, guardian called. DON notified. MD notified. resident sent to [local hospital] for further evaluation. 06/28/2021 13:29 (01:29 PM) Social Services Progress Notes (authored by SW GG) .Resident visited SW office over concerns with night nurse. A concern form was filled out. Resident was so upset that .wanted to call .guardian. SW dialed the guardian and overheard the conversation of .wanting to go to another place. Guardian is aware (Resident #140) doesn't want to be here .wanted to talk to the administrator so SW transferred call. Other SW was a witness to this conversation. SW to continue to monitor. 06/29/2021 (authored MD KK) ADMISSION H&P (history and physical) .readmitted with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the hospital discharge summary dated 06/25/2021 revealed that Resident #140 had been admitted to the hospital for Acute [CONDITION(S)]. Resident #152 On 07/21/2021 at 02:58 PM, Resident #152 was observed dressed and groomed lying in bed. Resident #152 had clear speech and was alert and oriented to person, place, time and situation. Resident #152 was interviewed regarding their experience with LPN A. Resident #152 stated, I am speaking for all the people on the 500 and 600 units, I am going home Friday and will never have to deal with her (LPN A) again. I was over on her unit but, I got transferred over to this unit about two weeks ago. The very first night I was down there I could see she (LPN A) was in a bad mood because she had to work both floors (the 500 and 600 hall). I went over to her and asked about my medication, and she barked at me. I said, 'Listen, I understand you probably are mad because you are by yourself (working the 500 and 600 unit).' She didn't say anything, I left and went back to my room. I went out (on the unit) at 4:00 AM, I couldn't find her anywhere, so I sat out in the middle of the unit waiting for someone to show up. There is an office with the door closed and it was locked. There were no lights on, I could tell by the bottom of the door. The window on the door had a paper taped up on it so you could not see anything inside the room, you see, she puts a piece of paper on the door so no one can see her, that is how I knew when she was working that shift. I knocked on the door, I see the lights flick on underneath the door. The door opens up about this much (Resident #152 motioned with his hand about 6 inches). It was [CNA DD]. I could tell she was sleeping; she was rubbing her eyes. I said, 'Listen, could you tell [LPN A] I am in a lot of pain and need my pain pills?' She says, 'She's busy.' Then [LPN A] appears from the room and says, I am logging stuff and will give you your medication when I get around to it!' I went back to my room and waited about a half an hour, still no sign of her. I went back to the room, I knocked, she opened the door and said, 'Knocking on the door isn't going to get you pain medication any earlier.' Then she said, 'You don't get any anyway.' I said, 'I get a prn (as needed) medication.' I told her I can have it every 4 hours. We started arguing, I said, 'If you weren' t sleeping, maybe people would get their pills around here!' She yelled at me and stated, 'You know what? I am not giving you your medication now. You can get them from someone else. You can find someone else to give it to you! I will not be giving you anymore meds.' She ended up getting another nurse to give me my meds because she didn't want to. Later, even though I was not in the wrong, I felt bad, and I was going to apologize to her. I went up to her and right away she said, 'Don't talk to me ever again!' I told her I was going to talk to someone and report her. Another time, she was nowhere to be found. She was not in the office. She was in a room on the 600 unit all the way down at the end (Resident #159's room) with [CNA DD]. I can prove it to you. For two hours (04:00 AM-05:45 AM), she (LPN A) would pop up because she knows people (Staff) start calling in. They both (LPN A and CNA DD) came out of the hall from the room, sure enough, I said, 'I knew you were in there!' She said, 'Don't talk to me I am never giving you your medicine again!' Later on, the [DON] came in. I went and reported this (that she was sleeping, will not give medications, and yells at everyone) to [NHA] and [DON] that morning. As I was telling them what happened, [DON] said, '[Resident #152], [LPN A] said the patients are too difficult and she (LPN A) can't get her work done, so she goes into other rooms to do her work.' They just made an excuse for her. I couldn't believe it, [DON] made an excuse for her. Just then, [Resident #159] pulled up in their wheelchair to complain and asked [DON and NHA], 'Could you please ask [LPN A and CNA DD] to stay out of my room at night?' [DON] asked [Resident #159], 'What are they doing?' [Resident #159] stated, 'Talking on phone and watching TV.' I put up my arms and said, 'See?' I knew she was here last night because there was paper on the window covering it up again and no one around. I went out in the hallway, and I go out there and asked people if they got their meds, they said no. They had to wait an hour. Is anything going to be done about this? Resident #152 was interviewed regarding what types of medications they were not receiving from LPN A and explained that they were in a car accident and were taking pain medication. Resident #152 explained they had abscesses on their buttocks and tailbone. Resident #152 stated, It felt like these abscesses were literally squeezing my nerves, I couldn't use my legs even. It is mostly my tailbone and hips that hurt. It is a shooting pain that goes down into my left leg. Its very painful. The pain was a 9 (out of 1-10 pain scale). Resident #152 also explained that they were at the facility for short term rehabilitation and finishing up an intravenous infusion of antibiotic therapy for the abscesses. A record review of the MDS dated [DATE] revealed that Resident #152 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the care plan for Resident #152 revealed the following: Focus-The resident has/is at risk for chronic pain related to recent abscess and has had back pain from MVA (motor vehicle accident). Date Initiated: 06/30/2021. Goal-The resident will have adequate pain control as evidenced by such things as decreased behaviors, irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying . Interventions-Administer pain medications as ordered. Give 1/2 hour before treatments or care. Date Initiated: 06/30/2021 LPN . A record review of the progress notes for Resident #152 revealed the following: 07/14/2021 08:02 (AM) Nurses' Notes (authored by Nurse A) .around 4 am patient was banging on the nursing station door opened the door asked the patient if they needed something patient said 'I need my pain pills right now they are late ' asked patient what pain medicatio [TRUNCATED]

This citation pertains to intake MI 9912. Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure consistent assessment and measurement and failed to implement interventions to prevent worsening and development of pressure ulcers (wounds caused by pressure) for three (R75, R135, and R155) of eight dependent Residents reviewed for pressure ulcers resulting in lack of implementation of interventions, development of a pressure ulcer, and worsening pressure ulcers and decline in overall health status. Findings include: Resident #75 On 7/20/21 at 2:54 PM, R75's Family Member Q was interviewed via phone and said, My family member was sent to the hospital because (their) bed sore developed an infection . The hospital said that the bedsore was really bad and was infected and may be down to the bone .they had to due surgery to clean out the wound. A review of the electronic medical record noted R75 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R75 requires extensive assistance with activities of daily living. A review of the care plan noted the following: The resident is at risk for pressure ulcer r/t (related to) incontinence, decreased mobility, [CONDITION(S)] with dependence on [CONDITION(S)], . type 2 DM .Date Initiated: 02/25/2021 .Revision on: 04/30/2021 .Interventions: Float heels over pillows while in bed as tolerated or heel lift boots while in bed as Tolerated Date Initiated: 03/08/2021 .Revision on: 03/08/2021 . Monitor dressing for adherence. Report loose, soiled or missing dressing to treatment nurse. Date Initiated: 07/07/2021 .Monitor/document/report PRN (as needed) any changes in skin status: appearance, color .wound healing, s/sx (signs and symptoms) of infection, wound size (length x width x depth), stage. A review of the Nursing Admission Evaluation dated 2/24/21 (R75's admitted ) noted Sacrum the following: Sacrum open area (Type not specified, wound not measured) A review of the Skin assessment dated [DATE] noted the following: Are there any new abnormal skin areas? (answer) No .Are there any existing abnormal skin areas A review of the Skin & Wound Evaluation dated 3/16/21 noted the following: Wound Type: Type: Pressure Ulcer .Stage 3 (Full-thickness skin loss) .Location: Coccyx .measurements Area 0.2 CM (centimeters), Length 0.7 CM, Width 0.4 CM, Depth 0.2 CM .Slough ( dead tissue separating from living tissue especially) A review of the Skin & Wound Evaluation dated 3/30/21 noted the following: Wound Type: Type: Pressure Ulcer .Stage 3 (Full-thickness skin loss) .Location: Coccyx .No Measurements .No Evidence of Infection .No Exudate (fluid that leaks out of blood vessels into nearby tissues) . healed Treatment- prophylactic (medical) cream. A review of the Skin & Wound Evaluation dated 7/9/21 noted the following: Wound Type: Type: Pressure Ulcer .Stage 2 (skin breaks open, wears away, or forms an ulcer) .Location: Right Buttock .measurements Area 0.6 CM (centimeters), Length 1.0 CM, Width 0.8 CM, Depth 0.1 CM. A review of the Skin & Wound Evaluation dated 7/13/21 noted the following: Wound Type: Type: Pressure Ulcer .Stage: Unstageable (Obscured full-thickness skin and tissue loss) .Location: Sacrum .measurements Area 2.0 CM (centimeters), Length 1.4 CM, Width 2.0 CM, Depth 2.0 .Slough ( dead tissue separating from living tissue especially) . wound bed- 80% necrotic tissue peri wound- +induration .undermining 2 CM 6-12 O'clock Sacrum wound merged with R buttock. Now measured as one A review of the Skin & Wound Evaluation dated 7/13/21 noted the following: Wound Type: Type: Pressure Ulcer .Stage: Unstageable (Obscured full-thickness skin and tissue loss) .Location: Left Elbow .measurements Area 58.5 CM (centimeters), Length 7.9 CM, Width 9.7 CM, Depth 2.0, Undermining 2.0 CM A review of the Skin & Wound Evaluation dated 7/14/21 noted the following: Wound Type: Type: Pressure Ulcer .Stage 2 (skin breaks open, wears away, or forms an ulcer) .Location: Right Buttock .measurements Area 0.2 CM (centimeters), Length 0 CM, Width 0 CM, Depth 0 CM .Slough ( dead tissue separating from living tissue especially). Area merged with sacral wound. Surveyor did not receive wound care documents as requested (7/21/21 8:29 AM) for the month of April, May, or June 2021. Resident #135 On 7/19/21 at 6:13 AM, observed R135 in bed on their back. R135 received oxygen therapy via [CONDITION(S)] and received enteral feeding via peg-tub. R135's heels were flat on the bed and not floated. Resident was not able to respond to name called or answer questions. On 7/20/21 at 2:26 PM, R135 was observed on their back, with their head facing the right side. On 7/21/21 at 7:45 AM, R135 was observed on their back, with their head facing the right side. On 7/21/21 at 9:20 AM, R135 was observed on their back, with their head facing the right side. On 7/21/21 at 9:40 AM, R135 was observed on their back, with their head facing the right side. On 7/21/21 at 10:02 AM, Wound Care Nurse U was interviewed and observed the wound care performed on R135. Wound Care Nurse U stated, (R135 developed a stage 4 pressure ulcer inhouse .but it is looking better. An observation of the stage four, deep sacral wound with noticeable Serosanguineous drainage (a type of wound drainage). On 7/21/21 at 10:40 AM, R135 was positioned with the head of the bed at about 30-45 degrees. R135's head was turned to the left side with their head tilted downward. On 7/21/21 at 12:15 PM, R135 was positioned with the head of the bed at about 30-45 degrees. R135's head was turned to the left side with their head tilted downward. On 7/21/21 at 1:22 PM, R135 was positioned with the head of the bed at about 30-45 degrees. R135's head was turned to the left side with their head tilted downward. A review of the electronic medical record noted R135 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R135 required total assistance with Activities of Daily Living (ADL). A review of the transferring hospital's documents dated 12/28/20 noted that the skin integrity was intact (skin that is not broken or cracked). A review of R135's progress note dated 12/29/20 at 18:52 (6:62 PM), created by Nurse AA, noted the following: Resident admitted from (transferring hospital) to the facility at 14:20 (2:40 PM) via ambulance. Resident remains comatose and unable to comprehend words. Vital signs within normal range. [CONDITION(S)], PICC line (Peripherally Inserted Central Catheter (PICC), is a thin tube that's inserted through a vein in the arm and passed through to the larger veins near the (heart) and peg tube (Percutaneous Endoscopic Gastrostomy used to receive nutrition directly through the stomach) intact. No skin issues noted. A review of R135's progress note dated 12/31/20 at 12:12 (12:12 PM), created by Physician BB, noted the following: Skin: warm and dry, no skin breakdown noted. A review of R135's progress note dated 1/07/21 at 12:09 (12:09 PM), created by Dietitian Y, noted the following: No abnormal skin areas noted at this time. A review of R135's progress note dated 1/07/21 at 14:10 (2:10 PM), created by Physician BB, noted the following: Skin: warm and dry, no skin breakdown noted. A review of R135's progress note dated 1/15/21 at 10:06 (10:06 AM), created by nurse practitioner DD, noted the following: Skin: warm and dry, no skin breakdown noted. A review of R135's care plan noted the following interventions: Avoid positioning the resident on (sacrum) (is a large, flat triangular shaped bone nested between the hip bones and positioned below the last lumbar vertebra (L5) Date Initiated: 12/29/2020, Revision on: 02/16/2021 A review of R135's progress note dated 1/21/21 at 12:02 (12:03 PM), created by Physician BB, noted the following: Skin: warm and dry, no skin breakdown noted. A review of R135's Skin & Wound Evaluation note, Effective Date: 04/27/2021 10:23 AM Noted the following: 24. How long has the wound been present? (Wound age when first assessed, after that it is auto calculated: 1/23/21 . Stage 4: Full-thickness skin and tissue loss .Wound Measurements: Area 26.5 CM by Length 6.6 CM by Width 5.4 CM, Depth 3.0 CM, Undermining 4.0. A review of R135's Skin & Wound Evaluation note, Effective Date: 05/04/21 11:58 AM Noted the following: 24. How long has the wound been present? (Wound age when first assessed, after that it is auto calculated: 1/23/21 . Sacrum .In-House Acquired . Stage 4: Full-thickness skin and tissue loss .Wound Measurements: Area 25.7 CM by Length 5.0 CM by Width 6.3 CM, Depth 3.0 CM, Undermining 4.0. A review of R135's Skin & Wound Evaluation note, Effective Date: 05/11/21 at 10:36 AM Noted the following: 4. Stage 4: Full-thickness skin and tissue loss .24. How long has the wound been present? (Wound age when first assessed, after that it is auto calculated: 1/23/21 . Sacrum .In-House Acquired . Stage 4: Full-thickness skin and tissue loss .Wound Measurements: Area 29.6 CM by Length 6.7 CM by Width 6.9 CM, Depth 4.0 CM, Undermining 2.0. A review of R135's Skin & Wound Evaluation note, Effective Date: 2/09/21 noted the following: Wound Type: Type: Pressure Ulcer .Stage: Unstageable (Obscured full-thickness skin and tissue loss) . Location: Sacrum .measurements Area 56.2 CM (centimeters), Length 6.3 CM, Width 12.4 CM. A review of R135's Skin assessment dated [DATE] at 2:00 PM noted the following: 5. Are there any existing abnormal skin areas? Answer: b. NO. A review of R135's progress note dated 2/15/21 at 15:26 (3:26 PM), created by Nurse U, noted the following: Wound/skin: (Family member notified regarding wound). A review of R135's progress note dated 2/23/21 at 13:40 (1:40 PM), created by Nurse Practitioner V, noted the following: Today is an initial consult requested by medical physician for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . measures 4.9 cm in length by 5.6 cm in width with a depth of UTD (unable to determine). Currently this wound base is 70% granular tissue 30% necrosis in the center of the wound with moderate serosanguineous drainage. Resident #155 A review of R155's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and readmitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident is severely cognitively impaired and requires total assistance from staff for bed mobility, transfers, dressing, eating, toileting, and hygiene. A review of R155's care plan revealed: Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Positioning wedge, Date Initiated: 05/07/2021. Turn and reposition q2hrs (every 2 hours) and prn (as needed), Date Initiated: 04/21/2021. Provide incontinence care Q2hrs and PRN. Date Initiated: 04/22/2021, Revision on: 04/22/2021. Skin inspections by CNA (Certified Nursing Assistant) during cares and showers/baths. Report changes to licensed nurse immediately. Date Initiated: 04/21/2021. The resident has/is at risk for pain r/t (related to) immobility, seizures and pressure ulcer, Date Initiated: 04/14/2021, Revision on: 07/20/2021. Administer pain medications as ordered. Give 1/2 hour before treatments or care. Date Initiated: 04/14/2021, Revision on: 04/22/2021. On 7/19/21 at 6:41 AM, during the initial tour, R155 was observed lying in bed, flat on their back. No turning wedge was present. R155 was observed with a [CONDITION(S)] and was receiving nutrition via tube feeding. An attempt at an interview revealed that R155 was unable to verbally respond to inquiry. On 7/19/21 at 9:36 AM, R155 was observed to still be lying flat in bed as Respiratory Therapist (RT) S provided [CONDITION(S)] care. On 7/19/21 at 9:40 AM, CNA W and Waiver Care Aide (WCA) X began to provide morning care to the resident. R155's brief was noted to be soiled with both urine and stool. CNA W indicated this was the first time on day shift they had changed R155 and when asked if midnight shift had changed the resident before they left, CNA W stated, Don't look like it .[they are supposed to] at about 6:30 - 7:00 AM. CNA W began wiping the stool from R155's buttocks and stated, Yeah they [didn't] clean [R155] .looks like new (wet) and old (dried) stool. Dried stool was observed to be stuck to R155's skin and required CNA W to wipe multiple times before coming off. The wound dressing on R155's sacral area was observed to be soiled and was removed by CNA W. A wound approximately the size of a small fist was revealed on R155's sacral area. Granulation tissue was noted near the left edge of the wound with more than half of the wound appearing to have dark necrotic tissue present. On 7/19/21 at 11:23 AM, R155 was observed lying in bed with a pillow under their left side. No turning wedge was present. The pillow did not appear to provide significant pressure offloading from R155's back. On 7/19/21 at 1:49 PM, R155 was observed lying in bed, now with a turning wedge present under their left side. On 7/20/21 at 8:45 AM, R155 was observed lying in bed with a pillow under their left side. No turning wedge was present. On 7/20/21 at 9:09 AM, Wound Care Nurse Practitioner (WCNP) V was present in the facility conducting wound rounds and was interviewed regarding R155's wound. WCNP V indicated that she had seen R155's sacral wound last week. WCNP V stated, We healed [R155's] wound in May and it re-opened .Stage 3 (full-thickness skin loss where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) was what I healed in May. Wound Care Licensed Practical Nurse (LPN) T reviewed his notes and stated, On 5/18 (2021) I stopped seeing [R155], from a quick glimpse. Upon inquiry about R155's current wound, WCNP V stated, Unstageable currently, was a three (Stage 3 pressure ulcer) and declined. LPN T indicated that he and the other wound care nurse (Wound Care Registered Nurse (RN) U) frequently get pulled off of daily wound care duties to work the floor as staff nurses and added that RN U was pulled off of wound care rounding today to work on the floor. When queried regarding who is responsible for monitoring residents for new skin impairments, LPN T stated, It's up to the floor nurses to let us (wound care) know of a new area or if an area re-opened. LPN T was then asked about R155's previous wound care assessment. LPN T pulled up a July 13th, 2021 wound assessment that noted R155's wound as Deteriorating. LPN T pointed out that when he went to assess R155's wound on 7/13, there was no dressing present, and therefore he documented such in the record. WCNP V confirmed that R155's wound had re-opened in the facility and that when she had assessed it last week (7/13), the wound having 90% necrotic tissue present was Concerning. A review of the Wound Evaluations for R155 did confirm that R155's previous wound, a pressure ulcer of the right buttock, was marked as Resolved on 5/18/21. No wound assessments were present after 5/18/21 until 7/1/21. The Wound Evaluations were reviewed and revealed: 7/1/21 - #2 - Pressure - Stage 3, Body Location: Sacrum, Deteriorating - 2 months old, Acquired: In-House Acquired, PUSH Score: 15. Area: 45.27 cm² (centimeters squared) + % (increase in size), Length 6.35 cm (centimeters) +707 %, Width 10.3 cm +1525 %, Deepest Point 0.2 cm +100 %; Granulation: Yes, % Granulation: 80%, Slough: Yes; % Slough: 20% (wound bed- 20% necrotic); Progress: Deteriorating . No corresponding wound care progress note on this date was found in the record. 7/7/21 - #2 - Pressure - Stage 3, Body Location: Sacrum, Stable - 2 months old, Acquired: In-House Acquired, PUSH Score: 14. Area 28.95 cm² -36 % (decrease in size), Length 4.36 cm -31 %, Width 8.16 cm -21 %, Deepest Point 0.3 cm +50 %; Granulation: Yes, % Granulation: 70%; Dressing appearance: Missing; Progress: Stable . No corresponding wound care progress note on this date was found in the record. 7/13/21 - #2 - Pressure - Stage 4, Body Location: Sacrum, Deteriorating - 2 months old, Acquired: In-House Acquired, PUSH Score: 13. Area: 38.78 cm² (centimeters squared) +34 % (increase in size), Length: 5.98 cm (centimeters) +37 %, Width: 8.56 cm +5 %; Granulation: Yes; % Granulation: 10%; Dressing appearance: Missing; Additional Care: Heel Suspension/Protection device, Incontinence management, Mattress with Pump, Nutrition/Dietary supplementation, Turning/repositioning program; Progress: Deteriorating; wound bed- 90% necrotic . The corresponding progress note from 7/13/21 written by WCNP V included, Plan: Patient has a moderately concerning reopened pressure ulcer that is large in size and extends from the sacrum to the right buttock area. Patient should be turned and repositioned per offloading protocol and maintain low-air-loss mattress. Maintain good hygiene and incontinence care . A review of R155's remaining Wound Evaluations did confirm that R155's previous wound, a pressure ulcer of the right buttock, was marked as Resolved on 5/18/21. No wound assessments were present after 5/18/21 until 7/1/21. On 7/20/21 at 9:39 AM, a wound care observation for R155 was made with LPN T and WCNP V. R155's turning wedge was present under their right side, however, the resident appeared to be lying mostly on their back with pressure not significantly offloaded. R155's incontinence brief was removed and was observed with dried stool and wound drainage present. No wound dressing was present on R155's wound. WCNP V indicated the wound was, At least 85% necrotic, and the depth of the wound was unable to be determined. WCNP V added, There's a PRN (as needed) order for a dressing so a new one should be put on when [the old one] is taken off. WCNP V continued and stated, I asked the nurse, [R155] has nothing ordered for pain, which is a problem because [R155] can't talk. When someone can't talk we need to watch the clinical symptoms for pain, like grimacing .the nurse is going to call the doctor. WCNP V then completed her full assessment of R155's wound and stated, The necrotic tissue is starting to separate. Still unstageable, going more onto the right buttock. Coccyx Stage 3 that re-opened that's unstageable and spread. Approximately 85% necrotic, 15% granulation tissue with moderate drainage, no induration, no odor .measurement of 5 (cm) by 9.2 (cm), about 0.6 (cm) longer (than last week). Upon the completion of wound care, R155's positioning wedge was noted to be placed under their left side. LPN T was queried regarding interventions for pressure ulcer management for R155 and stated, CNAs are supposed to reposition, make sure the residents are clean and dry. [They] should have put a new [wound] dressing on. LPN T was then asked to look at the weekly skin assessments for R155 in the medical record. LPN T reviewed the following under the assessments tab: 6/24/2021 Skin Assessment - V 4 Complete 6/9/2021 Skin Assessment - V 4 Complete 5/4/2021 Skin Assessment - V 4 Complete 4/22/2021 Skin Assessment - V 4 Complete 4/21/2021 Skin Assessment - V 4 Complete 4/13/2021 Skin Assessment - V 4 Complete When queried regarding the lack of weekly assessments present, LPN T stated, Nurses are supposed to do weekly skin assessments. R155's skin assessments dated 6/9/21 and 6/24/21 were reviewed at this time. The 6/9/21 skin assessment noted no new nor existing abnormal skin areas, and the 6/24/21 assessment noted no new abnormal skin areas and existing abnormal skin areas only as, [CONDITION(S)] and PEG (feeding tube) present. When queried regarding these skin assessments compared to R155's large wound assessed on 7/1/21, LPN T stated, Sometimes wounds pop-up out of nowhere when I'm looking at the records .All I can say is I was told there was a wound, so I came to assess it and took a picture and started treatment. On 7/20/21 at 12:23 PM, R155 was observed lying in bed turned toward their right side, with the turning wedge positioned under their left side. On 7/20/21 at 3:31 PM, R155 was observed lying in bed turned toward their right side, with the turning wedge positioned under their left side. On 7/20/21 at 4:08 PM, R155 was observed lying in bed turned toward their right side, with the turning wedge positioned under their left side. On 7/20/21 at 4:30 PM, R155 was observed lying in bed turned toward their right side, with the turning wedge positioned under their left side. On 7/21/21 at 11:23 AM, R155 was observed in bed with their turning wedge under their right side. The resident appeared to be lying moreso on their back than toward the left side. On 7/21/21 at 1:40 PM, R155 was observed in bed with their turning wedge under their right side, in the same position as observed at 11:23 AM. On 7/21/21 at 2:56 PM, R155 was observed in bed with their turning wedge under their right side, in the same position as observed at 11:23 AM. On 7/21/21 at 3:25 PM, R155 was observed in bed with their turning wedge under their right side, in the same position as observed at 11:23 AM. On 7/21/21 at 4:17 PM, R155 was observed in bed with their turning wedge under their right side, in the same position as observed at 11:23 AM. On 7/22/21 at 9:30 AM, Wound Care RN U was interviewed regarding R155's wound. It was noted in the record that RN U completed R155's Wound Evaluation on 7/1/21. RN U indicated she had been pulled to work the floor on 7/1/21 and when asked how she became aware of R155's wound, RN U responded that she believed the assigned aide brought the issue to her attention. RN U was asked how large the wound was assessed to be on 7/1/21 and stated, 6.3 (cm) by 10.3 by 0.2, sacral wound staged as a 3 at that time, 80% granulation and 20% slough. When queried regarding the facility's policy/procedure for monitoring residents' skin, RN U stated, Floor nursing should be doing a full body skin assessment weekly, the weekly wound round information is in addition to those .[they] assess skin under the 'assessments' tab. RN U explained that when wound care does their rounds, they focus on existing wounds that they are currently treating and aware of, and added, We rely on floor staff to notify us of any new skin issues. RN U was then asked when R155 was seen by the WCNP after the wound was noted to be re-opened on 7/1/21 and responded, The NP was off the following week and then saw R155 the next week (7/13/21). When queried regarding pressure ulcer management interventions for R155, RN U: stated, [R155] should be being turned and repositioned every two hours, and indicated it was up to the floor staff to carry out that intervention. Upon inquiry about care planning for wounds and skin management, LPN T indicated that they (wound care) are responsible for initiating and updating care planning for wounds and interventions. On 7/22/21 at 4:08 PM, the Director of Nursing (DON) was interviewed and queried regarding the facility's policy/procedure related to turning/repositioning dependent residents. The DON stated, Every two hours. When asked who is responsible for wound treatments and weekly skin assessments, The DON replied, Nurses are if wound care has not come through. Skin assessments are supposed to be done weekly by floor staff. I already know those are . (did not finish sentence). When queried regarding the re-opening of R155's pressure ulcer, the DON stated she was not familiar with the re-opening of R155's wound. A review of the facility's policy/procedure titled, Pressure Injury Prevention and Management, Date Implemented: 1/1/2021, revealed, .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .b. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .d. Nursing assistants will inspect skin during bath and will report any concerns to the resident ' s nurse immediately after the task .After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 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.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Maintain or improve nutrition and hydration status, where feasible .f. Interventions will be documented in the care plan and communicated to all relevant staff .

Based on observation, interview and record review, the facility failed to ensure that foot care and podiatry services were provided for two sampled residents (R20 and R126) of two residents reviewed for foot care resulting in, bleeding, long/thick toenails, pain, discomfort, difficulty wearing shoes, and unmet care needs. Findings include: Resident #126 On 07/19/21 at 11:42 AM, R126 was asked about the care they have been receiving in the facility and stated, My toenails are growing in the opposite way. R126 explained that their toenails had not been cut in over a year because the in-house podiatrist cut their toenail too far causing pain, and they refuse to allow them to touch them again. R126 explained that they do want their toenails cut by a different podiatrist because they are too long, cause pain and discomfort, and they are unable to wear their shoes for long periods of time. R126 also explained that because of the podiatrist cutting their toenail too far, they laid in bed for a few days because it hurt so bad. On 7/19/21 at 11:52 AM, the surveyor requested to observe R126's feet from the Director of Nursing (DON), who obtained R126's assigned nurse. Both of R126's feet and toenails were observed as extremely long, thick, and yellow. The toenail on R126's left foot was observed to be growing upward in the opposite direction. On 7/19/21 at 11:58 AM, the DON explained that R126 had been refusing podiatry services and explained that she would have the facility social worker provide the dates that the resident had refused podiatry services. A review of R126's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12/15 indicating an intact cognition. R126 also required extensive assistance for bed mobility, transfers, personal hygiene, and dressing. On 7/19/21 at 12:15 PM, Social Worker GG provided a list of dates that R126 declined podiatry services, and were listed as follows: 7/30/20, 10/1/20, 10/22/20, 12/10/20, 2/11/21, and 4/15/21. Social Worker GG was asked if they were aware that the last time R126 received podiatry services, they were cut too far causing pain, and they stated No, I didn't know that. On 7/20/21 at 11:37 AM, R126 was asked if they had told anyone why they were refusing podiatry services, and explained that they had told, Everyone. R126 explained that they told the social worker, the DON, and their assigned nurses why they did not want to see the podiatrist that comes into the facility, and wanted a new podiatrist to either come to the facility, or they wanted to locate their own in the community. A review of R126's medical records revealed the following progress notes: 3/3/2020 09:00 (9:00am) Nurses' Notes Note Text: Resident reported to writer that [their] left great toe was hurting [them] from when the podiatrist had seen [them] and clipped [their] toenails. Resident also stated [they] wanted to see the wound care nurse for further evaluation. Writer looked at residents Left great toe and notice some bruising to the tip of left great toe as well as black area to [their] left great toe and 2nd toe. Wound care notified. 3/3/2020 15:37 (3:37pm). Progress Note-General Note Text: Wound Care: This writer was requested to see resident re (regarding): Left Toe discomfort. Resident reported [they were] seen by podiatrist recently. Left great toe with [CONDITION(S)] and some inflammation, bruising observed over the tip of the great toe in the center of the inflamed and red area .[R126] reported discomfort on Left Great & 2nd toe. Attempted to see [them] earlier but [R126] was in too much discomfort even to lift [their] leg. This writer returned an hour later to do the assessment . 3/4/2020 22:26 (10:26am) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Date of service 3/4/2020. Patient was seen and examined awake alert .Assessment and plan 1. Left toe pain seen by podiatry and wound care service continue close monitor patient will need arterial Doppler bilateral extremity and podiatry consultation . 3/5/2020 13:48 (1:48pm) Nurses' Notes Note Text: Daughter alerted this nurse of complaints of pain on the left big great toe pain. Writer assess bilateral great toes. Noted left great toenail clipped midway, swelling noted, with redness at the front tip of left great toe. Complaint of pain during assessment. Resident attempted to strike nurse with a closed fist. Daughter present and was able to stop resident. Tylenol offered and accepted by resident. Resident received [MEDICATION(S)] (pain medication) at 1330 (1:30pm). Will continue to observe. 3/5/2020 16:26 (4:26pm) Nurses' Notes Note Text: This writer was informed of the ADON (Assistant Director of Nursing) re (regarding): discomfort and swelling. [Physician] called re; Left great toe inflammation. Orders received. For stat xray of Left foot . 3/6/2020 18:09 (6:09pm) Nurses' Notes Note Text: On [MEDICATION(S)] (antibiotic used to treat infections) for left toe inflammation. No adverse reactions noted. Pain meds given as ordered. will cont. (continue) to monitor. 3/6/2020 22:49 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Chief complaint right big toe pain. Patient was seen examined awake alert complaint for right big toe pain no fall no injury [they were] seen by infectious disease was started on p.o. (by mouth) antibiotic . Assessment and plan. 1. Left big toe pain rule out infection/PVD (peripheral vascular disease) patient was started on oral [MEDICATION(S)] and [MEDICATION(S)] for pain plan for arterial Doppler lower extremity follow-up with podiatry . 3/7/2020 17:38 (5:38pm) Nurses' Notes Note Text: resident is receiving [MEDICATION(S)] for left toe. no adverse reaction noticed. fluids encouraged. 3/9/2020 03:01 (3:01am) Nurses' Notes Note Text: Continues [MEDICATION(S)] oral ABT (antibiotic) for L (left) toe inflammation as ordered, no adverse reaction noted, will continue to monitor. 3/9/2020 20:23 (8:23pm) Nurses' Notes Note Text: On [MEDICATION(S)] for left toe inflammation. No adverse reactions noted. Pain meds given as ordered. will cont. to monitor. 8/12/2020 09:41 (9:41am) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Date of service 8/12/2020. Patient was seen and examined agitated restless complaining of left foot pain [they were] recently seen by podiatry . [they have] been complain of left foot pain no back pain no chest pain .Extremity no [CONDITION(S)] peripheral pulse positive severe discomfort (of) left big toe Assessment and plan. 1. Right foot pain .12 .Urgent podiatry consultation management continue current management . 8/29/2020 22:56 (10:56am) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . [Resident's Identifying Information] has been complain bilateral feet pain she was seen by podiatry service . Assessment and plan. 1. Bilateral feet pain seen by podiatry service rule out underlying peripheral vascular disease .6. medical record reviewed lab reviewed discussed with the nurse practitioner discussed with the staff and patient consult podiatry service . 9/23/2020 22:05 (10:05am) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Date of service September 23, 2020. Patient was seen and examined [they] complained of bilateral toes pain [they were] recently seen by podiatry no fall no injury no chest pain shortness of breath . 8. Patient need to seen by podiatry service pain control continue current medication monitor lab . 10/1/2020 09:29 (9:29am) Nurses' Notes Note Text: Resident refused Podiatrist care in spite of explaining the need of it. 1/9/2021 20:28 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient was seen examined comfortable not in distress denies any chest pain shortness of breath abdominal pain .8. Patient need to seen by podiatry service pain control continue current medication monitor lab . 4/19/2021 22:29 (10:29am) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Date of service 4/16/2021 .Patient was seen examined awake alert no distress complain of left big toe pain no fall or injury .Assessment and plan.1. Left foot left big toe pain patient need to follow-up with podiatry service .7. Medical record reviewed lab reviewed discussed with patient discussed with staff for podiatry consultation pain control . 7/21/2021 14:23 (2:23pm) Social Services Progress Notes Note Text: Podiatry- Resident was not fond of in-house podiatrist and [they] requested to see an outside specialist. SW (social worker) made appointment with the podiatrist of [R126's] liking . 7/22/2021 14:33 (2:33pm) Social Services Progress Notes Note Text: Resident decided to see Podiatrist here today. SW sat with [them] through the appointment. Other appt (appointment) was cancelled, daughter/guardian aware. CNAs (Certified Nursing Assistants) are soaking [their] feet and [they are] happy. SW to continue to monitor. On 7/22/21at 9:33 AM, Social Worker GG approached the surveyor and explained that R126 allowed podiatry to cut their toenails today. Social Worker GG explained that they sat with the resident the entire time to provide support and comfort. Social Worker GG was asked again if they had ever asked the resident why they were refusing podiatry services, and again explained that they had not, and did not provide any further explanation. On 7/22/21 at 2:52 PM, R126 was observed sitting in their wheelchair in their room. They were asked how they were feeling after having their toenails cut today and stated, My feet feel so good. Resident #20 On 07/19/2021 at 07:53 AM, Resident #20 was observed lying in bed with their eyes closed. Resident #20 had bilateral hand contractures and had been receiving their nutrition through enteral tube feeding (a tube placed in the stomach). Resident #20 had a specialty air bed (a bed utilized to assist with offloading pressure to the skin). At the foot of the bed, the top sheet was filled with dried crusty, dark brown and red drainage on where the Resident's feet were. There were approximately eight dried spots, ranging from the size of a nickel, to the size of a golf ball on the sheet. Upon lifting the sheet over the feet only, Resident #20 opened their eyes. The Resident was nonverbal, but did make eye contact. The Resident's feet were resting directly on the bed. There was no foot cradle or protective boots on the resident's feet. The left great toe nail was thick and black, and appeared soft. The left foot was turned inwards. The left second and third toenails were barely attached to the Resident's foot. Underneath the lifted toenails was soft, yellow and red fleshy tissue. The right foot great toe nail was almost off, exposing soft, yellow tissue. The right third and forth toes were also with no nails, and soft, with yellow and red drainage noted on the nail bed. On 07/19/2021 at 12:00 PM, Guardian TT was interviewed via phone, in regard to the skin care Resident #20 was receiving at the facility. Per Guardian TT, the Resident was receiving wound care at some point, and stated, But, that was a while ago. I am not aware of any different skin care treatments. We are just now starting to see the residents in the community, the ones not in facilities are priorities, then we will be heading into the facilities. A record review of the Treatment Administration Record and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #20 was most recently admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20 had a severely impaired cognition and was dependent or required extensive assistance with activities of daily living. On 07/20/2021 at 08:19 AM, Resident #20 was observed scooted down in bed, with their feet resting right against the foot board. There was dry skin observed scattered all over the foot board just underneath Resident #20's feet. Resident #20 had clean sheets on this time. The feet were inspected, and observed to be floated on pillows. The toes were in the same shape as the previous date, with no bandages or treatments in place. On 07/20/2021 at 02:33 PM, Resident #20 was lying awake, on their back, with their feet resting on a pillow. There was fresh blood with yellow drainage noted on the sheets and on the right third and forth toes, and the left second and third toe. On 07/21/2021 at 05:50 AM. Licensed Practical Nurse (LPN) A was interviewed in regard to the condition of Resident #20's feet. LPN A stated, I don't know, I wasn't aware of anything. I do know that the podiatrist was in there one morning. 07/21/2021 at 06:29 AM, Resident #20 was observed in bed lying with their eyes closed. The same sheets were on the bed as yesterday. Resident #20's heels were resting on a pillow. This time there was a flesh colored Band-Aid on the left middle toe. Resident #20's feet were pressed up against the foot board. There was yellow and brownish-red drainage noted on the pillow under the Resident's foot. A record review of the most recent skin assessment dated [DATE] revealed no concerns with Resident #20's feet. On 07/21/2021 at 09:32 AM, an observation of Resident #20's feet was made with Wound Care Nurse U. Resident #20 was lying in bed with no pillow under their head. The Resident's feet were resting on a pillow. The Wound Care Nurse U was asked to look at the Resident's feet and explained that the Podiatrist was in and had seen the Resident. Wound Care Nurse U was asked if there were any treatments or follow through with the Resident's feet and stated, The Podiatrist spoke to me about the toes and said to continue the treatment. The Wound Care Nurse U was asked what the treatment was and stated, He told me triple antibiotic ointment (TAO). The Wound Care Nurse U was asked if she was aware there was no treatment ordered and confirmed she was not aware. A record review of the podiatrist note dated 07/01/2021 for Resident #20 revealed the following: Diagnoses/Procedure-Toenails mycotic (fungal infection), thicken, discolored, dystrophic (fungal infection), painful, relieved with debridement (removal with scalpel) .Nails Right-Abnormal 1-5 (toes/toenails) are thickened, crumbly .musty odor, painful with debridement. Evidence of ingrown bilateral big toe, medial and lateral borders .mild [CONDITION(S)] (redness) .Nails Left-Nails Right-Abnormal 1-5 (toes/toenails) are thickened, crumbly, noted subungal debris (a collection of blood underneath the nail) .musty odor, painful with debridement. Evidence of ingrown nail left 1st, 2nd, 3rd toes .mild [CONDITION(S)] .Pedal Pulse Right: Abnormal +1/4. Dorasalis Pedis, +0/4 Posterior Tibial .Pedal Pulse Left: Abnormal. Same as Right .Debridement details: All nails were reduced. Painful mycotic nails were debrided .I&D (incision and drainage) (L) (Left) 1-3 and (R) (Right) 3 toe abscesses, <1 cc (cubic centimeter) exudate each, after partial removal of offending toenails using #15 blade and pressure. TAO/dressing applied on each toe . A record review of the care plan for Resident #20 revealed no specific care plan pertaining to their toes/feet. 07/22/2021 at 02:01 PM, Resident #20 was lying in bed resting, this time with soft boots on. The Resident had both the right and left toes wrapped with a flesh colored band aid. On 07/22/2021 at 04:39 PM, an interview was completed with the Director of Nursing (DON). The DON was asked what the current foot care was for Resident #20 and what was the facility doing for the Resident to treat their toes. The DON provided no explanation by the end of the survey process.

Based on observation, interview, and record review, the facility 1) failed to provide adequate feeding assistance/guidance during meals and adequately monitor food intake, for one sampled resident (R10) with a vision impairment and known weight loss, and 2) failed to ensure fresh water was within reach and/or offered to a dependent residents for one sampled resident (R55) of six reviewed for nutrition and hydration, resulting in actual and potential further weight loss and the likelihood of dehydration. Findings include: A review of R10's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS revealed that the resident's Vision - Ability to see in adequate light (with glasses or other visual appliances) was coded as, 4. Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects. R10 was assessed on the 4/24/21 MDS to require limited physical assistance of one person for eating (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance). A review of R10's care plan revealed: EATING: The resident requires assist of 1 with meals, Date Initiated: 08/28/2020, Revision on: 04/09/2021. Encourage fluids. Date Initiated: 07/18/2018. Monitor FAR (food acceptance record) and fluid intake and offer alternative choices for refused food and fluids PRN (as needed). Resident is blind .Date Initiated: 10/25/2016, Revision on: 07/18/2019. Monitor weights as indicated for significant changes. Date Initiated: 10/25/2016, Revision on: 10/25/2016. Prefers to eat meals in room and able to feed self despite having [CONDITION(S)] and being legally blind. Please provide tray set-up and assist resident prn (as needed). Date Initiated: 01/25/2017, Revision on: 11/07/2019. On 7/19/21 at 7:52 AM, R10 was observed resting in bed. The resident's breakfast tray was observed on their bedside table with all items still covered and the tray not set up. On 7/19/21 at 7:55 AM, during the initial tour interview, Resident #66 (R66), the roommate of R10, indicated that R10 had been awake for 48 hours and was now sleeping. R66 stated that R10 Has lost a lot of weight .[and] staff do not feed [R10] at all .[R10] has Dementia. R66 explained that they see the dietitian come in about twice a week to check on R10, and that they let the dietitian know (about staff). R66 explained that they felt the facility was lacking staff and stated, Aides who are here don't do what they are supposed to like they just did with [R10]. [In the] day time it's not too bad but problems are afternoon and midnight shifts. On 7/19/21 at 8:00 AM, R10 was observed stirring in bed. R10's breakfast tray remained on the bedside table. R10's face appeared thin. On 7/19/21 at 8:21 AM, no attempts by staff to get R10 to eat breakfast were observed before R10's breakfast tray was removed from their room. On 7/19/21 at 12:31 PM, an unidentified staff member was observed passing lunch trays. The staff member was observed to set the tray on R10's bedside table and exit the room. On 7/19/21 at 12:40 PM, no additional staff were observed to enter R10's room and the lunch tray remained on the bedside table. On 7/19/21 at 12:49 PM, no additional staff were observed to enter R10's room and the lunch tray remained on the bedside table. On 7/19/21 at 1:39 PM, Certified Nursing Assistant (CNA) E and Waiver Care Aide (WCA) CC were preparing to perform incontinence care for R10. CNA E stated she had last changed R10 when she got on shift (approximately 7 AM). CNA E indicated that R10 did not eat anything for lunch. Upon checking R10's incontinence brief, the resident appeared gaunt, and their brief was noted to be dry. On 7/20/21 at 8:56 AM, R10's breakfast tray was noted to be sitting atop the metal meal cart in the hallway. The tray appeared to have less than 25% of the food and drink missing. Upon entering R10's room at this time, R10 was observed sitting up in bed with their bedside table in front of them. A bowl of oatmeal, a milk, and water were observed on the table. R66 approached and indicated that R10 had drank their tea, but that staff had not helped the resident this morning. R66 stated, [They] just set [R10's] stuff down and left. The aide came in and took the tray and left the oatmeal, took all the food. R10 was not attempting to eat/drink the food on their table. R10 was interviewed at this time and asked if they were going to eat their breakfast this morning to which R10 responded, Oh, I hope to, I'm hungry today. R10 was asked if they knew there was a bowl of oatmeal in front of them and responded, No I did not. I can hear, but I can't see nothin'. R10's arms were covered with their blanket. R10 stated, I feel good today. R10 was asked if they knew there were two drinks in front of them to which the resident responded, No, I didn't, no. No one told me. I can't see. R66 stated, At 5:19 PM last night, the staff set [R10's] dinner tray on the bedside table and just left it. They did not attempt to help the resident eat. R66 could not recall the aide's name who brought the dinner tray in but explained, He came and took [R10's] tray and gave [R10] half [their] grilled cheese sandwich .[W]hen [R10 is] thirsty and wants water I have to go get it for [them]. On 7/20/21 at 9:04 AM, R10 remained in bed, and their drinks and oatmeal remained untouched. On 7/20/21 at 12:26 PM, R10 was observed sitting in bed. R10's head of the bed was up but the resident was slouched down and leaning over to the right side. R10's lunch try was sitting in front of them on their bedside table, however no staff were present in the room and the resident was not attempting to eat. R66 stated, Staff came in and set the tray up and left. R10's water was not within the resident's reach. R10's lunch plate included cut up chicken, bread with butter, plain noodles and vegetables, pudding, and tea with a lid covering the cup. R10 was interviewed and asked if they were hungry to which the resident stated, Somewhat, somewhat. What we got? Give me a small portion of all of it. R10 was asked if they were aware their lunch tray was in front of them to which the resident responded, No, I didn't. R10 continued to indicate that they were unable to see but did not move their arms to attempt to feel for the food in front of them. On 7/20/21 at 12:45 PM, WCA FF entered R10's room and asked the resident if they were finished with lunch. R10 was observed to attempt multiple times with much difficulty to feed themselves noodles with their hand, none of which made it into the resident's mouth. WCA FF was then observed needing to physically help R10 bring food (chicken) to their mouth with a fork, which the resident ate. WCA FF indicated that when she first started working at the facility, no one informed her that R10 is blind, and that she did not know for approximately two weeks. On 7/20/21 at 3:25 PM, R10 remained in bed. R10's bedside table that included a cup of water was observed to be widely out of R10's reach. On 7/21/21 at 8:22 AM, R10 was observed sitting up in bed and leaning towards their right side. R10's breakfast tray was in front of them with no staff present in the room. All of the lids on R10's drinks remained on the cups. R10's eggs were cut up but the resident was not observed to be eating/attempting to eat anything. It appeared as if 1-2 bites of food had been taken. R10 was asked if they are hungry to which they responded, Well, I was eating. When asked how much they ate, R10 stated, I don't know how they measure it, I don't even know what I had for breakfast! Can you tell me what I had? R10 was asked about the tray still present in front of them to which they responded, Oh, it's still here? What is it? R10 was asked if they could feed themselves and replied, I can if I know what I got. R10 was asked if they knew their breakfast tray was still there and stated, No I didn't, no I did not. R10 began feeling around on the table and the edge of their plate with their hand, attempting to find their fork. R10 picked up a piece of egg with their fingers and ate it. R10 then felt around the table for their oatmeal, however, no spoon was present in the bowl. On 7/21/21 at 8:35 AM, CNA Z entered R10's room, asked the resident if they were done eating, and removed the resident's breakfast tray. R10 was observed to not have eaten all of their breakfast. CNA Z was asked if they knew if R10 needed help eating. CNA Z responded, [R10] won't let you, [R10] eats when they want to eat. If [R10] doesn't want to eat, [R10] won't. When asked if any staff attempted to help R10 with breakfast this morning, CNA Z stated, We sat [R10] up, that's what we do. [R10 is] blind and wants to know where everything is and likes to feed [themselves]. When asked if R10 has Dementia, CNA Z indicated they did not know and said, [R10] is just [R10]. On 7/21/21 at 8:48 AM, Registered Nurse (RN) II, R10's assigned nurse for the shift, was interviewed and asked if R10 needed assistance during meals to which he responded, Probably .[R10] needs guidance to let [them] know what's on the tray. Place [R10's] hands right on the plate, that's what I do. [R10] will eat with their fingers sometimes if [they] know [what food] is there. You can't just set a tray and leave it because [R10] is blind. [R10's] kardex probably could be updated to a 'feeder.' A review of R10's medical record at this time revealed the following: 4/9/2021 14:17 (2:17 PM) Dietary Progress Notes Note Text: WEIGHT WARNING: Value: 115.2 Vital Date: 2021-04-09 13:40:00.0 -7.5% change [ 13.5% , 18.0 ] -10.0% change [ 15.4% , 21.0 ] Resident triggering for significant weight loss in 90 and 180 days. March weight not available, resident refused it. Re-weight confirmed weight loss .[R10] is legally blind and requires tray set up and assistance with meals from staff .Continue to provide tray set up and assistance with meals as needed. Encourage po (oral) intake . Continued record review revealed the following weights for R10: 7/14/2021 - 92.1 Lbs (pounds) 6/7/2021 - 113.6 Lbs 5/6/2021 - 113.6 Lbs 4/14/2021 - 113.8 Lbs 4/9/2021 - 115.2 Lbs 4/9/2021 - 114.0 Lbs 2/4/2021 - 133.2 Lbs 1/7/2021 - 137.2 Lbs 12/3/2020 - 135.8 Lbs 11/19/2020 - 136.2 Lbs 10/5/2020 - 134.2 Lbs 9/3/2020 - 135.4 Lbs 8/6/2020 - 134.2 Lbs And additional record review revealed the following: 7/16/2021 13:08 (1:08 PM) Dietary Progress Notes Note Text: WEIGHT WARNING: Value: 92.1 Vital Date: 2021-07-14 15:35:00.0 -5.0% change [ 18.9% , 21.5 ] -7.5% change [ 18.9% , 21.5 ] -10.0% change [ 30.9% , 41.1 ] July monthly weight obtained at 92.1# (pounds/lbs). Weight is triggering for a new significant weight loss. However, RD questions the accuracy of 21.5# loss in past 30 days. A re-weight has been requested to validate .[R10] requires tray set up assistance from staff at meals d/t (due to) .[CONDITION(S)] status, may also require feeding assistance at times . A review of R10's Point of Care (POC) documentation for Amount Eaten (%) revealed that on the following dates, the amount eaten was documented for only two meals: 6/22/21 through 6/25/21, 6/27/21, 6/28/21, 6/30/21, 7/1/21, 7/2/21, 7/4/21 through 7/12/21, 7/14/21 through 7/18/21, 7/19/21 (two meals marked as refused), and 7/20/21. No documentation of amount eaten was present on 6/26/21, 7/3/21, 7/31/21, and 7/17/21, and amount eaten for only one meal was documented on 6/29/21. On 7/21/21 at 2:42 PM, Registered Dietitian (RD) Y was interviewed regarding R10's nutritional status and weight loss. RD Y was asked what the facility's policy/procedure for obtaining re-weighs is to which she responded, The policy is that it's (re-weigh:) is required if there is a 5 lb or greater difference within 30 days or shorter .I expect the re-weigh is completed within 24 hours .I have been asking for [R10's] re-weigh, I did document that it's needed .I put interventions for weight loss in whether the weight loss is true or not. RD Y was then asked that since weight loss has been noted with R10, what level of assistance is expected to be provided for this resident during meals to which she responded, [R10] is blind/vision impaired .likes to feed [themselves] but definitely needs set-up assistance and needs guidance with [their] hands to feel things .and does need help to find what's on the tray. [R10] will sometimes get upset if [staff] try to provide full feeding assistance. When asked if that is the level of assistance R10 has always required, RD Y nodded her head Yes. When asked if she has observed staff providing the required level of assistance to R10 during meals, RD Y stated, Not every meal. I've brought it to staff's attention. If I see a new face (new staff member) and I'm down there, I say, 'Please make sure [R10 is] fed well and assistance provided. I've brought it to the attention of the unit manager and the floor nurses. When queried if staff should be documenting on R10's food acceptance record (FARs) for each meal, RD Y stated, My preference is to see the resident in person, you learn much more being in person. When queried regarding R10's FAR, RD Y acknowledged that amount eaten for all three meals was not documented on from 6/22/21 through 7/20/21. RD Y stated, There has been an order placed by the NP (Nurse Practitioner) that [R10] should be placed on feed assist at all meals. RD Y indicated she expects staff to carry out the order at all meals and stated, I don't feel [R10] has no desire to eat. [R10] does have a desire to eat, [R10] just needs help. I try to check on [R10] quite often and try to write about how I see [them] eating. When queried regarding the lack of re-weigh for R10 since the weight obtained on 7/14/21, RD Y stated, Hard to say. I can't speak for the floor staff. A review of R10's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Status: Active. On 7/21/21 at 02:59 PM, CNA E and Waiver Care Aide (WCA) CC were observed going into R10's room to obtain the resident's weight. CNA E was asked if the facility had requested the resident be re-weighed prior to today to which she responded, Oh yeah, but [R10] refuses a lot. CNA E indicated the refusal was documented but upon review of R10's record no documentation of such was found. CNA E and WCA CC pulled R10 up out of their wheelchair by the resident's underarms and grabbed the waist of the resident's pants to place R10 into the chair scale. When asked if they normally used a gait belt for transfers, CNA E said, Yes, and provided no further information. R10's weight was observed to be 106.6 lbs. CNA E and WCA CC then proceeded to help the resident get into bed. R10's weight of 113.6 lbs on 6/7/21 compared to the new weight of 106.6 lbs on 7/21/2021 reflected a -6.16% loss. On 7/22/21 at 4:08 PM, the Director of Nursing (DON) was interviewed and asked what the facility's policy/procedure for obtaining re-weighs is to which she responded, If there is a 5 lb difference (between new weight and previous weight), and the resident should be weighed three times before it's documented. When queried regarding the expectation during meals for a resident assessed to require 1 person assist for meals, the DON stated, One person assisting the resident for the entire meal. A review of the facility's policy/procedure titled, Weight Monitoring, Date Implemented: 1/1/2021, revealed, Policy: Based on the resident ' s comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident ' s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. The facility will utilize a systemic approach to optimize a resident ' s nutritional status. This process includes: a. Identifying and assessing each resident ' s nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary . 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident ' s specific nutritional concerns and preferences .4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident ' s assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status .c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed . On 07/19/21 at 7:19 AM, R55 was observed lying in bed rubbing their lips with the right hand and reaching over the side of the bed. R55 was asked what was needed and whispered inaudibly while rubbing their bottom lip. It was observed the R55's lips were dry and chapped. A cup of water was observed in the over-bed table approximately four feet away from R55's bed. On 07/19/21 at 11:06 AM, R55 was observed sleeping and had been groomed and dressed. The chapped lips had been cared for. R55's drinking water remained on the over-bed-table and was not within reach. Record review of R55's Electronic Health Record (EHR) revealed R55 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed R55 had a severely impaired cognition and needed extensive assistance with Activities of Daily Living (ADLs) including eating. On 07/22/21 at 10:34 AM, an interview was conducted with Certified Nurses Aide (CNA J). CNA J was asked if R55 could eat and drink unassisted and stated, [R55] needs to be fed. Very infrequent attempts to feed herself. She usually eats 90 to 100 %. I go in every few minutes to check on her. On 07/22/21 at 4:22 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the facility's policy and procedure for ensuring that drinking water was within reach and stated, It should be within reach. Review of the facility's policy and procedure titled, Hydration dated Reviewed/Revised: 10/30/2020 revealed, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. The policy and procedure did not address the placement of drinking water within reach of the residents, nor did it address the frequency of assisting dependent residents

This citation pertains to Intake#: MI 932 and MI 389. Based on observation, interview and record review, the facility failed to administer pain medications as ordered for three residents (Resident #93, #100, and #152) of three residents reviewed for pain control, resulting in excrutiating, prolonged pain and mental angish. Findings include: Resident #93. On 07/19/2021 at 11:37 AM, during an initial tour, Resident #93 was observed in their room sitting up in bed. The Resident was dressed and groomed and was rubbing both their legs. Resident #93 stated, I haven't gotten my pain medication, my legs hurt so bad! On 07/20/2021 at 08:28 AM, Resident #93 was observed dressed and groomed in their wheelchair. Resident #93 was interviewed and shared there experience with a nurse, Licensed Practical Nurse (LPN) A and stated, We don't get along, the nurse and I don't see eye to eye. Resident #93 was asked to elaborate and explained that their medications is supposed to be scheduled but LPN A does not give them, so (Resident #93) feels compelled to ask (for their scheduled pain medication). If I do get it, then I get it late. One day, I asked for my medication and fell asleep because it was taking so long. She finally came in and told me that she was going to report me to my doctor because I was nodding off! It was 1:00 AM! I was tired, she was insinuating that I was on too many drugs. Later on there was someone in my room, I could not see it was dark. It must have been an aide. I asked what they were doing in my room and she said that [LPN A] sent her in there to watch me because I was being 'disruptive'! I was humilliated! Resident #93 explained that they were at the facility for short term rehabilitation and that they had severe [CONDITION(S)] in their legs. Resident #93 stated, I was supposed to get my pain medicine at midnight and at 06:00 AM, my legs are the reason why I am here (at the facility for rehabilitation)! I ask for my medicine but, I don't get it! Look at my legs! They are supposed to be elevated. Resident #93 had [CONDITION(S)] (swelling) observed on their ankles and feet. A record review of the July 2021 MAR for Resident #93 revealed the following medication order: [MEDICATION(S)] Capsule 300 MG Give 1 capsule by mouth four times a day for Peripheral [CONDITION(S)] -Start Date-06/15/2021 1800. [MEDICATION(S)] Tablet 10-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 6 hours for Pain related to SPINAL STENOSIS, CERVICAL REGION .Start Date-06/08/2021. Upon further review of the MAR, the above medications were not given on July 11, July 13, July 16 and again not given on July 19th during the midnight shifts. A record review of the care plan for Resident #93 revealed the following: Focus-The resident is at risk for pain. Date Initiated: 06/27/2021 Goal-The resident will adequate pain control as evidenced by such things as decreased behaviors, irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying .Date Initiated: 06/05/2021. Interventions-Administer pain medications as ordered. Give 1/2 hour before treatments or care. Date Initiated: 06/05/2021 . A review of the Mimimum Data Set (MDS) assessment dated [DATE] for Resident #93 revealed an admission to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #93 had no behavior issues, needed assistance with most Activities of Daily Living (ADL) and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The pain section on the MDS revealed the Resident had no nonpharmocological interventions in place for pain, had frequent pain that was rated a 4 out of 10 (ten being the worst rating) at the time of the assessment. A record review of the progress notes revealed the following: 07/17/2021 07:22 (AM) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .request for c/o (complains of) persistent [CONDITION(S)] .has been on [MEDICATION(S)] 40 daily with little change . MUSCULOSKELETAL: Pain in legs, feet and hands PSYCHIATRIC: No history of depression or anxiety. GENERAL: The patient is in no apparent distress .is alert and oriented x3 . EXTREMITIES: .2+ [CONDITION(S)] . PMH (past medical history): Peripheral [CONDITION(S)] (painful nerve disorder affecting the extremeties), B/L (bilateral) LE (lower extremety) DVT (deep vein [CONDITION(S)]/blood clot), cervical stenosis (spinal cord and nerves compressed), [CONDITION(S)], [CONDITION(S)] (hypertension) . LE [CONDITION(S)] - continue [MEDICATION(S)] . Hand pain, cold, spasms - cervical x-ray showed degeneration [CONDITION(S)] - Increase [MEDICATION(S)] to QID Bilateral LE DVT - Repeat doppler .Pain - Continue [MEDICATION(S)] . On 07/21/2021 at 05:15 AM, LPN A was interviewed in regard to Resident #93 not recieving any pain medication the whole midnight shift for 07/19/2021. LPN A became defensive and stated, (Resident #93) asked for a pill at 10 (PM), it was too early (there is an hour grace period before and after the scheduled time to pass out medications) .When I came in to give it, I had to wake (Resident #93) up, which I am not sure how much pain you really are in if you are sleeping. Then (Resident #93) was nodding off, (Resident #93) has a history of drug use and it is up to me to notify the physician if they are on too much pain medication). LPN A was asked if nodding off during the midnight shift is appropriate given the time and nodded that it was appropriate to be tired at that time. LPN A was asked if it was appropriate to experience pain with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN A was asked if she had sent another staff member in Resident #93's room to watch them and stated, Do you think I would logically do that when we don't have staff? LPN A was asked if she got frequent complaints from residents of them not getting their medications from her and stated, I am sure they do complain about me. On 07/21/2021 at 05:30 AM, Certified Nursing Assistant (CNA) NN was interviewed. CNA NN explained that she worked down the 500 unit regularly and was familiar with Resident #93. CNA NN stated, Everything (Resident #93) said is 100% true (about LPN A) .I have texts all over my phone telling her (LPN A) that these people need their pills. I have to text her because I can't find her. No treatments get done down that hall, nothing. It is my set but I feel like I have the whole set. [LPN A] just sleeps at night, she is no where to be found. I have complained and nothing gets done. I have loads of texts, if you would have came in here 20 minutes earlier, you would have seen she was asleep. There are times that she (LPN A) will purposely wait til after the time that they can get their pain meds, so they can't get them. CNA NNstated, Sometimes, towards the end of her shift, I see her pulling all these meds and just popping them out, but I don't see her giving them out. I don't know if she is just wasting them and throwing them away or what. Resident #100 On 07/22/2021 at 09:57 AM, Resident #100 was observed dressed and groomed lying awake in bed. Resident #100 was interviewed in regard to pain. Resident #100 explained that their pain was more controlled now that they were not on the 500/600 Unit and stated, (LPN A) is just nasty. She never gave me my pills, or would be two hours late. That was common. She talks bad all the time. I don't even want to remember her. The first time I met her I said, 'Oh, you are new here? What is your name?' She said, 'I don't go like that, I am just here to give you your pills and that is it.' .one time she wasn't even on the floor, she took off, she was hiding from me. When she finally did come around, and I would ask for my medication, she would say, 'Your [MEDICATION(S)] is coming up, we will see how fast I move to give you it.' She would say this because we were arguing (about getting my pain pills). She's nuts! She's crazy! She hated me! I kept telling her 'You gotta go! .I didn't trust her either. I used to taste it to make sure she was giving me the same medicine. Resident #100 was about the pain they were experiencing and stated, I have been in pain for over [AGE] years. It's in my back , my knees, my legs. It is a 7, 8 or 9 at all times. It is constant! It hurts, I never sleep, I'm up all night. A record review of the progress notes for Resident #100 revealed the following: 6/3/2021 19:11 (07:11 PM) Nurses' Notes (authored by LPN A) resident became upset with nurse due to nurse bringing pain medication within the one hour grace period, resident assumped (sic) nurse didn't like them, nurse explained she had came in early to help and wasn't use to passing (their) meds at this time, however she indeed do apologize if this has cause any problems, resident remained agitated, and begame (sic) to verbal threaten nurse stating, 'i'll have your ass hung tomorrow if you keep this s#@t up.' nurse explained the hour before hour after, and anytime other would require permission from the prescribing MD (Medical Doctor), Resident went on calling nurse annoying [OBSCENITY] es. Nurse and witness exited room, notified administrator. Later while Nurse and aide went in to render care to roommate resident begun to yell aggressively, at nurse and aide making threats towards staff, stating how he could hang them, and how nurse better get my medication on time, or he would dig a hole for her. nurse and aide quitetly rendered care to roommate left. A record review of the MDS assessment dated [DATE] revealed that Resident #100 had a BIMS score of 15 out of 15, and was most recently admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #100 was independent with most Activities of Daily Living (ADL) and did not have any behavioral issues. Resident #100's pain section indicated no nonpharmacological interventions for pain, and that at the time of the assessment, Resident #100 had a pain rating of 4 out of 10, and had occasional pain. Resident #152 On 07/21/2021 at 02:58 PM, Resident #152 was observed lying in bed dressed and groomed. Resident #152 was asked about how their pain was handled while a resident on the 500/600 unit. Resident #152 stated, I am speaking for the people (currently on those units), I got transferred over to this unit about two weeks ago. The very first night I was down there, I could see (LPN A) was in a bad mood because she had to work both floors (500 and 600 hall). I went out and asked about my medicine and she barked at me. I said, 'Listen, I understand you probably are mad because you are by yourself (on the unit).' She didn't say anything, so I went back to my room. She never gave me my medicine, so I went out (in the hallway) at 4:00 AM. I couldn't find her. I see an office with the door closed. There was paper covering the window so you couldn't look in there. I could tell the light was off because of the bottom of the door. She puts on a piece of paper so no one can see her, that is how I knew when she was working for the nigtht. I knock on the door, I see the lights flick on underneath the door. The door opens up about this much (the resident utilized their hands to demonstrate about 6 inches) and a CNA (DD) pops up. I could tell she was sleeping, she was rubbing her eyes. I said, 'Listen, could you tell [LPN A] I am in a lot of pain and need my pain pills?' She says, 'She's [LPN A] busy.' Then, [LPN A] pops up from inside the room and said, 'I'm logging stuff and will give you your meds when I get around to it.' I waited about a half hour, stillnno sign of her. I went back to the room, I knock, (LPN A) yells, 'Knocking on the door isn't going to get you pain meds any earlier.' Then she said, 'You don't get any anyway!' I said, 'I get a prn (as needed) medication .I can have it every four hours.' We started arguing, I said, 'If you weren't busy sleeping, maybe people would get their pills around here!' She said to me, 'You know what? I am not giving you your meds now! You can get them from someone else! You can find someone else to give it to you! I will not be giving you anymore meds.' She was yelling at me. Then she would get another nurse to give me my meds because she doesnt want to because of that night. Later, I felt bad even though I did nothing wrong. I was going to apoligize and she said to me right away, 'Don't talk to me!' Another time, I tried to find her for my pain medicine, and it was the same thing, no where to be found. This time she was not in office, she starting going in a room on the 600 Unit all the way down the hall. I was in the hallway for two hours, she comes out around 04:00 AM - 05:45 AM, because she knows people start calling in. They both (CNA DD and LPN A) came out in the hall. I said, 'I knew you were in there!' She said, 'Don't talk to me! I'm never giving you your meds again.' Resident #152 was asked to describe the pain they were experiencing and explained that they were in a car accident and had developed internal abcesses on their buttocks and tailbone. Resident #152 stated, They (the abcesses) were squeezing the nerves. I couldn't use my legs at first. They (the abcesses) are shrinking now, that is why I am here, so I can get antibiotics through the IV (intravenous). My tailbone and hips hurt. It is shooting pain down the left leg. It is very painful. I rate it an eight or a nine (out of 10, on a pain scale). A record review of the MDS dated [DATE] revealed that Resident #152 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the care plan for Resident #152 revealed the following: Focus-The resident has/is at risk for chronic pain related to recent abscess and has had back pain from MVA (motor vehicle accident). Date Initiated: 06/30/2021. Goal-The resident will have adequate pain control as evidenced by such things as decreased behaviors, irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying . Interventions-Administer pain medications as ordered. Give 1/2 hour before treatments or care. Date Initiated: 06/30/2021 LPN . A record review of the progress notes for Resident #152 revealed the following: 07/14/2021 08:02 (AM) Nurses' Notes (authored by Nurse A) .around 4 am patient was banging on the nursing station door opened the door asked the patient if they needed something patient said 'I need my pain pills right now they are late ' asked patient what pain medication .referring to (Resident #152) said, 'my [MEDICATION(S)] it was due over a hour ago.' I explained that I will check on .medication that I will meet in .room in a few minutes, around two minutes later patient started banging on the nursing station door again and and screaming, 'I know you are not charting you are f#@king sleeping' opened the nursing station door and tried to explain that I was finishing up with something patient became extremely aggressive towards me pointing .finger in my face and said 'you are f#@king done [OBSCENITY] , I will have your job, I am going to get your a*s fired you stupid f#@king nurse, you are done, done, done' I tried to deescalate the situation and educate on .PRN medication, (Resident #152) continued to be very aggressive towards me and other staff members, patient walked to 400 unit, because patient was being very aggressive towards me had another nurse give .PRN [MEDICATION(S)]. 07/15/2021 07:30 (AM) Nurses' Notes (authored by SW GG) .Spoke to resident to be more patient with nursing and to be respectful. (Resident #152) had concerns about nurse and so I emailed the DON and Admin (NHA). (Resident #152) was saying (Resident #152) only has a few more days here .is on ABT (antibiotics) and going home after that's done. SW to continue to monitor. 07/19/2021 19:12 (07:12 PM) Nurses' Notes .Though out shift patient continues to ask for .Narcotics early, I continue to educate .on .medications including how often .can have them, around 6 pm patient walked up to medication cart and said, 'can you give me my [MEDICATION(S)] before you leave, like around 7 pm' explained .medication is due at 9 pm. 07/21/2021 19:04 (07:04 PM) Nurses' Notes .Resident stated .would like to get .[MEDICATION(S)] earlier because .would like to sleep earlier .pain is unbearable and resident stated that .does not get .PM [MEDICATION(S)] on time. Notified NP .and okayed to give it now. On 07/20/2021 at 04:42 PM, LPN A was interviewed via phone in regard to the Residents on the 500 unit not getting their pain medication. LPN A explained that staffing had been a challenge and that it was common for her to be by herself on the unit with 54 residents .LPN A was asked if the residents on the 500 Unit get their scheduled medications. LPN A did not directly answer the question but stated, I try to do my job like the ABC's (airway, breathing, circulation). I have trachs, tube feedings, IV's .These residents depend on me. I take care of the trachs first, the blood pressures, what else am I supposed to do? I have to prioritize. What would you do? I come to work, people call off, then what am I supposed to do? LPN A was asked if she ever does not give the residents on the unit their medications. LPN A was reluctant to answer but stated, I sometimes don't' take the keys to that cart (500 Unit), and they (the previous nurse) will just put them (the keys to the cart) in the top drawer. LPN A explained that by not accepting the keys to the 500 Unit, she was not accepting the responsibility of the patient load. LPN A was asked what happens when that happens and she explained that she tells the oncoming nure that she (the oncoming nurse) needs to talk to the doctor to see if those patients can get their meds late. On 07/22/2021 at 04:16 PM the Director of Nurses (DON) and Nursing Home Adminstrator (NHA) were interviewed in regard to pain management of the facility. The DON explained that the nurses do pain assessments on all new admissions, with new falls or injuries, and with MDS assessments. The DON was asked if she was aware that LPN A does not pass medications or accept the keys to the 500 Unit medication cart sometimes. The DON stated, I did not know that (nurse leaves without passing meds on unit). They should be passed an hour before or after. The DON was asked the expectations of when a resident is in pain, what should be done. The DON stated, I would expect that the nurse would give the resident their medications as ordered. A review of the facility policy titled Medication Administration dated 01/01/2021, revealed the following: Medications are administered by licensed nurses, or other staff who legally authorized to do so in this state, as ordered by the physician .

This citation pertains to intake #MI 238. Based on observation, interview, and record review, the facility failed to prevent physical and verbal abuse for one Resident (#701) of three residents reviewed for abuse, resulting in Resident #701 having a pillow placed over their head and called names and the likelihood of emotional distress and fear, based on the reasonable person concept. Findings include: On 1/28/2021 at 9:07 AM, an interview was completed with Confidential Witness A. Confidential Witness A explained that she was a new employee at the facility training for a Nurse Aide position. On January 14, 2021 and January 15, 2021, Confidential Witness A had been assigned to train with Certified Nurse Assistant (CNA) F. According to Confidential Witness A, she had been training with three other new employees (Noncertified Nurse Assistant/NCNA B, D, and E). On her last day of training, the five of them went to complete a brief change for Resident #701. According to Confidential Witness A, Resident #701 did not want be changed, but was changed anyway. During care, Resident #701 was combative and calling CNA F racial names. After the Resident was changed, CNA F then held the Resident's arm out with one arm and then placed a pillow over the Resident's head and face and pushed down on it for about ten seconds. The resident was not able to remove the pillow. While holding the pillow down, CNA F made repeated racial slurs to Resident #701, and then removed the pillow from their face. After the pillow was removed, Resident #701 kept yelling, You're going to jail! Confidential Witness A explained that NCNA B, D, and E were nervously laughing during the incident, but she did not. Confidential Witness A was asked what CNA F did after the incident and said CNA F stated, Why did I just do that? After the incident, they all had went to lunch. Confidential Witness A explained that she felt uncomfortable with what she had witnessed and had went to report the incident to Social Worker (SW) C. SW C then referred her to the Nursing Home Administrator (NHA). After Confidential Witness A spoke to the NHA, she then went to the locker room. CNA F, NCNA B, D, and E were also in the locker room. CNA F had addressed all of them and stated that there was an allegation of abuse against her with Resident #701 and that they all needed to collaborate so that they all could have the same story when interviewed. CNA F further explained to them that they needed to say that while rolling the Resident, that their head got pushed up against the pillow. Confidential Witness A, CNA F, and NCNA B, D, and E were all brought into the Director of Nursing's (DON) office. During that time, Confidential Witness A stated that they were all just talking about other issues, instead of the incident she reported, and then all the staff were asked to leave the room except for her and CNA F. At that time, the DON had asked her if she was sure that the incident was not a misunderstanding. Confidential Witness A felt uncomfortable and intimidated. In fear of retaliation from CNA F, she retracted her statement. Confidential Witness A then finished her shift out with CNA F, whom according to her, was being unusually nice to her, and then quit within fifteen minutes after her shift ending. Confidential Witness A stated, I felt it was all handled inappropriately. I was not comfortable working there. When I called to quit, someone who had not been familiar with the incident asked me why I was quitting and I explained to her what happened (Confidential Witness A was not sure who she spoke with on the phone) and she tried assuring me they would take care of the situation. My sister is a nurse and I explained to her what happened and she advised me to report it to the State Agency. Confidential Witness A was asked if she had ever worked with CNA F or had knew of her before her employment with the facility and stated, No, I just know that she has worked there for [AGE] years. On 2/1/2021 at 10:06 AM, NCNA B was interviewed via telephone in regard to the incident that had occurred around 1/14/2021 with the pillow and Resident #701. NCNA B was familiar with the incident and explained that the Resident had been combative with CNA F and had been calling her racial slurs. NCNA B explained that she had helped hold down Resident #701's legs during the brief change. NCNA B was asked why she held Resident #701's legs down and explained that she was helping CNA F because the resident was combative and needed to be changed. She further explained that she did not see what happened with the pillow because at one point she had stepped in the bathroom to wash her hands and re-glove. NCNA B further explained that she was eventually called in the DON's office, but was asked if she had any issues working at the facility and then was excused from the meeting. On 2/1/2021 at 11:10 AM, Resident #701 was observed resting in bed. Resident #701 was disheveled and had poor hygiene. Resident #701 was asked if they recalled an incident with a pillow being placed over their head a few weeks ago. Resident #701 stated, Of course. Resident #701 was asked if they remembered who did it, the Resident just grinned and did not make eye contact. Resident #701 was asked if they ever call the staff members names, the Resident responded, Yes and then repeated racial slurs. The Resident was asked if staff had called them names and stated, Yes and then stated, They call me [racial slur]. Resident #701 was hesitant during the interview and unable to describe any details of specific incidents. On 2/1/2021 at 11:45 AM, SW C was queried about what Confidential Witness A had reported to her. SW C explained that Confidential Witness A had come to her pretty shaken up and said that she needed to report an incident. SW C stated, I then asked her what type of abuse was she reporting? Resident to resident or staff to resident? Then she explained that [CNA F] had placed a pillow over Resident #701's head during care. At that point, I took her to the NHA. SW C was asked if she had to complete a statement or if anyone had followed up with her and stated, I had not heard anything else about the incident. SW C was asked if she believed what Confidential Witness A had reported to her and stated, I didn't think she was lying. On 2/1/2021 at 11:50 AM, Resident #701 was observed awake in bed. Resident #701 was questioned again about the incident with the pillow being placed over their head. Resident #701 was asked if they recalled the incident and stated, I already told you earlier what I knew. On 2/1/2021 at 11:58 AM, CNA F was queried via phone regarding the incident with Resident #701 and the pillow. CNA F did recall the incident. CNA F explained that the incident happened on 1/14/2021 or 1/15/2021 and that she had been training Confidential Witness A, NCNA B, D, and E. CNA F further explained that Resident #701 was a real nice guy and was never combative but, cusses and swears. She stated that the Resident was not even cussing or swearing at the time but joking around with her. CNA F stated, when Resident #701 was being rolled to the side (away from her) their face went in a pillow. CNA F was queried on what happened after the incident and explained that she went to lunch and was called in the office with Confidential Witness A, NCNA B, D, and E. She explained that everyone was talking and then the NCNA's were dismissed from the meeting and she was asked what happened and explained that Resident #701 was rolled and their head went in the pillow. CNA F was queried as to why she thought the incident had been reported to the NHA and DON and stated, I guess because they were a new CNA and weren't familiar with the job. CNA F was asked if she had given a statement and explained that she was not asked to. On 2/1/2021 at 12:30 PM, an interview was completed with the NHA. The NHA was asked what occurred with Confidential Witness A, CNA F and Resident #701. The NHA stated that Confidential Witness A had come to her to report an incident with Resident #701 and CNA F. The NHA explained that she then referred her to the DON. On 2/1/2021 at 12:33 PM, the DON was interviewed regarding what was reported to her in regard to the pillow being placed over Resident #701's head, CNA F and Confidential Witness A. The DON explained that Confidential Witness A recanted her story and said it must have been a misunderstanding. The DON was asked if there had been an investigation in regard to what Confidential Witness A had reported. The DON stated, There was nothing to investigate, she recanted her story. The DON was asked if it was normal procedure to interview the accuser and perpetrator at the same time and stated, I asked her (Confidential Witness A) if it was okay to bring in [CNA F] to find out what happened and she said it was fine. The DON was asked if she had interviewed SW C about what was reported to her and stated, I didn't know she knew anything about it. The DON was asked if she had interviewed Resident #701 and stated, Did you meet him? The DON further explained that when the incident was reported to her, that she did not know it involved abuse. The DON stated, We thought it was a clinical issue, like that the aides weren't repositioning correctly. The DON was asked why she felt Confidential Witness A would have felt the urgency to report a clinical issue. The DON stated, I don't know, she was a new CNA. The DON was asked if she had known the reason for Confidential Witness A to have quit the same day immediately after her shift and stated, I don't know, she was odd. On 2/1/2021 at 2:18 PM, NCNA D was interviewed via phone in regard to the incident involving Resident #701 and CNA F. NCNA D stated that there was a lot going on with Resident #701 and that the Resident was calling CNA F racial slurs. According to NCNA D, she never spoke to the DON or NHA alone regarding the incident. On 2/1/2021 at 2:27 PM, NCNA E was queried in regard to the alleged incident of Resident #701 having a pillow placed over their head by CNA F. NCNA E explained that the Resident was combative and that she had helped hold them down during care and that the Resident was not turned but the pillow had fell on [Resident #701]'s head. NCNA E further stated, She (CNA F) was doing the best she could. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 had been admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #701 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating a moderate impaired cognition and needed extensive assist with dressing and transfers. A review of the facility policy titled Abuse, Neglect and Exploitation dated 1/1/2021 revealed the following: Policy Statement-Our residents have the right to be free from abuse .Preventing abuse-Our facility is committed to protecting our residents from abuse by anyone including .facility staff .1. Our facility does not condone resident abuse by anyone .2. All personnel are encouraged to report incidents .such reports may be made without fear of retaliation .

This citation pertains to intake # 4. Based on interview and record review, the facility failed to establish STAT (a common medical abbreviation for urgent or rush/immediate) diagnostic test timeframe guidelines and complete physician ordered STAT labs in a reasonable time frame for one sampled resident (Resident #910) of one reviewed for a change in condition, resulting in the facility being unable to obtain STAT physician orders and a delay in treatment and/or diagnosis. Findings include: A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #910 was most recently admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #910 had a Brief Interview for Mental Status (BIMS) score of ,[DATE], indicating an impaired cognition. Resident #910 needed extensive assistance with activities of daily living. A record review of Resident #910's Progress Notes revealed the following: [DATE] 16:33 (4:33 PM) physician progress notes [REDACTED].Unable to answer review questions secondary to [DIAGNOSES REDACTED]. ,[DATE] (blood pressure/BP) 97.4 (temperature/T) 81 (pulse/P) 18 (respirations/R) 96% (oxygen saturation/SpO2) .Mouth is well hydrated and without [MEDICAL CONDITION]. ASSESSMENT: Afebrile (no fever) .PLAN: Continue supportive care . [DATE] 20:34 (8:34 PM) Nurses' Notes .Resident very weak, poor appetite, VS (vital signs)- 96.8 (T)-,[DATE] (BP)-,[DATE] sp,[DATE]% on RA (room air), notified NP (Nurse Practitioner C) & left msg (message), will continues to monitor. Authored by Nurse E. [DATE] 17:14 (5:14 PM) Nurses' Notes .IV (intravenous) placed in Left hand, 24 gauge. IV site without redness or swelling, easily flushed with NS (normal saline). IVF (intravenous fluids) started at 60ml (milliliters)/hr (hour). Authored by Nurse D. [DATE] 17:12 (5:12 PM) Nurses' Notes .resident noted with elevated temperature 102.3 (normal is 98.6), r-24, bp-,[DATE] (below normal), O2%-,[DATE] (normal is 90%-100%), writer called MD (Medical Doctor) orders was given for O2 via nasal canula as needed, stat chest x-ray, stat cbc/cmp (complete blood count/complete metabolic panel), and stat nose swab fesidenor COVID-10/flu (swab test for COVID-19 and influenza, a contagious respiratory virus) and to isolate resident .involved parties notified Authored by Nurse B. [DATE] 02:58 (AM) Nurses' Notes .Approx (approximately) @ 0135 (AM) writer enter res (resident's) room and noted res unresponsive, vitals unable to obtain. DON (Director of Nursing) on site pronounce res expired. Res family notified, attempt to notify NP (Nurse Practitioner) no response at this time. On [DATE] at 8:41 AM, the DON and Nursing Home Administrator (NHA) were interviewed in regard to the STAT lab orders that were ordered for Resident #910 on [DATE] and not obtained. The DON stated, There is no STAT time frame with the lab. I called them and they said that there is no STAT time. They don't have a STAT time frame for a nursing home. If it is truly STAT in nature, then we would just send them to the hospital. The DON was asked why Resident #910 was not considered to be sent to the hospital to have the tests taken and stated, I was the one who pronounced (Resident #910) dead. With (Resident #910) it happened so quick and we were advised at that time (during pandemic) to not send anybody to the hospital if possible, and treat them here (within the facility) if able. The NHA explained that they had a contract with their lab and do not have the ability to get STAT labs within a certain time frame and that the lab just come to get the specimen's when they can. On [DATE] at 9:18 AM, NP C was attempted to be interviewed via phone, however, no return call back was received by the end of the survey. On [DATE] at 9:18 AM, Nurse E was attempted to be interviewed via phone, however, no return call back was received by the end of the survey. On [DATE] at 9:19 AM, Nurse B was interviewed via phone in regard to the medical condition of Resident #910 on [DATE]. Nurse B stated, At that time, (Resident #910) seemed very dehydrated. (Resident #910) was running a fever too. I called the STAT labs in (to the lab company). Nurse B explained that she had called the lab company right away in hopes of receiving the results of the labs/X-ray and nasal swab soon. On [DATE] at 9:28 AM, Nurse D was interviewed in regard to the medical condition of Resident #910 on [DATE] and stated, I was asked to assist in placing the IV in because the other nurse couldn't get it in. At that time (Resident #910) had really bad skin turgor, (Resident #910) had sunken eyes, (Resident #910) looked dehydrated, I told the nurse to keep an eye on (Resident #910) because they didn't look too good. On [DATE] at 9:36 AM, Confidential Witness F was interviewed in regard to the tests ordered on [DATE] for Resident #910 that were not obtained. Confidential Witness F stated that her wishes were to keep Resident #910 comfortable in the facility but was disappointed that the labs were not done because she was in visiting Resident #910 on [DATE] for end of life visits. Confiedential Witness F further explained that she would have liked to have known if she and her family were exposed to COVID-19 while there to be cautious and quarantine if necessary. On [DATE] at 2:22 PM, the NHA was asked if the facility had the ability to obtain STAT tests and stated, We can, the contract states that they have four hours to process the results once the specimen is in. The NHA further explained that the lab goes to the facility to draw STAT labs as soon as they can, and have no timeframe to obtain the specimen. A review of the Care Plan (revised [DATE]) for Resident #910 revealed the following: Focus-The resident is at risk for dehydration . Goal-The resident will not experience fluid volume deficits as evidenced by skin turgor within normal limits, moist mucous membranes, and lab values within normal limits for resident's baseline . The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor . Interventions- .Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . A review of the laboratory agreement between the lab company and the facility revealed the following: .Responsibilities of (Lab Company) .3. (Lab Company) shall provide services on a STAT basis upon (Facility's) reasonable request. For the purpose of this Agreement, STAT means a request by (Facility) for a Service to be performed by (Lab Company) within (4) hour(s) of receiving the specimen of the arrival of the specimen at (Lab Company) or at a time other than as set forth . A review of the facility policy titled, Laboratory Diagnostics Tracking Guidelines revised ,[DATE] revealed the following: 5. STAT labs will be obtained per physician order 7 days per week . 9. The facility should have a system to monitor lab/diagnostic test daily . 11. The physician should be notified if the lab/diagnostic test is unable to be completed, reason why, and request for new orders . 15. STAT orders .a. If unable to obtain the STAT test within facility established time frames, the physician should be notified for further orders or resident sent to a provider who can perform such test. b. Documentation of the above should be completed in the resident's medical record as explained in the documentation section of this procedure.

This citation pertains to intake numbers: 2 and 9. Based on observation, interview and record review, the facility failed to initiate effective interventions timely to prevent the aggressive behavior of two residents (#701 and #702) of four reviewed for abuse, resulting in the escalation of aggressive behaviors and repeated verbal and physical abuse and mental anguish towards other residents. Findings include: Resident #701 A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #701 had a severely impaired cognition and had no mood or behavior issues. A record review of Resident #701's Progress Notes revealed the following: 1/7/2020 18:57 (6:57 PM) Nursing .Note .Resident arrived via ambulance from Hospital. Vital signs WNL (within normal limits). Resident was very aggressive and agitated, difficult to redirect. 1/8/20 10:55 AM .(Resident #701) .impulsive with some dressing task becoming slightly irritated and frustrated with some multiple instructions from spouse .is being followed for decline in mobility with debility due to Acute intractable abdominal pain, Severe constipation, Dementia, [MEDICAL CONDITION]/aggressive behavior . 1/12/2020 18:55 (6:55 PM) .Behavior Note .Resident agitated in the afternoon. Yelling and swearing at other residents. Getting close to their face and yelling. Also yells at staff. 1/13/2020 15:12 (3:12 PM) .Behavior Note .Continue to go up to other residents and yell at them. Swears at staff and residents. 1/14/2020 12:38 (PM) Nurses' Notes .Resident's agitation has been increasing. As well as yelling and swearing at employees and residents throughout the day. Contacted Social Services at 12:40 pm to order a psych evaluation with psych nurse. 1/15/2020 11:50 (AM) .Behavior Note .Resident is yelling and swearing at residents. Getting close to their faces. Swinging his arms around and balling his hands in a fist . 1/15/20 3:03 (PM) (Resident #701) has confusion can make very few needs known 2/2 (secondary to) advanced Dementia with behavioral changes/agitation. They were doing okay with exam for less than six minutes then became agitated, clinching fist, loud tone and bordering extreme upset and returned to quiet and serene when provider stood still taking steps backward . 1/16/2020 03:03 (AM) .Behavior Note .Resident slept well at night . Resident is very aggressive and combative. Continue to go up to other residents and yell at them. Swears at staff and residents. 1/16/2020 14:55 (2:55 PM) .Behavior Note .Continues to yell at staff and other residents. Hitting the couch while yelling. Getting up off the couch to yell at other residents. 1/17/2020 04:51 (AM) .Behavior Note .Resident yelling at staff and going into other resident rooms throughout the night. 1/18/2020 18:47 (6:47 PM) .Behavior Note .Resident starting to get agitated around dinner time. Resident swearing and talking to one's self. Telling other resident's 'what do you want.' 1/18/2020 20:04 (8:04 PM) Nurses' Notes .resident noted to display agitation and verbal aggression toward other residents/staff that interact with him. resident displays angry, defensive behavior verbally/body language in response to others non threatening/non aggressive interactions from residents/staff . 1/19/2020 00:43 (12:43 AM) .Behavior Note .aggressive body language verbal threats, cursing toward residents/staff . 1/23/20 18:42 (6:42 PM) .resident starts to get agitated and have outburst of yelling/swearing in front of other resident's faces. Periodically, walking around. 1/28/2020 08:32 (AM) .Behavior .Note .Continues to have outburst of yelling and swearing. Walking around. Resident goes up to other resident's faces and yells/swears at them. 1/28/2020 16:32 (4:32 PM) .Behavior .Note .Continues to have outburst of yelling and swearing. Walking around. Resident goes up to other resident's faces and yells/swears at them. On 1/29/20 at 12:32 AM, 8:32 AM and 4:32 PM, the following was noted in the Progress Notes: Continues to have outburst of yelling and swearing. Walking around. Resident goes up to other resident's faces and yells/swears at them. 2/1/2020 17:23 (5:23 PM) .Behavior Note .Resident walked into another resident's room and grabbed their can of peanuts that was on top of their dresser. Aide tried to take the can of peanuts. Resident got mad and was observed swinging his arms and fist to the aide. Also, was yelling at the aide . On 2/3/20 at 2:57 AM, 10:57 AM and 8:57 PM the following nurses notes were documented: Continues to have outburst of yelling and swearing. Walking around. Resident goes up to other resident's faces and yells/swears at them. 2/8/2020 16:17 (4:17 PM) .Behavior Note .Continues to yell and swear at staff and other residents. Yelling in other residents faces . 2/9/2020 06:40 (AM) .Behavior Note .Continues to yell and swear at staff and other residents. Yelling in other residents faces 2/11/2020 12:30 (AM) Behavior Note .Yelling and swearing at staff and residents. Resident has his hands in a fist and swinging his arms at staff and residents. Resident is out of [MEDICATION NAME] (antianxiety medication). Administered [MEDICATION NAME] (antipyschotic medication) at 1600 (4:00 PM). [MEDICATION NAME] was not effective. Resident continues the yelling and swearing after medication administration. On 2/12/20 at 2:09 PM, the follow Physician Note was documented: Chief Complaint / Nature of Presenting Problem: Increase anxiety, irritable with other residents History Of Present Illness .Patient visited today per request as he is reportedly having increased anxiety symptoms and irritability and argumentative with other residents lately. Constantly requires supervision assistance and redirection with ADLs. Currently on [MEDICATION NAME] 0.5 mg (milligrams) as needed for anxiety. Reported no increasing sedation or anything associated with medication use. Baseline mentation. 2/13/2020 16:32 (4:32 PM) .Behavior Note .Resident yelling at other residents. This resident was hitting the TV (television) in the common area . 2/13/2020 06:29 (AM) .Behavior Note . Continues to have outburst of yelling and swearing. Walking around. Resident goes up to other resident's faces and yells/swears at them. 2/16/2020 16:59 (4:59 PM) Nurses' Notes .(Unidentified Resident #1) was screaming at the end of the hallway. Aide and writer ran to both residents. Aide observed (Resident #701) swinging his arms at (Unidentified Resident #1). (Unidentified Resident #1) had their arms up as well. Aide and writer separated the two residents. When (Unidentified Resident #1) was asked what happened. They stated, what is wrong with him. He grabbed my arm. He's trying to hit me. [MEDICATION NAME] (prn/as needed) was administered to (Resident #701) Writer called administrator. Administrator said to petition him out 2/22/2020 13:42 (1:42 PM) Nurses' Notes .resident wandered into rm (room) 305-1 where he punched her in left shoulder after she yelled at him to leave. doctor, wife, administrator notified. resident sent to (hospital) in stable condition. 2/25/2020 04:42 (AM) .Behavior Note .Resident yelling in staff face and yelling at residents. 2/25/2020 15:56 (5:56 PM) .Behavior Note .Writer observed (Resident #701) put his hands around (Unidentified Resident #2) Unclear how the altercation started. 2/26/2020 19:35 (7:35 PM) .Behavior Note .(Resident #701) went to room [ROOM NUMBER]. when the (Unidentified Resident #3) told him to go out from her room he hit her on her legs with his hands. Later he went to room [ROOM NUMBER] and hit (Unidentified Resident #4) on her foot with chair. When writer accompanied with another nurse went to room [ROOM NUMBER] (Resident #701) was holding chair in his hands and when asked (Unidentified Resident #4),she voiced that (Resident #701) hit her on foot with chair. 2/26/2020 21:00 (9:00 PM) Nurses' Note .This resident hit the (Unidentified #3 & #4) resident . Send him out for Psych evaluation . 2/26/2020 22:49 (10:49 PM) .Behavior Note .Resident was very aggressive and agitated. He hit 2 residents . 2/29/2020 22:53 (10:53 PM) .Behavior Note .A one on one has been with the resident all day. Resident continues to yell, swear, and get agitated towards other residents and staff. 3/1/2020 17:29 (5:29 PM) .Behavior Note .Resident continues to yell and swear at residents and staff. Resident has a one on one . 3/2/2020 01:29 (AM) .Behavior Note .Resident continue to be combative to staff and yell at residents and staff. No 1 on 1 supervision at this time. Progress Notes indicated Resident #701 was yelling/swearing and/or combative to other residents on 3/2/20-3/4/20. 3/5/2020 19:06 (7:06 AM) .Behavior Note .Resident continues to yell and swear at other residents and staff. Resident gets near resident's and staff's faces. Also, continues to wander into other resident's rooms. Resident charged at resident aide this afternoon . 3/6/2020 02:13 (AM) . Behavior Note . Resident combative with staff. Continues to yell at staff and residents. Continues to try and go in other residents rooms . 3/6/2020 10:13 (AM) . Behavior Note . Resident combative, punched writer in the breast and stomach. Non-redirectable . 3/6/2020 16:44 (4:44 PM) Nurses' Notes . Resident extremely combative, attempting to hit staff, attempted to throw pill crusher at staff, attempted to choke writer. Resident screaming at staff. Very difficult to redirect . During review of Progress Notes, a 1:1 (one on one supervision) was noted to be with Resident #701 only during the dates of 02/27/2020-02/29/2020. A record review of the Care Plan for Resident #701 revealed the following: Focus-BEHAVIOR: The resident is verbally aggressive. He may swear and yell at other residents and staff. Resident becomes easily agitated with other residents and at times when there is loud noise. Resident ambulates independently and in and out of rooms. Can become physically aggressive when redirected. Resident is impulsive, and has poor safety awareness. Resident has diminished sense of others personal space and surroundings. Resident may become physically aggressive towards other residents when they yell at him for being in their rooms. Resident may have sporadic outbursts of anger, in which he may become physically aggressive towards residents and staff. Resident is combative with care. Date Initiated: 04/22/2020. Goal-The resident will verbalize understanding of need to control verbally abusive behavior through the review date. Revision on: 05/05/2020 Interventions- Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Redirect resident as needed to decrease chance of altercation between resident and other residents. resident has 1:1 r/t aggressive behaviors (Date Initiated: 02/27/2020) when agitated offer snacks, cookies chips have activity evaluate for structured activity Focus-physically aggressive or agitated r/t (related to) (left blank) Date Initiated: 04/22/2020. Interventions-Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/08/2020. On 07/08/2020 at 1:34 PM, Social Worker (SW) A was queried in regard to the aggressive behaviors and interventions for Resident #701 and stated, He was having some behaviors. We would petition him out and the hospital would send him right back. So, we petitioned him to neuropsych in Indiana. That was the only place that would take him. He went there and then came back and ended up going to the hospital and passed away there. He was seen (by psych) five times in January and five times in February. SW A was asked about allowing Resident #701 to come back to the facility knowing his aggressive behaviors towards other residents and stated, We took him back to the facility because we promised (to neuropsych facility) we would take him back, we had to sign a paper. SW A was queried in regard to not placing 1:1 supervision for Resident #701 sooner, knowing the physical aggressive behaviors that the resident had. SW A stated, That is a nursing judgement, I don't know. On 07/08/2020 at 2:22 PM, the Nursing Home Administrator (NHA) along with the Director of Nursing (DON) were both queried in regard to the behaviors and interventions for Resident #701. The NHA stated,We weren't here then (in charge at the facility), I can't really say what their (previous administration) thoughts were. The NHA and DON were queried in regard to placing 1:1 several weeks after Resident #701 had displayed, daily aggressive behavior towards staff and other residents but provided no explanation. Resident #702 On 07/07/2020 at 9:47 AM, Resident #702 was observed lying in bed, awake. Resident #702 was alert and oriented to person and had clear speech clear. Resident #702 was pleasant and was queried in regard to any altercations that they may have had with other residents in the facility and stated that they did not recall any incidents. A record review of the MDS assessment dated [DATE] revealed that Resident #702 had a BIMS score of 03/15, indicating a severe cognitive impairment and had no mood or behavioral issues. The MDS also indicated that Resident #702 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/08/2020 at 1:53 PM, Resident #702 was up in the common area of the facility watching TV. A record review of the Progress Notes for Resident #702 revealed the following: 1/15/2020 16:18 (4:18 PM) . Behavior Note .Yelling back and forth with another resident . in common area. About to physical fight . 1/15/2020 19:08 (7:08 PM) . Behavior Note . Resident continues to start an altercation with another resident. Standing face to face with the other resident. Has hands in a fist. Resident stating, we can go. Separating both residents. Both residents are able to walk. 2/1/2020 18:52 (6:52 PM) . Behavior Note . (Resident #701) came in after writer to see what was going on with the yelling of another resident. (Resident #701) yelled at resident (#702). Resident (#702) walked past resident (#701) and swinged his right arm backwards and hit resident (#701) on his arm. 2/11/2020 12:45 (PM) .Behavior Note .Resident misinterprets other resident's actions like staring. Resident will say, 'why do you keep looking at me. Do we have a problem. I'll do something about it 2/25/2020 15:44 (3:44 PM) . Social Services .Note . Resident was alleged of touching other resident, resident will be moved from room . 5/19/2020 11:15 (AM) Nurses' Notes . Resident observed grabbing at another residents left arm with aggression. Writer got in the middle of the dispute and separated them both. Resident re-educated on how to handle his emotions more proficiently, and to always walk away from any dispute that upsets him Progress Notes revealed 1:1 supervision for Resident #702 only from 2/26/2020-03/11/2020. A review of Resident #702's Care Plan revealed the following: Focus-(Resident #702) has shown a history of exhibiting verbally aggressive behavior such as yelling and swearing at other residents or staff. Resident, at times, believes that his room and the unit is his house and other residents are trespassing. He may also interpret other residents looking at him or coming near him as a threat. He may be protective of others, especially women. He may try to start physical altercations and ball up his fists. He has exhibited wandering into other resident's rooms and choosing to urinate on the floor. Date Initiated: 02/03/2020, revision on: 03/10/202. On 07/08/2020 at 1:34 PM, SW A was queried in regard to the physical behaviors of Resident #702 and stated, He is really pleasant, confused. He was on the Dementia unit but we felt he wasn't good on the unit. We discussed it as a team and felt he was more agitated on that unit. He was protector of the women. We were afraid he would hit someone down there. A record review of the facility policy titled, Abuse Prevention Program, revised 02/28/2018. Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptom. (Collectively, hereinafter abuse) . Preventing abuse-Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to our residents, family members, resident representative, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Abuse Identification, Training and Education 3. Our abuse prevention/intervention education program includes, but is not necessarily limited to, the following: Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; .

This citation has two deficient practice statements. This citation pertains to intake: 2 Deficient practice statement #1. Based on observation, interview, and record review the facility failed to provide adequate monitoring and supervision to prevent an elopement from the facility for one sampled resident (R901) who has a [DIAGNOSES REDACTED]. Immediate Jeopardy (IJ) for Resident R901, started on 1/31/20 at approximately 9:00 AM, when R901 exited the rear of the building through an inactive alarmed door, into a large parking and delivery area. R901 entered a neighborhood business office on a major busy street that is approximately 0.3 miles from the facility, using a walker, wearing jeans, a sweatshirt, tennis shoes, and a wanderguard on their ankle. According to www.weather.com, the temperature low for that day was 26 degrees. The deficient practice resulted in the facility unaware that R901 had exited the facility until R901 was brought back by the local police at approximately 9:45 AM, and the likelihood for serious injury, harm, or death. Findings include: The Immediate Jeopardy (IJ) started on 1/31/20 and was identified on 2/20/20. The Administrator was notified of the Immediate Jeopardy on 2/20/20 at 12:25 PM and was asked for a plan to remove the immediacy. The IJ was removed on 2/21/20, based on the facility's implementation of the removal plan as verified onsite on 2/21/20. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. On 2/20/20 at 9:57 AM, during a phone interview, with a Local Business Employee (LBE). The LBE stated, (R901) came in (office building) and it took no time at all to put two and two together that (R901) was not a customer to pay (their) insurance policy. LBE further explained, that it took awhile to obtain (R901's) name. Coworkers got on the computer to locate the family of (R901), 911 was called. I had asked (R901) point blank if that's where (nursing facility) (R901) was coming from and (R901) said 'No', and (R901) made it clear that (they) didn't want to go back. The LBE was asked what R901 was wearing, LBE stated, Very little, a sweatshirt, blue jeans and a pair of tennis shoes, no coat, hat, gloves or boots. I believe (R901) had on multiple shirts because (R901) had on something else underneath it. It was freezing, it was quite cold. The LBE was asked if they could recall the date and time that R901 walked into their business office. The LBE stated, Three weeks (1/31/20) ago on a Friday morning. On 2/20/20 at 10:00 AM, R901 was observed in their room laying in bed. Resident #901's assigned sitter was observed in the room and a wanderguard bracelet was observed on Resident #901's right leg. Resident #901 was unable to be interviewed due to an impaired cognition. On 2/20/20 at 10:30 AM, Certified Nursing Assistant (CNA A) was asked if they were here at the time of the elopement. CNA A stated I was here, I had saw (R901) about 45 minutes before (they) must have left out. It was around 9:00 am. Next thing I know they said to do a head count and they couldn't find (R901) and they asked me where (R901) was. CNA A was asked how many aides were working on that shift. CNA A stated, Just me and another CN[NAME] On 2/20/20 at 10:33 AM, an observation was made with Maintenance Staff B of the two exit doors located on Unit 100. The doors were observed with two alarms, one on the push door handle, one on the top left corner, and no wanderguard system. Maintenance Staff B was asked to demonstrate how the alarms operated. Maintenance staff B opened the door, the alarms sounded, he turned off the alarms with the key, and turned the key again to activate the alarms. On 2/20/20 at 10:49 AM, the Maintenance Director was asked about the door that R901 eloped out of. The Maintenance Director stated, The door at the end of the hall. The Maintenance Director was asked what happened and stated, The panic door was unarmed. The Maintenance Director was asked if someone checked the doors that morning and stated, We had an employee (Maintenance staff C) that said he checked the doors. The Maintenance Director was asked if there was any documentation of door checks prior to the elopement and stated, He said he checked them. He was suspended pending investigation. The Maintenance Director was asked if Maintenance staff C returned to work and stated, He found another job. On 2/20/20 at 10:55 AM, the Administrator was asked if the facility had any video of the path R901 took outside of the building. The Administrator stated, No. We don't know what path (R901) took, the police brought (R901) back. Staff saw (R901) at 9 am. I interviewed the (LBE) and couldn't remember how long (R901) was there. (R901) was there for a bit of a time because they were trying to figure out who (R901) was. We watched the camera footage and we saw what he (Maintenance Staff C) did. The Administrator further explained, (Maintenance Staff C) opened the door, he closed the door turned the panic alarm off with his key and failed to turn it back on. Administrator stated, I went down there and opened the door, and it didn't sound. He turned them off, and never turned them back on again. He did the majority of the doors that day. We found other doors on the unit that were not turned on. He was suspended at the time but he chose to resign. On 2/21/20 at 10:41 AM, Nurse D was asked if they were the assigned Nurse for R901 on 1/31/20. Nurse D stated, Yes. I had seen (R901) walking up and down the hall. (R901) turned and said 'I take this with me?', referring to (their) walker, and I told (R901) yes, keep that with you at all times. I'm not sure if that was the last time anyone had seen (R901). I am not regularly scheduled on the unit, I was helping out and just passing meds. On 2/21/20 at 12:41 PM, Nurse H was asked about R901's elopement and stated, About 8:25am I gave (R901) meds, we talked a bit and then I saw (R901) walking down towards the 200 unit and come back. I continued passing meds. A review of the police report dated 1/31/20 was received from the local police department and revealed that they were dispatched to a local business, Regarding an elderly person, who walked into the building and was very confused. The report goes on to explain that R901 wandered into the business mumbling and upon learning the resident's name, local business staff looked up R901's family member and contacted them, who reported that R901 resides at the nursing home not far away from the local business. R901's family member spoke to the responding officer and explained that, (R901) has a GPS tracker on their ankle due to (R901) leaving (the nursing home) before. The responding police officer took R901 back to the facility and spoke to the Administrator who explained that the alarm did not sound but should have, and that they would have someone watch R901 more closely. A review of the facility's Incident and Accident report noted, Date of Incident 1/31/20. Name: (R901). Time of incident:8:45 AM. Condition prior to incident: Confused/Disoriented. Incident Type: Elopement. Brief Description: DON (Director of Nursing) alerted writer that Resident was outside the facility . Further review of R901's medical record revealed, R901 was admitted on [DATE] with [DIAGNOSES REDACTED]. R901's Minimum Data Set (MDS) assessment noted, R901 required physical assistance from staff for activities of daily living and with an impaired cognition. A review of R901's care plan revealed, Focus: The resident is (SPECIFY: an elopement risk/a wanderer/wants to go home) r/t (related to) Disoriented to place, Impaired safety awareness Date Initiated: 11/04/2019. The resident is an elopement risk r/t Disoriented to time and place, Impaired safety wareness (awareness). Resident has Dx (diagnosis) of Dementia. (R901) is known to take (R901) wanderguard off and misplace it. This resident will admit that (R901) takes it off. Date Initiated: 11/04/2019. Revision on: 11/04/2019. Next revision included the above focus areas with an addition of, I walk around with my walker and have eloped before (today) Revision on: 01/31/2020. Goal: The resident will not exit the facility or enter an unsafe area unattended through the review date. Date Initiated: 11/04/2019. Revision on: 01/31/2020. Interventions: 1:1 supervision related to unsafe wandering. In place since elopement on 1/31/2020. Date Initiated: 02/05/2020. Identify pattern of wandering. (e.g. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise?) Intervene as appropriate. Date Initiated: 11/04/2019. Maintain consistent daily routine and consistent bedtime routine Date Initiated: 11/04/2019. Make frequent observations of my whereabouts, redirect me when I approach an exterior door Date Initiated: 1/31/2020. Revision on: 01/31/2020. Observe my whereabouts at all times. Date Initiated: 01/31/2020. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs pictures and memory boxes. Date Initiated: 11/04/2019. A review of R901's progress notes revealed the following: 10/7/2019 12:29 (PM) Nurses Note Text: Increased confussion (confusion) noted. Resident is restless and pacing the hallway back and forth. Denies any discomfort. afebrile . 10/15/2019 16:03 (4:03 PM) Nursing Evaluation Summary Late Entry: Note Text: Resident occasionally gets confused, attempts a couple times to work (walk) out of the door. 11/11/2019 08:25 (AM) Nurses' Notes Text: LATE ENTRY: Approx. (approximately) around 0655 (6:55 AM) door alarm sounded, when this writer went to see why door alarm was going off res (resident/R901) was observed being brought back into (facility) by staff . Administrator notified of incident. Res is in bed resting at this time, bed is in lowest position call light within reach. wctm (will continue to monitor). 11/11/2019 09:36 (AM) Nurses' Note Text: Q (every) 15 min (minutes) checks implemented every shift. The care plan was not updated to reflect the 11/11/19 exit of the building or the implementation of 15 minute checks. 1/31/2020 08:25 (AM) Nurses' Note Text: Resident accepted (their) morning medications from writer at approximately 8:25 am. Resident was seen in the hallway with walker walking around as (they) normally do daily. Resident at the time was alert and orient X (times) 2. Will continue to monitor. 1/31/2020 10:35 Nurses' Note Text: The DON (Director of Nursing) informed the writer that the resident left facility. The resident return to (their) room and (R901) now has a 1:1 sitter that was provided upon returning to the building. The resident vitals were done . A skin and pain assessment evaluation was done and there were no abnormal findings and no pain is noted. Notification to the family and a message was left to call the facility back regarding this matter. On 2/21/20 at 2:00 PM, the Director of Nursing (DON) was asked where 15 minutes checks are documented. The DON indicated that they are not documented because they are like a check and change. The DON was asked how does the facility know that they are being implemented, and explained that the Nurses are to ensure and verify that they are done by CNAs. A review of R901's Nursing Admission Evaluation dated 4/15/2019 revealed, Risk of Elopement/Wandering Review. Risk factors (checked) Yes, Resident cognitively impaired with poor decision-making skills. Does resident have a pertinent [DIAGNOSES REDACTED]. Elopement History was (checked) No. Continued review of R901's Risk of Elopement/Wandering Assessments noted three total assessments; #1. 8/1/19- Summary of Review Resident is at risk for elopement/wandering at this time. (Checked) Yes. Elopement/wander risk as evidence by: resident was in the courtyard trying to get people to take (R901) home. #2. Dated 10/08/19 - Summary of Review Resident is at risk for elopement/wandering at this time. (Checked) Yes. Elopement/wander risk as evidence by: non goal oriented wandering. #3. 1/31/20 - Summary of Review Resident is at risk for elopement/wandering at this time. (Checked) Yes. Elopement/wander risk as evidence by: resident left the faciity on [DATE]. Resident is on a 1:1 and has a working wanderguard on. A documented assessment after R901 got out of the building on 11/11/19 was not completed. On 2/21/20 at 3:08 PM, the Administrator was asked if R901 was on 15 minute checks at the time of the elopement and where are the checks documented. The Administrator stated, I would have to assume that (R901) was still on them. The Administrator was asked when Elopement assessments are to be completed. The administrator stated, Admission, quarterly, and as needed. A review of the facility's policy titled, Unsafe Wandering & Elopement Prevention Protocol Missing Resident Protocol dated, (MONTH) (YEAR), noted, Policy Statement: Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Nursing personnel must report and investigate all reports of missing residents. 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. 3. Interventions for unsafe wandering and elopement attempts will be entered onto the resident's care plan and medical record. 4. Should an elopement episode occur, the contributing factors, as well as the interventions' tried, will be documented on the nurses' notes. Abatement Plan Immediate Facility Action: F689 Elopement Element 1 Resident: #901 DOB (date of birth): BIMS (Brief Interview for Mental Status): 3 Diagnosis: [REDACTED]. Major [MEDICAL CONDITION], Dysphagia, Metabolic [MEDICAL CONDITION]. On (MONTH) 31, 2020 at approximately 9:45am the Sterling Heights Police Department brought Resident #901 back to the facility. It was identified through the investigation that Resident #901 was found at the (Insurance business) Office that is 0.2 miles from the facility. Case Number: 20- Upon return, Resident #901 was immediately assessed by a licensed nurse including Skin and Pain. She was immediately placed on 1 on 1 supervision. Resident #901 was reassessed for elopement risk and the care plan has been reviewed and revised to include 1 on 1 supervision by the DON on 1-31-20. Element 2 1. A resident roster was obtained and all residents' whereabouts were accounted for on 1/31/20. 2. Current residents were re-assessed via a new elopement assessment by a licensed nurse on 1-31-20 23 out of 241 residents are deemed to be at risk for elopement by 5:00pm. Residents identified were placed on added supervision e.g. 15 minute checks as indicated by the assessment. There were no new residents identified as an elopement risk at the time of the assessment 3. Of the 23 Residents deemed at risk for elopement, their care plan has been reviewed and updated by a licensed nurse on 1-31-20 by 5pm to include any changes or updates to their careplans requiring added supervision as indicated 4. Residents that are at risk have had their care plan reviewed and updated as necessary by a Licensed Nurse on 1/31/20. 5. Residents on admission are assessed for elopement. In the event that they are identified at risk, their careplans are updated as indicated to include interventions to keep them safe. - 15 minute checks, use of a wanderguard bracelet etc. 6. Door alarms checked for function by the Director of Environmental Services and Regional Director of Operations (RDO) on 1/31/20. Any areas of non-compliance were addressed at the time of observation. The non compliance identified was that 2 x doors on 100 unit were identified to have their panic alarms turned off and their screamer alarms either turned off or batteries requiring replacement. Those doors were addressed at the time of observation and all other doors throughout the facility were checked for compliance on 1/31/20 7. The Elopement Risk Binders were reviewed by SW (Social Worker)/Licensed Nurses to assure that all residents at risk for elopement are listed in the book and have a Resident Wandering Elopement Risk Identification sheet which was confirmed by the Administrator on 1/31/20. The elopement risk binders are located on each unit, at reception and in the therapy office. Element 3 1. The Wandering and Elopement Prevention Protocol / Missing Resident Protocol was reviewed by the Regional Director of Operations, Regional Director of Clinical, and Administrator on 1.31.20 and deemed it appropriate. The facility's Door Alarm protocol is present in the facility TELS computer program. The Environmental Service Director is responsible for ensuring that the maintenance workers check the door alarms daily and record their alarm checks in TELS. The Environmental Services Director checks the door alarms 3 x per week on random shifts to ensure compliance. 2. 22 out of 49 Licensed nurses, 27 out of 83 - Certified Nursing assistants, 35 out of 127 ancillary staff were re-educated on the Unsafe Wandering and Elopement Prevention Protocol / Missing Resident Protocol by the DON/SDC/Designee on 1/31/20. Any staff not educated by 1/31/20 will be provided with education prior to being allowed to work. Staff were fully educated by 2/6/20 3. An Elopement Drill was performed on 1/31/20 and staff responded to the door alarm appropriately. Elopement Drills are completed monthly and more often as indicated 4. 3/3 Maintenance Staff were educated on the process for checking the door alarms accurately by the Environmental Services Director on 1/31/20. Any staff not educated by 1/31/20 was educated prior to being allowed to work. 5. Residents deemed at risk for elopement who attempt to leave the building unattended will have their care plan updated. Resident will be reviewed in morning clinical M-F by the IDT, and placed in behavioral Standards of Care Meeting (S[NAME]). 6. Door alarms are checked daily by a member of the maintenance staff, and 3 times a week by the Director of Environmental Service at random Element 4 The Administrator or designee will audit 5 doors per week to ensure that the door alarms are functioning for 4 weeks and then monthly there after. Ongoing frequency of door monitoring will be determined by the QAPI Committee. The Administrator is responsible for sustained compliance. Deficient Practice Statement #2 Based on observation, interview and record review, the facility failed to follow elopement care plan interventions by falsely documenting that a resident at risk of elopement had on a wanderguard (a monitoring device for residents at risk of elopement), and failed to develop a care plan that reflects the accuracy of a resident at risk of elopement for two sampled residents (R902 and R903) of five sampled residents reviewed for accidents resulting in, inadequate monitoring and the potential for unmet safety precautions. Findings include: R902 On 2/20/20 at 10:55 AM, the Administrator provided a list of residents within the facility who had wanderguards. The administrator explained that there was one resident who refused to wear their wanderguard, and that was R902. On 2/20/20 at 12:30 PM, R902 was observed walking out of the dining room with a bag of personal belongings. An attempt to interview R902 was made however, they were unable to answer questions as they were confused. There was no wanderguard observed on the resident. A review of R902's medical record revealed that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R902's Minimum Data Set assessment ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 6/15 indicating a severely impaired cognition. Further review of R902's medical record revealed a care plan with the following, Focus: Resident at times can appear to be at risk for elopement R/T (related to) preferring for (R902) belongings to be packed in bags at (R902) bedside. Date Initiated: 02/04/2020 Revision on: 02/04/2020. Interventions: Wander alert bracelet. Date Initiated: 02/04/2020 Revision on: 02/04/2020. On 2/21/20 at 3:07 PM, an interview was completed with both the Administrator and Director of Nursing in regards to R902 not having a wanderguard in place. They explained that they have attempted to apply it but that they refuse to wear it. They were asked if this should be reflected in the care plan, and they provided no explanation. A review of R902's medical record did not reveal refusals of a wanderguard and/or attempts to remove one. R903 On 2/20/20 at 2:48 PM, R903 was observed laying in bed. R903 was interviewed about their stay in the facility and whether or not they had a wanderguard on their ankle. R903 stated, No, there's nothing on my ankle. An observation was made of both R903's ankles, and there was no wanderguard noted. A review of R903's medical record revealed that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R903's MDS assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 11/15 indicating a moderately impaired cognition. Further review of R903's medical record revealed a care plan dated with the following,Focus: COGNITION/COMMUNICATION/ELOPEMENT: Hi, My name is (R903) and I am AOX2-3 (alert and oriented) with some confusion . I do want to go home, so I am an elopement risk. Date Initiated: 12/23/2019 Revision on: 01/31/2020. Focus: The resident uses wander guard r/t (related to) exit seeking behavior. Date Initiated: 12/23/2019 Revision on: 12/23/2019. Interventions: WANDER ALERT and/or Personal Alarm: Wanderguard Date Initiated: 12/23/2019 Revision on: 12/23/2019. On 2/21/20 at 10:35 AM, Nurse J was asked to check the placement of R903's wanderguard. Upon entering the room, Nurse J checked R903's ankle and did not observe the wanderguard. R903 was asked by Nurse J where their wanderguard was located, and R903 stated, I cut it off a day or two ago with a pair of scissors. Upon looking in R903's nightstand, the cut wanderguard was located in the bottom drawer under other items. R903 was asked where they obtained scissors, and they stated, They're mine. A review of R903's medical record revealed the following order on 12/21/19, Check placement and function of wanderguard. Location Right Ankle every shift. A review of R903's (MONTH) Medication Administration Record [REDACTED]. On 2/21/20 at 11:31 AM, an interview was completed with Nurse F, assigned nurse for R903 on 2/20/20. It was brought to Nurse F's attention that R903's wandergaurd had been documented as in place on their shift. Nurse F was asked if they had checked the placement of R903's wanderguard on 2/20/20, and they stated, No. On 2/21/20 at 12:00 PM, an interview was completed with the Administrator in regards to their thoughts and expectations for R903's missing wanderguard, and they stated, I immediately sent my team to make sure everyone has a wanderguard . (R903) has on one now .I'm concerned about it but I didn't find out about it until today. On 2/21/20 at 3:07 PM, an interview was completed with both the Administrator and Director of Nursing were asked whether or not staff should be documenting that a resident's wanderguard is in place without checking, and they stated, No. A review of the facility's Unsafe Wandering & Elopement Prevention Protocol Missing Resident Protocol policy with a review date of 1/2019 outlined the following, 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. 3.Interventions for unsafe wandering and elopement attempts will be entered onto the resident's care plan and medical record.

This citation pertains to intake # 7. Based on observation, interview and record review, the facility failed to complete elopement assessments, implement interventions and provide adequate monitoring and supervision to prevent multiple and prolonged elopements from the facility, and/or failed to locate the missing residents for three (#'s 707, 708, and 711) of five residents reviewed for elopements, resulting in the likelihood of serious harm and/or death. Immediate Jeopardy (IJ) for Resident #707, who is cognitively impaired, exiting the building on 8/31/19 at approximately 6:00 PM - 7:00 PM and being found without shoes, crossing the middle of a busy intersection (15 Mile Road and Moravian). Resident #708 being gone from the facility from approximately 2:00 PM on 9/28/19 until 2:00 PM on 9/29/19 with facility staff being aware that the resident left the building and not attempting to locate the resident until 7:00 AM on 9/29/19. Resident #711 observed outside in the parking lot pushing their wheel chair toward 15 Mile Road on 8/7/19 at 9:45 PM. The Immediate Jeopardy (IJ) started on 8/7/19 and was identified on 10/8/19. The Administrator was notified of the Immediate Jeopardy on 10/8/19 and was asked for a plan to remove the immediacy. The IJ was removed on 10/9/19, based on the facility's implementation of the removal plan as verified onsite on 10/9/19. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with the likelihood of actual harm that is not immediate jeopardy. Findings include: Resident #707 On 10/8/19 at 12:43 PM, Resident #707 was observed dressed and groomed sitting in a chair in the dining room. Resident #707 was asked if they could go out of the facility if they wanted to and stated, Not no more. Resident #707 was asked if they had ever exited the facility (without staff permission) and smiled and stated, I had four dollars, I just wanted to go to the corner to get a pop and cigarettes, they (the facility) came and got me. Resident #707 was asked what was the date and time of the incident and stated they did not remember the date but said it happened around six at night. Resident #707 was unable to explain how they were able to get out of the facility but then stated, They put a card that goes on my leg, I cut it off. Resident #707 verified this by lifting up both their pant legs to demonstrate there was no bracelet on either ankle. Resident #707 then explained that it was time for them to smoke and stood up and independently walked to the area where the residents who smoke cigarettes go outside. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #707 was admitted to the facility on [DATE], and then readmitted to the faciliy on 9/12/19 with the [DIAGNOSES REDACTED].#707 had a Brief Interview for Mental Status (BIMS) score of 10, indicating a moderately impaired cognition and was independent with ambulation (walking). A record review of the Elopement care plan for Resident #707 initiated 9/4/19 revealed the following: Focus- The resident is an elopement risk related to impaired safety awareness Interventions- Maintain consistent daily routine and consistent bed time routine Wander alert to right ankle There were no other interventions care planned for elopement. A record review of the progress notes for Resident #707 revealed the following: 5/16/2019 15:07 (3:07 PM) Social Services Progress Notes .met resident on a 1:1 basis, resident is very oddly confused/ behaviors. SW (social worker) asked (Resident #707) what color their shirt was and they could not tell me they said, I don't even know, I asked them what the bed was and they said red .resident is very confused, poor historian with no family. SW to continue to monitor. 8/27/2019 10:19 (AM) Social Services Progress Notes .They come to our office wants to know where their cat is, and where Fred is, they want us to find him and bring him to them .continues to hallucinate and walk to our office asking about this 'Fred' guy. SW to continue to monitor. 8/31/2019 19:11 (7:11 PM) Nurses' Notes .Resident found wandering on 15 mile road, no shoes on only socks, (Resident #707) was brought in by incoming staff in the car. Monitoring for behavior. NS (nursing supervisor) was notified. Authored by Nurse [NAME] 8/31/2019 20:59 (8:59 PM) Nurses' Notes .Clarification: Resident was observed walking on the sidewalk of 15 mile road near facility at approximately 19:00hrs (hours) this tour. Resident given a ride to the facility by a staff member at that time. Resident reported that they were going for a walk to the store on the corner. Resident was observed leaving the facility and explained that they went out without shoes because it is a nice day. Resident educated on proper procedure for being signed out for leaves. Resident verbalized understanding. Authored by Nurse B. 9/4/2019 11:13 (AM) Social Services Progress Notes .Follow up from resident being outside, no psychosocial needs noted. Resident is a little agitated and keeps coming to social work office .Resident is sitting on couch and they can ambulate themself. (Resident #707) is very confused. SW to continue to monitor. 9/9/2019 19:32 (7:32 PM) Progress Note .Resident going out of front door with staff trying to redirect resident back iin (sic) building resident taking off running with staff unable to redirect resident back in building staff continues at side, resident stated they have to go and get their kids .resident returns to the building with staff administrator and MD (medical doctor) phoned new order obtained to transfer to .Hospital for mental status changes from MD .ambulance notified of transfer, endorsed to incoming nurse will continue to frequently monitor until transfer. 9/9/2019 20:02 (8:02 PM) Nurses' Notes .Resident transported to (Hospital) due to altered mental status change, elopement risk. Resident's MD and RP (responsible party) notified . 9/24/2019 04:19 (AM) Nurses' Notes .Resident returned to facility safely. No distress noted. Administrator and supervisor made aware. Resident on Q (every)15 minute visual checks. Easily re directed. Resident refuses to wear wanderguard (bracelet that alerts exit doors to alarm when near an opened door). Resident currently in bedroom resting with eyes closed. Safety maintained. Will continue to monitor. On 10/8/19 at 1:20 PM, an unknown staff member was asked to inform use of the code to get out the front door, the staff member loudly stated, Oh, sure, the code to get out is star, two, three, four! The staff member punched in the code and the door opened automatically. There were six residents around the front door/lobby area when the staff member stated the code out loud to open the door. On 10/8/19 at 2:00 PM, an interview was completed with the Administartor in regards to Resident #707 exiting the building on 8/31/19 and stated, Staff saw (Resident #707) exit and leave. They asked where (Resident #707) was going and they said they were going to the store to buy some cigarettes. The Administrator was queried to how Resident #707 got out of the building (if staff saw the resident) and stated, We looked at the camera, we could not tell how they got out. The Administrator was asked if Resident #707 had punched in the code to exit the door and stated, I am not sure, they were by the code (box) but not sure how they got out. The Adminstrator was queried as to how Resident #707 exited the building on 9/9/19 and explained that the resident had exited through the front door and then stated, Staff were chasing (Resident #707). They (Resident #707) didn't want to come in. As far as know, someone seen (Resident #707) get out. We put a wanderguard on their right ankle. The Administrator was queried about the exit on 9/24/29, but did not provide an explaination on how Resident #707 exited the facility on that occasion. On 10/8/19 at 2:19 PM, an interview was completed with Nurse GG via telephone regarding Resident #707 exiting the buidling on 9/9/19 and stated, I was punching out and they came and got me to help get (Resident #707) in the building. (Resident #707) was running. I could not catch up with them to be honest, one of the younger nurses was able to get them. On 10/8/19 at 2:25 PM, Nurse A was interviewed via telephone in regards to Resident #707 being found outside by her on her way in to work. Nurse A stated, I was coming (in a car) into work on Moravian. I was about to turn right on to 15 Mile Road and I seen a resident with no shoes on walking across 15 Mile Road. I had to make a U-turn and swing around to get (Resident #707). (Resident #707) was confused. I had not been familiar with (Resident #707) but they looked like a resident. I got them in the car and brought them in the building. They didn't give me any issues at all (getting in to her car). Nurse A was queried as to what she did once she got back to the facility and stated, I took (Resident #707) to their nurse. They (the nurse and staff) were very surprised (that the resident was outside in the road). They did not know that the resident was outside. Nurse A was asked if there was any staff outside looking for the resident when she saw the resident and brought the resident back to the facility and stated, There was no staff outside. Nurse A was asked if the intersection in which she found Resident #707 at was busy with traffic and stated, Yes, there was traffic present. Nurse A was asked if it was dark out and stated, No, it was sunny out still. Nurse A was asked if any of the administrative staff had followed up with her or got a statement from her following the incident and stated, No. On 10/8/19 at 3:33 PM, the Administrator was queried again about the elopement on 8/31/19 with Resident #707. The Administrator was asked how long Resident #707 was outside of the building on 8/31/19 and stated, Five to ten minutes. The Administrator was asked again how Resident #707 exited the building and stated, Through the front door, (Resident #707) is pretty alert, (Resident #707) probably pushed the code (to exit the building). The Administrator was asked where the resident was located and stated, (Resident #707 was seen going out of the facility. They were up near the party store and one of the nurses brought them back. The Administrator was asked if the door codes to exit the buildings were changed since the elopements and stated, No. The Administrator was asked if any staff members that were working had went outside and tried to retrieve Resident #707 when they exited the building on 8/31/19 and stated, No. On 10/9/19 at 7:38 AM, Nurse B (the midnight supervisor) was queried via telephone about the elopement of Resident #707 on 8/31/19 and stated, What happened was the (Nurse A)came and told me that she has picked up our patient. She said that (Resident #707) was at the corner of 15 Mile Road and Moravian, which is two buildings down. So, once she brought her back I went down to talk to the resident and asked (Resident #707) where they went and (Resident #707) told me that they just went up to the store and it was not big deal. I asked them why they weren't wearing shoes and (Resident #707) told me because it was warm out. I told (Resident #707) that they need to tell us when they are going out and I put a code bracelet (wanderguard) on that night because I didn't know if they were going to attempt to do that again. Nurse B was asked if the staff that was on duty knew that Resident #707 had been missing and stated, Nobody knew (Resident #707) left the building. When asked how long the resident had been outside, Nurse B stated, Well, the oncoming nurse brought them in, so some time before seven (PM). Nurse B was unaware of how long Resident #707 was outside. On 10/9/19 at 8:00 AM, the distance Resident #707 walked from the front door to the intersection they were found at was registered at 0.4 miles. On 10/9/19 at 9:48 AM, Nurse B was asked via telephone if the elopement protocol was followed for the 8/31/19 incident with Resident #707 and stated, We did not call a Doctor (Dr.) Walker (a made up doctor name that is paged over head by staff in the event of a missing resident) on (Resident #707) because we were not aware they were missing, if we had known we would have called it but the first time we were aware they were missing was when (Resident #707) was brought back to the facility. On 10/9/19 at 1:57 PM, the Director of Nursing (DON) was queried in regards to the elopement of Resident #707 on 8/31/19 and the procedure for missing residents and stated, I am supposed to be called. The staff are supposed to initiate Dr. Walker, everyone is supposed to stop and go and look for the individual. If they are not found, we get a description of the resident and call the police. If you see them go out, ask them to come in. The DON was asked how often staff should be checking on residents and stated, We like to keep an eye on the residents at least every two hours. If they get out, we lauch an investigation to find out how they got out, when was the last time they were checked on, where were they seen last and we look at the cameras. The DON was asked who would intiate that investigation and explained that she would and that an incident report would be filled out. The DON was asked if she had investigated the incident of Resident #707 being observed in the street on 8/31/19, and stated, I was not aware of the incident. Resident #711 A record review of Resident #711's progress notes revealed the following: 5/12/2019 01:34 (AM) Nurses' Notes .Resident woke up confused and walked out of exit door end of hall close to their room. Cna (Certified Nurse Aide) and writer brought resident back into their room. Writer reoriented patient to time, place, and situation .Writer will contiue to monitor. 6/6/2019 14:52 (2:52 PM) Progress Note .Observed packing all of their belongings, and placing on w/c (wheel chair), headed towards the door. When asked what (Resident #711) is doing, they stated, I'm leaving, I'm going home. CNA also stated that, two days prior, they attempted to go out side door, sounding the alarm. Code alert place to right ankle. Cooperative with placement. 8/7/2019 02:37 (AM) Nurses' Notes .Resident received at approx (approximately) 7:00/p (PM) in their room with all of their clothing and belongings thrown all over the floor. Writer asked resident what happened. Resident stated that they didn't know. Writer then administered HS (hour of sleep) medication and left room. Resident then came out of room and joined other residents in common TV (television) area. At approx 9:45/p (PM) resident observed outside in parking lot pushing their wheelchair toward 15 Mile Road. Staff observed resident and redirected resident back into building. Resident became physically violent and combative with several staff members as they were attempting to return them to the unit. Assigned nurse met resident and staff in hallway near front entrance door and asked resident where they were attempting to go. Resident replied 'Away from here to my home'. Assigned nurse explained to resident that they live here now and that they will take (Resident #711) to their room. Resident stated that they do not live here and began to swing at nurse as she attempted to push their wheelchair. Resident then planted their feet firmly on the floor and stated 'I'm not going back there and you can't keep me here against my will.' Nurse then contacted administrator to report resident having been in parking lot and their desire to leave facility tonight. Nurse made administrator aware that she was petitioning resident out for psych (psychiatry) evaluation. Police called . A record review of the MDS assessment dated [DATE] revealed that Resident #711 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #711 had a BIMS score of 09, indicating an impaired cognition and needed limited assistance with ambulation. A record review of the Elopement care plan (initiated 5/13/19) for Resident #711 revealed the following: Focus- The resident is an elopement risk r/t (related to) Disease process alzheimers Interventions- Maintain consistent daily routine and consistent bedtime routine There were no other interventions care planned for elopement. A record review of the Risk of Elopement/Wandering Review dated 5/13/19 revealed the following: Elopement History-2. Leaving facility without supervision when supervision required Answer marked Yes # of times Answer marked 1 Resident is at risk for elopement/wandering at this time Answer marked yes with a notation stating, resident trying to leave through emergency exit door. On 10/9/19 at 10:55 AM, the Administrator was asked about the details of Resident #711's incident and how Resident #711 exited the building on 8/7/19. The Adminstrator was unable to provide any information about the incident and no investigation was provided by the end of the survey. On 10/9/19 at 11:07 AM, an attempt was made to interview the nurse who authored the note on 8/7/19; a voicemail message was left but no phone call was returned by the end of the survey. On 10/9/19 at 2:04 PM, an attempt was made to interview the DON. The DON was asked how Resident #711 exited the building on 8/7/19 and stated, I am not aware of that elopement. A review of the facility policy titled Unsafe Wandering & Elopement Prevention Protocol Missing Resident Protocol revised (MONTH) of (YEAR) revealed the following: Policy Statement-Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 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. 3. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes . 4. Interventions for unsafe wandering and elopement attempts will be entered onto the resident's care plan and medical record. 5. Should an elopement episode occur, the contributing factors, as well as the interventions' tried, will be documented on the nurses' notes. 6. 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 attemptig to leave the premises, or suspected of being missing, to the licensed nurse in charge as soon as practical. Resident Observed Leaving the Premises-2. Should an employee observe a resident leaving the premises, he/she should: b. Obtain assistance from other staff members in the immediate vicinity . 3. Upon return of the resident to the facility, the Director of Nursing Services or Charge Nurse should: d. Complete and file an incident report; and e. Make appropriate notations in the resident's medical record. f. Complete an elopement assessment . Discovery of Missing Resident-4. Should an employee discover that a resident is missing from the facility, he/she should: a. Determine if the resident is out on an authorized leave of pass .1. The Licensed nurse will assign a staff member to begin a head count of all current residents . Nursing Services Duties Upon Return Of Missing Resident-5. Upon return of the resident to the facility, the Director of Nursing Services or Charge Nurse should: e. Complete and file an incident report; and f. Complete an elopement assessment. g. Make appropriate entries into the resident's medical record. Resident # 708 Record review revealed Resident #708 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required supervision to limited assistance to perform Activities of Daily Living (ADLs), and was able to propel themselves in a wheelchair independently. An interview was conducted with Resident #708 on 10/8/19 at 10:10 AM in their room. The Resident was observed sitting in a wheelchair without footrests. When queried regarding their ability to ambulate, Resident #708 indicated they were not able to ambulate very far because they had fractured their hip and stated, I get around in the wheelchair. Resident #708 further revealed they are able to self-propel themselves in the wheelchair outside. When asked how they exit and enter the building, Resident #708 stated, I know the door codes. Resident #708 proceeded to state the current codes for all the entry/exit doors of the facility. When queried how they knew the door codes, Resident #708 replied, Everybody (facility Residents) know them (codes), even the people who aren't supposed to. Review of Resident #708's care plans revealed the following care plans and interventions: -Potential for activities of daily living assistance related to: generalized weakness and gait/balance deficits (Initiated: 5/21/19; Revised: 9/9/19) -The resident has a potential for falls related to: Balance deficits. (Initiated: 9/4/19; Revised: 9/9/19) -The resident has an alteration in musculoskeletal status. (Initiated: 5/21/19; Revised: 8/20/19) Resident #708 did not have a care plan in place pertaining to Leave of Absences (LOA) from the facility and/or elopement. Review of Resident #708's Electronic Medical Record (EMR) documentation on 10/8/19 revealed the following Nurses' Notes: -9/29/19 at 7:55 AM: During the beginning of the evening shift if was brought to this writer's attention that this resident was gone throughout the day. This writer called the administrator after no one had seen the resident all evening. The administrator instructed this writer to keep her informed if the resident returned, which she had not, even by the morning shift. This resident is own responsible party and did not sign self out in the LOA book. The supervisors on the morning shift as well as the administrator were informed. -9/29/19 at 9:01 AM: Writer was informed by outgoing nurse and several staff members that resident was seen between 2 PM-3 PM 9/28/19 exiting the building. Writer initiated a facility wide search for resident, covering all areas of the building and the grounds of the facility. Resident was not located. Writer attempted to contact resident via cell phone number on file with unsuccessful attempt only reaching voicemail. Administrator and Medical Director was immediately contacted and informed of resident exit of the building. Writer notes that the resident is A/O X 4 (Alert and Orientated to person, place, time, and situation), able to make all needs known, self ambulate well without problems and leaves the building daily by self. No whereabouts of resident is known at this time, will continue to monitor and follow up. -9/29/19 at 1:49 PM: Writer observed resident self-propelling alone in wheelchair toward main entrance of the facility. Writer immediately contacted Administrator and Medical Director and informed them of resident return. Medical Director ordered for resident to be educated on LOA, policies and procedures. Writer educated resident as ordered and resident verbalized understanding and they will remain in compliance with facility and physicians order. Will continue to monitor. Additional review of Resident #708's medical record revealed Resident #708 did not have an Elopement Assessment completed. On 10/8/19 at 12:48 PM, an interview was conducted with Nursing Assistant C. When queried regarding Resident #708, Nursing Assistant C stated, (Resident #708) is pleasant. When queried regarding Resident #708's location being unknown by facility staff on 9/28/19 and 9/29/19, Nursing Assistant C stated, Oh yeah, (Resident #708) was gone for over 24 hours and no one knew where they were. When queried if they worked on either 9/28/19 or 9/29/19, Nursing Assistant C revealed they did. When asked if facility staff searched for the Resident, Nursing Assistant C stated, The Supervisor started looking for (Resident #708) at around 7:00 in the morning (7:00 AM). When asked why facility staff did not begin to look for Resident #708 until 7:00 AM on 9/29/19, Nursing Assistant C indicated they were not sure. Resident #708's Incident and Accident Reports (I and A's) reports for the previous six months were requested from the facility on 10/8/19 at 9:00 AM. Review of provided I and A's revealed the Resident did not have an I and A related to their exit from the facility on 9/28/19 to 9/29/19. An interview was completed with Resident #708 on 10/8/19 at 2:10 PM. When queried regarding their absence from the facility from between 2:00 PM to 3:00 PM on 9/28/19 until 1:49 PM on 9/29/19, Resident #708 revealed they exited the facility through the main entry door in their wheelchair. When queried where they went, Resident #708 stated, I went and spent the night with my (sibling). When asked how far their sibling lived from the facility, Resident #708 stated, Near (X) Mile Road and (X) Road (20 miles from the facility to intersection per Google Maps). When queried how they exited the facility, Resident #708 stated, I know the door codes. When asked how they got to their sibling's house, Resident #708 stated, My (Sibling) picked me up at CVS. Resident #708 then stated, They (facility staff) didn't even know I was gone until the morning. Nobody even called my cell phone. I didn't even have a voicemail. When queried how they were aware facility staff did not start looking for them until the morning, Resident #708 replied, When I came back, they (staff) said they started looking for me at like 7:00 in the morning. When asked if the facility attempted to contact the people they have listed as emergency contacts, Resident #708 replied, That would be my (child). No, they did not call them. A walker was observed against the wall in Resident #708's room. When queried regarding the walker and how they were able to ambulate at their sibling's house, Resident #708 replied, I can't walk far with the walker. I took my wheelchair to my siblings. When queried regarding medications, Resident #708 revealed they did not take any medications during the time they were not in the facility. When asked what occurred when they returned to the facility, Resident #708 stated, They (facility staff) just made me sign a form. On 3:10 PM at 10/8/19, an interview was conducted with the facility Administrator regarding Resident #708's exit from the facility on 9/28/19 and return on 9/29/19. When asked if they were aware the Resident had left the facility, the Administrator revealed they were made aware by facility staff. With further inquiry regarding the time they were made aware Resident #708 was missing, the Administrator indicated they were unsure of the time. When queried if the facility was aware of the Resident's whereabouts during the time they were not in the facility, the Administrator revealed the facility was unaware of the Resident's location during the timeframe. When queried if the facility searched for the Resident during the 24-hour, overnight timeframe when the Resident's whereabouts were unknown, the Administrator stated, No, we didn't because (Resident #708) is their own person. When asked if an I and A and/or an investigation were completed by the facility pertaining to Resident #708's elopement, the Administrator replied, No. With further inquiry, the Administrator stated, I was not concerned with (Resident #708's) welfare. I just assumed they were upset and left. When asked if they attempted to contact the Resident, the Administrator replied, We tried to call (the Resident). When asked how many attempts were made to contact the Resident and if a voicemail was left, the Administrator replied, I don't know. When asked if Resident #708's emergency contact was notified, the Administrator stated, No. With further inquiry pertaining to why they were unconcerned with Resident #708's welfare when they remained a Resident of the facility, the Administrator indicated Resident #708 is their own person. When asked why a Dr. Walker (Facility Missing Person Emergency Search) was not called until 7:00 AM on 9/29/19, the Administrator replied, I don't know. When queried if Resident #708 receives medications at the facility, the Administrator replied, Yes, I'm sure they do. When asked how Resident #708 received their medications during the timeframe when their whereabouts were unknown by the facility, the Administrator did not provide an explanation. When queried regarding facility policy/procedure pertaining to completion of I and A reports, the Administrator replied, I would have completed one if I would have been concerned about (Resident #708's) welfare. When asked why the missing Resident was not reported to the local authorities and the State Agency, the Administrator indicated they were not concerned with (Resident #708's) welfare. When queried regarding facility policy/procedure pertaining to completion of Resident elopement assessments, the Administrator stated, There should be elopement assessment for every Resident. When asked why there was not an elopement assessment in Resident #708's medical record, the Administrator did not provide an explanation and indicated they would review the Resident's medical record. An interview was conducted with Nurse A on 10/8/19 at 2:40 PM. When queried regarding Resident #708's elopement on 9/28/19 and return on 9/29/19, Nurse A stated, I worked in (Resident #708's unit) that night but I was not assigned to (Resident #708). I know the nurse assigned to (Resident #708) called the Administrator but the nurse supervisor came in in the morning and called a Dr. Walker then. When queried why a Dr. Walker was not initiated earlier, Nurse A indicated the Administrator was aware. When asked what time the Dr. Walker Code was called, Nurse A replied, About 7:00 AM. An interview was conducted with Nurse B on 10/9/19 at 8:50 AM. When queried regarding Resident #708's elopement from the facility on 9/28/19 and return on 9/29/19, Nurse B indicated they were informed the Resident had eloped from the facility overnight but were not working when it had occurred. When queried regarding facility policy/procedure pertaining to elopements and actions staff are supposed to take, Nurse B indicated if a Resident is observed leaving, staff are supposed to bring them back. When queried regarding policy/procedure if a Resident is not observed leaving but their whereabouts are unknown, Nurse B stated, We are supposed to call a Dr. Walker and search all the rooms including the grounds. If (the missing Resident) is not located within 30 minutes, we move up the line and call the Administrator, family, Police, and Doctor. An interview was conducted with Nursing Assistant E, Nursing Assistant G, and Nursing Assistant F on 10/10/19 at 11:48 AM. When queried regarding facility policy/procedure pertaining to Residents LOAs, Nursing Assistant E, Nursing Assistant G, and Nursing Assistant F indicated Residents sign themselves out in the book when they are leaving. When asked about the location of the LOA book, the Nursing Assistants pointed at a white three-ring binder sitting on a counter in a common area of the hall. When queried how they know if a Resident is able to

Based on observation, interview, and record review, the facility failed to provide assistance during meals for one sampled resident (R#188) of seven reviewed for nutrition, resulting in significant weight loss, missed meals, lack of feeding assistance/supervision/cueing, and the likelihood of further weight loss. Findings include: On 8/19/19 at 10:29 AM, R#188 was observed lying in their bed. On 8/19/19 at 10:33 AM, R#188 was observed to be up, ambulating independently. R#188 appeared short and thin, with sunken cheeks and thin extremities. R#188 sat on the couch in the common area to join a group activity. On 8/19/19 at 12:34 PM, R#188 was observed sleeping on the couch in the common area. No lunch tray was observed near the resident. On 8/19/19 at 12:43 PM, R#188 was observed to still be sleeping on the couch with no food tray. On 8/19/19 at 12:46 PM, Nurse G was queried regarding staff duties during meal times. Nurse G stated, We have three aides today. Normally two CNAs (Certified Nursing Assistants) help feed in the dining room and one goes around to rooms. On 8/19/19 at 12:57 PM, R#188 was observed to still be sleeping on the couch in the common area. Staff was observed collecting lunch trays. Nurse G was queried if R#188 had received a lunch tray. A lunch tray was not observed near the resident or in the resident's room at this time. Nurse G stated, I'm not sure if (R#188) got one, let me check. On 8/19/19 at 1:00 PM, Nurse G approached and stated, No, (R#188) did not get a tray. Nurse G retrieved R#188's tray. Nurse G was queried about what happens during meal times if there are less than three aides. Nurse G stated, Well, we do have a restorative aide that helps. There are days when it's really hard, I'm sure you can see. We've had two aides and I don't know how things get done. Today is pretty good for staffing but it's not always that way. On 8/19/19 at 1:21 PM, R#188 was observed sitting on the couch in the common area with a bedside table set up in front of them. R#188 was observed eating their lunch while a group activity was held. On 8/19/19 at 1:47 PM, a review of R#188's medical record revealed that on 02/13/2019, the resident weighed 94.6 lbs (pounds) and on 08/14/2019, the resident weighed 83 lbs (a 12.26 % loss over a six month period). The weights were listed as follows: 8/14/2019 83.0 Lbs 8/14/2019 83.0 Lbs 8/7/2019 82.6 Lbs 7/31/2019 84.2 Lbs 7/24/2019 83.8 Lbs 7/17/2019 83.4 Lbs 7/10/2019 84.4 Lbs 7/3/2019 86.4 Lbs 6/26/2019 87.6 Lbs 6/19/2019 86.8 Lbs 6/12/2019 86.8 Lbs 6/5/2019 85.4 Lbs 6/5/2019 85.4 Lbs 5/1/2019 90.8 Lbs 4/3/2019 90.4 Lbs 3/27/2019 89.8 Lbs 3/20/2019 91.6 Lbs 3/13/2019 89.0 Lbs 3/6/2019 90.4 Lbs 2/13/2019 94.6 Lbs On 8/20/19 at 12:19 PM, R#188 was observed sleeping on the couch in the common area while lunch trays were being served in the dining room and to resident rooms. On 8/20/19 at 12:25 PM, a staff member was observed taking R#188's lunch tray to their room. The staff member called for the resident to eat lunch. R#188 was observed to get up and walk toward their room, but turned around and came back to the couch. On 8/20/19 at 12:35 PM, R#188 was observed sitting on the couch in the common area with no lunch tray. Upon going to R#188's room, their lunch tray was observed to be sitting on the bedside table, uncovered. The resident remained on the couch. On 8/20/19 at 12:43 PM, R#188 was observed still sitting on the couch in the common area, with their tray still in their room. R#188 was observed to lay down on the couch. No interaction or prompting from staff was observed at this time. On 8/20/19 at 1:07 PM, R#188 was observed to now be lying in bed in their room. The resident's lunch tray was now gone. The resident was unable to appropriately answer interview questions. Upon walking to the dining room, R#188's tray with meal ticket was observed on one of the lunch carts. The resident's tray was untouched and included mandarin oranges, rice, peas, and ground meat with gravy. A review of R#188's medical record revealed a weight of 82.2 Lbs entered on 8/21/2019 at 7:26 AM. On 8/21/19 at 8:44 AM, R#188 was observed sitting on the couch in the common area while breakfast trays arrived on the unit. On 8/21/19 at 8:57 AM, CNA H was observed taking R#188's tray down to their room. CNA H called for the resident to come eat breakfast. The tray was placed in the resident's room on the bedside table. On 8/21/19 at 9:04 AM, 9:17 AM, and 9:20 AM, R#188 was observed still sitting on the couch in the common area. The breakfast tray remained covered in the resident's room. No staff was observed to prompt the resident to eat, offer assistance with breakfast, or offer any alternatives to the resident. On 8/21/19 at 9:31 AM, R#188 was observed still sitting on the couch in the common area. On 8/21/19 at 9:45 AM, R#188's breakfast tray was observed to be removed from their room. The resident remained sitting on the couch and was not observed to go into their room to eat since the tray was dropped off. On 8/21/19 at 12:30 PM, R#188 was observed on the couch in the common area. Lunch trays were being passed by staff at this time. An unopened oatmeal cream pie with the resident's name on it and dated AM 8/21 was observed sitting behind the nurse's station. On 8/21/19 at 12:40 PM, R#188 was observed on the couch in the common area. CNA L asked the resident if they wanted to go eat. The resident did not respond. CNA L asked if the resident would like to eat in the room. The resident mumbled to themselves. On 8/21/19 at 12:51 PM, R#188 was observed to be lying down on the couch in the common area with no lunch tray observed. No further interaction or prompting from the staff was observed. On 8/21/19 at 1:00 PM, R#188 remained on the couch in the common area. CNA H was observed collecting R#188's uneaten tray from their room. On 8/21/19 at 4:14 PM, Confidential Witness F was interviewed. When queried regarding R#188's weight, Witness F responded, It is a concern, up and down. (R#188) doesn't seem to have a good appetite. They told me it might be the disease or (R#188) may not like the food, I'm not sure. When queried if they bring in food for R#188, Witness F stated, I do bring some food from home sometimes. (R#188) seems to eat the food I bring or if I bring (R#188) home it's better. Maybe (R#188) doesn't like the food there, but sometimes (they) seem to like it. On (their) chart it says (R#188) is supposed to get some kind of assistance when (they) eat. They (facility staff) say that they try, but I haven't seen it with my own eyes if they really do. So, I'm not sure what happens when I'm not there. I usually try to go there at dinner time. What I see is, they bring the tray to (R#188's) room, and I don't see anybody sitting with (R#188) and helping or encouraging (them). It's not that (R#188) can't feed (themselves), (they) just need someone to sit there and push and encourage a bit, because that's what I do when I'm there. And I don't see them doing that when I'm there. I've seen (R#188) a couple of times in the dining room, and even when (R#188) sits at the table, I haven't seen anyone helping (them) eat. (R#188) really just needs encouragement. When queried regarding snacks or supplements provided to R#188, Witness F responded, I think they do provide it, sometimes I see peanut butter and jelly sandwiches or cookies there. I think (R#188) gets a supplement with medications. I'm not sure if (they) drink it, because they say (R#188) refuses to take (their) medication. They say (R#188) only takes it 50% of the time .I'm not sure what they're doing when (R#188) refuses. If and when (R#188) says no, I'm not sure if they try several times or if they just take no for an answer one time. When queried regarding the facility offering alternatives if R#188 doesn't eat their meal, Witness F stated, I don't think they're giving alternatives. I haven't seen them offer anything else if (R#188) doesn't eat. They leave the tray there for 30 to 45 minutes and then just come and pick it up, even when they see (R#188) didn't eat anything. I don't think they bring anything else out. I visited last night and (R#188) ate everything on (their) plate for dinner, but I think it was something that (they) liked. On 8/22/19 at 8:31 AM, Nurse G approached R#188 with the resident's breakfast tray and guided the resident to their room. On 8/22/19 at 8:39 AM, R#188 was observed walking in the hallway. R#188 appeared to be prompted by Nurse G back toward their room and to eat their breakfast. On 8/22/19 at 8:51 AM, R#188 appeared to have eaten some of their breakfast on their tray. On 8/22/19 at 8:55 AM, CNA H was queried regarding R#188's level of assistance needed during meals. CNA H stated, (R#188) will sit on that couch. We try to take the tray to their room but (the resident) will refuse to eat in the dining room or their room. (R#188) seems to do better with someone encouraging. I think probably, ideally, if we had enough staff to have someone sit with (R#188) that might help? When queried regarding alternatives offered to the resident if they do not eat, CNA H indicated they were unsure if the resident was offered alternatives. When queried if they thought if R#188 would eat if their tray was brought to the area with the couch the resident likes to sit on, CNA H stated, (They) might. On 8/22/19 at 9:33 AM, Nurse G was interviewed regarding R#188's level of assistance needed during meals. Nurse G reviewed the resident's most recent Minimum Data Set (MDS) assessment and indicated the resident required supervision of one person for cueing/supervision. Nurse G stated, So, someone to be with (R#188) to encourage. Do we always have the amount of staff to be doing that? I don't believe we do. (R#188) doesn't like to eat in the dining room. Everyone pretty much knows that. Sometimes (R#188) will eat on the couch if (they) won't go to (their) room. But, I took (R#188) (to their room) this morning for breakfast and encouraged (them) to eat. On 8/22/19 at 10:11 AM, Registered Dietician (RD) M was interviewed regarding R#188's weight loss, and assistance level required during meal times. RD M stated, (R#188) can be a little difficult to convince. The resident needs encouragement. (R#188's family member) brings in some things per the resident's choice. When queried regarding the resident requiring supervision of one person during meals, RD M indicated that included someone being with the resident and providing cues. RD M continued and stated, When we assessed, it involved a lot of cueing and a lot of encouraging. (R#188) does need encouragement but doesn't like to be pushed too much. I want to see some encouragement though, even if (R#188) refuses, I still just want to see some of that. Food preferences seem to depend on the day. On 8/22/19 at 11:16 AM, the Director of Nursing (DON) was interviewed and queried regarding the meaning of supervision of one person during eating, specifically related to a resident with known weight loss. The DON stated, I would expect to see nurses or CNAs encouraging, and checking on the resident after helping set up a tray. I would expect them to be asking if the resident would like to eat, and encouraging the resident to eat. Ask if they are hungry. If they see the resident isn't eating, offer something else. I expect supervision, cueing, checking periodically, and encouragement to be provided. A review of R#188's Minimum Data Set (MDS) assessment dated [DATE] revealed the following: The resident was admitted into the facility on [DATE], required supervision (oversight, encouragement or cueing) of one staff for eating, and had medical [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed R#188's Cognitive Skills for Daily Decision Making, were assessed as, 2. Moderately impaired - decisions poor; cues/supervision required. Review of Section K - Swallowing / Nutritional Status revealed an entry of 2. Yes, not on physician-prescribed weight-loss regimen, to the question, Loss of 5% or more in the last month or loss of 10% or more in last 6 months. Review of Section [NAME] - Behavior revealed an entry of 0. Behavior not exhibited, to the question, Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Review of R#188's physician orders [REDACTED].Supervision during meals. Magic Cup at dinner. Fortified nutritional juice at lunch, Diet, Active 10/29/2018. Review of R#188's progress notes revealed the following: 12/5/2018 13:24 (1:24 PM) S[NAME]-Nutrition/Hydration Weight gain/loss; Hydration concern: Weight on 12/5 97 .(Called R#188's family member) and updated about the weight status . stated that (they want R#188) to be assisted 1:1 at meal times, '(R#188) can feed self but .needs someone to be sitting with (them) during meal times to encourage .all the times to finish .meals' .Provide assistance/encouragement/cueing with meals. 3/6/2019 14:52 (2:52 PM) Dietary Progress Notes Note Text: RD reviewed (MONTH) weight- 3/6 90.4# (Lbs). Non significant weight loss 30 days (1.7%) compared to weight obtained on 2/6 at 92#, Non significant weight loss in 90 days (6.9%) compared to weight obtained on 12/6 at 97.2#. Significant weight loss compared to admission weight obtained on 10/17 at 107.5# . 3/28/2019 09:32 (9:32 AM) S[NAME]-Nutrition/Hydration Weight gain/loss; Hydration concern: Wt on 3/27 89.8#, 3/20 91.6, 3/13 89, 3/6 90.4 Weight down by 1.8# this week .Called (R#188's family member) who stated that (R#188) eats when (they are) there with her but .needs a lot of encouragement with meals . 6/6/2019 12:37 (12:37 PM S[NAME]-Nutrition/Hydration Weight gain/loss; Hydration concern: WEIGHT WARNING: Value: 85.4 Vital Date: 2019-06-05 11:59:00.0 -5.0% change ( 5.9% , 5.4 ) -10.0% change ( 12.1% , 11.8 ) Monthly weight indicate significant weight loss in 30 (5.9%) and 180 (12.1%) days . Review of R#188's P[NAME] Response History, for ADL (activities of daily living) - Eating - Eating Support Provided, from 7/22/19 to 8/20/19 revealed: No documentation for eating support provided for breakfast or lunch on 7/25/19, 7/26/19, 7/30/19, 8/3/19, 8/4/19, 8/8/19, 8/9/19, and 8/10/19, dinner on 8/15/19, breakfast or lunch on 8/16/19, and 8/17/19. The following dates had no documentation entered for eating support provided: 8/2/19, 8/6/19, 8/7/19, and 8/19/19. Review of R#188's care plan revealed the following: The resident is at risk for nutritional declines r/t (related to) medical dx (diagnoses) including acute kidney failure,[MEDICAL CONDITION](hypertension), Alzheimer's, [MEDICAL CONDITION], dementia, [MEDICAL CONDITION], anxiety. Hx (history) of Significant weight loss, noted with further weight loss (6/5/19). Date Initiated: 10/15/2018 Revision on: 06/06/2019. Resident will consume adequate nutrition on a daily basis in order to maintain body weight without significant changes through the next review date. Date Initiated: 10/15/2018 Revision on: 05/01/2019 Target Date: 10/21/2019. Monitor FAR (food acceptance record) and fluid intake and offer alternative choices for refused food and fluids PRN (as needed). Date Initiated: 10/15/2018 Revision on: 10/15/2018. Provide encouragement/cueing/supervision with meals. Date Initiated: 10/15/2018. A review of the facility's policy titled, Assistance with Meals, reviewed/revised 4/2019, revealed: a. All residents will be encouraged to eat in the dining room. b. Nursing staff and/or trained feeding assistance (sic) if utilized will serve resident trays and will help residents who require assistance with eating. c. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.

Based on interview and record review, the facility failed to assess fall risk status and implement baseline interventions related to fall risk, for one sampled resident (R#190) of three reviewed for falls, resulting in a fall and femur/[MEDICAL CONDITION]. Findings include: A review of R#190's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE], was severely cognitively impaired, and required extensive assistance from staff members for bed mobility, transfers, dressing, toilet use, and hygiene. Further review revealed medical [DIAGNOSES REDACTED]. Review of R#190's admitting medical [DIAGNOSES REDACTED]. Multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing (Primary Diagnosis) Date: 4/11/19. Muscle weakness (GENERALIZED) (Secondary Diagnosis) Date: 4/9/19. Difficulty in walking, not elsewhere classified Date: 4/9/19. Cognitive Communication Deficit Date: 4/9/19. A review of R#190's acute care hospital discharge document titled, After Visit Summary, dated 4/5/19 - 4/9/19, revealed the following: .(P)resents with bruising on .posterior right rib cage. (Family) report they do not know how the bruising occurred. Patient has dementia, A&O x 1 (alert and oriented times one) to self at baseline. Patient ambulates independently without a cane or walker. However (family) reports patient is unstable on .feet at times .history is unreliable due to dementia .Today home nursing noticed the bruising on the patient's rib cage .Impression: Right 10th and 11th rib fracture; cause unknown. Suspect unwitnessed fall/injury .Precautions: Fall precautions. A review of R#190's assessments revealed no fall risk assessment completed from 4/9/19 to 4/12/19. A review of R#190's care plan revealed no care plan areas related to risk for falls and/or fall prevention until 4/16/19. A review of R#190's Nursing Admission Evaluation, dated 4/9/19 revealed: Cognitive skills for decision-making: Needs assist with decisions at this time. Is the resident cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits, or disoriented)? Yes. Does the resident ambulate independently, with or without the use of an assistive device (including a wheelchair)? No. Can the resident walk without assistance? No. The Nursing Admission Evaluation, evaluation dated 4/9/19 did not include a fall risk assessment for R#190. A review of R#190's progress notes revealed the following: 4/10/2019 11:09 (AM) Social Services Progress Notes Note Text: This writer met with (R#190) to introduce self and welcome .to the facility. Resident .admitted for Rib Fractures from (acute care hospital). Resident completed BIM (Brief Interview for Mental Status) assessment. Resident scored 3/15 (indicating severely impaired cognition). Resident is AOx1 and is able to make .needs known . Written by Nurse AA: 4/12/2019 15:59 (3:59 PM) Pertinent Charting-Falls Note Text: Date of Fall: 04/12/2019 Situation Details: Resident reportedly was observed on the floor on the laying on the right side. Complained about pain to the left hip. MD (medical doctor) notified, X ray of the left hip ordered. Assessment: (blank) Mitigating Factors: (blank) Environmental Factors: (blank) Interventions: Wheel chair to remain locked at all times, and resident to be placed at close monitoring. MD Notification: Notified Responsible Party Notification: Notified Comments: (blank). 4/12/2019 23:42 (11:42 PM) Nurses' Notes Note Text: Resident x-ray results revealed a fx. (fractured) left femur (thigh bone) at the surigical (sic) neck (hip area). Doctor notified and new order obtained to send to hospital for the fx. Ambulance service notified, administrator notified, supervisor and responsible party. Resident refused for writer to perform a skin assessment. A review of R#190's radiology report dated 4/12/19 revealed: Results: Intertrochanteric [MEDICAL CONDITION]. Appear subacute. Superior and lateral displacement. No dislocation. Osteopenia. Conclusion: Recent [MEDICAL CONDITION] as above. A review of the incident/accident report for R#190's fall on 4/12/19 revealed: Date of incident: 4/12/19. Time of incident: 1:05 PM. Brief Description: Observed laying on right side on the floor just outside of the dining room. (Signed by Nurse AA). When was resident last seen: sitting in the w/chair (wheelchair) at lunch. Environmental factors: N/A. List Care Planned Interventions Prior to Fall/Accident: (blank). Were planned interventions in place? Yes. When was resident last seen? Before lunch. What were they doing? Watching TV. Time of last meal/snack: Lunch. Last Care Provided/By Who: (blank). Resident's explanation of incident (even if confused): My hip hurts. Level of assistance resident required: 1/2. List Staff/witnesses that were present at time of incident: None. Any other information that is important to know? (blank). Immediate interventions implemented: MD notified and x-ray ordered. Comments: (blank). Pain to touch on the left hip. 4/16/2019 16:39 (4:39 PM) Progress Note-General Note Text: .(R#190) admitted .A&OX1, to self only. Transferred to bed, with 2 max assist. Skin warm and dry. No open areas noted. 8 staples to upper left femur, and 8 staples to left lower femur, dry and intact. No drainage noted. Minimal redness noted to top of incision line. Bruises noted to BUE (bilateral upper extremities), and top of hands. Bruise noted to medial, upper thigh .Bed in low position, call light in reach. 4/17/2019 15:23 (3:23 PM) S[NAME]-Falls New Fall/Follow-Up: Follow up on falls on 4/12/19 Situation (where/when/what/who): Resident was observed on right side on the floor just outside the dining room. Injury/No injury: Resident was complaining of left hip pain. Factors involved (acute condition/environment, etc.): (blank) Notifications: MD/RP (Doctor/Responsible Party). Analysis of interventions to implement: X-rays ordered and results positive for fracture, resident was sent to hospital for further evaluation, Resident did return to the facility on [DATE]. Therapy to assess for a possibly lapbuddy Referrals: Therapy Comments: Fall Risk 10. On 8/22/19 at 9:18 AM, Nurse AA was interviewed regarding R#190's fall on 4/12/19. Nurse AA reviewed the progress note they had written, and was queried about the blank assessment areas and if they had any more information to add. Nurse AA responded, No, I honestly don't remember. It was a while ago and I'm not normally on that unit. Nurse AA was then asked if they would expect a resident admitted with a low BIMS score and rib fractures resulting from a suspected fall/injury to have interventions in place to monitor and prevent further fall or injury. Nurse AA stated, Yes, definitely. Nurse AA was unable to provide any further information regarding R#190's fall. On 8/22/19 at 11:16 AM, the Director of Nursing (DON) was interviewed and asked what the facility's policy is regarding fall assessments on admission. The DON stated, On admission there are a slew of assessments that need to be done. I believe there is one specifically for falls. A fall risk assessment. The DON was then asked what she would expect to see on a baseline care plan for a newly admitted resident with a low BIMS score, fractured ribs, and suspected fall/injury at home. The DON stated,I am expecting interventions and a focus area for falls during that baseline period. We want to do everything we can to make sure they don't come in here and fall. If they're falling out there, they're going to come in here and fall. We need to make sure we have measures in place right away to prevent any injuries. When queried regarding expectation for documentation pertaining to a fall that happens in the facility, the DON stated, We are supposed to document what we observed, what we investigate when a situation happens. A review of the facility's policy titled, Care Plans - Baseline, revised 7/26/17, revealed, Policy Interpretation and Implementation: 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission and will include, but not limited to; (A) Initial goals based on admission orders [REDACTED]. (C) Dietary orders. (D) Therapy orders. (E) Social Services. (F) PASARR recommendations, if applicable. 2. The facility will review the Attending physician's orders [REDACTED]., dietary needs, medications, and routine treatments, etc.), and implement a nursing care plan to meet the resident's immediate care needs. A review of the facility's policy titled, Falls - Clinical Protocol, reviewed/revised 6/2018, revealed, 1. As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task; a. The Falls Risk Evaluation is completed upon admission, quarterly, and with significant change in status. 1. Based on the assessment a care plan will be developed and implemented to address identified risk. This will be revised as necessary. 3. Goals of the plan of care may include the interdisciplinary team, physician, resident and responsible party when possible. a. Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. 4. Interventions should be developed and implemented per the assessed needs. 1. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. b. Often, multiple factors in varying degrees contribute to a falling problem. c. Once a fall occurs it is important to gather as much information as possible; i. Observe for evident trauma ii. Observe to determine what the resident was attempting to do if possible iii. Observe for environmental hazards which may have contributed iv. If the resident is able, what does he/she state happened v. Staff present and responders, what did they see/hear.

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to complete regular and thorough skin assessments and implement timely interventions to prevent and/or treat pressure ulcers (wounds caused by pressure) for four (#'s 18, 54, 198, and 538) of six Residents reviewed for pressure ulcers, resulting in lack of repositioning for Residents with pressure ulcers and Resident #18 developing a facility acquired, unstageable pressure ulcer, pain, and the likelihood for decline in overall health status. Findings include: Resident #18 On 8/20/2019 at 11:12 AM, Resident #18 was observed in their room in bed, positioned on their back. A Prafo brace (brace for foot drop) was noted on the Resident's right foot and a soft heel boot was noted on the left foot. Both of the Resident's heels were positioned directly on the bed. An interview was completed with the Resident at this time. When queried regarding the brace on their right foot, Resident #18 replied, Don't even know when it is supposed to be on. With further inquiry, Resident #18 indicated Therapy staff had told them only to wear the brace when they were in bed but nursing staff either leave it on or don't put it on. When asked about pain, Resident #18 stated, I get pills but my (right) foot hurts. Resident #18 further revealed their heel has been hurting for quite some time. When asked if a nurse had assessed their foot and heel, Resident #18 indicated they did not really look at it. When queried regarding frequency of repositioning, Resident #18 indicated staff only reposition them when they change them which is very infrequently and never when they are in their wheelchair. Record review on 8/20/19 revealed Resident #18 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited to total assistance to perform Activities of Daily Living. The MDS further revealed the Resident had functional limitations in ROM in both upper and lower extremeties and had recieved Restorative Nursing passive ROM one time in the previous seven days, no active ROM, and splint or brace assistance three times in the the previous seven days. Review of Resident #18's care plans at this time revealed a care plan entitled, ROM (ACTIVE): (Resident #18) would benefit from or requires) a restorative Active Range of Motion for impaired physical mobility of Bilateral Ankles (Initiated : 11/12/18). The care plan included the following interventions: -BUE (Bilateral Upper Extremity) pulley as tolerated 3-5 times per week (Initiated: 3/5/19; Revised: 7/3/19) -Nustep at 7 as tolerated 3-5 times per week (Initiated: 3/5/19) Observe for changes in ROM and report to nurse. Review of Resident #18's Progress Note documentation at this time revealed in (MONTH) (YEAR), Resident #18 was admitted to the facility with a pressure ulcer on their coccyx. Review of S[NAME]-Skin documentation revealed the following: -5/8/18: Resident was admitted coccyx pressure ulcers and excoriation to the peri area. The coccyx 4.5 (centimeters- cm) X 2.0 cm x 0.1 cm (and) the right coccyx 1.0 cm X 0.5 cm X 0.1 cm . - 5/22/18: Late Entry . admitted with pressure ulcer to coccyx 3 cm X 2 cm X UTD (Unable To Determine). right coccyx closed . -6/5/18: (Resident #18) was admitted with coccyx pressure ulcer 2.0 cm X 0.6 cm X 0.2 cm . -6/14/18: (Resident #18) was admitted with coccyx pressure ulcer that measures 2.0 cm X 0.6 cm X 0.2 cm wound is stable . -6/21/18: (Resident #18) was admitted with coccyx pressure ulcer 1.5 cm X 0.5 cm X 0.1 cm granular base . -6/28/18: (Resident #18) was admitted with coccyx pressure ulcer that had decreased significantly in size 0.2 cm X 0.2 cm X 0.0 cm . -7/3/18: (Resident #18) was admitted with coccyx pressure ulcer that measures 0.2 cm X 0.2 X 0.0 cm 80% slough . -7/18/19: (Resident #18) was admitted with coccyx pressure ulcer to coccyx 0.3 centimeters (cm) X 0.3 (cm) X 0.0 cm non blanchable [DIAGNOSES REDACTED] . An interview was conducted with Nurse N on 8/21/19 at 9:08 AM. When queried regarding Resident #18's skin, Nurse N indicated the Resident had a pressure ulcer previously which had healed. Nurse N then stated, There is no treatment now just cream if they need it. At 11:12 AM on 8/21/19, an observation of incontinence care for Resident #18 was completed with Nursing Assistant T and Nurse N. When queried regarding Resident #18's skin under the brace on their right foot, Nurse N removed the Residents boot. A dark colored and reddened area with a slightly raised blister was observed directly on the Residents heel. The blister was irregularly shaped and approximately the size of a nickel. The surrounding dark and reddened skin was approximately the size of a half dollar. When asked, Nurse N stated the area was mushy. Nurse N was observed assessing the reddened skin surrounding the blistered area. The skin was observed to not be blanchable. When queried, Nurse N revealed the skin was not blanchable and stated they would inform wound care. When queried Resident #18 stated, The boot has been hurting my heel. When asked if they informed staff, Resident #18 replied, Yes, they started putting a piece of foam around my heel a long time ago. On 8/21/19 at 11:34 AM, Wound Care Nurse P and Wound Care Nurse O entered Resident #18's room. After assessing the Resident's heel, Nurse O stated, It's a blister. We will do skin prep with border foam. Nurse P then stated, It is non-blanchable in the center and mushy. With further inquiry, Nurse P indicated the pressure ulcer was a stage one. With further inquiry regarding how a blister is a stage one pressure ulcer, Nurse P then stated, I'm going to call it a Deep Tissue Injury (DTI- pressure ulcer with unknown depth). Record review of Resident #18's skin assessment documentation on 8/21/19 revealed a Skin assessment dated [DATE]. The assessment was signed by Nurse N and indicated the Resident had no new or existing skin areas. An interview was conducted with Nurse N on 8/21/19 at 12:18 PM. When queried if they worked on 8/19/19, Nurse N replied, I didn't work on Monday. When asked about the Skin Assessment completed by them on 8/19/19 if they did not work, Nurse N reviewed Resident #18's medical record and stated, I remember now. I just locked the assessment. Someone else did it but didn't lock it so it showed up incomplete. When asked who completed the assessment, Nurse N indicated they were not sure. When queried if they completed a skin assessment and looked the Resident's heels, Nurse N stated, I didn't. I just locked the assessment. An interview was conducted with Resident #18 on 8/21/19 at 12:53 PM. The Resident was in their room, positioned on their back in bed. When queried if facility staff completed a skin assessment on Monday, 8/19/19, Resident #18 rolled their eyes and stated, No and no one looked at my heels. Resident #18 further indicated staff do not routinely complete skin assessments. On 8/21/19 at 3:16 PM, Resident #18 was observed in their room in the facility. The Resident was in bed and positioned on their back with their heels directly on the mattress. An interview was conducted with Nurse Q on 8/22/19 at 11:25 AM. When queried if they were assigned to care for Resident #18 on 8/19/19, Nurse Q indicated they did. When queried if they completed the Resident's skin assessment on that day and if they took off the Resident's boot to assess the skin on their heel, Nurse Q replied, No, I guess I didn't (remove the boot to assess heel). An interview was conducted with the Director of Nursing (DON) on 8/22/19 at 1:06 PM. When queried regarding Resident #18, the DON revealed they were unfamiliar with the Resident. When asked about the Resident developing a DTI pressure ulcer at the facility, skin assessment completion/documentation, and positioning, the DON stated, I will educate staff. No further explanation was provided. Resident #54 On 8/20/19 at 10:30 AM, Resident #54 was observed in their room in bed. The Resident was positioned on their back with legs bent inward and their heels and lateral side of their feet positioned directly on the mattress. Both of the Resident's hands were observed to be positioned in a fist. When spoke to, Resident #54 would inconsistently attempt to look in the direction of the voice but did not make eye contact and did not attempt to communicate. Record review on 8/20/19 revealed Resident #54 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident does not speak, is rarely/never understood, and requires extensive to total assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had a stage three pressure ulcer (full thickness loss). Review of the MDS dated [DATE] also revealed the Resident had a stage three pressure ulcer. Review of Resident #54's care plans at this time revealed a care plan entitled, (The Resident) has a pressure ulcer to the Coccyx . (Initiated: 6/6/16; Revised: 8/18/17). Care plan interventions included: -Administer treatments as ordered and evaluate for effectiveness (Initiated: 6/6/16) -Daily skin evaluations by licensed nurse if current pressure ulcer . (Initiated: 8/18/17) -Educate resident/family regarding the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes (Initiated: 6/6/16) -Educate the resident/family/caregivers as to causes of skin breakdown; including; transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning (Initiated: 6/6/16) -Evaluate nutritional status. Serve diet as ordered, monitor intake and record (Initiated: 6/6/16) -Evaluate/record/monitor wound healing weekly Measure length, width, and depth were possible. Evaluate and document status of wound perimeter, wound bed and healing progress. Report improvements and decline to the MD (Initiated: 6/6/16) -Float heels (Initiated: 1/10/18; Revised: 1/22/18) -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -Inform the Physician/resident/family/caregivers of any new area of skin breakdown (Initiated: 8/18/17) -Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated (Initiated: 8/18/17) -(Resident #54) needs assistance to turn/reposition frequently SIDE TO SIDE OFF BACK LAL (Low Air Loss MATTRESS TO BED, place foam CUSHION TO CHAIR when resident gets up AND HEEL LIFT BOOTS AAT. Unable to amb (ambulate) via room/hall at this time (Initiated: 6/6/19; Revised: 8/4/17) Review of Resident #54's progress note documentation at this time revealed the following pertaining to the Resident's pressure ulcer: -6/3/16: . PRESSURE ULCER OF SACRAL REGION, STAGE 3 . -11/12/18: Writer called into room by (Resident family) . who expressed concerns regarding Resident's sacral treatment order. (Family) asked when and why this treatment was changed to one with no dressing and reported they were concerned Resident would again [MEDICAL CONDITION] (infection throughout the body) due to e-coli contamination of wound. Writer attempted to contact Doctor without success. Writer called (different) Doctor and obtained order to change treatment. New order written with bordered foam dressing . -7/10/19: Late Entry wound care measurements to coccyx 0.6 (centimeters- cm) X 0.3 cm X 0.5 cm which is showing slight improvement. Continue with current treatment -8/14/19: 11:26: (Resident #54) has a pressure ulcer to the coccyx 0.4 cm X 0.4 cm X 0.5 cm. 100% granular base with no changes. On 8/21/19 at 9:24 AM, Resident #54 was observed in their bed in their room in the facility. The Resident was positioned on their back with their heels positioned directly on the mattress. The Resident did not have heel boots in place. At 10:27 AM on 8/21/19, Resident #54 was observed in their room with clear fluid covering their chest from their tracheotomy and mouth. The Resident was positioned on their back in bed with their legs slightly bent inward and their heels positioned directly on the mattress. No heel boots were observed. On 8/21/19 at 12:56 PM, Resident #54 was observed in their bed. The Resident remained in the same position, on their back with their heels directly on the mattress. Heel boots were not in place. On 8/21/19 at 3:15 PM and 5:33 PM, observation occurred of Resident #54 in their room in the facility. The Resident was positioned on their back with their heels directly on the mattress, without heel boots in place, during both observations. On 8/22/19 at 9:10 AM, Resident #54 was observed in their bed, positioned on their back in their room in the facility. The Resident did not have heel boots in place. Wound care observation for Resident #54 occurred on 8/22/19 at 12:22 PM with Nurse Q and Nursing Assistant R. Prior to beginning the treatment, Resident #54 was observed in bed, positioned on their back with their heels directly on the mattress and no heel boots in place. The removed dressing had a small amount of gray colored drainage. The wound was irregularly shaped and approximately the size of a quarter. The edges of the wound were pale in color and unattached. The bed was unable to be visualized due to the depth of the wound. When queried regarding wound measurements, Nurse Q indicated the wound care nurses in the facility obtain the measurements. When asked about the depth of the wound, Nurse Q measured the wound depth and stated, It's 1.5 cm. Nurse Q reapplied the dressing. After completing the dressing change, heel boots were not applied on the Resident. When queried regarding heel boots, Nursing Assistant R indicated the Resident did not have any. When asked about turning the Resident every two hours, Nursing Assistant R indicated they do the best they can but are unable to turn everyone every two hours when they have 17 to 19 Residents every shift. An interview was conducted with the Director of Nursing (DON) on 8/22/19 at 1:06 PM. When queried regarding Resident #54, the DON revealed they were unfamiliar with the Resident. When asked about observations of the Resident not being repositioned and heel boots not being in place, the DON indicated they would educate staff. No further explanation was provided. A request for all notes pertaining to Resident #54, including wound care and skin notes was made on 8/22/19 at 12:50 PM. Review of facility provided documentation did not include additional documentation and/or measurements pertaining to the Resident's pressure ulcer. 198 Record review revealed that R#198 was admitted into the facility on [DATE] and readmitted with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed #198 had a severely impaired cognition and needed extensive to total assistance with Activities of Daily living (ADLs) including bed mobility. Section G0400 of the MDS, (the section that indicates the resident's functional range of motions of the extremities) was coded 0 for upper body range of motion (ROM) and 0 for lower body ROM. Further record review revealed there was no care plan regarding contractures. Further record review revealed pressure ulcer treatments were not documented on the Medication Administration Record (MAR) or in the progress notes on 8/12/19, 8/14/19, 8/17/19, and 8/18/19. On 8/19/19 at 1:22 PM, #198 was observed lying in bed with a positioning wedge under the left arm but appeared to be facing the right of the bed. Though under the sheet and blanket, R#198's knees were flexed up toward the abdomen and chest. A dressing was observed on #198's left wrist. #198 was awake made eye contact but did not respond verbally. At 3:30 PM, #198 was again observed lying in bed with a positioning wedge under the left arm and the knees flexed up. On 8/20/19 at 8:18 AM, #198 was observed lying in bed in semi-fowlers position (head of bed raised to 35 to 40 degrees). The positioning wedge was under the left arm and a pillow appeared to be between the legs and #198 continued to appear facing the right. At 10:44 AM, #198's positioning wedge was observed with the positioning wedge under the torso and facing right. At 1:36 PM, #198 was again observed lying in bed facing the right, and the positioning wedge was on the left side of the bed but not touching the resident's body and a pillow no longer appeared to be between the legs. On 8/21/19 at 5:20 AM, R#198 was observed sleeping in bed in semi fowlers position positioning wedge with the wedge under the left arm and continued to face the right. A pillow did not appear to be between the legs. On 8/21/19 at 7:35 AM, a wound care observation was conducted with Nurses O and P. #198 was facing the right and the positioning wedge was on the floor. A pillow was between the legs. #198 was severely contracted (inability to move joints). Nurses O and P repositioned #198 to face left and proceeded to administer wound care. When wound care was completed on the pressure ulcers on the right side of #198 was repositioned to face the right, A wound that was not listed on #198's skin assessments or on the Treatment Administration Record (TAR) was observed on the resident's right inner lower leg. Nurse O stated, It looks like a skin tear, probably from when they turn (#198) or get (#198} up for a shower. Upon completion of the wound care, Nurse P released #198's right leg and without the pillow the wound of the right inner lower leg and the bunion of the left foot were touching. Later in the hall, Nurse O was asked if the Certified Nurses Aides (CNAs) turned and repositioned the residents adequately and stated, No. Nurse O was asked about the positioning wedge and the pillow not being in place at every observation and stated, (#198) doesn't move at all. The nurses are supposed to check on (#198) being turned and repositioned. Nurse O was asked about R#198 not receiving Pressure Ulcer treatment on 8/12, 8/14, 8/17, and 8/18/2019 and stated, I know that on Sunday the midnight Nurse did not do it so we did it on Monday. #538 Record review revealed #538 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed R#538 had a Brief Interview for Mental Status (BIMS) score of six and needed extensive assistance with Activities of Daily Living (ADLs) such as bed mobility and transferring. On 8/21/19 at 9:14 AM, #538 was observed lying in bed flat on their back. When greeted #538 stated, I'm not too good today. My lower back and butt hurt so bad I had to stop my physical therapy. #538 was asked about the pain or offered a pain pill and stated, No. On 8/21/19 at 11:44 AM, #538 was observed sitting in a recliner in the room. #538 was asked if a pain pill was given and stated, Yes, but my back and butt are sore from laying flat all the time. Can't I get up? Can't they let me walk around? Record review revealed #538 was readmitted for m the hospital on [DATE] and the nurse assessed #538 to have a sacral pressure wound 4 centimeters (cm) x 1.8 cm. #198's MAR revealed a pressure ulcer treatment order was obtained on 8/16/19, however a pressure ulcer treatment was not documented on the MAR or in the progress notes. On 8/21/19 at 11:55 AM, CNA LL was asked about #538 needing assistance with turning and repositioning and stated, (#538) needs help with everything. I repositioned (#538) an hour ago while (538's) son was here. On 8/22/19 at 8:35 AM, #538 was observed in bed sleeping flat on the bed. On 8/22/19 at 12:44 PM, the DON was asked about the facility's policy and procedure regarding initial wound care and stated, The Nurse that found the wound should have started the treatments and documented it.

Based on observation, interview and record review, the facility failed to document comprehensive Range of Motion (ROM) assessments, implement and consistently provide ordered Restorative Nursing Services and treatments to maintain and/or prevent decline in mobility for two (#'s 18 and 54) of six Residents reviewed for limited ROM, resulting in Residents not receiving ordered Restorative Nursing services, lack of documentation of ROM status, contracture development and worsening, and the likelihood for pain and further decrease in mobility. Findings include: Resident #18 On 8/20/2019 at 11:12 AM, Resident #18 was observed in their room in bed, positioned on their back. An alternating air mattress was noted on the Resident's bed. A Prafo brace (brace for foot drop) was noted on the Resident's right foot and a soft heel boot was noted on the left foot. Both of the Resident's heels were positioned directly on the bed. An interview was completed with the Resident at this time. When queried regarding the brace on their right foot, Resident #18 replied, Don't even know when it is supposed to be on. With further inquiry, Resident #18 indicated Therapy staff had told them only to wear the brace when they were in bed but nursing staff either leave it on or don't put it on. When asked why they had the boot on their right foot, Resident #18 indicated they had developed foot drop (contracture) while at the facility. When asked about the heel boot on their left foot and mobility, Resident #18 revealed they had less mobility in their foot than before. When asked if they were receiving Restorative Nursing services, Resident #18 replied, I'm supposed to but I don't. With further inquiry, Resident #18 stated, Restorative leaves at 3:00 PM and my Aide don't get me up (out of bed) in time. Record review on 8/20/19 revealed Resident #18 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited to total assistance to perform Activities of Daily Living. The MDS further indicated the Resident had impaired mobility in both upper and lower extremities. The Restorative Nursing section of the MDS indicated the Resident received Passive ROM (PROM) once in the previous seven days, no Active ROM (AROM), and splint/brace assistance 3 times in the previous seven days. Review of Resident #18's care plans at this time revealed a care plan entitled, ROM (ACTIVE): (Resident #18) would benefit from or requires) a restorative Active Range of Motion for impaired physical mobility of Bilateral Ankles (Initiated: 11/12/18). Care plan interventions included: -BUE (Bilateral Upper Extremities) pulley as tolerated 3-5 times per week (Initiated: 3/5/19; Revised: 7/3/19) -Nustep at 7 as tolerated 3-5 times per week (Initiated: 3/5/19) -Observe for changes in ROM and report to nurse (Initiated: 3/5/19) -Stop if you meet joint resistance or if the resident verbalizes/exhibits symptoms of pain (Initiated: 3/5/19) -Supervise AROM and provide verbal/tactile cues as needed to complete task (Initiated: 3/5/19) On 8/21/19 at 10:41 AM, Resident #18 was observed laying in their bed, positioned on their back. The Prafo boot was not in place on the Resident's right foot. The foot was observed to be pointed downward, away from the Resident's head. When queried if they were able to move their right foot, the Resident moved their foot slightly but did not demonstrate full ROM. When asked about the brace not being in place, Resident #18 gestured toward the clock on their bedside table and replied, (Nursing Assistant T) took it off at 9:00 AM. An interview was completed with Nursing Assistant T on 8/21/19 at 10:48 AM. When queried regarding Resident #18's right foot brace, Nursing Assistant T indicated they removed the brace. When asked when the Resident is supposed to wear the brace and for how long, Nursing Assistant T did not provide a response. Record review on 8/21/19 of Resident #18's health care provider orders revealed the following orders: -Order: Restorative Nursing 3-5 times per week Nustep #7 as tolerated BUE pulley as tolerated . Active 7/3/19 -Adjustable PRAFO (brace) for the Right foot to be on when patient is in the bed for foot drop and contracture . Active: 6/8/19; End Date: 2/8/20 Record review on 8/21/19 of Resident #18's Restorative Nursing documentation for the past 30 days revealed the Resident had received Restorative Nursing services on the following days: -7/23/19 -7/27/19 -7/28/19 -7/29/19 -7/31/19 -8/10/19 -8/15/19 -8/20/19 On 8/22/19 at 11:17 AM, an interview was conducted with Physical Therapist EE. When queried regarding Resident #18, Physical Therapist EE indicated they had just completed the Resident's assessment. Physical Therapist EE then stated, (Resident #18) developed a contracture, foot drop on the left. (Resident #18) already had foot drop (contracture) in the right. There is a 20 degree decline in the left now (contracture). I am going to order a hard (Prafo) boot for the left too. When queried how often and when the Resident is supposed to wear the Prafo boot on their right lower extremity, Physical Therapist EE stated, Recommend when they are in bed. Review of PT Evaluation and Plan of Treatment documentation, dated 8/22/19 revealed, Assessment Summary: Clinical Impressions . L (Left) ankle declined by 20 degrees . recommend: Prafo to prevent further ankle contracture . Continue FMP (Functional Maintenance Program - Restorative Nursing) for follow up . Risk Factors . the patient is at risk for contractures . Resident #54 On 8/20/19 at 10:30 AM, Resident #54 was observed in their room in bed. The Resident was positioned on their back with legs bent inward and their heels and lateral side of their feet positioned directly on the mattress. Both of the Resident's hands were bent inward toward their wrists and their fingers were observed to be positioned with the fingers inward in a fist. When spoken to, Resident #54 would inconsistently attempt to look in the direction of the voice but did not make eye contact and did not attempt to communicate. Record review on 8/20/19 revealed Resident #54 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident does not speak, is rarely/never understood, and requires extensive to total assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had impaired Range of Motion (ROM) in both upper and lower extremities and had not received any Restorative Nursing services in the past seven days. Review of Resident #54's care plans on 8/20/19 revealed an active care plan entitled, Splint/Brace to Bilateral Hands by Restorative (Initiated and Revised: 8/20/17). The care plan included the interventions: -After removal of the splint, cleanse the skin and apply (SPECIFY: protective or moisturizing lubricant) (Revised: 8/20/17) -With removal of brace/splint, observe the skin for red or open areas and notify the nurse if present (Revised: 8/20/17) -Other Observe for any discomfort or pain (Revised: 8/20/17) Review of Resident #54's medical record documentation on 8/21/19 did not reveal any documentation of Restorative Nursing since (MONTH) (YEAR). On 8/21/19 at 5:03 PM, an interview was conducted with the Assistant Director of Nursing (ADON). When queried regarding Restorative documentation for Resident #18, the ADON stated, I'm going to be honest with you, they (Restorative Staff) could have gotten pulled to the floor. I got pulled to a different facility and I wasn't here so I really don't know. When queried regarding observation of Resident #54's contractures and Restorative Nursing services for the Resident, the ADON indicated they would need to review the Resident's medical record. A review of Resident #54's medical record with the ADON at this time revealed Resident #54 had not received Restorative Nursing services since (MONTH) (YEAR). When asked about Resident #54's care plan indicating they were receiving Restorative Nursing services, the ADON was unable to provide an explanation. When queried regarding the facility policy/procedure for Restorative Nursing services, the ADON stated, We get a referral from therapy. When asked if the purpose of Restorative is to prevent contractures and worsening of contractures, the ADON replied, Yes. When asked how contractures and worsening of contractures were being prevented if Residents were not receiving Restorative Nursing as ordered, the ADON stated, I see what you are saying. When queried how the facility assesses and monitors Resident contractures to know if the contractures are getting worse, the ADON stated, I will have to get back to you. An interview was conducted with the ADON at 5:19 PM on 8/21/19. When asked, the ADON revealed, Therapy does measurements of contractures quarterly. On 8/22/19 at 10:56 AM, an interview and record review was completed with the ADON and Therapy Director GG. When queried regarding monitoring of ROM and contractures, Therapy Director GG indicated Therapy staff assess Residents on a quarterly basis and provided written Range of Motion Assessment documentation dated 8/30/18, 2/25/19, and 5/20/19 for Resident #54 was provided. Review of the assessments with Therapy Director GG and the ADON reviewed that on 2/25/19 no assessment of the Resident's ROM was completed. The assessment form revealed, Pt (patient) resistant to all ROM, unable to assess. Attempted PROM when pt (patient) became agitated and resistant to PROM. Comparison of the documented Extremity Movement on the assessment forms dated 8/30/18 and 5/20/19 revealed Resident #54 experienced worsening in their ROM. When queried if the documented assessment data indicated the Resident's contractures had worsened, Therapy Director GG replied, Yes, some of them. When queried why the Resident was not receiving Restorative Nursing, no explanation was provided. An interview was conducted with the Director of Nursing (DON) on 8/22/19 at 1:06 PM. When queried regarding Restorative Nursing Services for Resident #18 and Resident #54, the DON revealed they were unfamiliar with the Residents. When queried regarding Resident #18 developing a contracture, Resident #54's contracture worsening, and lack of Restorative Nursing services, the DON did not provide an explanation. Review of facility policy entitled, Restorative Nursing Program (Reviewed/Revised 3/2019) on 8/22/19 revealed, The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility Programs based on technique: Range of motion (passive); Range of motion (active); Splint or brace assistance . The following types of residents could benefit from a Restorative Program(s) but limited to Contracture prevention and/or management . Contracture Prevention and Management . Anyone can make a referral to the Restorative Nursing Program .

This Citation has Three DPS Statements: DPS Statement One: Based on observation, interview and record review, the facility failed to implement meaningful interventions to prevent falls for one (#155) of three Residents reviewed for falls, resulting in lack of implementation of interventions for a Resident with repeated falls, Resident #155 suffering a right femoral neck fracture, unnecessary pain, and the likelihood for medical complications [REDACTED]. Record review on 8/20/19 revealed Resident #155 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited to extensive assistance to perform Activities of Daily Living (ADLs). Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform all ADLs. Record review on 8/20/19 revealed Resident #155 was transferred to the hospital on [DATE] following a fall with uncontrolled pain and injury on 6/22/19. The fall resulted in the Resident fracturing their right femur neck and requiring surgical repair of the injury. Review of progress note documentation in the medical record revealed the following progress note documentation pertaining to the fall: -6/22/19 at 4:59 PM: Note Text: Writer was notified by staff member that a resident was on the floor in room.Writer observed resident laying on her back between the beds in residents room . Resident stated that their right leg hurt with a pain rating of 5 (scale 1-10). Writer administered PRN (as needed) pain medication. Dr notified. New orders received for X-ray of right hip, knee, and Femur . -6/22/19 at 9:37 PM: Note Text: (Resident #155) has received [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] for pain and still appears very uncomfortable. (Family) is at bedside and (family) is on phone with (Resident). Family decided they wanted (the Resident) sent to hospital. Administrator and Dr contacted. -6/23/19 at 12:20 AM: Note Text: Resident left facility via (ambulance)to Hospital at 12:10 AM. (Family) were at bedside at time of transfer. Further review of Resident #155's medical record at this time revealed the Resident had fallen multiple times within the facility prior to and after the fall on 6/22/19 in which they suffered a fracture. The dates of the falls included: -12/8/18 -1/23/19 -1/26/19 -1/27/19 -7/10/19 -7/15/19 -7/17/19 -8/3/19 -8/10/19 -8/11/19 Review of Resident #155's medical record documentation revealed the following progress notes pertaining to the falls: -8/11/19: Note Text: Date of Fall: 8/11/19 . -8/10/19: Date of Fall: 8/10/19. Situation Details: Resident observed sitting on buttocks in front of w/c (wheelchair). Assessment: PROM (Passive Range of Motion) performed without difficulty. Denies pain and discomfort at this time. Small abrasion noted to right elbow. Mitigating Factors: none; Environmental Factors: none; Interventions: Auto locking breaks to W/C . -8/3/19: Note Text: Date of Fall: 8/3/19. Situation Details: Resident observed sitting on buttocks in room by the doorway. Assessment: Denies pain . No injury noted. Mitigating Factors: Environmental Factors: Interventions: Residents socks were not non skid socks. They were replace with no skid socks . -7/17/19: Note Text: Date of Fall: 7/17/19. Fall Shift 7/8- No delayed injury noted. No s/s of pain or discomfort. Will continue to assess . -7/15/19: Note Text: Date of Fall: 7/15/19. Situation Details: (Resident #155) observed by staff sitting on the floor next to bed. (Resident) was leaning against the bed with a pillow from the bed noted between them and the bed. (The Resident) stated that they were looking for another sock. Noted: one foot did not have a sock on. Bed was in low position. Assessment: No injuries noted . denies pain. No injury noted. Mitigating Factors: (Resident #155) was looking for socks. (The Resident) has some confusion and poor safety awareness. Environmental Factors: none. Interventions: CNA staff to ensure (Resident) is dressed and has socks on and assist up to w/c when awake in bed . -7/10/19: Note Text: Date of Fall: 7/10/19. Situation Details: Resident was observed sitting on buttocks between bed and wheelchair on floor . PROM performed without difficulty. No s/sx (signs/symptoms) of pain or discomfort noted at this time. Mitigating Factors: none. Environmental Factors: none. Interventions: completed . -1/27/19: Note Text: Date of Fall: 1/27/19. -1/26/19: Note Text: Date of Fall: 1/26/19 . -1/23/19: Note Text: Date of Fall: 1/23/19. Situation Details: Resident observed on the floor in sitting position by walker in Jawa lodge (walker seat had thick fur [NAME]et). Resident stated, I was sitting on walker seat and got slid. Assessment: no injuries. no c/o (complaints of) pain, vitals under vital editor. no injuries. Mitigating Factors: Environmental Factors: Interventions: make sure walker is free from clutter . -12/8/18: Note Text: Date of Fall: 12/08/18. Situation Details: Writer was notified by CNA that the resident was observed sitting on the floor with their back resting against the bed frame within the residents room. No signs of injury noted. Resident denies pain at this time . No injury noted. Mitigating Factors: Environmental Factors: Interventions: Care plan updated . Review of Resident #155's care plans on 8/20/19 revealed a care plan entitled, The resident is at risk for falls r/t (related to) fall in facility Gait/balance problems, Medications r/t Use of [MEDICAL CONDITION] medication (Initiated: 10/27/16; Revised: 1/23/19). Care plan interventions included: -Anticipate and meet the resident's needs based on nursing assessments (Initiated: 12/7/18) -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Initiated: 12/7/18) -Non-skid socks (Initiated and Revised: 12/8/18) -Encourage rest periods as needed to avoid overtiring (Initiated: 12/7/18) -Encourage rest periods in-between tasks to avoid overtiring (Initiated: 10/27/16) -Ensure eye glasses are clean and on resident when awake (Initiated: 12/7/18) -Bed in lowest position when not providing care (Initiated: 1/23/19) -Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (Initiated: 1/23/19) -Ensure (Resident) is fully dressed to prevent from attempting to dress self (Initiated and Revised: 7/15/19) -Get (Resident) up into w/c when awake in bed to prevent from getting up unassisted (Initiated and Revised: 7/15/19) -Nonskid strip to side of bed by door from the top of bed to foot of bed (Initiated: 9/8/17) -Replace non-skid strips to door side of bed (Initiated: 7/10/19) -Offer to assist to bathroom when awake (Initiated: 8/3/19) -Provide for activities of daily living such as incontinence care, transfers, ambulation, as written in the activities of daily living plan of care (Initiated: 1/23/19) -Transfer self may need limited assist if feeling weak. Depends on the day (Initiated: 10/27/16; Revised: 4/9/19) -Auto locking breaks to W/C (Wheelchair) (Initiated: 8/10/19) Resident #155 also had an active care plan entitled, The resident needs activities of daily living assistance related to weakness (Initiated: 1/23/19; Revised: 1/23/19). The care plan included the intervention, Encourage the resident to use call bell to request assistance (Initiated: 1/23/19). On 8/21/19 at 9:56 AM, Resident #155 was observed in their room. The Resident was awake with their eyes open and laying in bed. The Resident's right leg was hanging off of the bed. The Resident was dressed but did not have shoes on. The Resident did not have a fall mat in place on either side of their bed. Non slip strips were noted on the right side of the bed. The strips were approximately six inches apart and when walked on, were noted to not prevent slipping due to spacing. An interview was conducted with the Resident at this time. The Resident was pleasantly confused. When queried regarding falling within the facility, Resident #155 was unable to recall the fall or what had occurred and stated, My hip really hurts. The Resident's call light was observed behind the Resident's pillow and not within reach. When asked about their call light, the Resident indicated they did not know where it was. On 8/21/19 at 5:32 PM, Resident #155 was observed in the dining room area of the facility sitting in a wheelchair with foot rests in place. The Resident was pleasant but displayed flight of thought when speaking and was observed placing their feet on the floor. Other Resident's sitting at the table with Resident #155 were observed attempting to calm the Resident and telling them to stay in their wheelchair. No staff were observed intervening and/or assisting the Resident. On 8/22/19 at 12:04 PM, an interview was conducted with Unit Manager Nurse HH and Nurse N. When queried regarding Resident #155's falls within the facility and interventions in place to prevent falls, Unit Manager HH stated, Well, they are getting PT (Physical Therapy) now and we are keeping (Resident #155) in their wheelchair. With further inquiry, Unit Manager HH stated, (Resident #155) was ambulatory and did just about everything for themselves before they fell and broke their hip. When asked about the Resident's ordered level of assistance needed for care prior to their fall on 6/22/19, Unit Manager HH reviewed the medical record and indicated the Resident required one assist. With further inquiry pertaining to the care plan indicating the Resident required one assist, their history of falls, and their statement indicating the Resident was ambulatory and able to do most things for themselves, Unit Manager HH did not provide clarification. When asked about interventions in place to prevent falls prior to the Resident's fall with fracture, Unit Manager HH reviewed the Resident's care plan and indicated the facilities normal fall precautions were in place. At this time, Nurse N stated, (Resident #155) is very impulsive. They have always been. When asked if the Resident was a fall risk prior to the fall with fracture on 6/22/19, Nurse N and Unit Manager HH both indicated the Resident was. When queried what occurred when the Resident fell on [DATE] and 1/27/19 as the documentation in the medical record did not specify what occurred, Unit Manager HH and Nurse N indicated they were unable to recall. When asked what interventions were implemented after Resident #155 broke their femur and returned to the facility on [DATE] from the hospital, Unit Manager HH stated, We put auto locks on the wheelchair on 8/11/19 and replaced the non-slid strips next to the bed on 7/11/19. When asked if those interventions were implemented after the falls that occurred on 8/10/19, 8/11/19, and 7/10/19, Unit Manager HH indicated they were. When queried if any new interventions were implemented after the fall with fracture, Unit Manager HH reviewed the Resident's care plan and revealed no new interventions were implemented. When asked why the Resident did not have fall mats in place to prevent injuries, Unit Manager indicated mats were not implemented. No further explanation was provided. Upon request for all Resident #155's Incident and Accident Reports pertaining to falls, the following Incident and Accident Reports were received and reviewed on 8/22/19: -12/8/18: Level of Assistance the Resident Requires: One . Immediate interventions implemented: Care Plan updated, No slid socks . On 12/8/18 at 2:15 PM, Resident was observed sitting on the floor with back against the bed in room. Statement was I was trying to get to the bathroom . -1/23/19: Level of Assistance the Resident Requires: One . Result of Investigation: On 1/23/19 at 4:30 PM, Resident observed in sitting position on the floor by walker . Root cause was Resident had placed coat on wheelchair sear and when went to sit down, slid off . -6/22/19: Resident Physically Impaired . Location: Resident Room . Injury Type: No apparent injury . Level of Assistance the Resident Requires: One . Immediate Interventions Implemented: Care plan updated- staff to monitor and remind Resident to use walker at all times even during short distances . Result of Investigation: On 6/22/19 at 4:55 PM, Resident observed on floor in room laying on back between beds one and two. Resident statement was I just fell , I didn't have my walker. Resident's walker was locked on the other side of the bed . was transferred to hospital and admitted with [DIAGNOSES REDACTED]. -7/10/19: Level of Assistance the Resident Requires: One . Immediate Interventions Implemented: None . Results of Investigation: On 7/10/19 at 4:15 PM, Resident was observed sitting on buttocks between bed and wheelchair in room on the floor. State was non-sensible . -7/11/19: Level of Assistance the Resident Requires: One . Immediate Interventions Implemented: None . Results of Investigation: On 7/11/19 at 9:00 AM, Resident observed on floor next to bed in sitting position. Stated . was looking for their other sock and slid out of bed . Staff to get Resident out of bed as soon as awake . -8/3/19: Results of Investigation: On 8/3/19 at 4:55 AM, Resident was observed sitting on buttocks in room doorway calling for help. Statement was I just slipped . Staff will offer to assist to bathroom when awake . Incident and Accident Report did not include information pertaining to assistive devices and/or safety measure in use at time of fall. -8/11/19: Immediate Interventions Implemented: Brought to common area, auto locking brakes to wheelchair . Results of Investigation: On 8/11/19 at 9:00 PM, Resident observed sitting on buttocks in front of wheelchair. Statement was I slipped . Root cause was Resident attempted to self-transfer, wheelchair brakes weren't locked . An interview was conducted with the Director of Nursing (DON) on 8/22/19 at 1:14 PM. When queried regarding Resident #155's falls within the facility including the fall on 6/22/19 with resulting fracture, staff statement of the Resident being impulsive, interventions to prevent falls, and observations, the DON stated, I'm not familiar with it. When asked if the interventions implemented were appropriate for what occurred when the Resident fell and why no new interventions were implemented when the Resident returned from the hospital, the DON did not provide an explanation. When queried why Incident and Accident Reports were not received for all falls documented in Resident #155's medical record, the DON did not provide an explanation. Record review of facility policy entitled, Falls - Clinical Protocol (Reviewed/Revised: 6/2018) revealed, As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling . Based on the assessment a care plan will be developed and implemented to address identified risk. This will be revised as necessary . Interventions should be developed and implemented per the assessed needs . For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall . The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling . Deficient Practice Statement #2 R#61 Based on observation, interview, and record review, the facility failed to safely reheat the food for one sampled resident (R61) of seven residents reviewed for accidents, resulting [MEDICAL CONDITION] the resident's wrist and thigh. Findings include: On 8/19/19 at 9:33 AM, R61 was observed in bed wearing a gown and eating breakfast. R61 was also observed with a kerlix gauze wrapped around their right lower arm. R61 was asked what happened to their arm. R61 said, I have a burn on my wrist and thigh from hot food. The Certified Nurse Aide (CNA) DD warmed my food last week and placed it on my lap. It (burns) really hurt. I have neurological problems and cannot feel stuff immediately. They made me sign this paper saying that they educated me about using the microwave. I don't use the microwave. I always ask CNA DD to warm my food. They told us at resident council that the dietary people would be warming the food. I did not do anything wrong. I just signed it anyway. On 8/20/19 at 1:40 PM, a review of R61's medical record noted a medical history of [REDACTED]. The care plan initiated on 6/1/18 noted the following: Skin inspections by CNA .Report changes to licensed nurse immediately. The resident's Brief Interview for Mental Status (BIMS) score notes a 14/15 indicating an intact cognition. A review of the medical record dated 8/13/19 noted the following: Licensed Practical Nurse J Description: Blisters Interventions: Ointment and bordered gauze applied. Physician notified: Yes Responsible Party notification: Ones own RP (responsible party) The medical record did not note the details of how R61 obtained the blisters. A review of the the Incident and Accident report dated 8/13/19 noted the following: Three blisters observed to residents skin. One to residents right thigh, two residents right forearm. Residents explanation/opinion of how injury occurred noted: Resident does not remember but stated (R61) remembers carrying a plate of food there. Element 1: On (MONTH) 13th at approximately 6PM, (R61) was observed in a residents room .(R61) requested CNA DD to heat up the food that (R61) had brought into facility-food was in a black container with a plastic lid. CNA DD honored (R61's) request and went to heat up (R61) food in the employee break room microwave. Upon return, (R61) requested for CNA DD to place the food in (their) lap so that (CNA DD) could assist (R61) back to their room .At around 7pm that evening, (CNA DD) was assisting (R61) with getting ready for bed. (CNA DD) noted resident to have a small blister to right thigh and to right wrist. (CNA DD) notified Licensed Nurse CC observation .(CNA DD) received a one to one education on the process of having Dietary Staff heat up residents food on (MONTH) 15, 2019. On 8/21/19 at 4:24 PM, CNA DD was interviewed about the incident of warming R61's food on 8/13/19. CNA DD said, They (R61) were in another resident's room. (R61) asked me to warm their food. I took it to the microwave and warmed it myself. I set the microwave on three minutes. It (the food container) did not feel hot to me. I had to sign a policy about not microwaving residents' food afterwards. A reviewed of the Resident/Family Education Record dated 8/16/19 at 12:18 PM noted: Resident was educated on the use of microwaves to warm up personal food. It was explained to the resident that no staff is allowed to warm up anything for the residents in a microwaves because they have no way of checking the temperature of the item being warmed safely for handling or consuming. The only exception to the use of a microwave is if the kitchen staff only when available is able to warm up items so that it can be monitored for safe temperatures. Also, food is only to be set on a bed side table or hard surface furniture never placed on the residents lap or handed to the resident. The policy for Food Brought by Family/Visitors dated on 4/23/18, noted the following: Reheating of foods 9. Facility staff will reheat appropriate foods upon resident request. On 8/22/2019 at 8:06 AM, the Administrator was interviewed regarding the burn to R61. The Administrator said, On the 14th we identified that (R61) had blisters, we discussed it with the resident. We educated the resident that we cannot warm the food. The Administrator was asked regarding the policy for outside food noted that facility staff will reheat food and why (R61) was educated. The Administrator said, (R61) can be demanding, so we wanted (R61) to know that only dietary could warm food. On 8/22/19 at 11:19 AM, the Director of Nursing (DON) was interviewed regarding expectation of documenting incidents in the medical record. The DON said, They (staff) should document any incident that occur to residents in the medical record Deficient Practice Statement #3 R #166 Based on observation, interview, and record review, the facility failed to properly administer the medications of one sampled resident (R166) of seven residents reviewed for accidents, resulting in medications being stored in an unsafe area, and the potential for accidents. Findings include: On 8/19/19 at 9:53 AM, R166 was observed laying in bed. They were asked how thet were doing and stated, I do not like it here. The food is awful, and I do not like how they (staff) treat me. I don't like the medications they give me, so I don't take them. R166 was asked if they declined the medications. R166 said, No, I just throw them over there in my drawer. R166 opened the top drawer of their nightstand and numeorus loose pills and medication cups were observed. On 8/19/19 at 10:19 AM, Nurse BB was interviewed and asked to look in the nightstand drawers located in R166's room. After permission from the resident, Nurse BB found five loose pills. Nurse BB was asked what the policy and procedure is for administering medications, and if they knew what the pills were. Nurse BB said, Two of the pills were [MEDICATION NAME], one was Cipro, and one was Vitamin. We are supposed to watch the residents take their medication and write down the ones that are refused. On 8/20/19 at 2:54 PM, A review of R166's medical record noted the following diagnoses, Muscle Weakness, Psychoactive Substance Abuse, and Depression. The care plan dated 7/12/19 noted, anticipate and meet the residents needs based on nursing assessments. On 8/21/19 at 10:03 AM, R166 was observed sitting on the side of their bed. They were asked if they were taking their medications since the previous interview. R166 said, The nurse put my [MEDICATION NAME] on the table and walked out. I did not take it. I flushed it down the toilet. After that, I told the nurse that I did not want the pills. A review of the Facility assessment dated [DATE], noted the following: Specific Care and Practice: Build relationship with resident/get to know him/her; engage in conversation. Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information in to the care planning process. On 8/22/19 at 11:19 AM, The Director of Nursing (DON) was interviewed and informed that R166 was not taking some on their medications and that five pills were found in their nightstand drawer. The DON was asked what the expectation was for nurses when administering medications. The DON said, They are expected to ensure that residents take their medications.

This citation pertains to intake MI 982. Based on observation, interview, and record review, the facility failed to identify and provide a safe environment related to exposed metal brackets for 1 (#905) sampled resident, resulting in resident injury upon falling out of bed. Findings include: On 4/17/19 at 2:08 PM, an interview was conducted with Confidential Witness A regarding R#905's stay at the facility. Witness A stated the following: On (MONTH) 2nd (2019) (R#905) was admitted to the facility and when we got to the room, room [ROOM NUMBER], I immediately told the nurse that the post on the bed, is dangerous, (R#905) is going to fall and is going to fall on it. It was Bed 1 on the left side of the room. The nurse told me that's a management issue, take it up with management. I left around 6:00 PM and of course at 7:30 PM they called me that (R#905) fell out of bed and then again not long after that (they) fell again onto that steel post. I told them, 'Really? (R#905) fell on ce at 7:30 PM and you didn't do anything or move them and then waited for them to fall and get hurt right after that?' Witness A described the posts as hollow metal pieces on both sides of the bed frame, near the head of the bed. Witness A continued stating, (R#905) had to go to the emergency room (ER) for a couple of hours because of it! I told the nurse it was dangerous, it was somewhat of a railing but had no handle in it. I had them move (R#905) into a different room because I didn't want them in there with those steel posts. Witness A described R#905's injury from the post as, Bruises to the right side of the face and cuts on (their) head from the edges of the hollow metal post. You could tell that's what (R#905) hit (their) head on. It was very obvious. And I knew that was going to happen. On 4/23/19 at 5:36 AM, during the initial tour, Bed 1 in room [ROOM NUMBER] was observed to have a hollow metal post on the left side of the bed and a metal post with an assist bar locked into place on the right side of the bed. A review of R#905's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident required extensive assistance from staff for transferring. The resident's MDS did not include a Brief Interview for Mental Status (BIMS) score but indicated the resident's Cognitive Skills for Daily Decision Making were, Moderately Impaired - decisions poor; cues/supervision required. A review of R#905's record revealed the following: Progress note written by Nurse B: 1/2/2019 19:00 (7:00 PM) Pertinent Charting-Falls, Note Text: Date of Fall: 01/02/2019 Situation Details: observed patient lying on back on a floor next to bed .Mitigating Factors: (blank) Environmental Factors: (blank) Interventions: call light within reach bed in lower position when not providing care . On 4/23/19 at 9:09 AM, Nurse B was contacted via phone and queried regarding R#905's falls at the facility and their pertinent documentation. Nurse B stated, We have a lot of people that fall, I know (R#905) had a couple of falls, I don't remember sending them to get any stitches. But I'm pretty sure (they) fell a couple of times when (they) came in. I believe (R#905) had dementia. Continued review of R#905's progress notes revealed a note written by Nurse C: 1/2/2019 22:17:29 (10:17 PM) writer notified by CNA (Certified Nursing Assistant) that resident was observed on floor. noted moderate bleeding from lateral right temple. resident stated repeatedly my head hurts. unable to obtain blood pressure. sent to hospital via 911, taken by stretcher via ambulance to (acute care hospital). daughter notified, MD notified of transfer. A review of the Incident/Accident report written by Nurse C revealed: room [ROOM NUMBER]-1, Date of Incident 1/2/19, Condition Prior to incident: Confused/Disoriented, Location: Resident Room, Incident Type: Unobserved Fall. This Section for Falls or Accidents: Place of fall/accident: Res Room, Environmental Factors: (blank), List Care Planned Interventions Prior to Fall/Accident: (blank), Were planned interventions in place? (blank), If no, list reasons: (blank), When was resident last seen, what were they doing: (blank), Immediate interventions implemented: (blank) . R#905's emergency room Discharge Instructions dated 1/3/19 at 5:13 AM were reviewed and revealed instructions for abrasion and facial contusion care. A progress note dated 1/3/2019 07:06 (7:06 AM) revealed: Nurses' Notes Note Text: resident returned to facility (sic) at 0645, was put in to room [ROOM NUMBER] bed one for safety. vital signs stable. no sutures were placed. all scans of head and neck were negative. resident is resting comfortably at this time bed in low position. On 4/23/19 at 9:37 AM, Nurse D was interviewed regarding R#905. Nurse D indicated they never saw the resident until (R#905) came back from the ER after falling. Nurse D indicated R#905 had, Facial bruising and abrasions and I believe it was on the right side. Nurse D reviewed the positioning bar and metal post in room [ROOM NUMBER] Bed 1. Nurse D stated, It's a spoke one (inserted into tube and held in place by metal spoke), it can be pressed out and removed. Nurse D indicated when removed, a hollow metal post is left on the side of upper part of the bed. Nurse D also indicated they did not take care of the resident when they were in room [ROOM NUMBER]. A progress note dated 1/9/2019 10:57 revealed: S[NAME]-Falls New Fall/Follow-Up: New Falls, Two falls on 1/2/19 7pm and 10 pm, Situation (where/when/what/who): Resident was observed sitting on the floor next to bed, Injury/No injury: no injury on the first fall, Second fall resident had bleeding noted to right temple and right lateral face. Factors involved (acute condition/environment, etc.): (blank) . On 4/23/19 at 10:26 AM, Nurse C was contacted for an interview via phone and a voicemail was left for call back. No call back from Nurse C was received prior to exiting the facility. On 4/23/19 at 11:40 AM, the Nursing Home Administrator (NHA) was queried regarding any incidents involving R#905 that resulted in having to go to the hospital. The NHA indicated they believed R#905 had hit their head on something and had to go to the hospital. At this time, The Assistant Director of Nursing (ADON) was asked by the NHA to review the bed in room [ROOM NUMBER]. On 4/23/19 at 11:45 AM, Bed 1 in room [ROOM NUMBER] was reviewed with the ADON. The ADON acknowledged that there was one positioning bar on the right side of the bed and a hollow post on the left side of the bed. The ADON indicated the entire piece, including the hollow post, is able to be removed from the bed. When queried, the ADON could not recall if there were any complaints made about the posts on the bed. When asked if the post(s) could be unsafe in the resident's sleeping environment and result in injury if a resident rolled out of bed, the ADON stated, Theoretically, yes, anything's possible. Someone could hit their head on there. A review of R#905's care plan revealed the following: The resident will have no complications related to skin impairment. Date Initiated: 01/02/2019 .Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 01/02/2019. A review of the facility's policy titled, Bed Safety, revised 2/8/2011, revealed: Our facility shall strive to provide the safest possible sleeping environment for the resident that prevents/reduces hazards .1. The resident's sleeping environment shall be designed based on an interdisciplinary assessment of the resident's safety, medical, comfort, and freedom of movement needs, as well as input from the resident and family regarding previous sleeping habits and bed environment . A review of the facility's policy titled, Falls - Clinical Protocol, revised 12/2013, revealed: 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 .

This citation pertains to intake # . Based on observation, interview and record review, the facility failed to ensure a timely orthopedic follow up appointment, complete daily surgical incision care and daily skin checks underneath a brace/cam boot (a brace with velcro straps used to keep the leg and foot immobilized) for 1 (#906) of 3 sampled residents reviewed for infections, from a total sample of 17, resulting in an infected surgical incision, pain, and delayed healing. Findings include: On 7/10/18 at 8:45 AM, Resident #906 was observed sitting up at the edge of the bed eating breakfast. Resident #906 had a bandage present on their left heel. There was a soft heel boot present on the floor next to the bedside stand. Resident #906 was queried in regards to the soft boot and bandage on the left heel. Resident #906 stated, I'm trying to break it (the boot) in, it is a new boot. I fell at home and fractured my left leg in 3 different places. There were three large scars observed on the leg of Resident #906, one on the left inner thigh, left ankle and left outer thigh going across the top portion of the thigh. On 7/10/18 at 11:00 AM, a record review of the face sheet and Minimum Data Set (MDS) assessment for Resident #906 was completed. The face sheet revealed that Resident #906 was admitted to the facility and discharged on the same day on 11/11/17, and then readmitted on [DATE] with the [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #906 had a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognition and needed some assist with Activities of Daily Living (ADL's). On 7/10/18 at 12:34 PM, Resident #906 was observed sitting up at the edge of their bed eating lunch. Resident #906 stated, I missed my first ortho appointment, so I went to my ortho doctor for a check up in January, they (the ortho Doctor) removed the brace and said that my incision was infected and that I had a heel ulcer. It was from the brace. They (the nursing home staff) didn't know that they could take it (the brace) off and clean up my incision and stitches. On 7/11/18 at 9:53 AM, a further record review was completed and revealed the following: Admission Nursing Evaluation 11/28/18-Skin assessment reveals sutures present on left thigh, left ankle surgical incision and bruising. On 7/11/18 at 10:40 AM, a record review of the orthopedic consults for Resident #906 revealed the following: 1/2/18-Findings and Recommendations from Consultation: 1) Mild [MEDICAL CONDITION] left knee Orders-1) Keflex 500 Milligrams (mg) qid (4 times per day)x 7 days. 2) F/u (follow up) with (hospital) orthopedic surgeon 1/4/18-(Resident #906)-To have daily wound care . It is okay to remove (Resident #906) brace for wound care and dressing changes. On 7/11/18 at 10:46 AM, a record review of the Treatment Administration Record (TAR) was completed for Resident #906, and revealed the following: November thru (MONTH) 27,2017-No treatment orders for the surgical wound/sutures, or for the inspection of the skin underneath the brace. Order on TAR for 12/27/17 - 2/2/18 stated, Cleanse left lower extremity suture sites with NS (normal saline), dry, apply ABD pads x 3 over surgical sutures . January (YEAR)-Order and treatment stated, Remove brace to L leg and check skin for breakdown every day and night shift. Start date 1/3/18, discontinued 1/18/18. On 7/11/18 at 11:00 AM, a record review of the care plan for Resident #906 revealed no skin care plan initiated in regards to the surgical wound and brace care. On 7/11/18 at 2:50 PM, an interview was completed with the Director of Nursing (DON) in regards to checking underneath braces for wounds and completing incision care. The DON stated, We would normally check the splint and make sure it isn't rubbing on anything and that it is fitting right. The DON was also queried in regards to the delay in the orthopedic consult for Resident #906, the DON stated, We would normally call the ortho Doctor to set up an appointment. During the interview, the Administrator entered, but did not offer any further explanation of the missed ortho appointment, incision care and skin checks under the brace of Resident #906. On 7/12/18 at 9:20 AM, Resident #906 was up in their wheelchair. Resident #906 was queried on allowing staff to check the skin integrity while wearing the brace. Resident #906 stated, I didn't know they were supposed to, no one tried. Resident #906 also stated, When I was at the Doctor's (ortho) I knew something was wrong when they removed the brace for the first time. It was very painful. It (the incision) was swollen and had pus coming out of it. It had opened up here (pointing to a long pink scar with a large widened area). They had a hard time getting the staples out because they were embedded in my skin. They immediately called my son and he left work and came right down and took pictures and everything. He immediately went to the office (at the facility) and complained. A policy for surgical incisions and brace care was requested but not received by the end of the survey.

This citation pertains to intake # . Based on observation, interview and record review, the facility failed to prevent the development of an unstageable left heel pressure ulcer (a skin wound caused by friction or pressure on the skin that has necrotic, or dead tissue present) by not checking the integrity of the skin daily under a brace/cam boot (a brace with velcro straps used to keep the leg and foot immobilized) for 1 resident (#906) out of 2 residents reviewed for pressure ulcers, from a total sample of 17, resulting in a pressure ulcer, pain, and delayed rehabilitation. Findings include: On 7/10/18 at 8:45 AM, Resident #906 was observed sitting up at the edge of the bed eating breakfast. Resident #906 had a bandage present on their left heel. There was a soft heel boot present on the floor next to the bedside stand. Resident #906 was queried in regards to the soft boot and bandage on the left heel. Resident #906 stated, I'm trying to break it (the boot) in, it is a new boot. I fell at home and fractured my left leg in 3 different places. There were three large scars observed on the leg of Resident #906, one on the left inner thigh, left ankle and left outer thigh going across the top portion of the thigh. On 7/10/18 at 11:00 AM, a record review of the face sheet and Minimum Data Set (MDS) assessment for Resident #906 was completed. The face sheet revealed that Resident #906 was admitted to the facility and discharged on the same day on 11/11/17, and then readmitted on [DATE] with the [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #906 had a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognition and needed some assist with Activities of Daily Living (ADL's). On 7/10/18 at 12:34 PM, Resident #906 was observed sitting up at the edge of their bed eating lunch. There was a bandage present on the left heel. Resident #906 was queried in regards to the bandage on their left heel. Resident #906 stated, I missed my first ortho appointment, so I went to my ortho doctor for a check up in January, they (the ortho Doctor) removed the brace and said that my incision was infected and that I had a heel ulcer. It was from the brace. They (the nursing home staff) didn't know that they could take it (the brace) off and clean up my incision and stitches. On 7/11/18 at 9:53 AM, a further record review was completed and revealed the following: Admission Nursing Evaluation 11/28/18-Skin assessment reveals sutures present on left thigh, left ankle surgical incision and bruising. Under the category Heel problems, there was no notation of a pressure ulcer. Bath Time Skin Anatomy Diagram 11/28/18-Under #4 Heel no notation of a wound. Skin Assessments dated 12/2/17, 12/9/17, 12/16/17 and 12/30/17 stated there were no abnormal skin areas. On 7/11/18 at 10:40 AM, a record review of the orthopedic consults for Resident #906 revealed the following: 1/2/18-Findings and Recommendations from Consultation: 3) Pressure ulcer left heel Orders-F/u (follow up) with (hospital) orthopedic surgeon 1/4/18-(Resident #906)-to have daily wound care. (Resident #906) is on decubitus ulcer precautions. It is okay to remove (Resident #906) brace for wound care and dressing changes. On 7/11/18 at 10:46 AM, a record review of the Treatment Administration Record (TAR) was completed for Resident #906, and revealed the following: November thru (MONTH) (YEAR)-No treatment orders for the left heel, or for the inspection of the skin underneath the brace. January (YEAR)-Order and treatment stated, Cleanse with wound cleanser, Pat dry. Apply skin prep q (every) shift and prn (as needed) to L (left) heel wound every day and night shift. Start date 1/2/18, discontinued 4/30/18. Remove brace to L leg and check skin for breakdown every day and night shift. Start date 1/3/18, discontinued 1/18/18. On 7/11/18 at 11:00 AM, a record review of the wound notes and care plan for Resident #906 revealed the following: 6/5/18 physician progress notes [REDACTED].>Reason for Appointment-Wound Care Wound location-Left heel Type-Pressure Dimensions-1.7 centimeters (cm) x 1.5 x UD (undetermined) Assessments-Unstageable pressure ulcer of left heel 7/12/18 Wound History Screen Location Name: L heel Length/Width/Depth: 1.2/1.0/UTD cm Tissue Type: Slough (dead tissue) Skin Care Plan (initiated 1/3/18) Focus-The resident has pressure ulcer to left heel . On 7/11/18 at 2:50 PM, an interview was completed with the Director of Nursing (DON) in regards to checking underneath braces for wounds. The DON stated, We would normally check the splint and make sure it isn't rubbing on anything and that it is fitting right. During the interview, the Administrator entered, but did not offer any further explanation of the skin checks under the brace of Resident #906. On 7/12/18 at 9:20 AM, Resident #906 was up in their wheelchair. There was a bandage present on the left heel. Resident #906 was queried on allowing staff to check the skin integrity while wearing the brace. Resident #906 stated, I didn't know they were supposed to, no one tried. Resident #906 also stated, When I was at the Doctor's (ortho) I knew something was wrong when they removed the brace for the first time. It was very painful . They immediately called my son and he left work and came right down and took pictures and everything. He was mad. He is an ICU (intensive care unit) nurse so he knows! He immediately went to the office (at the facility) and complained. On 7/12/18 at 11:13 AM, a record review of the facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol revised 11/28/17 revealed the following: 1. An admission evaluation helps identify residents at risk of developing a pressure ulcer/pressure injury (PU/PI) .Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. The admission evaluation helps define those initial care approaches. 6.a. The plan of care for prevention and/or treatment of [REDACTED]. 7.a. Norton Plus or standardized skin risk assessment weekly . On 7/12/18 at 11:17 AM, a record review was completed of Resident #906's Norton Plus Pressure Ulcer Scale (a tool used to determine the risk of pressure ulcer development) dated 11/28/17 revealed a score of 14, indicating a moderate risk. On 7/12/18 at 11:35 AM, an interview was completed with the Wound Care Registered Nurse (RN I) in regards to the left heel wound of Resident #906. RN I stated, It is healing, it started in January. It is from a brace.

This citation pertains to intake # MI Based on interview and record review, the facility failed to prevent a significant medication error by administering 120 milligrams (mg) of [MEDICATION NAME] (a controlled opioid medication used to treat severe pain) to the wrong resident (Resident #706) during a medication pass with a new Licensed Practical Nurse (LPN B) who was in training and under the supervision of Registered Nurse (RN A) for 1 (#706) of 2 residents sampled for medication errors, from a total sample of 6, resulting in an Immediate Jeopardy ( IJ) for Resident #706 receiving the wrong medication and suffering from severe respiratory depression requiring four doses of [MEDICATION NAME] (a medication utilized to overturn the effects of narcotic medication), emergency services and hospitalization . The immediate jeopardy (IJ) was identified on 5/21/18. The Administrator was notified on 6/6/18 at 10:22 AM and a plan of correction was requested to remove the immediacy. The IJ was removed on 5/24/18, based on the provider's implementation of corrective actions on 5/24/18, as verified onsite on 6/6/18, during the completion of the partial extended survey. Findings include: On 6/5/18 at 1:30 PM, a record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #706 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS also revealed that Resident #706 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/5/18 at 1:36 PM, a record review of the Progress Notes dated 5/21/18 revealed the following: At 9:00 AM resident (#706) was given medication in error, [MEDICATION NAME] 120 mg by mouth. Medication error identified at approximately 10:00 AM. Resident (#706) assessed by writer, observed resident (#706) alert and oriented x 3 at baseline mentation, neuro checks within normal limits, VS (vital signs): BP (blood pressure) 157/96, P (pulse) 57, R (respirations) 17, SpO2 (oxygen saturation) 95% on room air, T (temperature) 97.9. (Resident #706) is his own Responsible Party and (they) are aware of the error. Resident educated on signs and symptoms of adverse reactions and to notify the nurse. (Doctor) was notified and new order was received to monitor vitals and neuro checks to assess mentation. At 12:20 PM Resident noted with decreased respirations, unresponsive to verbal stimuli. Physician notified, [MEDICATION NAME] dose given from E-kit (emergency medication kit) as ordered. EMS (Emergency Medical Services) contacted, second dose [MEDICATION NAME] given by EMS. Resident returned to baseline mentation, alert and oriented x 3. Resident was transported to (hospital) for medical evaluation. On 6/5/18 at 2:05 PM, an interview was completed with RN A over the phone. RN A was queried about the medication error that involved Resident #706 and LPN B. RN A stated, That day I was preparing meds (medication), I even wrote the name down and room number on the cup (that contained the medication). The orientee (LPN B) was behind me (unable to fully view the computer screen). I didn't follow (LPN B-in to the room to pass the medications to Resident #706) because I was all alone by myself on the unit. Usually I have a partner (another nurse taking half the unit) but they (the facility) pulled her to another unit. When (LPN B) seen the picture of the other (Resident), she told me she gave the wrong medication to the wrong (Resident). I followed the protocol. I told the supervisor and called the doctor. I checked on (Resident #706), then I had another emergency with another resident with a blood sugar. The other resident's blood sugar was 36, so I was dealing with that and told (LPN B) to check on (Resident #706). I had to give [MEDICATION NAME] (a medication used to to treat low blood sugar) to the other resident and call the ambulance. Another nurse came to me and asked me to check on (Resident #706) to see if that was how (they) normally were, when I checked on (Resident #706), he was pale, not responding. I did not see his chest rise and fall. I called the doctor, gave him [MEDICATION NAME], he didn't respond. Luckily the EMS was still here for the other patient so I asked them to come in. They ended up giving (Resident #706) 3 other doses of [MEDICATION NAME] and (Resident #706) finally woke up and was alert and oriented x 3-4. (Resident #706) went to the hospital .They (the facility) suspended me and called me the next day to inservice me. I told them now to not give me an orientee if I am by myself because it is too much. Normally I would have followed her (LPN B) in the room (during medication pass). I am too rushed to get everything done. It is 37 patients .I asked them to not put (Resident #706) in the same room with the same first name if they came back from the hospital, they (the facility) told me they wouldn't do that anymore. On 6/5/18 at 2:15 PM, a record review of the Performance Improvement Form (Form #412) dated 5/21/18 revealed that LPN B had a date of hire on 5/14/18. The form stated the following: Reason for Counseling/Corrective Action: As standard medication pass, a nurse should not take medications to a resident that was prepared by another nurse. The form was checked as a Written Warning. On 6/5/18 at 2:20 PM, a record review of LPN B's orientation paper work titled, Medication Administration Review: [DEVICE] (stomach tube) Post Test revealed that LPN B got question #3 wrong. Question #3 asked the 5 Rights of Medication Administration are: Right Medication, Right Time, Right Documentation, Right Dose and Right Route. LPN B had answered the question incorrectly by circling True. The answer should have been False since Right Resident was not included as one of the 5 Rights of Medication Administration. On 6/5/18 at 2:25 PM, a record review of the Medication Administration Record (MAR) and the Individual Resident's Controlled Substance Report for the roommate of Resident #706 revealed that twelve 10 mg tablets of [MEDICATION NAME] were signed out by RN A at 9:00 AM on 5/21/18. On 6/5/18 at 2:30 PM, a record review of the incident report dated 5/21/18 revealed that Resident #706 had received [MEDICATION NAME] in error. Was monitored. And send to hospital after receiving [MEDICATION NAME]. On 6/5/18 at 2:33 PM, a record review of the Medication Discrepancy Report dated 5/21/18 revealed that Resident #706 had received 120 mg of [MEDICATION NAME] (12 tabs). On 6/5/18 at 3:20 PM, an interview was completed with the Administrator in regards to the medication error involving Resident #706. The Administrator had explained that LPN B was a brand new nurse and that the nurse orientating (RN A) was responsible for the medication pass and LPN B. The Administrator also stated pharmacy was consulted about the error and that the facility was revamping the orientation process. The Administrator also explained that the facility is now utilizing Name Alerts for residents that share a room and have similar names. On 6/5/18 at 3:30 PM, a review of [MEDICATION NAME] was completed based on the Physician's Desk Reference (PDR) website and revealed the following: For the treatment of [REDACTED]. Use extreme caution to avoid overdosage; it is safer to underestimate a patient's daily oral [MEDICATION NAME] requirement. Due to the potential for delayed toxic effect (e.g. respiratory depression), clinical guidelines recommend does titration (changes) every 3 to 5 days. On 6/6/18 at 11:00 AM, an interview was completed over the phone with LPN B. LPN B stated, I remember that day very vividly. It was my very first day on the floor. (RN A) just handed me a cup of pills, I went into (Resident #706)'s room and they took the pills. Later that day (RN A) brought up (Resident #706) on the computer screen/MAR and I told her I had already gave them their meds, then we put two and two together. I checked on (Resident #706) and they were not waking up. I did a sternal rub and everything, so I went and got (RN C). During all this, we (LPN B and RN A) also had a blood sugar incident with another person so it was a crazy first day that I will never forget! Next time when I give medications I will look at the picture of the resident, ask them to verify their name and also their birth date. On 6/6/18 at 11:15 AM, an interview was completed with RN C. According to RN C, he had went back into the room to check on Resident #706 and stated, (Resident #706) was not responding. I couldn't remember if they were hard of hearing or not so I went to see if that was their baseline .when I did a sternal rub, all he did was groan. That is when I knew we had to start the process (to transport out to the hospital). On 6/6/18 at 12:00 PM, an interview was completed with RN D. RN D was the staff development nurse. RN D stated, Well, what should have happened was (LPN B) should have been in observation mode only. She should have just been shadowing (RN A). She (LPN B) should not have been passing pills. On 6/6/18 at 12:12 PM, an interview was completed with the interim Director of Nursing (DON). The DON did not offer an explanation about the medication error incident involving Resident #706 but did explain that there were no further medication errors. On 6/6/18 at 12:30 PM, a record review of the facility policy titled Administering Medications revealed the following: 2. The DON will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders . 5. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medical record; c. Calling resident by name; and d. If necessary, verifying resident identification with other facility personnel. 12. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication . 16. As required or indicated for medication, the individual administering the medication will record the resident's medical record . 17. Medications ordered for a particular resident may not be administered to another resident . Plan of Correction to remove the Immediate Jeopardy: June 6, (YEAR) As a result of the finding of immediate jeopardy by the survey team on (MONTH) 6, (YEAR) related to resident #706 - Resident #706 received his roommates medication [MEDICATION NAME] 10 mg; -during medication pass with a new Licensed Practical Nurse who was in training and under the supervision of a Registered Nurse. Resident # 706 was admitted to facility on 4/12/18 with the [DIAGNOSES REDACTED]. Resident #706 no longer resides in the facility, was discharged to the hospital on (MONTH) 21, (YEAR). He was subsequently discharged home from the hospital Total of 260 residents. 4 out of 260 residents were receiving [MEDICATION NAME] as of (MONTH) 25, (YEAR) and were re-reviewed on (MONTH) 5, (YEAR). By (MONTH) 25, (YEAR) each of the 4 resident's [MEDICATION NAME] orders were reviewed by the Director of Nursing or designee and were deemed appropriate. Medication Errors for the past 30 days were reviewed by the Director of Nursing by (MONTH) 25, (YEAR). There were no medication errors identified. The Unit Managers will bring all medication incident reports to the daily clinical meeting, Monday to Friday for review, and a root cause analysis will be conducted. The Director of Nursing will report Medication Errors to the QAPI Meeting Monthly. Registered Nurse A and LPN B were suspended at the time of the medication error on (MONTH) 21, (YEAR). Registered Nurse A returned to work on (MONTH) 24, (YEAR) and LPN B returned to work on (MONTH) 29, (YEAR). Prior to working the floor, Registered Nurse A and LPN B were retrained on Med Pass and both received corrective action for failure to follow the medication administration process. 33 out of 34 Licensed Practical Nurses (1 x LPN is on military leave); 19 out of 19 Registered Nurses and 19 out of 19 Administrative Nurses were retrained by the Staff Development Nurse or Designee on Med Pass - The rights of Medication Administration, the role of being a Preceptor, acceptable professional standards and principles, including the Nurse who prepares the medication must be the nurse who administers the medication to the properly identified resident, by (MONTH) 25, (YEAR), or on the commencement of the next scheduled shift. 260 out of 260 residents names were reviewed by the Nurse Managers and name alerts were placed on their name plate and in Point Click Care by (MONTH) 25, (YEAR) and moving forward if there is a room move or a new admission. Medication Policy was reviewed on (MONTH) 23, (YEAR) by the Director of Nursing and was deemed appropriate. Med Pass Observations of Licensed Nurses completed by the Director of Nursing or Designee were initiated on (MONTH) 25, (YEAR) and are ongoing. To prevent this type of medication error from recurring, Administrator or Designee will ensure that a name alert is placed on the resident room name plate, the med cart and in Point click Care. Medication Administration process and name alerts will be audited weekly. The Director of Nursing is responsible for sustained compliance.

This pertains to intake # MI 598 and MI 705. Based on observation, interview and record review, the facility failed to ensure the physical safety and mental well-being for 1 (#901) of 3 sampled Residents reviewed for abuse from a total sample of 5, after allegations were made by Resident #901 of being stalked by Resident #903, who had a history of [REDACTED].#901, and placed all other residents at risk for serious harm, injury and/or death. An Immediate Jeopardy ( IJ) arose when Resident #901 reported to the Social Worker, concerns of being stalked by Resident #903 and interventions were not implemented to ensure Resident #901's safety and prevent the Resident to Resident abuse that occurred on 8/11/17. The IJ was identified on 9/12/17 at 4:00 pm. The Administrator was notified of the Immediate Jeopardy (IJ) on 9/12/17 at 6:02 PM. A plan to remove the immediacy was requested. The IJ was removed on 9/13/17 based on the facility's implementation of the plan for removal as verified onsite. Although the IJ was removed, the facility's deficient practice was not corrected and remains as isolated. Actual harm that is not immediate jeopardy. Findings include: On 9/11/17 at 7:40 PM, a phone interview with Resident #901 was conducted. Resident #901 stated, I went outside by the Java Lounge and (Resident #903) followed me. (The Resident) punched me in my eye about 10 times and in my chest a bunch of times. Another Resident pulled (Resident #903) off of me. Resident #901 then indicated she got back into the facility and called 911 on another Resident's phone. The Resident indicated the incident occurred about 8:00 PM on Friday in August but did not recall the date. Resident #901 revealed that Resident #903 was taken off of one on one status (staff that is assigned to be with a resident at all times) after the Resident had attacked and hit other Residents. Resident #901 stated, (Resident #903) had threatened to go after me. (Resident #903) was stalking me. Resident #901 indicated they had gone to the Social Worker and stated, I told the Social Worker before that I thought (Resident #903) was stalking me. She just blew me off then. Resident #901 stated, If they would have put her back to one on one she might not have gotten to attack me on Friday. On 9/12/17 at 9:30 AM, an observation was made of the Java lounge area and patio. The Java lounge had chairs and tables in the area and two doors leading out to the patio. A staff member indicated that a button was pushed to open the door to enter outside and that Residents can come and go as they wish. The patio was fenced in. On 9/12/17 at 10:30 AM, a review of Resident #901's medical record revealed an admission date of [DATE] and a readmission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment, dated 6/6/17, revealed a Brief Interview of Mental Status score of 8 which indicated moderate cognitive impairment. On 9/12/17 at 10:35 AM, a review of Resident #903's medical record revealed an admission date of [DATE] with a discharge date of [DATE] with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE] revealed a BIMS score of 14 which indicated the Resident was cognitively intact. On 9/12/17 at 11:00 AM, a review of the investigation for the incident that occurred at the facility on 8/11/17, involving Resident #901 and #903, was completed and revealed the following: Resident #901 A document authored by Nurse A. Date of incident: 8/11/17. Time of incident: 8:00 PM. Witness: (Witness B) Brief Description: (Resident #901) stated she was sitting in the chair in the patio when (Resident #903) walked up to her and started punching her multiple times in the face, chest, R (right) shoulder. (Resident#901) stated she couldn't understand what she was saying to her. (Witness B) then got (Resident #903) off her. Injury Type: The box for No apparent injury was marked. Mental Status: AxO 4 (alert and oriented to person, place, time and situation) Pain Scale (0-10): 6 Treatment: Call 911 is circled. Action taken: The box for Police Notified was marked. The document entitled Quality Assessment and Assurance Investigation Report, authored by Nurse C, dated 8/30/17, indicated: Any precipitating event: Arguments between (Resident #901) and (Resident #903) a few weeks ago. Results of Investigation: IDT (interdisciplinary team) met regarding incident on 8/11/17. Resident stated I was sitting in the chair on the patio when resident (#903) walked up to me and started punching me multiple times in the face, chest and r shoulder. Investigation completed resident (#903) assigned one on one care. Resident #903 A document authored by Nurse D Date of incident: 8/11/17. Time of Incident: 8:00 PM. Brief Description: It was reported to writer that Resident (#903) punched Resident (#901) in the face. When resident was asked, she reported she was running off at the mouth since yesterday so I walked up to her and punched her in the face. The document entitled Quality Assessment and Assurance Investigation Report, not signed or dated, revealed the following: Results of Investigation: Resident was placed on 1 to 1 and is on placement for discharge to another facility. Further review of the investigation documents entitled, Statement of Witness, revealed the following: Name and Position of Witness: (Resident #901) Statement of Witness: Writer interviewed (Resident #901) regarding occurrence with Res. (Resident) (#903). (Resident #901) states she was sitting on west patio when Res. (Resident #903) starting saying something to her. She states she did not know what she said. (Resident #901) states resident (#903) walked over grabbed her walker and began hitting her in her face about 10 times then her (R) (right) shoulder and chest. (Resident #901) states that another resident came over and pulled Resident (#903) off her. She then went inside with the other Resident and they called 911. She then observed Res. (#903) come in from patio. Police then came and (Resident #901) state she made a report. Name and Position of Witness: (Resident #903) Statement of Witness: Writer interviewed (Resident #903) regarding Resident (#901). (Resident #903) stated that she was sitting on West patio. When she became upset at (Resident #901) for thing she had been saying. (Resident #903) stated Yes I went over and hit her once or twice. I am sick of her lying. Name and Position of Witness: (Witness B) Statement of Witness: Writer interview (Witness B) regard occurrence between Resident #(901) and resident #(903). (Witness B) states that about 8:30 p he and Resident #(901) were sitting on west patio, he in a chair and her on the bench. When Resident # (903) approached them saying something he could not hear. Then Resident #(903) began punching 4 to 7 times with closed fist to face, chest and (R) shoulder. (WitnessB) states he stood up and pulled resident off He state resident #(901) and himself came inside called 911 in hallway when resident #(903) entered building from patio. On 9/12/17 at 11:25 AM, a review of Witness B's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. A review of the MDS revealed a BIMS score of 9 which indicated moderate cognitive impairment. On 9/12/17 at 11:30 AM, a review of documents provided by the facility, were for incidents involving Resident #903, revealed the following information: A document authored by Nurse (A) Date of incident: 5/12/17. Time of Incident: 7:20 PM. Incident Type: The box Observed was marked. Brief Description: Witness stated she tried to redirect (Resident #903) multiple times. (Supplemental Resident #155) was calling her names and upset (Resident #903). (Resident #903) strike (Supplemental Resident #155) in the face with closed fist. Quality Assessment and Assurance Investigation Report: Results of Investigation: IDT met regard incident on 5/12/17. Resident struck resident in the face with a closed fist. Resident (#903) petitioned to hospital. Upon return resident (#903) assigned one on one care. A document authored by Nurse (C) Date of incident: 5/18/17. Time of Incident: 1:30 PM. Brief Description: Reported to writer resident was observed on west patio rubbing resident (#905) right thigh and groin area. Quality Assessment and Assurance Investigation Report: Results of investigation: IDT team met regarding incident on 5/18/17. Reported to writer resident was observed on west patio rubbing resident (Resident #905) right thigh and groin area. Residents on frequent observation. A document authored by Nurse (G) Date of incident: 5/25/17. Time of Incident: 9:00 PM. Brief Description: Resident (#905) stated that she allegedly smack Resident in face. Quality Assessment and Assurance Investigation Report: Results of Investigation: IDT team met regarding incident on 5/25/17. Resident (#905) stated resident smacked him in the face. Resident petitioned to hospital. Upon return resident (#903) moved to another room [ROOM NUMBER] on 1 assigned to resident (#903). Social work to follow up. Further review of Resident #903's medical record revealed a progress note entitled, Type: Nurses' Notes, Effective Date 5/14/17 at 11:19 (AM). The progress note stated: Resident continues to verbalize she wants to punch others, 'I am going to get all those nosey [***] es, I'll knock them all out' Resident continues on continuous staff monitoring. A review of the progress notes for Resident #901 revealed a progress note entitled, Type: S(NAME)-Behavior, effective date: 8/12/2017 14:29 (2:29 PM), created by Social Worker H, on 8/14/17 at 14:46. The progress note stated, Behavior displayed: Making exaggerated claims against another resident. Rt (resident) claims another resident punched her in the face, chest and right arm multiple times. Upon investigation no bruising was noted to any area of her body. History of behaviors: none confirmed. Interventions attempted: SW (social worker) has attempted to intervene . Comments: SW to monitor mood and behaviors. Further review of Resident #901's medical record revealed a progress note entitled, Type: Social Services Progress Notes, Effective Date: 6/14/2017, Author: (Social Worker H) revealed, SW spoke with (Resident #901) regarding behaviors to another resident in that she and other residents are making mean comments towards another resident. SW discussed that it is a form of bullying and we as a facility will not tolerate it, we have a responsibility to make everyone well safe and cared for. SW asked that if she could not say anything nice to just avoid speaking to the other resident. SW will continue to monitor. On 9/12/17 at 1:35 PM, an interview was conducted with Social Worker (SW) H. The SW was queried about the progress note that was created on 8/14/17 by SW H and stated, (Resident #901) came to my office, no apparent bruises on the arm or face, (the Resident) pushed the sweater down to see her arm It was Monday morning. (Resident #901) came to tell me what happened. When queried about what the SW meant by exaggerated claims, the SW stated, (Resident #901) went from punching her once to 10 times all in the same time. It kept growing. The SW was queried about Resident #901's history of behaviors and the note from 6/14/17 and stated, (Resident #901) was targeting on (Resident #903) at this time. When queried about any interventions in place at this time, the SW stated, I talked to her about it. (Resident #901) agreed to be mindful and keep her distance. For a little bit they did but you still run into people. When queried about establishing interventions, the SW responded, I don't think we documented, we just did temp readings with them, watched them. The SW stated, I think she was instigating the situation. The SW was queried about the procedure to monitor the two residents and stated, Just keep an eye on them. The SW was queried if Resident #901 had voiced any concerns prior to the incident occurring on 8/11/17 and stated, A week or so before, (Resident #901) came to talk about her [MEDICAL CONDITION] and (Resident #901) felt (Resident #903) was stalking her. I asked her, why do you come to this side of the building? She didn't answer. The SW was queried that after Resident #901 voiced allegations of Resident #903 stalking Resident #901, what interventions were put in place, the SW H stated, We were just doing observations, keeping an eye on them. Staff was suppose to be keeping track of their whereabouts. When queried about the documentation, the SW stated, If you don't document then it's not done. Upon review of the medical record with the Social Worker, no documentation was noted. On 9/12/17 at 3:40 PM, an interview was conducted with the Director of Nursing regarding the facility policy for one on one staffing with a Resident. The DON stated, There is not a one on one policy. It is an intervention we do on resident safety . The IDT decides a resident would benefit one on one on the incident report. It is communicated to staffing and supervisors. The DON explained that the staffing department schedules a staff member to do the one on one with a resident and the supervisors are made aware. When queried about documentation for one on one care, the DON stated, There is no specific one on one care that is documented. When queried further on how the facility knows that staff is actually providing one on one care, the DON stated, It is scheduled. The DON was queried when Resident #903 was receiving one on one care and stated, We would have to look at the schedules. I know it was care planned. Upon looking at the care plan, for Resident #903, with the DON, no interventions were implemented for one on one care. The DON stated, I do not see it right now, I will have to look for it. The DON was queried how a Resident is taken off one on one care and stated, The IDT would determine that and take the resident off. Then it would be removed off the care plan. When queried if the IDT should document the determination to take a Resident off one on one care, the DON stated, Yes. A review of Resident #903's progress notes revealed no documentation of a determination to take Resident #903 off of one on one care. On 9/12/17 at 3:50 PM, a review of the facility's policy entitled, Abuse Prevention Program with a policy revised date of 11/28/16 and 7/21/2017 revealed: Policy Interpretation and Implementation, Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents . Our abuse prevention program provides policies and procedures that govern, as a minimum: .Identification of occurrences and patterns of potential mistreatment/abuse; .Timely and thorough investigations of all reports and allegations of abuse; .An ongoing review and analysis of abuse incidents; and The implementation of changes to prevent future occurrences of abuse. Abuse Identification, training and Education: .Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues . Expect all personnel, .to report any signs or suspected incidents of abuse to facility management immediately. On 9/13/17 at 11:10 AM, an interview was conducted with the Director of Nursing regarding the incident on 8/11/17 with Resident #903 and Resident #901. When queried why Resident #903 did not have interventions in place after Resident #901 voiced feelings of being stalked, the DON replied, I don't know, I was not in that position during that time. There is an opportunity to improve and go forward. On 9/13/17 at 1:30 PM, an interview with the DON was conducted to establish when Resident #903 started one on one. A review of staffing logs for the unit where Resident #903 resided, revealed no room number or Resident assigned to the staff that was scheduled for one on one care. When queried how it is known which Resident was assigned the one on one staffing, the DON stated, Because (Resident #903) was the only one receiving one on one. After reviewing the staffing logs, the DON indicated that Resident #903 received one on one staffing from May 14, 2017 to July 28, 2017 and stated, Again after the incident on August 11th until discharged to the hospital on Saturday. When queried about the lack of documentation of the determination to remove Resident #903 from one on one the DON stated, Correct, there is none. When queried if any Resident can receive one on one staffing if showing aggressive behaviors towards others, the DON stated, Yes they can. We don't have to wait until something happens to do something about it. Removal plan for IJ of Abuse on 9/12/2017 As a result of the finding of immediate jeopardy by the survey team on 9/12/17 related to resident #901 being stalked by resident #903, who had history of physical abuse towards other residents, the facility has reviewed the below to determine causation. Findings include: Resident# 901 was admitted to facility on 12/12/2016 with the [DIAGNOSES REDACTED]. Resident #903 no longer resides in the facility, she is currently in the hospital for pneumonia, The facility initiated an involuntary discharge on 8/17/17 and was not appealed. The facility does not feel she will be readmitted . Resident #901 no longer resides in the facility and not return is expected. Total of 257 residents, The 130 residents that have a BIMS score of 9 per the MDS assessments or higher have been interviewed by the IDT regarding resident to resident abusive behaviors from other residents on 9/12/17 Do you feel safe in this facility? Is there any time that you have felt threatened by another resident? Do you know who to report any feelings of abuse to? The Abuse Coordinator/Administrator will review all alleged abuse. Of the 130 residents questioned, there were 13 residents that voiced concerns. If a resident voices any events, the Administrator/Abuse Coordinator will immediately interview the resident, ensure their safety, notify the police and the State of Michigan. The Administrator/Abuse Coordinator will notify Psych services for assistance with psychological harm and provide emotional support. The Administrator/Abuse Coordinator will notify the resident's responsible party of the event immediately. 13 Resident's response to questions had varied answers: The facility abuse coordinator/ Administrator will review responses and investigate any potential abuse allegations for these 13 residents by the end of the day 9/13/17 end report to the SOM any allegations that come forth. The remaining 127 Residents that are cognitively impaired that have a BIMS score 8 or below per the MDS assessment have been assessed by Unit managers/DON for s/s of abuse using a skin assessment on 9/12/17 Any signs of physical abuse? out of 127 residents had no findings of physical abuse noted on their skin assessments. Social services and licensed nurses will monitor these residents for s/s of fear (grimacing, shaking, guarding). The administrator has reviewed the last 2 months of behavior documentation to ensure no other abuse has occurred, A previous incident involving resident did occur on 5/12/2017 related to this resident striking another resident in the face, the facility petitioned the resident out to the Psych unit for evaluation, she returned back to the facility with no new orders and the facility placed her on 1:1 supervision. The absence of resident #903 was supervised in recognition of resident #901's allegations of being stalled by resident #903 as reported to the Social worker and failure to prevent the incident that occurred on 8/11/17. All staff have been educated that if a resident indicates fear of resident or staff that the Administrator/Abuse Coordinator is contacted immediately. Systemic changes include: When resident to resident abusive behaviors occurs the facility staff will: immediately separate the residents Ensure residents safety by providing 1:1 supervisor for residents as needed Notify Administrator/Abuse Coordinator immediately. Nurses will complete a physical assessment to ensure no harm Social services will complete an assessment to ensure psychological stability. Psych-services will be notified for additional support if needed. Administrator/Abuse Coordinator will ensure other residents safety by interviewing other like residents for identification of previous events. Administrator/Abuse Coordinator will interview staff witnessing the event for prior history of resident to resident abusive behavior. The Administrator/Abuse Coordinator will screen grievances as well as Incident Reports daily Monday-Friday for possible events that involve resident to resident abusive behavior. The facility will be initiating weekly Behavior IDT meetings to ensure all residents are safe from resident to resident abuse. The Administrator/Abuse Coordinator has reviewed the Abuse policy and has deemed it appropriate. All current staff will be re-educated on the Abuse policy regarding resident to resident abusive behavior, reporting guidelines and investigation by the DON/designee on 9/12/2017, any staff not currently working will be re-educated prior to their next scheduled day to work. During this education, staff will be questioned about other potential residents whose behaviors are abusive. The facility has updated the Standard of Care policy to include the IDT meetings prior to the removal of increased supervision for residents with abusive behaviors. The Social Services Director has been re-educated on the Abuse policy by the Administrator/Abuse Coordinator on 9/13/17. 171 out of 311 facility staff have been re-educated on the Facility Abuse policy on 9/12/17, Staff not yet re-educated, will receive the education prior to their return to work. In the re-education staffs were asked if they are aware of any resident to resident abusive behavior that has not already been reported. 22 out 58 contracted staff, including Therapy, Beautician, [MEDICAL TREATMENT] and agency staff have been be re¿ educated on 9/12/17 and 9/13/17, staff not re-educated will be prior to working their next scheduled shift. Any contracted staff not re-educated by 9/15/17 will be removed from the ability to remain on the schedule. All staff will be-educated prior to their next scheduled shift or at least by 9/15/17, if they are not re¿ educated by 9/15/17 at midnight, they will be removed off the schedule. The Administrator/Abuse Coordinator will audit incident reports for possible abuse daily M-F and via phone on the weekends. Social services will complete random interviews of residents for verbalization of feeling safe in their environment. The Medical Director has been informed of the IJ for resident to resident abuse on 9/13/17 by the Administrator and has re-educated the Medical Director on the Abuse Policy. The Administrator/Abuse Coordinator is responsible for continued compliance.

Based on observation, interview and record review, the facility failed to fully implement the Restorative program services, evaluate the goals and progress and provide restorative services for 5 (#'s 903, 906, 907, 914, 926) of 33 sampled residents, resulting in functional decline, increased weakness, with repeated falls and decreased quality of life. Findings include: Resident #903 On 7/17/17 at 1:20 PM, Resident #903 was observed lying in bed. The room was very cluttered with an oxygen concentrator, bedside table, a large box on the floor with clothes in it, a wheelchair and 2 walkers. The resident had just finished a lunch of spaghetti, garlic toast and salad. When asked if the resident ever ate in the dining room, Resident #903 responded, I don't. It's too far away from my room. I'm too weak. On 7/17/17 at 3:30 PM, a record review revealed, that Resident #903 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had full cognitive abilities and required 1 person assistance with bed mobility, transfers, dressing eating, hygiene, bathing and toileting. The resident required supervision with ambulation in the room and was independent with ambulation in the hallway. Resident #903's Restorative Care Plan indicated, Restorative Nursing Services 2-3 times a week as tolerated, Goal- Maintain functional ability per PT (Physical Therapy) summary per next review, Interventions- Short distance ambulation 25 feet with FWW (front wheeled walker) with wheelchair close follow as tolerated. The ADL (activities of daily living) Care Plan indicated, The resident has an ADL self-performance deficit related to impaired balance, Goal- The resident will improve current level of ADL's through the review date. The Mobility Care Plan indicated, Resident has limited physical mobility related to weakness/decreased mobility: The resident will participate in therapy per each order/goals. On 7/18/17 at 2:40 PM, a review of the Incident and Accident (I&A) reports for Resident #903, indicated the resident had 5 falls between 9/10/16 and 6/8/17. All occurred while the resident was transferring, ambulating or toileting themselves in their room. An interview with Certified nursing assistant ( CNA) C, on 7/18/17 at 3:00 PM revealed, I oversee the program, when asked who oversees the restorative care program. When further queried if there is a nurse overseeing restorative services, CNA C responded, No. I do that and there is another CNA/RNA (restorative nursing assistant) who assists with restorative. The Therapists write the FMT (Functional Maintenance Therapy) plan. The Unit Managers write the Care Plan. There is no notes. No one writes notes. It is a check off system. We do that (documentation). Resident #905 On 7/17/17 at 10:45 am, a record review revealed that resident #905 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated the resident had poor cognitive function and required a total of 2 person assistance with all care, except for eating and only required 1 person to assist with tube feeding. On 7/17/17 at 3:44 pm, a review of the Care Plan/At Risk for Falls indicated, Staff to don (put on) left hand splint in the morning and doff (take off) in the afternoon. (CNA, RNA (Restorative nursing assistant). A Care Plan/At risk for Skin Impairment related to bedfast, immobility, indicated, left hand splint on 4-6 hours daily, as tolerated, check skin pre and post for redness. On 7/18/17 at 3:44 pm, a review of the Restorative check off documentation for Resident # 905 from 9/12/17 - 9/18/17 indicated the resident had documentation for the Splint/Brace, on 7/12/17 at 10:13 am, 7/13/17 at 1:58 pm, 7/17/17 at 2:59 pm and 7/18/17 at 2:59 pm. Passive ROM (range of motion) was documented on 7/12/17 at 10:13 am and 7/18/17 at 2:59 pm. Resident #907 On 7/17/17 at 11:30 am, a record review revealed that Resident #907 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had poor cognitive function and required extensive 2 person assistance with transfers and extensive 1 person assistance with bed mobility, dressing, hygiene, bathing and toileting. The resident was able to feed themself with 1 person assistance and per the MDS did not ambulate during the assessment period. On 7/18/17 at 11:45 am, review of the Care Plan indicated, Restorative nursing services 2-3 times per week as tolerated, Maintain functional mobility as per PT summary through next review, Ambulation with 1 person assist with FWW as tolerated, AROM (active range of motion) to BLE (bilateral lower extremities) to all planes, times 20 reps (repetitions) times 3 sets as tolerated. An interview with Staff C on 7/18/17 at 3:45 PM, provided, She has been on restorative services for a long time, but there is no documentation of it. I looked. On 7/19/17 at 9:00 am, Staff C indicated she had found some Restorative documentation for Resident #907. Restorative, documentation from 6/21/17 - 7/9/17 indicated the resident had received 3 days of restorative services over the 19 day period, for ambulation with a rolling walker and 1 assist. There was no documentation provided from 7/10/17 - 7/18/17. A review of the I&A's for Resident #907 on 7/19/17 at 9:45 am, revealed the resident had fallen 13 times from 1/2/17 - 7/17/17. Each incident involved the resident trying to transfer themself from bed or wheelchair in the room and bathroom. On 3/30/17 the resident was observed face down in the hallway after falling from the wheelchair. The resident obtained 2 skin tears and bruising and swelling on the face. On 4/30/17, the resident experienced an abrasion to the forehead after falling from the wheelchair. An interview with the Director of Nursing (DON) on 7/19/17 at 11:00 am revealed, (Staff C) oversees Restorative Services. The DON was queried whether a licensed nurse oversaw the restorative program to ensure the residents were receiving the care as ordered, the DON responded, No nurse is overseeing the Restorative program. In the past there was someone. When the DON was informed that the residents were not receiving Restorative Services as indicated in their care plans, she responded, I'll have to check on that. On 7/19/17 at 1:15 PM, a review of the facility policy titled, Restorative Nursing Program Implementation, dated 9/2014, revealed, The goal of Restorative Nursing includes maintaining independence in activities of daily living and mobility, which is critically important to most people. Further, functional decline can lead to .complications of immobility, such as incontinence and pressure ulcers. Restorative Nursing, the highest functional level has been achieved or can be improved. The goal becomes prevention or minimization of functional decline or impact on activities of daily living .Document refusal in the chart .Revisit at least quarterly .Each program must be evaluated by a licensed nurse (per state requirements), Nursing staff must supervise the program .Monthly review by a licensed nurse with documentation that addresses progress . Resident #914 On 7/18/17 at 7:15 a.m., resident # 914 was observed sitting in a wheelchair in the dining room next to Family Member D. There was a large yellow and purple bruise on the left side of the forehead that extended down to the left eye and left cheek bone. When Resident #914 would speak, she spoke in Albanian. According to Family Member D, she has fallen a couple of times. Family Member D stated, She is going down hill. She used to live at home and was walking around. On 7/18/17 at 7:30 a.m., a record review of the face sheet and MDS revealed that resident #914 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that the resident was severely cognitively impaired, required extensive assist with transfers and limited assist (hands-on guidance) with ambulation (walking) and bed mobility. On 7/18/17 at 8:55 a.m., Nurse Unit Manager F was interviewed regarding resident #914's ability to walk. Nurse F stated, She can walk, but she walks when she wants to. Her family walks her. Nurse F was unable to confirm if Resident #914 was on any type of restorative program. On 7/18/17 at 9:00 a.m., an interview was completed with Certified Nurse Assistant (CNA) G, who was assigned to care for Resident #914. CNA G was asked if staff had ever walked Resident #914. CNA G stated, Family walks her, she can walk. On 7/18/17 at 11:00 a.m., an interview was completed with the head Restorative Aide C. According to Restorative Aide C, once therapy is completed, the therapy department creates a restorative program, or FMP (Functional Maintenance Program). Restorative aide C also explained that the FMP includes range of motion (ROM) and ambulation. When queried about Resident #914's FMP program, Restorative Aide C stated, I spoke to therapy about her (Resident #914), they are working on a program for her if she is appropriate. On 7/18/17 at 11:20 a.m., an interview with Physical Therapy (PT) Manager A in regards to a FMP for Resident #914. PT A stated, Everyone gets on a restorative program (after therapy). She didn't have one because we thought she was going home, so we did not do one for her. She has a huge language barrier and was not following anything. Family was working with her. Therapy notes were reviewed with PT A at this time, PT discharge summary documentation revealed, that Resident #914 had met her goals. According to the documentation, Resident #914 had not been discharged from therapy because of non-participation in therapy. On 7/19/17 at 1:35 p.m., an interview was completed with the Director of Nursing (DON) in regards to Resident #914 being on a restorative program. The DON stated, I am not sure why she (Resident #914) was not on restorative. Resident #926 On 7/18/17 at 1:05 p.m., Resident #926 was observed lying in bed awake and was nonverbal. Both legs were contracted (locked in a flexed position) at the knees and each hand was contracted. There was a palmar guard (a hand protector that keeps the fingernails from pressing into the palm and keeps the skin dry) on the right hand. There was no protector or splint present in the left hand. During this observation, Family Member E was present and queried regarding the resident's left hand. Family Member E stated, She (resident #926) had a brace that was given to her at the hospital. They (the facility) lost it for six months and never replaced it, now they found it (the brace) and it won't fit anymore, her hand has gotten worse. Family Member E grabbed the brace out of Resident #926's closet. The brace was soft, blue with Velcro straps and about the length of the resident's left forearm. Family Member E was asked about a restorative program for Resident #926 and stated, They (the facility) don't do anything with her. On 7/19/17 at 8:20 a.m., a review of the face sheet and MDS assessment revealed that resident #926 was admitted into the facility 5/24/16 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed that the resident was severely cognitively impaired, incontinent of bowel and bladder and required extensive two person assist with bed mobility and was dependent for transfers and bathing. On 7/19/17 at 8:55 a.m., Physical Therapy (PT) A was interviewed regarding range of motion and PT A stated, We do ROM measurements every three months, then we give those to restorative. PT A was asked about the left hand splint for Resident #926. PT A did not have an explanation, as to whether or not a program was developed for the hand contractures or splint. PT A confirmed that resident #926 was last on the therapy caseload in December of 2016. On 7/19/17 at 9:15 a.m., a review of the Range of Motion Assessment for Resident #926 was completed and revealed the following: 5/26/16: (Left) wrist and hand flexion: WFL (within functional limits). 8/27/16: (Left) wrist and hand flexion: WFL (within functional limits). 2/16/17: (Left) wrist and hand flexion: (ability of hand to close): 90 degrees. Normal readings are 0-90 degrees (hand can move from no flexion to complete 90 degree flexion). 3/20/17: (Left) wrist and hand flexion: 70-90 degrees, 90-70 degrees for extension. 6/5/17: (Left) wrist and hand flexion: 90 degrees. Comments: Left hand is in a flexed position. On 7/19/17 at 9:20 a.m., a review of the Rehabilitation Services Therapy Screen Request dated 5/31/17 indicated , Family states the resident (#926) is approved for medicaid. The sister wants to know can she (Resident #926) be evaluated for PT/Restorative. A request for the therapy screen was done, however it was not received by the end of survey. On 7/19/17 at 9:30 a.m., a review of the Occupational Therapy Discharge Summary for Resident #926 dated 12/17/16 revealed under discharge status and recommendations: RNP (restorative nursing program): To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs has been completed with the IDT (interdisciplinary team): splint or brace care. On 7/19/17 at 11:05 a.m., an interview was completed with Occupational Therapist (OT) B in regards to the restorative program for Resident #926's left hand. OT B stated, She (Resident #926) should have had a restorative program put in place. On 7/19/17 at 1:35 p.m., an interview was completed with the DON in regards to Resident #926's left hand contractures/brace and restorative program. The DON stated, Restorative is responsible for putting splints on. I will have to get with therapy to find out about her (Resident #926). On 7/19/17 at 3:55 p.m., a record review was completed of the facility policy titled, Restorative Nursing Program Implementation revised 9/2014 revealed the following: Determine if the resident is willing and able to participate-document refusal in the medical record with education regarding risks and benefits. Determine resident and/or family goals for restorative care.

This Citation has Two Deficient Practice Statements: 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 six (#'s 903, 907, 908, 910, 914, and 916) of 11 Residents reviewed for safety and falls, of a total sample of 33, resulting in Resident #903 having multiple falls with injuries that included a toe fracture (break) and head injury, Resident #907 falling and hitting their head and face with resulting bruises and abrasions, and Resident #916 suffered three falls that resulted in head injuries and two hospitalization s. Findings include: Resident #916 On 7/17/17 at 1:00 pm, a record review revealed that resident #916 was admitted into the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had intact cognition and required assistance with all Activities of Daily Living (ADLs) other than eating. The Resident required two person assistance with transfer and ambulated with use of a walker. On 7/17/17 at 1:15 pm, a review of the Fall care plan indicated the following: Actual falls related to (r/t) Balance deficits. History of falls. On 7/19/17 at 9:45 am, Resident #916 was queried regarding the multiple falls. \ Resident # 916 acknowledged having multiple falls at the facility, but was unable to verbalize why these falls occurred. On 7/19/17 at 10:12 am, Resident #916's Incident and Accident Reports related to falls were reviewed with the Director of Nursing (DON) and revealed the following: Fall #1: 11/12/16 at 3:00 am. Resident # 916 observed sitting on buttocks next to bed. Intervention: Resident's tray table in place Fall #2: 11/27/16 at 12:30 pm. Resident #916 was observed on the floor between the beds. The Resident hit their head, obtained a hematoma, and was sent to the hospital emergency department for diagnostic testing. Intervention: No new interventions implemented At this time, the DON was queried why there no new intervention were implemented following fall and the DON stated, We have been having trouble getting care plans updated. Fall #3: 12/26/16 at 6:00 pm. Resident #916 observed trying to get out of the way of another Resident and was then observed on the floor on her side. Intervention: No new interventions to care plan following this fall. At this time, the DON was queried why no new intervention were implemented following fall and the DON stated, Yes, depending on the root cause. Fall # 4: 1/30/17 at 1:45 pm. Resident #916 observed on buttocks on floor in the hallway. Intervention: No new interventions to care plan following this fall. When queried, the DON did not provide an explanation regarding why no fall prevention interventions were implemented following this fall. Fall #5: 2/20/17 at 8:30 pm. Resident #916 bumped into staff and fell on the floor. Intervention: Ensure Resident is wearing non skid socks or rubber sole shoes Fall #6: 2/27/17 at 2:00 pm. Resident #916 observed on the floor in front of bed. The Resident indicated they struck their head on the tray table and suffered a bruise on their forehead. Intervention: No new interventions to care plan following this fall. When queried, the DON stated, We are having care planning issues. Fall #7: 3/7/17 at 5:30 am. Resident #916 observed sitting on the floor by bed. Intervention: Lab work ordered Fall #8: 3/18/17 at 7:00 pm. Resident #916 observed on the floor by bed. Intervention: No new interventions to care plan following this fall. When queried regarding interventions, the DON did not provide an explanation. Fall #9: 4/1/17 at 10:55 pm. Resident #916 observed outside of the nurses station on floor. Intervention: No new interventions to care plan following this fall. Fall #10: 5/2/17 at 2:30 am. Resident #916 observed on floor of bedroom. Intervention: No new interventions to care plan following this fall. When queried regarding interventions, the DON did not provide an explanation. Fall #11: 5/16/17 at 7:44 pm. Resident #916 observed on bedroom floor. Intervention: No new interventions to care plan following this fall. When queried regarding interventions, the DON did not provide an explanation. Fall #12: 5/19/17 at 3:15 pm. Resident #916 observed sitting on bathroom floor. Intervention: No new interventions to care plan following this fall. When queried regarding interventions, the DON did not provide an explanation. Fall #13: 6/16/17 at 7:00 pm. Resident #916 observed on bathroom floor lying face down. Resident suffered a hematoma on the left side of forehead and laceration on lip and had to be sent to the hospital for emergency treatment. Intervention: No new interventions to care plan following this fall. When queried regarding interventions, the DON did not provide an explanation. Fall #14: 7/18/17 at 4:15 am. Resident #916 observed sitting on her buttocks next to the bed. Intervention: No new interventions to care plan following this fall. When queried regarding interventions, the DON did not provide an explanation. Resident # 908 On 7/18/17 at 11:00 a.m., a record review of the face sheet and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #908 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that the resident was severely cognitively impaired and required limited assist with transfers and ambulation and had impairment with one lower extremity. On 7/18/17 at 10:30 a.m., the resident was observed in his wheelchair in the common area at the nurses station and did not have brake extenders on the wheelchair. On 7/18/17 at 11:15 a.m., a review of the fall incident reports for resident #908 revealed the following with interventions noted and/or care planned in parenthesis: Fall #1: 3/17/17-Observed on floor in hallway lying on left side (urinalysis ordered). Fall #2: 4/17/17-Observed on floor in front of wheelchair (wheelchair assessed;therapy to screen). Fall #3:4/30/17-Observed on floor lying on left side (placed in common area). Fall #4: 5/5/17-Observed laying on floor in hallway (therapy to screen). Fall #5: 5/8/17-Observed sitting on footrests in wheelchair (psychiatry to evaluate; therapy to screen). Fall #6: 5/19/17-Observed on knees in front of wheelchair (no new interventions identified). Fall #7: 5/24/17 (1:00 p.m.)-Observed on buttocks on footrests (med review). Fall #8: 5/24/17 (5:45 p.m.)-Observed in hallway on floor in front of cafeteria (placed in common area). On 7/18/17 at 11:30 a.m., a record review of the resident's Falls care plans (there were two in the medical record) initiated on 6/15/16 revealed the intervention: Built up brake extenders on wheelchair initiated 6/15/17. The other Falls care plan dated 8/17/16 had the intervention initiated the same date as the care plan to determine the causative factors (of the fall). On 7/18/17 at 1:20 p.m., Resident #908 was observed resting in bed with his eyes closed. Resident #908 had his wheelchair parked at the bedside. There were no brake extenders on the wheelchair. During this time, Certified Nurse Assistant (CNA LL) was assigned to care for Resident #908. When asked about the wheelchair and brake extenders, CNA LL stated, No, he doesn't have them (brake extenders) on; Normally you tell the nurse or unit manager and then they have to tell maintenance. On 7/19/17 at 12:30 p.m., an interview was completed with the Director of Nurses (DON). The DON was queried in regards to the fall interventions put into place for Resident #908. When asked about the missing fall interventions (brake extenders to wheelchair) and for the fall on 5/19/17 and the lack of new interventions for 5/24/17 and 4/30/17, the DON did not offer an explanation. Resident # 910 On 7/18/17 at 10:10 a.m., record review of resident #910's face sheet and MDS revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that Resident #910 was severely cognitively impaired, and required limited assist with transfers and bed mobility. On 7/18/17 at 7:15 a.m. and 7/19/17 at 2:20 p.m., Resident #910 was observed resting in bed with eyes closed. There were no nonskid strips on the floor in the room next to the bed. On 7/18/17 at 10:45 a.m., a review of the care plans and fall incident report dated 2/15/17 revealed that Resident #910 was observed on the floor in her room at the foot of the bed. The report stated the intervention was to add non skid strips to the bed side. The fall care plan did not have the non skid strips listed as an intervention at the time of the survey. On 7/19/17 at 1:15 p.m., an interview was completed with the DON in regards to Resident #910 not having nonskid strips to the floor at her bedside. The DON stated, Maybe they (the staff) got rid of them (nonskid strips). Sometimes after awhile they drop off (interventions). Resident #914 On 7/18/17 at 7:15 a.m., an observation was made with Resident #914 while in the dining room. Resident #914 was in her wheel chair sitting next to Family Member D. There was a large yellow and purple bruise on the left side of her forehead that extended down to the left eye and left cheek bone. Resident #914 had a sad/worried frown. When Resident #914 would speak, she spoke in Albanian. According to the son, she has fallen a couple of times. Family Member D stated, She is going down hill. On 7/18/17 at 7:30 a.m., a record review of the face sheet and MDS was completed for Resident #914. According to the face sheet, Resident #914 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that Resident #914 was severely cognitively impaired, needed extensive assist with transfers and limited assist with ambulation and bed mobility. On 7/18/17 at 8:05 a.m., a record review for Resident #914 of the fall incident reports revealed the following with interventions in parenthesis: Fall #1: 4/19/17-Observed on floor on buttocks (neuro checks done). Fall #2: 4/25/17-Observed on knees on floor attempting to open blinds (moving to memory care unit). Fall #3: 5/31/17-Observed on right side on floor (placed in visible areas). Fall #4: 6/25/17-Observed on left side in front of the wheelchair (make sure properly positioned). Fall #5: 6/26/17-Observed on buttocks near bed (reminded to use call light). Fall #6: 6/28/17-Observed lying near bedside (therapy to evaluate). On 7/18/17 at 8:30 a.m., a record review of the fall care plans (there are two) was completed For Resident #914. The Falls care plan dated 4/25/17 had the intervention initiated 6/27/17 that stated, limit time in room. On 7/18/17 and 7/19/17 the following observations were made of Resident #914 sitting in her wheel chair alone in her room tucked in between a bedside dresser and bedside table against the wall: 7/18/17 at 8:50 a.m., 10:25 a.m. and 1:25 p.m. 7/19/17 at 8:05 a.m. and 10:30 a.m. On 7/19/17 at 1:20 p.m., an interview was completed with the DON in regards to ineffective interventions for Resident #914 and no new interventions for the fall on 6/28/17. The DON stated that therapy was to evaluation Resident #914 on 6/28/17. The evaluation was requested, however never received by the end of the survey. The DON was unable to provide an explanation as to the ineffective interventions and for the observations of Resident #914 alone in her room when the fall care plan stated to limit time in room. On 7/19/17 at 12:50 p.m., a record review of the facility policy titled, Falls-Clinical Protocol revised April 2016 revealed the following: Under Cause Identification/Response #1-For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. Under Monitoring and Follow-Up #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 (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. Resident #903 On 7/17/17 at 1:20 pm, Resident #903 was observed lying in bed in their room. The room was very cluttered with an oxygen concentrator, bedside table, a large box on the floor with clothes in it, a wheelchair and 2 walkers. I broke my toe trying to get through there. The resident commented, We have a lot of stuff in here it is hard to get through to the bathroom. The resident had just finished a lunch of spaghetti, garlic toast and salad. When asked if the resident ever ate in the dining room, Resident #903 responded, I don't. It's too far away from my room. I'm too weak A record review on 7/17/17 at 3:30 pm indicated the following: Resident #903 was initially admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had full cognitive abilities and needed 1 person assistance with bed mobility, transfers, dressing eating, hygiene, bathing and toileting. The resident needed supervision with ambulation in their room and was independent with ambulation in the hallway. On 7/18/17 at 2:40 pm, a review of the Incident and Accident (I&A) reports for Resident #903, indicated the resident had 5 falls between 9/10/16 and 6/8/17. All occurred while the resident was transferring, ambulating or toileting themselves in their room. On 5/24/17, the resident was transferred to the hospital after falling twice on 5/23/17: at about 3:45 pm the resident bumped their head and about 7:00 pm fractured the left foot 4 th toe. 9/10/16: The resident said they fell in their room and had bad back, left knee and left shoulder pain. Intervention: Education provided. 2/16/17: Resident stubbed toed on bedside table. Intervention: Resident encouraged to keep walkways clear. 5/23/17: Resident sitting on floor at foot of bed, Legs gave out and fell . Resident complains of recent jerky movements and dropping things. Intervention: X-ray left foot. 5/23/17: Resident observed sitting on bottom in the doorway of the room and stated, .was trying to get help. Intervention: Sent to hospital for medical workup. 6/8/17: Resident was trying to transfer to the toilet. Intervention: Intervention: Education to ask for help. A review of the Care Plans provided the following: The Fall Care Plan- (The resident) is at risk for falls related to Gait/balance problems, Goal: The resident will not sustain serious injury through the review date, Interventions: Last updated 5/23/17 to include PT eval and Resident is to wear surgical shoe provided by hospital when ambulating. There was no mention to ensure the resident's room was free of clutter. The Restorative Care Plan- Restorative Nursing Services 2-3 times a week as tolerated, Goal- Maintain functional ability per PT (Physical Therapy) summary per next review, Interventions- Short distance ambulation 25 feet with FWW (front wheeled walker) with wheelchair close follow as tolerated. There was no documentation that indicated Resident #903 received Restorative services 2-3 times a week. The ADL (activities of daily living) Care Plan- The resident has an ADL self-performance deficit related to impaired balance, Goal- The resident will improve current level of ADL's through the review date. The care plan indicated the resident could ambulate and toilet self in their room. The MDS dated [DATE] needed 1 person assistance with toileting and 1 person supervision with ambulation in the room. The Mobility Care Plan-Resident has limited physical mobility related to weakness/decreased mobility: The resident will participate in therapy per each order/goals. On 11/28/16 the care plan indicated the resident needed 1 assist with transfers. On 12/27/16, the care plan indicated the resident could transfer themselves. The MDS dated [DATE] indicated the resident needed 1 person assistance with transfers and toileting and 1 person supervision with ambulation in the room. The care plan had not been updated. On 7/19/17 at 9:35 am, an interview with CNA (Certified Nursing Assistant) P provided, When she moved in there was not enough room for (the resident's) belongings. When queried why the resident had repeatedly fallen, CNA P replied, She would let us know if she needs help. On 7/19/17 at 10:00 am, an interview with Resident #903 revealed, It takes a long time to answered the call light, when asked why the resident tries to take themselves to the bathroom. Resident #907 On 7/17/17 at 11:30 am, a record review revealed Resident #907 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] indicated the resident had poor cognitive function and needed extensive 2 person assistance with transfers and extensive 1 person assistance with bed mobility, dressing, hygiene, bathing and toileting. The resident was able to feed self with 1 person assistance and per the MDS did not ambulate. A record review on 7/18/17 at 11:45 am, revealed the following for Resident #907: Resident #907 fell 14 times between 1/2/17 and 7/17/17 and was injured twice, hitting their head/face with abrasions and bruising. 1/2/17: Resident stated trying to turn in bed. Intervention: Reeducation. 1/6/17: Observed sitting on bottom yelling for help. Intervention: Medical work up 1/22/17: Observed laying in bathroom doorway. Intervention: Offer to toilet after dinner. 2/10/17: Observed sitting on floor in front of bathroom. Intervention: Offer to toilet after dinner. 2/12/17: Observed laying on floor in hallway. Intervention: OT eval. 3/17/17: Observed in bathroom between wheelchair and toilet. Intervention: Non-skid strips to bathroom floor. 3/18/17: Observed on the floor next to the bed. Intervention: Medical work-up. 3/20/17: The resident was about to transfer self and bumped leg on the wheelchair. Intervention: Pad wheelchair. 3/28/17: Trying to get out of bed into wheelchair, found on the floor. Intervention: Assist rail to bed. 3/30/17: Observed laying face down on the floor in hallway, stated My nose hurts. Intervention: Dycem to wheelchair, encourage to stay in highly visible areas. 5/7/17: Witnessed leaning forward and fell out of wheelchair. Obtained an abrasion to the forehead. Intervention: Tilt wheelchair. 5/12/17: Observed laying on back between the beds. Intervention: Placed on frequent checks. 7/9/17: Observed laying on back between wheelchair and chair. Intervention: None provided. 7/17/17: fell in the bathroom. Interventions: None provided. A Fall Care Plan- Review date 6/12/17, At risk for falls as (the resident) has weakness and impaired vision, Goal: Will have reduced risk for injury through 90 days. No new interventions were provided from 6/12/17 to 7/19/17 and the resident had fallen twice. A Care Plan- Restorative nursing services 2-3 times per week as tolerated, Maintain functional mobility as per PT summary through next review, Ambulation with 1 person assist with FWW as tolerated, AROM (active range of motion) to BLE (bilateral lower extremities) to all planes, times 20 reps (repetitions) times 3 sets as tolerated. On 7/17/17 at 1:15 pm, Resident #907 was observed laying in bed, talking to themselves. The call light was on. CNA O entered the room and stated, (The resident) is a fall risk. An interview with CNA P on 7/18/17 at 10:45 am revealed, Lately (the resident) has fallen. I don't know why. An interview with Staff C on 7/18/17 at 3:45 pm, provided, She has been on restorative services for a long time, but there is no documentation of it. I looked. On 7/19/17 at 9:00 am, Staff C indicated she had found some Restorative documentation for Resident #907. Restorative, documentation from 6/21/17-7/9/17 indicated the resident had received 3 days of restorative services over the 19 day period, for ambulation with a rolling walker and 1 assist. There was no documentation provided from 7/10/17-7/18/17. On 7/19/17 at 10:45 am, an interview with Nurse Q revealed, (The resident) is a fall risk. Yes, she can get up on her own. (The resident) fell on [DATE] in the evening in the bathroom and is not supposed to be alone. When asked if Resident #907 was receiving Restorative services to assist with ambulation and transfers, Nurse Q responded, I did not know they were on Restorative services. An interview with the Director of Nursing (DON) on 7/19/17 at 11:00 am revealed, (Staff C) oversees Restorative Services. No nurse is overseeing the Restorative program. In the past there was someone. When the DON was informed that the residents were not receiving Restorative Services as indicated in their care plans, she responded, I'll have to check on that. The DON was queried on what measures could be used to aid in preventing Residents #'s 903 and 907 from falling and injuring themselves and replied, Education, but it is not effective for someone that is confused. If the cause is due to cognition we could choose an alarm or the most appropriate intervention. The DON did not indicate what might be the most appropriate intervention for either resident. The DON was further queried on why a large box of clothing had been sitting on the floor of Resident #903's room for a year/the room was cluttered and stated, Housekeeping can help with that. On 7/19/17 at 1:20 pm, a review of the facility policy titled, Falls-Clinical Protocol, dated 4/2016, revealed, 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 .an initial plan of care will be developed and implemented .this will be revised as necessary .The MDS will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls, 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 individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the residents falling and will re-evaluate the continued relevance of current interventions. Deficient Practice Statement #2 Based on observation, interview and record review, the facility failed to maintain wheelchairs in a safe manner for one (#901) of one Residents reviewed for wheelchair functionality and appropriate maintenance, of a total sample of 30, resulting in the potential for injury related to malfunctioning wheelchair brakes. Findings include: Record review on 7/17/17 at 1:50 PM revealed Resident #901 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #901 required extension to total assistance to perform Activities of Daily Living (ADL's) and was severely cognitively impaired. On 7/18/17 at 9:55 AM, observation of ADL care, and transfer from bed to wheelchair, for Resident #901 by Staff AA and Staff Z occurred. Staff AA and Staff Z utilized a mechanical lift with a sling to transfer the Resident out of their bed and into their wheelchair. After Staff AA and Staff Z positioned Resident #901 in the mechanical lift sling, they raised the Resident in the lift and positioned the sling over the wheelchair. When the staff began to lower the Resident into the wheelchair, the wheelchair was observed to be unlocked. When queried regarding the wheelchair not being locked, Staff Z stated, I just saw that, I was hoping that you wouldn't see that. Staff AA and Staff Z proceeded to manually hold the wheelchair and complete the transfer. The wheelchair brakes were examined further at the time. The right wheelchair brake was in the unlocked position. When queried, Staff AA stated, It is stuck there (unlocked). I can't get it to lock. Observation of Resident #901's left side wheelchair brake revealed the bolt that held the wheelchair brake in place was completely unscrewed and unsecured. When queried, Staff Z stated, It won't lock, it's to loose. An interview and observation of Resident #901's wheelchair was conducted with Maintenance Director CC on 7/18/17 at 10:15 AM. When queried regarding the Resident's wheelchair brakes, Maintenance Director CC stated, Yes, that's broke. Both sides (wheelchair brakes on both sides of wheelchair) are broke. Maintenance Director CC further stated, That is not safe at all. When queried regarding the last time that maintenance services were performed on Resident #901's wheelchair, Maintenance Director CC stated, I will have to look that up. On 7/18/17 at 10:50 AM, an interview was completed with Maintenance Director CC. When queried, Maintenance Director CC stated, The last time the wheelchair was checked was in April (2017). It is done every three months. Record review of provided documentation entitled, Direct Supply TELS, Mobility Aids: Conduct Wheelchair Inspection (Dated 4/11/17) at this time indicated the Resident's wheelchair had been inspected by facility maintenance staff on 4/11/17. When queried regarding facility policy and/or procedure regarding maintenance and/or of equipment, Maintenance Director CC stated, We check them every three months. I don't think there is an actual policy about it. When queried regarding facility procedure for broken or damaged equipment, Maintenance Director CC replied, They (staff) let somebody know so a work order can get put in. An interview was completed with the Director of Nursing (DON) on 7/19/17 at 3:35 PM. When queried regarding wheelchair maintenance and safety within the facility, the DON replied, I heard about that. (Maintenance Director CC) got it taken care of for (Resident #901). A facility policy/procedure related to Resident wheelchair and equipment maintenance and/or repair was requested by not received by the conclusion of the survey.

This Citation Pertains to Intake Number MI 332 Based on interview and record review, the facility failed to prevent physical abuse for 1 (# 902) of 1 sampled cognitively impaired resident of 21 residents reviewed for abuse, from a total sample of 33, resulting in the resident being physically held down by staff in order to receive care and having a banana smashed on their face. Findings include: On 7/17/17 at 12:45 PM, record review revealed that Resident #902 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, was always incontinent of bowel and bladder, and required limited assistance to perform Activities of Daily Living (ADL's). On 7/17/17 at 3:50 PM, an interview was conducted with Unit Manager W regarding Resident #902, Unit Manager W stated, (The resident) is very confused. They can be combative and resistant to care at times. On 7/17/17 at 4:00 PM, facility provided Incident and Accidents Reports and Investigations were reviewed and revealed that an incident involving resident # 902 occurred on 6/12/17. The following documentation was included in the facility provided Incident and Accidents Report and investigation: It was alleged by (Supplemental Resident #159) . that the nurse assistants while providing care smeared bowel in the face of (Resident #902) and was abusing (the Resident) Residents and staff were interviewed regarding the incident. (Resident #902) was assessed by the nurse for pain and shows no signs and symptoms. (Resident #902's) skin was assessed and no skin alterations were noted. The resident was assessed by social services and displays no signs of psychosocial distress .During the investigation it was determined (Resident #902) was being provided care by two nurse assistants and during the care another nurse assistant entered the room. When the third nurse assistant entered (the Resident's) room they attempted to hold the resident to allow the other nurse assistants to finish the care. The Resident continued to be combative and spit in the face of the third nurse assistant. All three nurse assistants left the room and informed the nurse of the resident becoming combative. It was determined through investigation that third nurse assistant had reentered the room with a banana and placed it in the face of the resident after the resident refused the banana. The facility investigation report further indicated, All three nurse assistants were interviewed, the Resident did not have bowel on their face based on interview and the nurse assistant cleaned any residue left from the banana off (Resident #902's) face. Further review of the facility investigation at this time revealed Certified Nurse Assistant (CNA) GG placed the banana in Resident #902's face after the resident refused the banana. Statement of Witness forms for the following individuals were included in the facility provided investigation report: Supplemental Resident #159 Interview Statement, Not Signed, Dated 6/12/17 at 11:00 AM: I had a hard time last night, I did not see anything. The curtain was drawn . Two Aides came into the room to change (Resident #902) . (Resident #902) started screaming and kicking before they (CNA's) started to change (the Resident). The two CNA's held her down and muffled (the resident) to change them. The CNA's got the towel in (resident #902's) face that had poop on it. Nurse HH, Not Signed and Not Dated That night me and another nurse and all three CNA's came in and . CNA GG said (Resident #902) just spit in my face. CNA GG started washing their face. (CNA KK and CNA II) came and said (Resident #902) is scratching and kicking us and (the Resident) soiled and they did not want to leave (the Resident) like that. Me and Nurse JJ told them to do the best you can, they said (the Resident) was fighting them. Nurse JJ, Not Signed and Not Dated I wasn't the nurse. Nurse HH and I were sitting charting. Nurse HH said the CNA's came down and said (Resident #902) spit in one of their faces . The CNA came out with a big glob of spit . CNA II, Signed and Dated 6/13/17 It was me and CNA KK on . check and change for (Resident #902's room). Resident #902 is a two person (assist) because (the Resident) like to fight . We attempted to change and (Resident #902) started fighting. I assuming CNA GG heard all the commotion come in and assisted. (CNA GG) held (Resident #902's) arms while I changed (the Resident). (Resident #902) spit in (CNA GG's) face. CNA GG was mad but they walked out. Me and CNA KK proceeded the check and change and (the Resident) spit at us but we finished then left. Nurse was notified. (Nurse's) direction was to just leave (the Resident) because they are combative. We had (Resident #902) undressed and didn't want to leave (the Resident) exposed. CNA KK, Signed and Dated 6/13/17 CNA II asked me to help change (Resident #902). We started changing (the Resident) as we was CNA GG came into the room started talking. (Resident #902) became combative . spit in CNA GG's face. CNA GG left out. I runned behind and also CNA II. We went back to finish (Resident #902) began hitting and cursing CNA GG came back in with a banana and put it to (Resident #902's) face. I told (CNA GG) just gone head cuz we got (the Resident) and I left out the room after CNA II was done. CNA GG and the nurse stated (Resident #902) was a [***] and that (the Resident) was crazy. (Resident #902) asked why was it three people in (room). (The Resident) stated that they was only one person assist. CNA GG, Dated 6/13/17, Signed and Dated 6/15/17 Resident #902 was screaming don't touch me [***] . I went in the room and said what's wrong (Resident #902)? They (CNA II and CNA KK) said need to change you you're soaking wet. To which (the Resident) stated it doesn't take two [***] es to change me. (Resident #902) was hitting CNA II and CNA KK. I tried to calm (the Resident) down. I held her arms to try to calm her down. She then spit in my face. CNA II and CNA KK were just trying to change (Resident #902). They were trying everything to get (the Resident) to calm down so they could change (Resident #902). I only went in to help the CNA's calm down. Facility staffing sheets for nursing and CNA staff were requested at this time for 6/12/17 and 6/13/17 from the facility Administrator. On 7/18/17 at 7:15 AM, an interview was completed with Nurse HH. When queried regarding Resident #902, Nurse HH stated, Nurse JJ and I were sitting in the office finishing our charting. CNA GG came in and said (Resident #902) just spit on me. The other two CNA's (CNA II and CNA KK) came in and said (the Resident) was kicking and fighting them. They (CNA II and CNA KK) went back in there (Resident #902's room) because they were in the middle of changing the Resident to finish what they could. When queried further, Nurse HH stated, Happened maybe around 9:45 PM to 10:30 PM. I know CNA II and CNA KK went back in (Resident #902's) room but I don't know if CNA GG did or not. When asked when they saw or assessed the Resident after the CNA staff reported that the Resident was combative with care, Nurse HH replied, No, the next time I saw Resident #902 when I gave med's around 5:30 in the morning. (The Resident) just don't like to be bothered, always gets upset but then is calm after that. On 7/18/17 at 8:08 AM, an interview was completed with CNA KK. When queried regarding Resident #902, CNA KK stated, We told the nurse and they didn't care, said (Resident #902) was crazy. CNA GG came back in the Resident's room and smashed a banana on (Resident #902's) face. CNA GG had it (banana) peeled, broke it up and pushed it in (Resident #902's) face. I asked CNA GG to leave. CNA GG didn't say nothing to (Resident #902) or to us. Just walked in and shoved it in (Resident #902's) face. We told the nurse and she didn't do nothing. She said that [***] is crazy (referring to Resident #902) so what. When queried regarding what time the incident occurred, CNA KK replied, It was around 10:30 PM, (Resident #902) is our last check and change for the shift. CNA KK further stated, (Resident #902) got combative as soon as they saw CNA GG come in the room. We told CNA GG we didn't need no help but they kept coming back. With additional inquiry, CNA KK stated, It was abuse. I reported it to the charge nurse that is what I am supposed to do. I was gonna talk to the Director of Nursing the next day if they (charge nurse) didn't report it but when I came in, somebody did already. An interview was completed with Nurse JJ on 7/18/17 at 8:24 AM. When queried regarding Resident #902, Nurse JJ stated, I wasn't (the Resident's) nurse that night. I was in the Nurses station and one of the CNA's came in and said the Resident wasn't being cooperative with them. I really wasn't paying attention to them talking (Nurse HH and CNA's) so I don't know anything else that was said. An interview was completed with Resident #902 on 7/18/17 at 1:20 PM. Resident #902 was observed lying in bed in their room and awake. The Resident was pleasantly confused, alert to self only, and unable to participate in complex conversation. On 7/18/17 at 1:25 PM, an interview was completed with Supplemental Resident #159. When queried regarding the incident involving Resident #902, Supplemental Resident #159 stated, Two aides (nursing assistants) came in to clean (Resident #902) up. I think another one (nursing assistant) came in too. I could hear it, I could tell they (nursing assistants) muffled (Resident #902's) face. Then I heard something else and one aide say you don't want anyone to see that and then said wash (Resident #902's) face off. With further inquiry, Supplemental Resident #159 stated, I was a nurse and something wasn't right with what went on. (Resident #902) isn't even my friend, I don't really even like them but what those workers (nursing assistants) did to (Resident #902) ain't right. It scares me, could happen to any of us. On 7/18/17 at 1:45 PM, an interview was completed with CNA II. When queried regarding Resident #902, CNA II stated, I was (Resident #902's) CNA, I'm always her CNA. I always ask for help, me and CNA KK went in there to change (Resident #902). CNA GG was another CNA (working that shift). CNA GG came in (the Resident's) room and we didn't ask for their help. (The Resident's) pants were off, CNA GG went out and came back in when we were walking out (of the Resident's room) because (Resident #902) was screaming. I reported it to Nurse JJ and another nurse that (Resident #902) was trying to scratch (us). Nurse JJ said don't go through all of that, if (Resident #902) wants to sit in it (bowel movement), let them sit in it. We explained to Nurse JJ that (the Resident) was exposed and we didn't want to leave them like that. We (CNA II and CNA KK) went back in and (Resident #902) was calm. CNA GG came in again and started holding (Resident #902's) hands down and (Resident #902) spit in CNA GG's face. Whenever CNA GG came in the room, (Resident #902) got all riled up. We told the nurse that CNA GG held (Resident #902) down and that (the Resident) spit in CNA GG's face. When queried further regarding the nurse, CNA II stated, Told Nurse JJ and they said okay, I'll take care of it. CNA GG stayed back and they closed the door (nurses' station). CNA GG just came into the room so hostile. When queried regarding a banana, CNA II stated, At one point I had to go out and went to get towels. When I got back, CNA KK and CNA GG was arguing. CNA KK wanted CNA GG to leave the room. CNA KK said CNA GG shoved a banana in (Resident #902's) face. I saw the banana on the bedside table. (Resident #902) kept trying to spit at CNA GG again. CNA GG finally left. CNA II proceeded to state, I didn't actually see CNA GG shove the banana in (Resident #902's) face but I could see them doing something like that. With further inquiry, CNA II stated, CNA GG always had an attitude because there were so many Residents that didn't want (CNA GG). When asked why, CNA II stated, CNA GG could be nasty with the way they talk to people, that was just their character. When asked if they reported anything further to the nurse, CNA II replied, No, I already reported that CNA GG held (the Resident) down and I told you the response I got to that. On 7/18/17 at 2:20 PM, the 500 unit facility staffing assignment book was reviewed. The staffing assignment sheets for 6/12/17 and 6/13/17 were not in the book. All other assignment sheets for the months of June and July 2017 were present in the staffing book. An interview was conducted with Unit Manager W at this time. When queried regarding the staffing sheets for 6/12/17 and 6/13/17, Unit Manager W replied, They asked for them yesterday and I took them to administration. On 7/19/17 at 8:50 AM, an interview was completed with CNA GG. When queried regarding Resident #902, CNA GG stated, I worked on the unit and there were two new CNA's trying to change (Resident #902). I went into (the Resident's) room and grabbed (the Resident) because they were hitting and scratching on the two CNA's in the room. (Resident #902) spit in my face. I went back to re-approach, I had a banana. When queried further regarding the banana, CNA GG stated, Normally, if you give (Resident #902) something, they will stop being combative. Like how you would bribe a baby. When I tried to give (Resident #902) the banana, they slapped it out of my hand. When queried further regarding the other two CNA's in the room, CNA GG stated, I don't know their names for sure. They were new though, I trained them. When queried who the nursing staff was that was working at the time of the incident, CNA GG replied, I believe it was Nurse HH and Nurse JJ. On 7/19/17 at 12:05 PM, an interview and record review was completed with the Director of Nursing (DON). When queried regarding Resident #902 and the facility investigation completed regarding abuse, the DON reviewed the Facility Incident and Accident Investigation reports and then stated, (Supplemental Resident #159) reported it the next morning. The incident happened 6/12/17. CNA II and CNA KK were providing care and the Resident was resistant to care. CNA GG came in and held the Resident's arms down. The Resident spit in CNA GG's face and went to the Nurses station and told Nurse HH. CNA GG then went back into Resident #902's room with a banana and put it in the Resident's face. We were able to validate that CNA GG did take a banana into (Resident #902's) room by reviewing the hall cameras and determined that (CNA GG) should have never went back into the (Resident's) room. When queried regarding the statements in the facility Incident and Accident Investigation report that indicated nursing staff were notified of event and did not report the event, the DON stated, The nurses that were working did not say that they were notified. When asked what the facility policy/procedure is for reporting abuse, the DON stated, Staff report to the charge nurse after hours. They can also report to the Administrator or myself. When queried further regarding the statements in the facility Incident and Accident Investigation report that indicated the nurse and CNA GG called (Resident #902) a [***] , the DON replied, We were not able to substantiate that occurred. When asked why the facility Incident and Accident Investigation Statement of Witness forms were not all signed by the witnesses, the DON replied, It depends on the situation. We don't always get them signed by the person if it is from a Resident or completed on the phone. The DON then stated, CNA GG was let go because of the incident and CNA II and CNA KK had to complete abuse education. When asked why the nursing staff that was working at the time of the incident did not have to complete abuse education, the DON did not provide a response. The DON then stated, I think it is really a matter of education. Record review on 7/19/17 at 5:25 PM of facility policy titled Abuse Prevention Program (Revised 11/28/16) revealed, Residents have the right to be free from abuse . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review of facility policy entitled Abuse Investigations on 7/19/17 at 5:30 PM revealed, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. This policy further revealed, Witnesses will be required to sign and date any witness report they make . Regardless of how minor an accident or incident may be, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned . A Report of Incident/Accident must be completed for all accidents or incidents .An employee witnessing an accident/incident or event involving a resident, employee , visitor, etc., must report such occurrence to his or her immediate supervisor as soon as practical. Do not leave an accident victim unattended unless it is absolutely necessary to summon assistance; and the Nurse Supervisor/Charge Nurse must be immediately informed of accidents or incidents so that medical attention can be provided . The Nurse Supervisor/Charge Nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident .A completed Report of Incident/Accident must be submitted to the Director of Nursing Services. Review of facility policy entitled Reporting Abuse to Facility Management (Revised 11/28/16) on 7/19/17 at 5:35 PM revealed, The Administrator must be immediately notified of alleged abuse/neglect or incidents of abuse/neglect. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, DON, or individuals designated will immediately (not to exceed 24 hours if the suspicion does not result in serious bodily injury. NO LATER THAN 2 HOURS IF THE EVENTS THAT CAUSE THE SUSPICION RESULT IN SERIOUS BODILY INJURY) notify the following persons or agencies of such incident as indicated by State or Federal Licensure Policy. Facility staffing sheets for nursing and CNA staff were requested for 6/12/17 and 6/13/17 but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to ensure that 4 (#'s 901, 906, 918, and 926) of 9 sampled residents reviewed for pressure ulcers (wounds caused by pressure) from a total sample of 33, did not develop unavoidable, re-occurring pressure ulcers and received timely, appropriate, and planned interventions to prevent pressure ulcer development, resulting in pressure ulcer development, unnecessary pain, and the potential for infection and deterioration in overall health status. Findings include: Resident #901 On 7/17/17 at 1:50 PM record review revealed that Resident #901 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #901 required extension to total assistance to perform Activities of Daily Living (ADL's) and was severely cognitively impaired. The MDS further revealed Resident #901 had a stage two pressure ulcer with an onset date of 4/5/17. Review of the initial MDS dated [DATE] revealed the Resident did not have a pressure but was at risk for developing pressure ulcers. On 7/17/17 at 2:10 PM, Resident #901 was observed positioned on the left side with triangular shaped positioning pillow. When asked questions, the Resident's only response was Uh and Huh. On 7/17/17 at 3:35 PM, Nurse Y was queried regarding Resident #901's pressure ulcer, Nurse Y stated, The onset date was 4/20/17. It (pressure ulcer) started out as a stage two. With further inquiry, Nurse Y stated, It was facility acquired. Record review on 7/17/17 at 4:00 PM of facility provided Gentell Fastcare: Facility Report (Dated 7/14/17) indicated Resident #901 had a stage three (full thickness tissue loss) pressure ulcer on their right ischium. On 7/18/17 at 6:35 AM, Resident #901 was observed lying in bed, positioned on the left side. A wheelchair was observed on the right side of the Residents bed. The wheelchair did not have a pressure reduction pad on the seat. Review of Resident #901's care plans on 7/18/17 at 8:00 AM revealed the following pressure ulcer care plan and interventions: The resident has pressure ulcer development to right ischium related to Immobility history of pressure ulcers (Date Initiated: 01/09/2017, Revision on: 05/10/2017). Interventions: Administer medications as ordered. Evaluate/document for side effects and effectiveness (Date Initiated: 01/09/2017) Administer treatments as ordered and evaluate for effectiveness (Date Initiated: 04/06/2017) Daily skin evaluations by licensed nurse if current pressure ulcer (see TAR (Treatment Administration Record) (Date Initiated: 04/06/2017) Educate the resident/family/caregivers as to causes of skin breakdown; including; transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning (Date Initiated: 04/06/2017) Evaluate nutritional status. Serve diet as ordered, monitor intake and record. (Date Initiated: 04/06/2017) Evaluate/record/monitor wound healing. Measure length, width, and depth were possible. Evaluate and document status of wound perimeter, wound bed and healing progress. Report improvements and decline to the MD (Medical Doctor) (Date Initiated: 04/06/2017, Revision on: 04/26/2017) Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Inform the Physician/resident/family/caregivers of any new area of skin breakdown (Date Initiated: 04/06/2017) Lotion to dry skin (Date Initiated: 01/16/2017) Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage (Date Initiated: 04/06/2017) Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated (Date Initiated: 04/06/2017) Pillow between legs at all times resident will remove on daily basis monitor and chart when pillow is removed per resident (Date Initiated: 04/06/2017, Revision on: 05/10/2017) Provide incontinence care promptly as needed (Date Initiated: 01/09/2017, Revision on: 01/09/2017) Resident to have pillow placed between knees at all times (Date Initiated: 04/07/2017) Resident to lay down after meals (Date Initiated: 06/16/2017) Showers and skin assessments twice per week (Date Initiated: 01/16/2017) Skin inspections by CNA during cares and showers/baths. Report changes to licensed nurse immediately (Date Initiated: 04/06/2017) The resident needs assist of 2 to reposition at least every 2 hours, more often as needed (Date Initiated: 04/06/2017, Revision on: 04/06/2017) The resident requires pressure cushion to chair and pillow between knees at all times (Date Initiated: 04/06/2017, Revision on: 04/06/2017) The resident requires supplement protein, amino acids, vitamins, minerals as ordered to promote wound healing (Date Initiated: 04/06/2017) Treat pain as per orders prior to treatment/turning, etc. to ensure the resident's comfort (Date Initiated: 04/06/2017) Use mild cleansers for peri-care (Date Initiated: 04/06/2017) Yellow dot program (Date Initiated: 05/05/2017) Review of Resident #901's Treatment Administration Record (TAR) occurred at this time. Daily skin evaluations by licensed nurse, as indicated on the Resident's care plan, were not included on the TAR. On 7/18/17 at 8:35 AM, Resident #901 was observed lying in their bed, positioned on their left side. The Resident had not changed positions from previous observation. On 7/18/17 at 9:30 AM, observation occurred of wound care treatment and dressing change to Resident #901's right ischium pressure ulcer with Nurse Y and Nurse V. Upon entering the room, Resident #901 was observed lying in their bed, positioned on their left side. The Resident had not changed positions from previous observation. Upon removal of the Resident's sheets and hospital gown to complete the wound care treatment, the Resident's brief was observed to be visually wet and soiled with urine. Nurse Y and Nurse V pulled the brief down on the right side and did not remove the brief to complete the wound care treatment and dressing change. After removal of the previous dressing by Nurse Y, the pressure ulcer was observed to be slightly larger than a nickel in size and irregular shaped. The wound bed was red in color and had a pen tipped sized opening in the center of the wound that was draining thick, yellow colored drainage. Nurse Y cleansed the wound and applied the treatment and dressing. Nurse Y and Nurse V then reapplied Resident #901's soiled brief and exited the Resident's room. On 7/18/17 at 9:45 AM, an interview was completed with Nurse Y. When queried regarding Resident #901's brief being soiled at the beginning of the wound care treatment and why care to restore the Resident's hygiene was not provided, Nurse Y replied, I didn't notice it. On 7/18/17 at 9:50 AM, an interview was completed with Unit Manager Nurse V. When queried regarding Resident #901's brief being soiled at the beginning of the wound care treatment and why care to restore the Resident's hygiene was not provided, Nurse V stated, I didn't notice that it was wet. I will get the aides (nursing assistants) to clean (the Resident) up. On 7/18/17 at 9:55 AM, observation of ADL care for Resident #901 by Staff AA and Staff Z occurred. During care, Resident #901's brief was observed to be soiled with both urine and stool. Following care, Staff AA and Staff Z utilized a mechanical lift to get the Resident out of bed and into their wheelchair. The Resident's wheelchair did not have a pressure reduction device or pad present on the seat of the chair. When queried the frequency that Resident #901 was in their wheelchair, Staff AA and Staff Z both indicated that the Resident gets up in their wheelchair daily. On 7/18/17 at 10:05 AM, an interview was completed with Staff AA. When queried regarding a pressure reduction pad or device for Resident #901's wheelchair, Staff AA replied, They never had one. When queried regarding Resident #901's mattress, Staff AA stated, It is one of the fall ones with the raised edges. With further inquiry regarding if the Resident's mattress was a pressure reduction mattress, Staff AA stated, No, it's just a regular fall prevention mattress. When asked if the Resident moves themselves in bed, Staff AA replied, No, don't really move at all by themselves. On 7/19/17 at 9:15 AM, an interview was conducted with Staff Y. When queried regarding the onset date of 4/5/17 indicated on the Residents MDS completed on 4/17/17, Nurse Y stated, This (right ischium) isn't (Resident #901's) first facility acquired pressure ulcer. With additional inquiry regarding the number of facility acquired pressure ulcers that Resident #901 had developed while at the facility, Nurse Y replied, (The Resident) had one on their knee that we got healed up. I think there have been several but I would have to look it up. When queried regarding interventions in place for Resident #901 to prevent the development of pressure ulcers, Staff Y stated, Keep (the Resident) clean and dry, reposition them every 2 hours, and they have a wedge for repositioning. With additional inquiry regarding the intervention of keeping the Resident clean and dry when observation occurred of the Resident being left in a soiled brief following the dressing change on 7/18/17 at 9:30 AM, Staff Y was unable to provide an explanation. When queried why the Resident did not have a pressure reduction pad/device on their wheelchair, Staff Y stated, They should have one. When queried regarding a pressure reduction mattress for Resident #901, Staff Y replied, I think (Resident #901) doesn't have one because of a fall. When asked if a pressure reeducation mattress would be beneficial for the Resident due to their history of pressure ulcer development, Staff Y stated, Yes, it wouldn't hurt. On 7/19/17 at 9:45 AM, an interview was conducted with Staff Z. When queried regarding Resident #901, Staff Z stated, They never had one (pressure reduction pad) on their wheelchair. When queried if the mattress on the Resident's bed was a pressure reduction mattress, Staff Z replied, No, it is a regular one. On 7/19/17 at 9:50 AM, an interview was completed with Unit Manager Nurse V. When queried regarding a pressure reduction pad or device on Resident #901's wheelchair, Nurse V stated, I'm not sure why they don't (have one). When asked is Resident #901's mattress was a pressure reduction mattress, Nurse V replied, They have a concave (raised edge) mattress for safety due to falls. When queried further regarding Resident #901's fall's within the facility, Nurse V stated, I think they have had one but that was the intervention that we put in place after the fall occurred in March (2017). With further inquiry regarding if a pressure reduction mattress would be an appropriate intervention due to Resident #901's development of pressure ulcers within the facility and the Resident's limited mobility, Nurse V stated, (The Resident) has the concave mattress because of the fall. They don't have a pressure reduction mattress. When queried if Resident #901 had a pressure reduction mattress in place prior to their fall and placement of the concave mattress, Nurse V replied, No, they had a regular mattress. When queried regarding other Residents in the facility that have pressure ulcers and specialty pressure reduction mattresses and facility policy/procedure for pressure ulcer prevention, Nurse V replied Some (Residents) do. A Resident in this hall has an alternating air mattress but Hospice ordered that. Nurse V further stated, (Resident #901) should have a chair (wheelchair) cushion (pressure reduction pad/device). I also believe that (the Resident) is on the yellow dot program. When inquired regarding the yellow dot program, Nurse V stated, It is a yellow dot outside of their name by the door (of their room). It is a reminder for frequent repositioning (of the Resident). When asked if staff documented when Residents were repositioned, Nurse V did not provide a response. On 7/19/17 at 10:00 AM, an interview was completed with Staff Z. When queried regarding the meaning of yellow dot next to Resident's names outside of the rooms meant, Staff Z stated, I think it means that they are a fall risk. On 7/19/17 at 10:05 AM, an interview was completed with Staff AA. When queried regarding the meaning of yellow dot next to Resident's names outside of the rooms meant, Staff AA stated, I don't know. On 7/19/17 at 10:10 AM, an interview was completed with Nurse VV. When queried regarding the meaning of yellow dot next to Resident's names outside of the rooms meant, Nurse VV stated, I don't know. I think it means fall risk. On 7/19/17 at 11:00 AM, an interview was completed with Nurse Y. When queried, Nurse Y stated, (Resident #901) did have another facility acquired pressure ulcer on their right medial (inside) knee but it is healed now. That is why we do the pillow in-between (the Residents) knees. An interview was completed with the Director of Nursing (DON) on 7/19/17 at 3:35 PM. When queried regarding Resident #901's facility acquired pressures ulcer, the Resident not having a pressure cushion to their wheelchair as indicated in the care plan, and not receiving prompt perineal care to restore hygiene, the DON stated, They don't have a pressure reduction pad on their wheelchair? I will have to look into that. When queried regarding the Resident not having a pressure reduction mattress, the DON did not provide a response. Resident #906 Record review on 7/17/17 at 2:30 PM revealed Resident #906 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Residents Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident required extensive to total assistance to perform Activities of Daily Living (ADL's) and was severely cognitively impaired. Additional review revealed that Resident #906 was admitted to Hospice Services on 6/23/17. An interview was completed with Nurse Y on 7/17/17 at 3:40 PM. When queried regarding Resident #906's pressure ulcers, Nurse Y stated, (The Resident) has three pressure ulcers. Two of them the Resident was admitted with and one was facility acquired. When queried further regarding the pressure ulcers that Resident #906 was admitted to the facility with, Nurse Y replied, They had them when they came back from the hospital. Record review on 7/17/17 at 4:00 PM of facility provided Gentell Fastcare: Facility Report (Dated 7/14/17) indicated Resident #906 had the following pressure ulcers: -Left lateral (outside) malleolus (ankle), Onset date: 6/5/17, Stage three -Right medial (inside) heel, Onset date: 4/20/17, Unstageable -Sacrum, Onset date: 5/17/17, Unstagable Review of Nurses' Note documentation in Resident #906's medical record revealed the following documentation: - 4/28/17 at 1:13 PM: Resident arrived via ambulance X 2 attendants. Alert to self. Resting in bed. -4/28/17 at 5:33 PM: Alert, non verbal. Re admit from (Hospital). Combative during assessment and care . Has open area to buttock and right heel, left heel is red. Lift boots applied . -5/4/17 at 12:30 PM: Spoke with (family) and updated on pressure ulcer to left ischium and right medial heel, left ischium is 100% slough, and right medial heel is necrotic and dry, (family member) has concerns about wounds . -5/10/17 at 1:51 PM: Ambulance here to pick up resident, resident noted with increased respiratory distress, audible wheezing noted. temp increased to 103.1 auxiliary SPO2 85% (oxygen saturation) . Area to right heel, and buttock . -5/17/17 at 5:10 PM: admitted from hospital via ambulance X 2 attendants . Has red area to left hip. Open areas to buttocks, left heel has open area, left heel red and boggy. No S/S of pain. -5/18/17 at 11:21 AM: Resident re-admit to facility with sacrum ulcer 7.0 cm x 3.0 cm x utd 20% slough, low serous drainage, o odor o signs of infection, right medial heel 2.5 cm (centimeter) x 3.0 cm x utd 100% necrotic and dry, left heel is intact . -5/19/2017 at 12:06 PM: Resident re-admit from hospital with . intact medial heel 100% necrotic and dry, sacrum 20% slough. -6/7/17 at 8:15 AM: Wound skin assessment to Left Lateral Malleolus completed by WCT per nurse's verbal communication. Open area present, 3.0 cm x 2.2 cm x utd, 100% Necrotic, 0 drainage, 0 Odor, 0 complaints of pain . Unit Manager aware. -6/12/17 at 12:25 PM: .Resident's Sacral/Coccyx wound significantly worse in condition per the wound care Ambulance called for transport to the ED . -6/16/2017 at 8:03 PM: Resident re-admit with pressure ulcer to right medial heel 4.5 cm x 3.0 cm x utd 100% necrotic tissue with edges open, left lateral malleolus pressure ulcer 3.0 cm x 2.5 cm x utd 100% necrotic with open edges, sacrum pressure ulcer 13.0 cm x 9.0 cm x utd 100% necrotic with tendon exposed foul odor and mod serous drainage treatments in place . -6/23/17 at 11:39 AM: Spoke with (Resident family) and updated on pressure ulcer to sacrum 100% necrotic with foul odor infection present spoke about hospice and if Resident does not go on hospice possible sending Resident out to hospital to have wound evaluation done . -6/23/17 at 4:39 PM: Resident was admitted to Hospice. On 7/18/17 at 9:30, record review of facility provided Gentell Fastcare: Wound History documentation for Resident #906 revealed the left lateral malleolus pressure ulcer was first observed 6/5/17 and was originally documented as unstageable. Review further revealed the Residents sacrum pressure ulcer was first observed 5/17/17 and originally documented as unstageable and the right medial heel pressure ulcer was first observed on 4/20/17 and originally documented as unstageable. On 7/18/17, at 10:20 AM, observation of wound care was completed with Nurse Y and Unit Manager V. The following observations of treatment for [REDACTED]. -Coccyx/sacral Pressure Ulcer: The removed dressing was noted to have yellow colored drainage and a faint odor. The coccyx/sacral area wound was irregularly shaped and the open area of the wound was slightly larger than the approximate size of a dollar bill. The greater portion of the open wound was on the left side of the Resident's buttocks area. The wound bed was observed to have full tissue loss and was a beefy red color with small amounts of sloth and granulation tissue observed on the wound base. -Right Medial Ankle Pressure Ulcer: The prior, removed dressing was noted to have a scant amount of yellow colored drainage. The wound bed was observed to be irregularly shaped and slightly larger than the approximate size of a half-dollar coin. The wound bed had a necrotic cap with redness noted along the distal (bottom) edge of the wound. Left Lateral Ankle: Shadowing was observed the prior dressing prior to removal. A moderate amount of copious (thick), green and gray colored drainage was observed on the dressing removed by Nurse Y. The wound bed was approximately the size of a half dollar, irregularly shaped. The wound bed was further observed to be red in color with white and yellow colored slough. During wound care, Resident #906's brief was observed to be soiled with urine. Following wound care, Nurse Y and Nurse V proceeded to put the soiled brief back on Resident #906. When queried regarding the Resident's brief being soiled, Nurse V replied, If it's wet, it's just damp. I will send a nursing assistant in (to change the Resident's brief). When queried regarding replacing a soiled brief over the new dressings and wound healing, Nurse V did not provide a response. Record review on 7/18/17 at 11:40 AM of Resident #906's care plan pertaining to pressure ulcers entitled Resident admit with pressure ulcer to sacrum, right medial heel, Left Lateral Malleolus related to Dehydration, Disease process, History of ulcers, immobility, Nutritional deficits recent [DIAGNOSES REDACTED]. -Administer medications as ordered. Evaluate/document for side effects and effectiveness. (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Administer treatments as ordered and evaluate for effectiveness (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Avoid positioning the Resident on back (Date Initiated: 03/20/2017, Revision on: 05/18/2017) -Daily skin evaluations by licensed nurse if current pressure ulcer (see TAR) Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Educate the resident/family/caregivers as to causes of skin breakdown; including; transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Evaluate nutritional status. Serve diet as ordered, monitor intake and record. (Date Initiated: 03/20/2017, Revision on: 04/21/2017 -Evaluate/record/monitor wound healing weekly and prn (as needed). Measure length, width, and depth were possible. Evaluate and document status of wound perimeter, wound bed and healing progress. Report improvements and decline to the MD. (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain adherence. Document alternative methods (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx(signs/symptoms) of infection, wound size (length x width x depth), stage (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Provide incontinence care every 2 hour and as needed (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Skin inspections by CNA (Nursing Assistant) during cares and showers/baths. Report changes to licensed nurse immediately (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested (Date Initiated: 03/20/2017, Revision on: 04/21/2017 -The Resident requires foam cushion when in wheelchair and bil (bilateral) heel lift boots in bed and chair (Date Initiated: 03/20/2017, Revision on: 05/10/2017) -The Resident requires supplement protein, amino acids, vitamins, minerals as ordered to promote wound healing (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Use mild cleansers for peri-care (Date Initiated: 03/20/2017, Revision on: 04/21/2017) -Resident can be combative with treatments approach with calm tone and reassure Resident explain treatments before attempting to do (Date Initiated: 05/10/2017) -Yellow dot program (Date Initiated: 05/10/2017) An interview with Nurse Y was completed on 7/19/17 at 9:40 AM. When queried regarding Resident #906's facility acquired left lateral malleolus pressure ulcer and interventions in place to prevent pressure ulcers, Nurse Y stated, (The Resident) had heel boots in place. When queried how often the heel boots were removed and the Resident's skin assessed, Nurse Y replied, I don't know that, I would assume every day. When queried they would anticipate a necrotic pressure ulcer to develop within one day of having a skin assessment completed, Nurse Y replied, No. On 7/19/17 at 9:50 AM, an interview was completed with Unit Manager Nurse V. When queried regarding Resident #906's facility acquired pressure ulcer, Nurse V stated, (The Resident) has an air mattress on their bed now that came from Hospice I think and they have had heel boots. With further inquiry, Nurse V stated, The nursing assistants do skin checks when they are providing care to Residents. When asked where the skin checks are documented, Nurse V did not provide a response. On 7/19/17 at 10:00 AM, an interview was completed with Staff Z. When queried regarding the meaning of yellow dot next to Resident's names outside of the rooms meant, Staff Z stated, I think it means that they are a fall risk. On 7/19/17 at 10:05 AM, an interview was completed with Staff AA. When queried regarding the meaning of yellow dot next to Resident's names outside of the rooms meant, Staff AA stated, I don't know. On 7/19/17 at 10:10 AM, an interview was completed with Nurse VV. When queried regarding the meaning of yellow dot next to Resident's names outside of the rooms meant, Nurse VV stated, I don't know. I think it means fall risk. An interview was completed with the Director of Nursing (DON) on 7/19/17 at 3:35 PM. When queried regarding Resident #906's facility acquired pressures ulcer and the development of a necrotic pressure ulcer on the Resident's left lateral ankle while the intervention was in place to wear heel boots and perform skin monitoring, the DON stated, I will have to look into that and let you know. When queried regarding the Resident not receiving prompt perineal care to restore hygiene, the DON did not provide a response. Skin assessment documentation for Resident #906 prior to the development of the left lateral ankle pressure ulcer was requested on 7/18/17 at 10:40 AM but not received prior to the conclusion of the survey. Record review on 7/19/17 at 4:15 PM of facility policy entitled Pressure Ulcers/Skin Breakdown- Clinical Breakdown (Revised 3/23/11) revealed The nurse shall assess and document/report the following: a. Vital signs, b. Full assessment of pressure sore including location, stage length, width and depth, presence of exudates or necrotic tissue, c. Pain assessment, d. Resident's mobility status, e. Current treatments, including support surfaces. Record review on 7/19/17 at 4:20 PM of facility policy entitled Repositioning (Revised 12/2014) revealed, A turning/repositioning program includes a continuous consistent program for changing the Resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. The plan is based on the Resident's individualized assessment and takes into account pressure redistribution devices and surfaces . Residents who are in bed should be on a every 2 hour turning plan, . Residents with a Stage I or above pressure ulcer, every 2 hour turning may be inadequate, Residents who are in a chair may need to be on a every 1- 2 hour repositioning program based on individual assessment, If ineffective, the turning and repositioning frequency may be increased, Review the Resident's care plan to assess for any special needs of the Resident. Resident #926 On 7/19/17 at 8:20 a.m., a record review of the face sheet and Minimum Data Set (MDS) assessment was completed on Resident #926. According to the face sheet, Resident #926 was admitted to the facility on [DATE] and then readmitted on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that Resident #926 was severely cognitively impaired, incontinent of bowel and bladder and needed extensive two person assist with bed mobility and was dependent for transfers and bathing. On 7/18/17 at 1:05 p.m., Resident #926 was observed in her room lying on her back with Family Member E at her bedside. Resident #926's legs were contracted at the knees and her heels were resting on the mattress. According to Family Member E Resident #926 was unable to move her legs and stated, They don't have enough staffing here. They don't reposition her or change her fast enough. Family Member E also explained that Resident #926 did not have the physical ability to utilize a call button to notify staff when she needed assistance. On 7/19/17, observations were made at 11:40 a.m., 1:00 p.m., and 3:55 p.m.: Resident #926 was lying on her back, legs flexed at knees with heels resting directly on bed mattress. On 7/19/17 at 1:20 p.m., a record review of the care plans for Resident #926 was completed and revealed the following: Resident at risk for pain due to decreased mobility, [MEDICAL CONDITION]. Intervention: Assist with repositioning frequently. Date not included on printed copy of care plan. The Resident has ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Stroke, requires total assist with all daily ADL's. Initiated 06/07/2016. Intervention: encourage resident to keep heels elevated while in bed resident does not tolerate heel lift boots or heels up on pillow per family due to extreme perspiration issues. staff to anticipate and perform residents needs. Both interventions initiated 07/08/2016. On 7/19/17 at 2:00 p.m., an observation was made with Wound Nurse Y of an unstagable wound to the coccyx area of Resident #926. The wound was small, round with a red, moist wound bed. There was no odor and little drainage. The skin around the wound was pink and appeared to be scarred tissue. According to Wound Nurse Y Resident #926 had been admitted with the wound and it had improved since admission. Resident #918 On 7/17/17 at 1:30 PM, a review was completed of Resident #918's medical records, it revealed the Resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #918's most recent Minimum Data Set (MDS) assessment, dated 7/9/17 indicated the Resident was cognitively intact. 7/17/17 at 3:25 PM, an interview was conducted with Resident #918. The Resident indicated they were admitted to the facility with a pressure ulcer on their coccyx but that they acquired additional pressure ulcers during the time they had been at the facility. The Resident spoke about sitting in urine soaked brief for an extended period of time, as the facility is understaffed and the CNA's are not able to respond to Resident care needs in a timely manner. On 7/18/17 at 9:20 AM, Resident #918's wound care was completed by Nurse ZZ and Nurse AAA. There was a strong odor noted in the hall outside the room and inside the Resident's room. The Nurses reported they just cleaned the Resident prior to completing wound care. The Resident has a wound on the left upper thigh and right buttock. Nurse ZZ and AAA, explained the wounds on the buttocks have always been large at the Resident refuses to lay on their side, and always lays on their back. On 7/18/17 at 3:15 PM, an interview was conducted with Unit Manager YY in regards to interventions for Resident #918's pressure ulcers. The Unit Manager reported the Resident has been offered the pressure relieving mattress twice and has refused both of these time. The Unit Manager added due to the Resident's weight the Resident does not like to be repositioned in bed. There were no other interventions provi

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to prevent significant weight loss for 1 (#907) of 3 residents reviewed for weight loss from a total sample of 33 residents, resulting in Resident #907 experiencing a 16 percent (% ) weight loss in 5 months, becoming increasingly weaker and repeatedly falling. Findings Include: On 7/17/17 at 11:30 am, a record review revealed that Resident #907 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS), dated [DATE] indicated the resident had poor cognitive function and required extensive 2 person assistance with transfers and extensive 1 person assistance with bed mobility, dressing, hygiene, bathing and toileting. The resident was able to feed self with 1 person assistance and per the MDS did not ambulate. On 7/17/17 at 1:15 PM, Certified Nurse Assistant (CNA) O entered the room and stated the resident ate 50% for lunch. On 7/18/17 at 10:55 am, the resident was observed sleeping in bed. The breakfast tray was still at the bedside with eggs and bacon cut up in small pieces, about 75% was eaten. On 7/18/17 at 11:15 am, a review of Weights for Resident #907 from 2/8/17 to 7/12/17, 17.3 lb. weight loss = 16.29% severe weight loss over 6 months. 2/8/17: 106.2 lbs. (pounds) 3/6/17: 101.4 lbs. 4/6/17: 98.2 lbs. 5/8/17: 95.6 lbs. 5/31/17 : 93 lbs. 6/15/17: 93.1 lbs. 6/28/17: 91.2 lbs. 7/5/17: 89.2 lbs. 7/12/17: 88.9 lbs. A review of the Incident and Accident (I& A) reports for Resident #907 from 2/7/17 to 7/17/17, revealed the resident fell 11 times, while attempting to transfer self, with several instances of skin lacerations and bruising. A review of the Care Plans for Resident #907 revealed the following: Nutrition Care Plan, The resident is at risk for nutritional declines, including unintentional weight loss .Goal: Resident will consume adequate nutrition, including 100% of supplements to maintain body weight without any significant changes through the next review date, Interventions: Monitor weights per facility policy for significant changes .Provide supplements as ordered .encourage to eat in the dining room. The Care Plan had not been updated since March, 2017. ADL (activities of daily living) Care Plan, .Must wake (the resident) for meals and assist to the dining room . A dietary note dated 6/27/17 by Staff CCC indicated the resident had choked on a cookie on 6/21/17 and the [MEDICATION NAME] maneuver was performed. The resident's diet was changed to mechanical soft texture on 6/23/17. The resident had lost 13.1 lbs. = 12.3% significant weight loss from 2/8/17, until the time of the note on 6/27/17. From 6/15/17 to 7/12/17 the resident lost 4.2 lbs. = 4.37% in less than 30 days. There was no further documentation or indication that the dietitian was aware that the resident continued to lose weight. A Dietary note, written by Staff DDD dated, 7/17/17 at 4:19 PM provided, (The resident) has a steady slow weight loss .She is offered Ensure 4 oz. (ounces) QID (4 times a day) with fair to poor acceptance Will continue to encourage intake of meals and supplements. I don't feel adding more food or supplements is the solution as she is already not taking what she is offered. We could try some ice cream and increased desserts. There was no mention of the amount of food or supplements eaten. The Care Plan was not updated to include ice cream or increased desserts, at the time of exit on 7/19/17. On 7/19/17 at 12:23 PM, Dietitian N was queried on the amount of weight Resident #907 had lost since 2/8/17 and responded I'll have to look at the weights. Dietitian N calculated the weight loss for Resident #907 and responded, (The resident) had a 16.3% weight loss from 2/8/17- 7/12/17. I was not aware that (Resident #907) had a significant weight loss. When Dietitian N was queried on what interventions were put into place from 6/27/17 to 7/19/17 to prevent further decline in the resident's weight, he responded, there were no new interventions, That I can tell. When asked what the food acceptance documentation indicated for meal consumption, Dietitian N stated, Breakfast today (7/19/17) 95%, yesterday (7/18/17) Breakfast was 75%, Lunch 100% and Dinner not available. When queried on the amount of Ensure that the resident was drinking, Dietitian N provided, The documentation indicates the Ensure was taken, but does not indicate the amount taken. When further asked how the Dietitian would know how much ensure the resident drank, he responded, I would have to ask, to see if (the resident) is drinking the Ensure. Dietitian N indicated, he had not done this and stated, I would rather try something that would be appropriate. I would have to investigate. Dietitian N was queried on how he would become aware of a resident's continued weight loss, including significant weight loss and replied, There is an MDS list to prioritize resident's to assess. There is a portal for significant changes and verbal reports from staff. The Dietitian indicated he had not been made aware of the resident's severe weight loss. The Dietitian who wrote the note on 6/27/17 was a consulting Dietitian and Dietitian N was the only full-time Dietitian for the facility. An interview with the Director of Nursing on 7/19/17 at 2:00 PM, indicated she was not aware that Resident #907 had a severe weight loss, but was aware the resident had repeated falls from weakness. On 7/19/17 at 2:35 PM, a review of the facility policy titled, Nutrition (Impaired) Unplanned Weight Loss-Clinical Protocol, dated 6/20/16, revealed The Physician and staff will closely monitor residents who have been identified as having impaired nutrition .Evaluating the care plan to determine if the interventions are being implemented and whether they are effective .evaluating the resident's response to interventions .observing for and documenting any sustained decline in appetite and/or food intake. Making note of how added supplementation, double portions or reduced calories has affected this .Observing for and reporting significant weight gain or loss .

This citation has two Deficient Practice Statement: Deficient Practice #1 Based on observation, interview and record review, the facility failed to provide routine tracheotomy care for 2 (#'s 905 and 926) of 3 sampled residents reviewed for tracheotomy care from a total of 33 sampled residents, resulting in the potential for a compromised airway and infection for artificial airway dependent residents. Findings include: Resident #926 On 7/19/17 at 8:20 a.m., a review of the face sheet and Minimum Data Set (MDS) assessment revealed that Resident #926 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that Resident #926 was severely cognitively impaired, incontinent of bowel and bladder and needed extensive two person assist with bed mobility and was dependent for transfers and bathing. On 7/18/17 at 1:05 p.m., Resident #926 was observed lying on her back with Family Member E at the bedside. The resident had a tracheotomy (trach) present (an artificial tube leading down the air way to promote normal breathing). There was sputum all around [MEDICAL CONDITION] was saturating the bandages present under the [MEDICAL CONDITION] collar and thick, yellow sputum present on [MEDICAL CONDITION]. Family Member E stated, They don't have enough staffing here. They are scared to do [MEDICAL CONDITION], I can tell because they don't want to do it, [MEDICAL CONDITION] disposable. She ( #926) has already been sent to the hospital once because of it (the trach) being clogged. It was full of dried thick phlegm and the ER (emergency room ) doctor told me it was because it was not being cleaned enough. On 7/19/17 at 8:00 a.m., Resident #926 was observed lying on her back in bed. There was thick yellow sputum coming out of [MEDICAL CONDITION] pressing against [MEDICAL CONDITION]. Around the collar, the bandages were saturated with yellow sputum. On 7/19/17 at 8:25 a.m., a review of physician's orders, progress notes and Treatment Administration Record (TAR) was completed. There was only one order present in the physician orders in regards to [MEDICAL CONDITION]. The order read: Change [MEDICAL CONDITION] weekly . (The blue tube is the tube that extends out of the [MEDICAL CONDITION] and hooks up to the oxygen. It is independent from [MEDICAL CONDITION] is not attached to the trach). The TAR for June and July revealed weekly blue tubing changes done on 6/2/17, 6/9/17, 6/23/17, 7/5/17, and 7/12/17. According to the progress notes, the last [MEDICAL CONDITION] was completed by a respiratory therapist on 6/19/17. On 7/19/17 at 12:45 p.m., the Director of Nursing (DON) was interviewed and was queried [MEDICAL CONDITION] for Resident #926. The DON began to review the electronic medical record looking [MEDICAL CONDITION] and stated, I don't see any (trach care). I see where they change the tubing weekly, that's it. Maybe it is just a standard of care. Upon further review of the medical record, the DON stated, I see that they (nursing staff) d/c'd (discontinued) [MEDICAL CONDITION] on 6/2/17. She (#926) must have been discharged to the hospital or something. On 7/19/17 at 2:10 p.m., an interview was completed with Nurse H who was the assigned nurse for Resident #926. Nurse H was queried in regards [MEDICAL CONDITION] for Resident #926. Nurse H stated, I did it (trach care) this morning. When asked if she replaced [MEDICAL CONDITION] during [MEDICAL CONDITION], Nurse H said she did. When asked where this (the [MEDICAL CONDITION]) was documented, Nurse H was unable to verify it and stated, I don't see it on the TAR or MAR (Medication Administration Record), I don't see it (the order [MEDICAL CONDITION]), but I did it. I will fix that and write it (the order [MEDICAL CONDITION]) today. On 7/19/17 at 3:35 p.m., a review of the facility policy titled, [MEDICAL CONDITION] Care revised 6/26/16 indicated, #1. [MEDICAL CONDITION] should be changed as indicated, and every three months. #8. Provide [MEDICAL CONDITION] care as often as needed, at least twice daily and change inner cannula at least once every 24 hours. Resident #905 On 7/17/17 at 9:25 am, resident # 905 was observed sitting in an upright position in bed and was receiving oxygen therapy via a mask to the [MEDICAL CONDITION] at 10 liters/minute. On 7/17/17 at 2:05 PM, upon entering Resident #905's room to observe medication pass, a document [MEDICAL CONDITION] was observed on a clip board on the counter. It had the resident's name on it and was dated July 2017 with the following headings: Suction kit,[MEDICAL CONDITION], and inner-cannula and were signed out each day until 7/12/17. There was nothing documented after 7/11/17. Nurse Q was queried on why the form was not completed and responded, I don't know. On 7/17/17 at 10:45 am, a record review revealed that resident #905 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive deficits and required total assistance with 2 persons for bed mobility, transfers, dressing, hygiene/bathing and toileting. The resident needed total 1 person assistance with eating via the feeding tube. On 7/18/17 at 10:25 am, a review of the Treatment Administration Records (TAR's), for Resident #905 indicated the following: [MEDICAL CONDITION] was to be changed every 7 days and was not documented as changed on 7/10/17. The inner-cannula of [MEDICAL CONDITION] scheduled to be changed daily [MEDICAL CONDITION] and was not documented as being completed on 5 of the last 10 days: 7/7/17, 7/8/17, 7/10/17, 7/15/17 and 7/16/17.[MEDICAL CONDITION] was to be completed and documented 2 times a day (days/nights) and was not documented as completed on 5 of 10 days: 7/7/17, 7/8/17, 7/10/17, 7/15/17 and 7/16/17. On 7/19/17 at 3:25 PM, Confidential Person R reviewed [MEDICAL CONDITION] on the clipboard in the resident's room and stated, I don't know, when queried why all of the missing documentation on [MEDICAL CONDITION] from 7/12/17 - 7/16/17 was now filled in. When asked how you would know, after several days, if the care was actually completed, Confidential Person R responded, I don't know. An interview with the DON on 7/19/17 at 2:00 PM, revealed, They weren't? when the DON was informed the [MEDICAL CONDITION] care was not documented as completed on multiple days for the resident and also provided, My expectation is the nurse [MEDICAL CONDITION] per protocol and as ordered. Deficient Practice #2 This citation pertains to Intake #MI 879 Based on observation, interview and record review, the facility failed to provide IV (intravenous) catheter maintenance to prevent exposure to infectious organisms and ensure IV patency for 3 (#'s 921, 925, 931) of 3 residents reviewed for IV catheters, from a total sample of 33 residents, resulting in the residents not receiving routine IV site dressing changes or IV catheter saline flushes and Resident #921 was transferred to the hospital with shaking and mental status changes, possibly related to infection. Findings Include: On 7/17/17 at 9:30 am, during the initial tour, Resident #921 was observed lying in bed, watching TV. An IV (intravenous) pole with an IV antibiotic bag and bottle -[MEDICATION NAME] was near the bed. They were not dated. When the resident was asked if they were receiving antibiotics, the resident did not know. During a tour of the 500/600 medication room, on 7/17/17 at 10:05 am, 2 IV bags of [MEDICATION NAME] were in the refrigerator with Resident #921's name on them. Confidential Person R stated, I don't know if (the resident) still gets that. During a medication pass observation on 7/17/17 at 2:35 PM, Nurse Q was queried if the resident was receiving any IV medications, and after looking in the EMAR (electronic medical record) stated, I guess not. An observation of the IV catheter and dressing, revealed the IV was a midline and the dressing was dated 7/10/17. On 7/18/17 at 9:45 am, the resident was observed lying in bed watching TV. The IV pole was gone. A record review on 7/18/17 at 1:45 PM revealed, Resident #921 was initially admitted to the facility on [DATE] and readmitted on [DATE] and 7/7/17 with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was non-ambulatory and needed extensive 2 person assistance with bed mobility, transfers, dressing, hygiene/bathing and toileting. The resident was able to feed self with set up assistance and had full cognitive abilities. On 7/18/17 at 2:00 PM, a record review revealed the following: The Medication Administration Records (MAR's) for July 2017, revealed the resident received IV [MEDICATION NAME] and IV [MEDICATION NAME] from 7/7/17 to 7/11/17. The antibiotic had not been given for 6 days and was still hanging in the room on 7/17/17. There was no order for IV flushes of the midline catheter, until 7/17/17 at 6:41 PM, Flush line every 12 hours per order. Observe insertion site for redness, warmth, [MEDICAL CONDITION], drainage, Notify MD Medical Doctor) prn (as needed), site care, dressing changes per order. The resident had the catheter for 11 days prior to having routine catheter flushes. The Treatment Administration Records (TAR's) for Resident #921, indicated there was an order dated 5/7/17 to perform, Transparent dressing and catheter cap changes every 7 days on night shift. Clean IV area to left arm and change dressing every week and prn (as needed). The July 2017 TAR indicated the IV site cleansing, dressing and cap changes did not occur on 7/2/17 or 7/16/17. A review of the care plans for Resident #921 indicated, there was no care plan to address IV maintenance and care until 7/18/17, Central line, Risk for Infection related to PICC line, Patency of Central line will be maintained without signs and symptoms of infection . This was the day the resident was discharged to the hospital to rule out infection. An interview with Nurse T on 7/19/17 at 9:50 am provided, (The resident) was sent to the hospital yesterday for a change of mental status. On 7/19/17 at 2:38 pm, a progress note dated 7/18/17 at 3:30 am, indicated the resident was sent to the hospital for mental status change and rule out infection. Resident #931 On 7/19/17 at 1:25 PM, Resident #931 was observed lying in bed watching TV. The resident said he was receiving an IV antibiotic for a urinary tract infection [MEDICAL CONDITION] and cough. The resident had a PICC (Peripherally Inserted Central Catheter) line in the left arm. The dressing did not have a date or initials of the nurse that applied it. The resident stated the PICC was inserted on 7/14/17, but the PICC line was not checked for proper placement, with an x-ray until 7/17/17 at 4:58 PM, so the antibiotic did not start until the 4th day after placement. On 7/19/17 at 2:29 PM, an interview with Confidential Person M revealed, The PICC line was place at 9:30 PM Friday, 7/14/17, they did not have an order for [REDACTED].#931's bed. They had the resident's roommates name on them. No one there ever gets all of the pieces together. (The resident) had to wait all weekend, due to poor communication, (and) suffers because of it. There is not enough staff ever. A record review on 7/19/17 at 3:15 PM indicated, Resident #931 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE], indicated the resident had full cognitive abilities and needed extensive 2 person assistance with bed mobility, transfers, dressing, bathing and toileting and extensive 1 person assistance with hygiene. The resident was able to feed self with set up assistance. Resident #931 was receiving IV [MEDICATION NAME] (an antibiotic). It was held on 7/14/17-7/16/17, while awaiting PICC line placement. On 7/18/17 at 3:00 PM, a record review indicated an order was received for Dressing and cap changes. On 7/17/17 at 6:39 PM, an order was received for IV maintenance flushes to keep the IV line patent. The IV catheter was not properly maintained for 4 days after insertion. On 7/19/17 at 3:30 PM, a review of the care plans for Resident #931, revealed there was no care plan addressing IV care or infection/uti. A review of the facility policy titled Peripheral IV and Midline IV dressing Changes, dated 10/2015, indicated, The purpose of this procedure is to prevent catheter related infections .Replace peripheral IV or Midline dressings by sterile procedure every 7 days .label dressing with date, time and intials .document the procedure in the medical chart. A policy for PICC lines and Central line maintenance was requested and not provided at the time of exit. An interview with the Director of Nursing on 7/19/17 at 4:00 PM provided, My expectation is the nurse provides IV care per protocol and as ordered. Resident #925 Record review on 7/19/17 at 8:00 AM revealed Resident #925 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Admission assessment dated [DATE] revealed the Resident required limited assistance to perform Activities of Daily Living (ADL's) and was cognitively intact. Additional review of the medical record at this time revealed the Resident was receiving intravenous (IV) antibiotic therapy due to infection. On 7/19/17 at 8:55 AM, Resident #925 was observed lying in bed in their room. An IV pole with pump and no medications was present in the room. An empty IV medication administration bag was observed laying on the Resident's bed. The medication was labeled for administration to Resident #925 but did not include a date and/or time in which the medication had been administered. When queried, Resident #925 stated, They (staff) must have left it there. I don't know. On 7/19/17 at 9:10 AM, an interview was completed with Unit Manager X. When queried regarding the IV medication bag on Resident #925's bed, Unit Manager X replied, I don't know why that's there. It shouldn't be. On 7/19/17 at 2:30 PM, Resident #925 was observed lying in bed in their room. The Resident had a Peripherally Inserted Central Catheter (PICC) line in their upper left arm. The PICC line indicated the catheter was a Power PICC on the catheter tubing. An interview was completed with Unit Manager X on 7/19/17 at 2:25 PM. When queried regarding the method that was being utilized to flush Resident #925's PICC line, Unit Manager X reviewed the Resident's clinical record and then stated, We just use the SASH (Saline, Additive, Saline, [MEDICATION NAME]) method. It isn't a Power PICC, the hospital tells us if it is. The only time we don't use [MEDICATION NAME] to flush is if it is a Power PICC. On 7/19/17 at 2:40 PM, observation of Resident #925's PICC line was completed with Nurse U. After looking at the Resident's PICC line, Nurse U stated, It says Power PICC on it. What does that mean? When asked about the method utilized to flush Resident #925's PICC line, Nurse U stated, We do the SASH method. With addition inquiry, Nurse U stated, I use about 4 cc (cubic centimeters) of [MEDICATION NAME] when I flush it. On 7/19/17 at 2:45 PM, an interview was completed with Unit Manager X. When inquired why [MEDICATION NAME] was being utilized to flush Resident #901's PICC line when the Resident has a Power PICC, Unit Manager X replied, It must not have been passed on to us from the hospital. When queried how many times the Resident's PICC line had been flushed with [MEDICATION NAME], Unit Manager X reviewed the Resident's medical record and replied, Since they got here on the tenth. It would have been flushed with [MEDICATION NAME] every time they got antibiotics. Record review on 7/19/17 at 3:00 PM revealed Resident #925's Medication Administration Record [REDACTED]. An interview was completed with the Director of Nursing (DON) on 7/19/17 at 3:35 PM. When queried regarding Resident #925's Power PICC line being flushed with [MEDICATION NAME], the DON did not provide an explanation.

This Citation has Two Deficient Practice Statements. Deficient Practice Statement Number One: This citation pertains to Intake Number MI 591. Based on observation, interview, and record review, the facility failed to provide monitoring and supervision to prevent elopement from the facility, through a bedroom window at approximately 11:00 PM of one (#703) of one Residents reviewed for elopement risk, out of a total sample of nine. An Immediate Jeopardy (IJ) arose when the facility identified the Resident as severely cognitively impaired (Brief Interview Mental Status (BIMS) Score 7) and as a risk for elopement, but failed to implement planned and effective interventions and monitoring to prevent actual elopement from the facility and facility staff were unaware of the Resident's whereabouts for approximately 12 hours in which the Resident walked approximately 0.7 miles to a local business and took a cab approximately 15 miles to an individual residence resulting in the potential for serious harm, injury, or death. The Administrator was notified of the Immediate Jeopardy on 7/11/17 at 4:30 PM. A plan to remove the immediacy was requested. The Immediate Jeopardy was identified on 7/8/17 at 11:00 p.m. The IJ was removed on 7/12/17 based on the facility's implementation of the plan removal as verified onsite. Although the IJ was removed, the facility's deficient practice remains at isolated. Actual harm that is not immediate jeopardy. Findings include: Record review on 7/11/17 at 8:45 AM revealed Resident #703 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #703 was severely cognitively impaired and required limited assistance to perform activities of daily (ADL's). On 7/11/17 at 9:00 AM, review of Nurses Progress Notes in Resident #703's medical record revealed the following documentation authored by Nurse K on 7/9/17 at 8:01 AM: Writer went into Resident room at approximately 5:00 A.M. to give medication and observed that Resident was not in bed or restroom. Writer begin to search room by room for Resident without success. Writer called over head for staff to search for Resident, but to no success. DON (Director of Nursing) called and message left in regards to situation. 911 called and arrived at approximately 6:00 A.M. Administrator, Administrator Assistant, Assistant DON was called and message left. Writer was last seen Resident around 11:00 P.M.-12:00 A.M. in room. On 7/11/17 at 9:45 AM, Resident #703 was not in their room in the facility. Observation of the Resident's room revealed that the window in the room was unable to be opened further than approximately 10 inches. An interview occurred with Nurse P at this time. When queried regarding the Resident's whereabouts, Nurse P stated, They are at dialysis today. When queried further, Nurse P stated, (The Resident) was moved to this room after everything happened (elopement). Nurse P further stated, I have taken care of the Resident a couple times before but I have never had any problems. An interview was completed with Social Worker N and Social Worker O on 7/11/17 at 10:00 AM. When queried regarding Resident # 703, Social Worker N stated, The Resident has a guardian and an OBRA (Omnibus Budget Reconciliation Act) caseworker but the Resident doesn't think they need a guardian. (Resident #703) thinks that they can leave the facility and go live with their friend. The Resident wanted a day pass and their Guardian was okay with it but wanted the friend to visit (the Resident) here at the facility first. (Resident #703) is very impulsive and unaware of consequences. With further inquiry, Social Worker N stated (Resident #703) took a taxi to the friend's house. The friend actually brought the Resident back to the facility. When asked how far the friend's house is from the facility, Social Worker O replied, Like 15 miles. When asked where the Resident would have gotten money for a taxi, Social Worker N stated, From their trust fund. Social Worker N further stated, The Resident said they originally walked over to a gas station but they (gas station) wouldn't call a cab. The Resident said they walked to Business X and someone there called a cab for them. At this time, Social Worker O stated, Especially at 10:30 at night, they (Business X staff) probably thought they were doing (the Resident) a favor. With (Resident #703's) cognitive and speech deficits, (the Resident) sounds like they have been drinking (alcohol) when they talk if you didn't know what was going on. Social Worker N then stated, (Resident #703) didn't take their helmet with them either. When queried regarding the helmet, Social Worker N stated, I believe (the Resident) has to wear it because of a head injury but I'm not 100 percent sure about the details. On 7/11/17 at 10:20 AM, an observation of the room Resident #703 was residing in at the time of the elopement occurred. At the time of the elopement, the Resident's bed was stationed closest to the window within the room. The window in the room opened by sliding and had a screen present. A metal stop with a screw was observed to be present in the window at this time that stopped the window from being able to be opened greater than approximately 12 inches. On 7/11/17 at 10:35 AM, an observation of distance from facility to Business X occurred. Business X was 0.7 miles away from the facility. Observation revealed that in order to walk to Business X from the facility, Resident #703 had to cross a major road intersection as well as walk across a major road with four traffic lanes. On 7/11/17 at 10:50 AM, review of Resident #703's medical record revealed the following care plans and interventions: Risk for elopement related to leaving facility without signing out and or telling staff. Expressed the desire to go to friend's home (Date Initiated: 05/22/2017, Revision on: 07/09/2017). Interventions: Engage in activities (Date Initiated: 05/22/2017) Evaluate elopement risk as needed (Date Initiated: 05/22/2017) Offer fluids unless contraindicated (Date Initiated: 05/22/2017) Offer snacks if expresses/appears hungry (Date Initiated: 05/22/2017) Wander alert bracelet (Date Initiated: 05/22/2017) At risk for injury self, and other Residents related to non-complaints with rules- no smoking in the building. Resident is a smoker (Date Initiated: 03/17/2017, Revision on: 07/09/2017). Interventions: Inform Resident of smoking policy of (Facility); Inform Resident of time allowed to smoke; Inform Resident of smoking zone, this does not include smoking in room, bathroom with garbage can, or anywhere inside the building; Resident is not to have cigarette or lighter in their possession, at any time; Discourage Resident from borrowing cigarette from other Residents (Date Initiated: 03/17/2017) Resident is a one on one for supervision related to smoking in facility (Date Initiated: 07/03/2017) Resident to wear apron while smoking supervised (Date Initiated: 07/09/2017) Resident will be provided with supervised smoking at designated facility smoking times (Date Initiated: 06/28/2017, Revision on: 07/09/2017). Review of Resident #703's Risk for Elopement Assessments revealed an assessment dated [DATE] that identified the Resident as an elopement risk and included the documentation, Walking out front door to go to (Nearby City). Review of facility provided Incident and Accident Report/Investigation on 7/11/17 at 11:10 AM revealed the following: On July 9th 2017 at 5:53 am (Resident #703) was noted to not be in their room, the nurse began searching the facility along with other staff members. They were unable to locate (the Resident) and notified the Director of Nursing (DON) and Administrator and also notified emergency services (911). Police arrived at approximately 6:00 am. The police called for a tracking dog and was unsuccessful in tracking the Residents scent. The police posted an amber alert with no further information. The Assistant Administrator obtained a phone number of a past friend to the Resident and the friend verified the Resident's location and returned the Resident to the facility at 1:45 PM. The Guardian and Physician have been notified. On 7/11/17 at 11:50 AM, an interview and record review of Resident #703's trust account occurred with Business Manager Q. Review revealed the most recent withdrawal from Resident #703's trust account occurred on 7/5/17 in the amount of 20.00 dollars. Prior to 7/5/17, the last withdrawal occurred on 5/5/17 in the amount of 50.00 dollars. An interview was completed with the roommate of Resident #703 on 7/11/17 at 12:10 PM. When queried, the roommate stated, I remember. I was tired and went to bed around 7:15 PM. I didn't hear or see nothing after that. On 7/11/17 at 12:20 PM, an interview occurred with Nurse P. When queried regarding Resident #703's dialysis treatments and transportation, Nurse P stated, The transportation company takes them. It's a bus. (Resident #703) goes by themselves. I was told after they left that since they are a one on one (a staff member is supposed to be with them at all times) that someone (staff) will have to go to dialysis with them. I didn't know, nobody went with them today. On 7/11/17 at 12:25 PM, an interview was completed with Nurse R. When queried, Nurse R stated, The last time that I saw (Resident #703) was a little before 9:00 PM (on 7/8/17). Nurse R further stated, (Resident #703) had been previously assigned one on one staff but we have not been doing that on nights when we do not have enough staff. We had multiple (staff) call in's and no call/no shows that shift. I helped out with med pass and then went to work on my supervisor duties. When queried further regarding one on one staff for Resident #703, Nurse R stated, I wanna say it (one on one staff) had been ordered for at least one week or longer. I think it was because (the Resident) was smoking in inappropriate areas. I never actually saw that happen though. An interview was conducted with Dialysis Staff T on 7/11/17 at 1:20 PM. When queried regarding Resident #703, Dialysis Staff T stated, We were not aware that (Resident #703) had left the facility, no one told us about that. Dialysis Staff T further stated, There is a staff from the facility here now. With further inquiry, Dialysis Staff T stated, There was an incidence around August 2015 when (Resident #703) tried to run away but they haven't done that since. I think (the Resident) likes it here. On 7/11/17 at 1:45 PM, an interview was completed with Witness U. When queried regarding Resident #703, Witness U stated, (Resident #703) was on my porch at around 12:30 AM on 7/9/17. I was getting ready for bed and I heard noises out on my porch so I went to see what it was. When I opened the door (Resident #703) was standing there. With further inquiry, Witness U stated, (Resident #703) told me they took a cab to my house. They said they left the nursing home and walked down to (local Business) and someone called them a cab. With additional inquiry, Witness U stated, (Resident #703) told me they had to wait almost an hour for the cab to come and now that I know where the nursing home is, it had to be a pretty long cab ride. Witness U proceeded to state, I didn't know what nursing home (Resident #703) was from but I knew that I needed to get them back. They are diabetic and would need their med's but (Resident #703) couldn't tell me the name (of the nursing home). I was going through the phone book trying to figure it out. Then I got a call from the nursing home and they asked me to bring him back so I did. An interview was completed with Manager Y from Business X on 7/11/17 at 2:00 PM. When queried if they were aware of any employees calling a cab for a male on Saturday night, 7/8/17, Manager Y stated, No, but I will ask employees and let you know. When queried regarding the time Business X closes, Manager Y replied, The doors are locked right at closing time and no one can get in. Midnight on Saturday and 10:00 PM on Sunday. An interview was completed with Staffing Coordinator Staff W on 7/11/17 at 2:25 PM. The facility provided staffing sheets for 7/8/17 and 7/9/17 were reviewed with Staff W at this time. When queried regarding specific staff working on the unit Resident #703 was residing in, Staff W stated, We had a lot of call-in's and no-calls/no-shows. With further inquiry, Staff W stated, I don't know. I can't say who worked where (on what units) if they (staff) don't fill out the sheets. I don't know. On 7/11/17 at 2:40 PM, a phone interview was attempted to be completed with Nursing Assistant M. The phone number provided by the facility for Nursing Assistant M was out of service. On 7/11/17 at 2:43 PM, a phone interview was attempted to be completed with Nursing Assistant L. Nursing Assistant L did not answer the phone and a message was unable to be left due Voicemail full. On 7/11/17 at 2:45 PM, Staff W provided another phone number for Nursing Assistant M. The phone number provided by the facility for Nursing Assistant M indicated Phone does not accept incoming calls. On 7/11/17 at 2:55 PM, an interview was completed with Nurse K. When queried regarding Resident #703, Nurse K stated, For the last couple of days, (The Resident) was saying they wanted out of there. They were on fluid restrictions and didn't want to be. I seen him stand in the doorway, I don't know the exact time. I saw (the Resident) when I was going up the hall. When I went to give them their med's in the morning, (the Resident) wasn't there. I looked for (the Resident) and had other staff look too. With further inquiry, Nurse K stated, I saw (Resident #703) in the hall. When queried regarding the last time that they entered Resident #703's room, Nurse K replied, Around 5:00 PM. When queried if they entered to room to care for Resident #703's roommate after 5:00 PM, Nurse K stated, No, you don't have to do anything with the roommate. When queried regarding staffing on the midnight shift, Nurse K replied, I was the only nurse for the 700 and 800 halls so I sit in the hall to chart. When queried if they entered Resident #703's room between 11:00 PM and midnight, Nurse K replied, No. I was going into another room at that time. On 7/11/17 at 3:15 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding the facility investigation pertaining to Resident #703's elopement from the facility not including interviews of the Nursing Assistants that were working, the DON replied, I don't know. When questioned regarding staffing on the midnight shift on 7/8/17, the DON stated, We were short. The nursing supervisor was the nurse and the nurse's aide. When queried if that is typical, the DON replied, No, there was a nurse that was a no show, a nursing assistant that was a no show, and a nursing assistant that called in. With further inquiry regarding how long the nursing supervisor assisted on the unit and how the nursing supervisor was able to be both nurse and nursing assistant, the DON did not provide a response. When queried if the facility had a policy and/or procedure pertaining to staffing, the DON stated, No, I've never seen one. The supervisor just calls everyone on the phone list (to ask if they can work). If they can't get anyone then they should call me or the Administrator. When queried regarding the facility policy/procedure if staff have been called and no one is available to work after the DON and/or Administrator are notified, the DON did not provide a response. On 7/11/17 at 6:13 PM, during an interview with Manager Y from Business X, Manager Y stated, I talked to the other manager and some employees and no one said they called a cab for anyone this weekend. There was someone that came in and asked them to call for a cab the Sunday before but that was all that anyone said. On 7/12/17 at 9:58 AM, a phone interview was attempted to be completed with Nursing Assistant M. The phone number provided by the facility for Nursing Assistant M was out of service. On 7/12/17 at 10:00 AM, a phone interview was attempted to be completed with Nursing Assistant L. Nursing Assistant L did not answer the phone and a message was unable to be left due Voicemail full. On 7/12/17 at 10:45 AM, an interview was completed with Resident #703. When queried, Resident #703 stated, I left and went to my buddy's house. I took a cab. When asked how they got a cab, Resident #703 stated, I called from Business X. I wanted a pass to go to my friends but they (facility) wouldn't give me one so I just left. With further inquiry related to the cab and the cost, Resident #703 stated, It cost 40.00 dollars. It's my money, I got it from here. Resident #703 further stated, I pushed the screen out of the window a couple days before I left when I was mad. I just opened the window and went out. When asked what time they left the building through the window in their room, Resident #703 stated, It was around 9:00 PM or 9:30 PM, it was still light outside but getting a little dark. I knew no one would know because no one checks. Then I walked down and called the cab. I had to wait 45 minutes for the cab to come. On 7/12/17 at 2:15 PM, an interview and record review was completed with Unit Manager C. When queried regarding what interventions were updated on Resident #703's care plan entitled Risk for elopement related to leaving facility without signing out and or telling staff. Expressed the desire to go to friend's home (Date Initiated: 05/22/2017, Revision on: 07/09/2017), Unit Manager C reviewed the care plan and stated, No, no updated interventions for elopement. When queried regarding the intervention Resident is a one on one for supervision related to smoking in facility (Date Initiated: 07/03/2017) listed on the care plan entitled, At risk for injury self, and other Residents related to non-compliance with rules- no smoking in the building. Resident is a smoker (Date Initiated: 03/17/2017, Revision on: 07/09/2017), Unit Manager C stated, Yeah, supposed to be one on one care. When queried if the Resident had one on one care on 7/8/17 midnight shift, Unit Manager C replied, No. With further inquiry, Unit Manager C stated, No, (the Resident) wouldn't have gotten out if they had one on one care. We have staffing issues. When queried further regarding staffing on 7/8/17 midnight shift, Unit Manager C replied, There was one nurse and one nursing assistant. Another nursing assistant came to the unit at 2:00 AM. On 7/12/17 at 3:30 PM, an interview was completed with the facility Administrator. When queried regarding Resident #703's care plan interventions not being updated following the Resident's elopement from the facility, the Administrator stated, I don't know what the care plan interventions are. Resident #703's care plan was reviewed with the Administrator at this time. Following review, the Administrator stated, So what do you mean? When asked if the Resident's care plan interventions were going to be updated, the Administrator stated, Okay, I will make sure that gets done then. On 7/12/17 at 4:00 PM, the DON provided Resident #703's elopement care plan with the updated intervention, One to one supervision related to elopement. Record review on 7/12/17 at 4:10 PM of facility policy entitled Unsafe Wandering and Elopement Prevention Protocol Missing Resident Protocol (Revised September 2016) revealed, All residents who are at risk for harm because of unsafe wandering will be assessed by the interdisciplinary care planning team . 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. Review of the facility policy entitled Admission Assessment and Follow Up: Role of the Nurse (Revised 11/2013) at this time revealed, Conduct the following assessment/evaluations and document findings in the medical record/electronic health record (EHR) as applicable: . Risk of elopement/wandering review if prompted by the nursing Admission Evaluation Data form. The facility IJ Plan of removal: Element #1 Resident #703 was noted to be at the home of a friend and returned back to the building on 7/9/2017 at 1:45 PM. The police and guardian were notified of the resident's return to the facility at approximately 2:00 PM. Nursing completed a physical assessment upon return to the facility and the resident complained of left foot pain, upon assessment the left foot is noted to be slightly swollen, resident stated the pain is from walking to the gas station. The physician was notified and ordered for a stat x-ray of the left foot to rule out any injuries. The x-ray results are negative. The resident's elopement assessment has been re-done upon return to the facility and he remains at risk for elopement. Resident #703's care plan has been reviewed and remains current. Social Services completed an assessment of the resident upon return and noted BIMS score to be improved to a score of 13 at 4:26 PM on 7/9/17. The residents room has been moved to a different room and the window has been secured so it only opens 8 inches on 7/9/17 at approximately 3:30 PM. Resident will remain on 1:1 supervision related to elopement risks. Element #2 The facility has re-assessed 256 Residents for elopement risk on July 9, 2017. 28 out of 256 residents remain at risk for elopement. Those 28 residents at risk for elopement have had their care plans and Kardex remain current and include the risk factors and interventions needed to ensure the residents safety on July 9, 2017. A facility wide audit was done on July 9, 2017 to ensure that the code alert was in place on all identified residents. All resident room windows in the facility were checked and secured on 7/9/17 to ensure they only open a maximum of 8 inches. Element #3 The Unsafe Wandering & Elopement prevention protocol-Missing resident protocol policy was reviewed by the DON and Administrator and deemed appropriate. The facility has re-educated 23 out of 75 Licensed Nurses, 24 out of 87 Nurse Aides, and 30 out of 89 ancillary staff on the Unsafe Wandering & Elopement prevention protocol-Missing resident protocol on July 9th, 2017 by the Nursing management, and facility has educated 86% of total staff and all remaining staff including contingent will be educated prior to working. All resident rooms and common areas windows were checked and secured on 7/9/2017. The facility has completed elopement drills every shift on 7/9/2017 to ensure validation of education. (2:30 PM, 10:00 PM, 6:00 AM). Drills will continue for 10 days on random shifts. Element #4 The DON/designee will audit to ensure that all new admits to the facility are assessed to determine risk for elopement 2x/weekly for 4 weeks, followed by 1x weekly for 4 weeks and then monthly until substantial compliance is achieved, maintained & approved by the facility and began on July 9, 2017. The Maintenance Director/Designee will audit windows for weekly for 4 weeks and monthly thereafter and began on 7-9-17 Element #5 The Administrator will report to the facility QAPI Committee monthly. The Administrator is responsible for sustained compliance. Date of Compliance: 7/9/17 Deficient Practice #2 This citation pertains to MI intake # . Based on observation, interview, and record review, the facility failed to implement new interventions and follow interventions already in place for 1 (#705) of 3 sampled residents for falls from a total of nine sampled residents, resulting in repeated falls and a potential for continued falls and injury. Findings include: On 7/11/17 at 9:00 a.m., a review of the face sheet and Minimum Data Set (MDS) assessment revealed that Resident #705 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #705 was dependent for transfers and needed extensive two person assist with bed mobility. The MDS also revealed that Resident #705 was severely cognitively impaired. On 7/11/17 at 9:10 a.m., Resident #705 was observed awake, laying in bed uncovered. He was confused and unable to communicate in complete sentences. Resident #705 's bed was at mid-height and there were no fall mats on the floor or present in the room. On 7/11/17 at 9:35 a.m., Resident #705 was observed resting with his eyes closed in bed. The bed was still at a mid-height level and there were no fall mats on the floor. On 7/11/17 at 10:40 a.m., a review of the nurses notes revealed that Resident #705 had multiple falls in the facility in a short period of time. The notes revealed the following information on falls: 6/17/17: Observed laying on back on floor at left side of bed. The intervention was to place Resident #705's bed in a low position while not providing care. 6/25/17: Observed on floor. No new interventions provided. 7/4/17: Observed with head and half of body on floor and legs in bed. There was left eye redness with swelling and a bump on his left forehead with redness. No new interventions provided. The incident report was requested for this fall but not provided by the end of the survey. On 7/11/17 at 11:00 a.m., an observation of the facility beds were mechanically controlled and are able to be lowered position close to the floor. Resident #705's bed was not at the lowest position. Resident #705's bed was the same type of bed and was able to be in a low position. On 7/11/17 at 11:15 a.m., a review of the fall care plan dated 6/29/17 revealed the following interventions: 6/19/17-Floor mats (fall mats). 6/17/17-Low bed when not providing care. On 7/11/17 at 2:05 p.m., an interview was completed with the Director of Nursing (DON) in regards to the interventions put into place following Resident #705's falls on 6/25/17 and 7/4/17. The DON began to review the nurses notes and care plan and stated, He had a UTI (Urinary Tract Infection) and we did a medical work up. When queried in regards to the fall mats not being on the floor (or in the room) and the bed not being in a low position, the DON stated, Well, he used to be on a different unit and he just recently moved down to that unit. When queried as to who follows up on the falls and interventions the DON explained that the team meets in the mornings and discusses the falls and determines proper interventions and then the unit manager completes the investigation. On 7/11/17 at 2:50 p.m., an interview was completed with the Unit Manager C. Unit Manager C was queried about the interventions put into place for Resident #705 following the 7/4/17 and 6/25/17 falls. After review of the medical records, Unit Manager C stated, He was confused and had a UTI at the time. On 7/11/17 at 3:00 p.m., a record review of the facility policy titled, Falls-Clinical Protocol revised April 2016 revealed the following: Cause Identification/Response #4. Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include; c. Adaptive equipment needs. #6. The care plan and CNA (Certified Nurse Assistant) care card should be updated as interventions change. Post Fall Analysis/Treatment/Management #3. Update the plan of care with new or revised interventions. Monitoring and Follow-Up #1. The staff will monitor and document the individual's response to interventions intended 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 (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions.

This citation pertains to intake#: MI 440, MI 279 and MI 836. Based on interview and record review, the facility failed to thoroughly assess a resident immediately after a fall, monitor a resident for injury post fall, and implement new interventions after a fall for two ( #'s 701 and 705) of six residents that were sampled for falls, from a total of six sampled residents, resulting in a fall with fracture that went undiagnosed and untreated for [REDACTED]. Findings include: Resident #701 On 5/15/17 at 10:05 a.m., record review revealed that Resident #701 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #701 required extensive assist with transfers and ambulation, and had a Brief Interview Mental Status (BIMS) score of 04, indicating cognitive impairment. On 5/15/17 at 10:10 a.m., an interview was completed with Family Member A. Family Member A stated, They do not have any documentation of my dad's fall. I didn't even know of the fall until later on. My dad was so sick when he finally went to the hospital that they couldn't even do surgery to repair his hip. He ended up dying! On 5/15/17 at 1:50 p.m., a review of the, Physical Therapy Treatment Encounter Note(s) dated 4/13/17 was completed. Resident #701 was showing, vastly different weight bearing status and had less range of motion in the left leg. The note also stated that Resident #701 was in, significant pain and the therapist reported it to the physician assistant and requested an X-Ray and doppler (a test used to check circulation). According to the Progress Notes dated 4/13/17, Resident #701 was seen by the physician for difficulty bearing weight and edema (swelling) in the left extremity. An X-Ray of the left hip and knee was ordered and a doppler. On 5/15/17 at 1:55 p.m., a review of the X-Ray completed on 4/13/17 revealed that Resident #701 had a acute/subacute (new) mildly displaced periprosthetic (area around the previous hip replacement rod) proximal femur (hip) fracture. According to the progress notes, the following actions occurred on 4/14/17: 15:22 X-Ray results faxed to the physician (no response). 19:30 Physician aware of results of X-Ray, orders for Resident #701 to be transferred to the hospital. 20:30 Resident #701 was sent to the hospital, never returning back to the facility. On 5/16/17 at 8:50 a.m., the Director of Nursing (DON) was interviewed and stated, she had started an internal investigation because she thought that Resident #701 had an injury of unknown origin because of the fracture. During the investigation, the DON had found out that Resident #701 had fallen on 4/12/17, and the nurse in charge of his care did not document the fall, fill out an incident report or report the incident to the oncoming nurse, family or responsible party, the supervisor or the physician. The DON also stated that she had terminated the nurse because there were previous incidents where the nurse failed to follow up and notify the proper personal of resident changes. When queried as to why the nurse did not document or report the incident, the DON stated, she said she just forgot. The DON was also queried as to what interventions the nurse put into place following Resident #701's fall, the DON stated, I don't think she did any new interventions or anything. On 5/16/17 at 9:00 a.m., a record review of the statement written by the nurse that was terminated was completed. According to the statement, Resident #701 was found on the floor between 11:15-11:30 p.m. on 4/12/17. He was assisted back up into bed. There was no vital signs, pain assessment, neuro checks, interventions, or notification of the occurrence reported to the on coming nurse, responsible party, or physician. There was no documentation of the incident in the medical record. On 5/16/17 at 9:40 a.m., an interview was completed with Licensed Practical Nurse (LPN) D. LPN D was the on coming nurse in charge to care for Resident #701 on the day shift following the fall. LPN D stated, I was never told about the fall. On 5/16/17 at 9:50 a.m., an interview with Physical Therapist Assistant (PTA) B was completed. PTA B stated, I needed help to get him (Resident #701) up, which was unusual for him, he was totally in pain. I did light exercises with him, and requested an X-Ray because I knew something was definitely wrong! On 5/16/17 at 10:00 a.m., a review of the facility policy titled, Falls-Clinical Protocol revised April 2016 revealed the following: Cause Identification/Response-#1. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. Provide emergency care and assessments as indicated. The Physician and Responsible party should be notified as soon as the resident is stabilized. Document findings in the resident's medical record . An accident/incident report will be completed and forwarded to the DON as part of the facility's internal Quality Assessment and Assurance Program. This citation pertains to MI 279 Resident #705 On 5/15/17 at 11:26 a.m., progress notes dated 5/13/17 for Resident #705 was reviewed. It was revealed that resident was in room and showed no sign of life. Nurse was called to the room by Certified Nurse Assistant (CNA); resident was pronounced at 9:00 a.m. by Unit Registered Nurse (RN). Doctor and son of resident was notified. Funeral Home was contacted and body was released on 5/13/2017. Review of the Clinical Record on 5/15/17 at 12:15 p.m., revealed that Resident #705 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #705 was severely impaired for cognition, and had disorganized thinking, long term and short term memory deficits. Resident #705 required extensive assistance with one person assist for all Activities of Daily Living (ADL) help. On 5/15/17 at 1:22 p.m., a review of the Fall Risk Evaluation dated 4/27/17, revealed resident had 3 or more falls within 90 days. On 5/15/17 at 1:36, a review of Care Plan dated 9/6/16, revealed a history of falls and noted that resident would often walk through halls, holding on to others for support while walking. On 5/15/2017 at 3:25 p.m., review of Falls/Incident Report, revealed the resident had 16 falls since January 2017. 01/6/17: Resident observed sitting in chair in the day room and attempted to get up and chair leaned to the left. Resident fell over the left side of chair onto the floor. Family and doctor notified. Intervention: Call light within reach, toilet often. 02/21/17: Resident observed on the floor in the hallway, lying on her back. No injury noted. Family Option Service and Doctor notified. Intervention: Rest periods encouraged. 02/25/17: Resident observed laying on her right side with right shoulder bent back and under body. Another resident was laying on top of her. Resident was sent to hospital. Intervention: Hospital for evaluation 02/27/17: Resident observed lying on back next to bed. No injuries noted. Family Option Service and Doctor notified. Intervention: PT evaluation. 03/01/17: Resident observed on floor beside her bed in supine position. No apparent injury. Doctor and family notified. Intervention: Concave Mattress 03/02/17: Resident observed sitting on buttock in front of the couch. Family Option Service and doctor called. No injury noted. Intervention: Alternative Seating 03/07/17: Resident observed laying on right side in hallway by dayroom. It was noted that resident tripped over foot rest of another wheelchair. Laceration to the head. Resident sent to the hospital for evaluation. Family Option Services and doctor called. Intervention: Hospital evaluation 03/14/17: Resident observed sitting on buttock in the common area near the linen room door. No apparent injury. Family and doctor called. Intervention: Screened by Physical Therapy. 03/16/17: Resident observed sitting on buttock on floor in hallway outside of room 313. Family Option Service and doctor called. No apparent injuries. 03/19/17: Resident lost balance and fell backward on the floor. No apparent injury. Family and doctor contacted. Intervention: PT evaluation 03/27/17: Resident observed sitting on floor in hallway. Skin tear to left arm noted. Family Option Service and doctor contacted. treated for [REDACTED]. 04/09/17: Resident was observed sitting on buttock in hallway. No apparent injury. Family Option Service and doctor contacted. 04/19/17: Resident noted with small bruise/red area to right eye. Right eye also noted to have green drainage. Resident rubbing/itching eye. Family Option Service and doctor notified. Resident seen by physician. 04/24/17: Resident observed lying on her back in the middle of the floor in room 311. Small bump to back of head. Family Option and doctor called. Intervention: Neuro check were completed and were negative. Intervention: Brought to chair in common area. 04/24/17: Resident was observed on the floor, lying on her back. When resident was rolled over, blood were observed on floor. Family and doctor notified. Intervention: Resident was brought to the nurses station. Doctor and hospice called. 04/27/17: Resident was observed sitting on the floor on the side of her bed holding herself up with her right hand and holding her face with her left hand. Laceration above right eye, bruising and swelling of right eye, mouth and nose. Family Option Services notified. Resident was assessed by nurse and Doctor notified to send resident out to hospital for further evaluation. On 5/16/17 at 11:30 a.m., a call was made to the Family Option Service. A call was received from Family Option Service on 5/17/17 at 9:30 a.m. When queried about resident, E of Family Option Service stated, Calls were received on 3/30/17, 3/17/17, 2/22/17, 2/27/17 and 4/27/17 regarding resident falling. The fall on 2/27/17 was regarding a fall with a possible dislocated shoulder. No other information noted. On 5/16/17 at 1:22 p.m., during an interview with Director of Nursing (DON) and Administrator, when queried about the intervention for Resident #705, DON stated, I can't say the interventions didn't work. We try different things. Review of the facility's policy titled Falls - Clinical Protocol revised April 2016 documented the following: .IPOC/Comprehensive Care Plan: Interventions should be developed and implemented per the assessed needs. In addition, interventions for direct care givers should be placed on the CNA care card or similar format. The care plan and CNA care card should be updated as interventions change. .Monitoring and Follow-Up: The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If the individual continues to fall, the interdisciplinary team should re-evaluated 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.

This citation refers to intake #MI 974. Based on interview and record review, the facility failed to prevent an elopement from the facility for one (#701) of four residents reviewed for the risk of elopement, out of a total of four sampled residents. This resulted in an immediate jeopardy (IJ) when Resident #701 exited the building on 9/1/16 without staff knowledge. The facility was not aware of the elopement until a visitor entering the building alerted the facility of Resident #701's location outside the facility. This deficient practice had the potential to result in serious harm and/or injury and required immediate corrective actions. The Administrator was notified of the Immediate Jeopardy on 9/15/16 at 3:05 pm. A plan to remove the immediacy was requested. Immediate Jeopardy was identified on 9/15/16 at 2:00 pm. The immediacy was removed on 9/15/16 at 5:00 pm, based on the facility's implementation of the plan of removal as verified on site by the surveyor. Although the immediate jeopardy was removed, the facility deficient practice was not corrected, and remained isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: On 9/15/16 at 10:00 am, review of the clinical record for Resident #701 revealed the following. Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #701 was placed in the memory care unit of the facility. According to the minimum data set assessment (MDS), dated [DATE], Resident #701 had severely impaired cognition, wandering behavior and required limited assistance for ambulation. The Risk of Elopement/Wandering Review, dated 7/13/2016, reflected Resident #701 was at risk for elopement due to cognitive deficits, psychotic disorder, independent ambulation and wandering aimlessly. The care plan, dated 6/2016, reflected Resident #701 was at risk for elopement related to exit seeking with no rational purpose and history of elopement. The interventions included observe for effectiveness of code alert and take picture of resident upon admission and alert front desk of elopement risk. Further review of the care plan for risk of elopement revealed no evidence of interventions to monitor Resident #701's wandering in the facility and to redirect Resident #701 from facility exits. An incident report, dated 9/1/16, reflected that Resident #701 had exited the building and was found in the parking lot of the facility at 8:35 pm. Resident #701 was last seen by his assigned Certified Nurse Assistant (CNA) at 8:00 pm. During an interview on 9/15/16 at 11:00 am, the Director of Nursing (DON) reported Resident #701 had been observed by his assigned Certified Nursing Assistant (CNA) at 8:00 pm, seated in the common area adjacent to the nurses station, with four other Residents of the memory care unit. This area faces a facility exit door. The DON stated Resident #701 had eloped from the facility around 8:20 pm. At that time, the Nursing Supervisor of the memory care unit had left the nurses station and the three Certified Nursing Assistants (CNA) were attending to other residents who were in their rooms. Resident #701 along with the other four residents seated in the common area adjacent to the nurses station were left without direct supervision from staff until the alarm sounded at approximately 8:30 pm. The DON further stated that the video tape recording of the incident showed Resident #701 proceeded toward the exit door as soon as the Nursing Supervisor left the nurses station. The three CNAs were not visible in the area in direct supervision of the residents until the alarm sounded. The DON stated the video was no longer available for review. On 9/15/16 at 1:00 pm, a written report of the incident, provided by the DON reflected, .The staff member observed another resident at the door and moved that resident away from the door and the staff member assumed that the resident she removed was the resident that set the alarm off. The staff member guarded the door until the nurse came and secured the alarm on the door. After notification to the receptionist that the resident was outside, the evening supervisor was immediately notified and facilitated the elopement process. ( ) The facility aubmitted the following to remove the immediacy on 9/15/16. The facility identified that a resident eloped out of the facility on 9/1/16. The following was implemented immediately as listed below: · The Resident was brought back into the building. · Nursing assessment was conducted. · The family and physician were notified. Resident was returned safely to his room and was assessed to have no injury. · All residents in the facility were reassessed for elopement risk. · Care plans were updated for those identified at risk. · Elopement and wandering identification books updated as needed. · Facility reeducated all staff on elopement and wandering policy 9/1/16 and no employee was allowed to work without receiving education. · Education was immediately initiated for all staff on 9/1/16 to ensure that when staff respond to a sounding door alarm to check the parameter, and that when staff observe a resident outside that they stay with the resident to ensure safety of the resident and attempt to bring resident back into facility. · Residents who are identified to be at risk at for elopement, kardex was reviwed and revised to reflect that they are at risk. · Elopement drills were conducted on all three shifts as follows: o 9/2/16 1:37pm o 9/2/16 10:27pm o 9/6/16 3:52am. · Elopement drills will be conducted by maintenance once weekly times 4 weeks and at minimum monthly on all shifts. · The facility initiated a dedicated activities program for the memory care unit (300 Hall) as listed below: o 9:00am- 9:45 am Lodgers Breakfast o 9:45am - 10:15 am Exercise and Music in common area o 10:15am- 10:30am Pass out water to group o 10:30 am- 11:00 am Simple trivia in common area o 11:00 am - 11:45am - Folding towels ,sorting socks, hanging up clothes on hangers from laundry baskets in dayroom o 11:45- 12:30 pm Sensory and Reminiscing - olfactory scents, touch therapy , visionary items example - apple pie scents, apples, baking, lilac scents, lilac flowers discuss each item presented with memories. o 12:30 -1:30 pm Lodgers Lunch o 1:30-2:00 pm -Arts and crafts, coloring, painting and sanding wood in dayroom

This citation refers to intake #MI 537 Based on interview and record review, the facility failed to implement precautions to keep one sampled resident (#724) of 12 sampled residents for abuse of a total of 30 sampled residents, free from physical and mental abuse, resulting in an actual avoidable physical trauma causing pain and continued mental and emotional anxiety. Findings include: On 8/24/16 at 2:20 p.m., record review of the face sheet for Resident #724 revealed that he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is cognitively intact. On 8/25/16 at 8:20 a.m., Resident #724 was observed to be dressed, well groomed, and in his bed watching TV. Resident #724 explained an incident that occurred a few weeks ago on 8/11/16. Resident #724 stated, Just a few days before the attack, I was walking in the hallway and he (Resident #725) was in front of me. I asked him to please move, and he said, 'You'll wait until I'm done nigger. He muttered some other things but I can't remember the exact words. Then, that following Saturday I came out of my room, I suddenly felt someone jump behind me, grab the back of my shirt and tear it, then he started punching me. My ribs are still sore all down my left side. I was a block layer for [AGE] years and I can take a lot of pain, but these (pointing to his ribs on his left side) are very painful. It hurts to even cough. I take pain medication to help with the pain. Resident #724 also stated, The thing is, [AGE] years ago I was attacked and almost murdered by a friend of mine that was on drugs. Now I am having flashbacks and nightmares all over again from this last attack. The whole situation brought back bad memories for me. I have [MEDICAL CONDITION], so it all came back to me again. The nurse that broke us up kept saying, 'I knew this was going to happen!'. On 8/25/16 at 11:15 p.m., record review of the Progress Notes for Resident #724 reveals the following: 8/11/16 14:15 Nurse Z wrote, observed Resident (#724 and #725) punching each other then Resident (#725) came out of his wheelchair and on top of Resident (#724) and continued to punch him. Writer pulled Resident (#725) off of Resident (#724). 8/11/16 13:10 Social Worker X wrote, Resident #724 agreeable to psychosocial therapy. 8/13/16 11:06, the Nurse Practitioner completed a general exam and ordered an X-Ray of the left rib to rule out fracture and ordered Biofreeze for pain. 8/17/16 15:38 Social Worker Y documented, Visited with resident today after his LOA (leave of absence). He was defensive and stated his wheelchair had just rolled away and he fell . Social worker asked if he had been drinking and he said he did have 2 beers while on his LOA because he had a bad day. He talked about the incident that happened many years ago .and the recent attack brought back memories and he has difficulty sleeping. On 8/25/16 at 10:30 a.m., Social Worker Y was queried about the Resident # 724's nightmares and [MEDICAL CONDITION] flash backs triggered by the physical altercation with Resident #725. Social Worker Y stated, I check on him every day to make sure he is doing okay. He is also seen by psych. On 8/25/16 at 11:30 a.m., record review of the Care Plan dated6/16/16 revealed the problem: The resident (#724) receives antipsychotic medication r/t (related to) [MEDICAL CONDITION] d/o, post traumatic [DIAGNOSES REDACTED], mood disorder, [MEDICAL CONDITION]. Goal, No increase in symptoms of emotional discomfort or strain. Interventions, Observe for environmental stressors such as excessive heat, noise, overcrowding, intervene as indicated. On 8/24/16 at 11:40 p.m., a record review of the investigation involving the altercation involving Resident #724 and 725 was completed. The incident report completed on 8/11/16 revealed no injuries. The police were called and a misdemeanor ticket for assault and battery was issued to Resident #725. On 8/25/16 at noon, record review of the face sheet revealed that Resident #725 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. According to the MDS assessment dated [DATE], Resident #725 had physical behavorial symptoms directed toward others 1-3 days in the last week and had daily verbal behavioral symptoms directed towards others. The MDS also revealed that he was short-tempered, easily annoyed and rejected care. On 8/25/16 at 12:15 p.m., a record review of the Progress Notes for Resident #725 revealed the following: 8/11/16 15:27 Nurse LL documented, Resident signed AMA (against medical advice). 8/11/16 15:13 SW X documented, Aggressive behavior, altercation with another resident, combative, verbally abusive, refuse care and tx(treatment). Easily agitated, uses vulgar language, combative, refuses care. Separated from other resident. Petition for hospitalization . Aggressive and refusing to go to hospital. Uncooperative with EMT (Emergency Medical Technician). Police Intervention. 8/9/16 22:50, Nurses Notes state, Resident (#725) verbally abusive with staff .yelling I'll get you [***] es. 8/9/16 15:57 Assistant Director of Nursing documented, Team met to discuss altercation on 7/27/16, yelling obscenities at another resident 'told that mother [***] to shut up' .7/27/16 15:26 Social Worker X documented, Resident #725 is a danger to himself and others. He refuses meds and treatments. He yells, swears, and threatens staff and residents. Makes inappropriate sexual advanced toward female staff. He is often combative with staff, swinging and punched staff. He denies his behavior, very easily agitated and aggressive. Petition for hospitalization complete. 7/29/16 13:55 Nurse LL documented, writer was in room educated resident regarding meds and vitals resident stated to writer come closer, writer stated I'm fine I can hear you from this distance. Resident rolled over in bed and sucker punched writer in the jaw/mouth. Writer left room notified social work and DON. 7/29/16 08:29 Social Worker X documented in the medical record, Writer informed 7/28/16 afternoon that Resident #725 was physically aggressive with another resident whom was the room mate of Resident #725 and the room mate had requested a room change and was transferred out. Social Worker X and Y were queried as to who the resident was that asked for the room change, neither could remember which resident that was. 7/28/16 04:32 Nurses' Notes revealed, Resident in room stated he was scared and pointed to Resident #725 (the room mate). This resident also stated that bed 2 was going to hit him if he didn't shut up. 6/30/16 admission progress note states, Uncooperative per EMT and very combative on transport to facility. On 8/25/16 at 5:30 p.m., Nurse LL was interviewed regarding the physical altercation she had with Resident #725. Nurse LL stated, I was talking to him about his medications and he asked me to come closer, when I did, he just hit me! I was startled at first! After that they sent him to the hospital, but he came back! I was scared because if he would do that to me, then what would he do to another resident? On 8/25/16 at 11:00 a.m., record review of the hospital records revealed the patient, was aggressive, hostile and uncooperative, he (Resident #725) left AMA and then later returned and primary doctor did not want to admit him back . Hospital notes also stated, He (Resident #725) was going to need placement at discharge, did not answer any questions and turned his head and put his hand in the face of the doctor indicating for the doctor to get out. On 8/25/16 at 10:30 a.m., the social worker Y was queried about the placement of Resident #725. Social Worker Y stated, We didn't have anywhere for him to go. Psych was trying to work with him. He had a mom, she wasn't doing much for him. We sent out referrals. On 8/25/16 at 10:50 a.m., an interview regarding appropriate placement for Resident #725 was done with Social Worker X. Social Worker X stated, I tried getting the Disability Network to help out with subsidized housing, but he (Resident #725) turned them down. We petitioned him out and got him out before for hitting a nurse but the hospital kept him and sent him back in two hours. This last time, he refused to be petitioned out but finally agreed to go AMA. On 8/25/16 at 10:55 a.m., the Admissions Coordinator AA was queried about the admissions screening process of residents. Staff Member AA stated, We get a referral from the hospital, psych reports, [DIAGNOSES REDACTED]. If there are concerns we send our hospital liaison to the hospital to meet the patient. I don't think we did that with this resident (#725). We didn't think there was any concern, he had a wound and just needed antibiotics. He lived alone. He was young, he was just verbally aggressive. On 8/25/16 at 3:00 p.m., the Administrator was interviewed regarding the physical altercations that Resident #725 had with Nurse LL on 7/29/16 and then with Resident # 724 on 8/11/16. The Administrator stated, We kept a close eye on him after the incident. He mostly kept in his room that is why we didn't feel like he was a threat to anyone. When it happened we finally got a hold of his mom. His mom said he was physically abusive to his caregiver at home. I also talked to admissions about screening residents before they come in, especially with any psych history. I wasn't here at the time they admitted him (#725). On 8/25/16 at 3:10 p.m. the DON was queried regarding the altercations with Resident #725 and #724 and Nurse LL. The DON stated, We updated his care plans and removed the nurse from his care. He just refused to take any medications or be seen by psych. 8/25/16 at 4:30 p.m. the policy titled Abuse Prevention Program Revised October 2012 was reviewed. It states, Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of [REDACTED]. ( )

This citation pertains to MI 721 Based on interview and record review, the facility failed to prevent actual physical abuse and involuntary seclusion for one (#901) of three residents reviewed for abuse, out of a total of a total sample of three, resulting mental anguish, anger, and the potential for further abuse. Findings include: On 6/2/16 at 10:00 a.m., Resident #901's closed record was reviewed. Resident #901's face sheet indicated an admission into the facility on [DATE]. The clinical record indicated that she had the following Diagnoses: [REDACTED]. Resident #901's admission Minimum Data Set (MDS) assessment, dated 4/6/16 indicated that her cognition was severely impaired and that she required extensive assistance with all activities of daily living (ADLs). On 6/2/16 at 10:30 a.m., review of the facility's investigation summary report, undated, revealed the following documentation: This facility is reporting an allegation of abuse by staff members: CNA A(Certified Nursing Assistant A), and RN B (Registered Nurse B). These two employees were immediately suspended as well as two employees that witnessed the incident, CNA C and LPN (Licensed Practical Nurse D) . Resident #901 was admitted to the facility on [DATE] with a primary dx (diagnosis) of unspecified [MEDICAL CONDITION]/Mood Disorder. Resident #901 requires one person extensive assistance with ambulation. She is fed by staff per resident's request due to being blind. Resident is independent with bed mobility. She requires one minimal assistance with toileting and one stand by assistance with transfers . Other Dx (diagnoses) include Diabetes, [MEDICAL CONDITIONS] ([MEDICAL CONDITIONS]), Retina Dystrophy with [MEDICAL CONDITIONS], and CKD ([MEDICAL CONDITION]) . Resident #901 has been deemed incapable of making decisions regarding medical and financial legal matters. Her son (Son #1) is her Responsible Party . On 5/26/16 at approximately 9:00 a.m., Resident (Supplemental Sampled Resident #128) reported to Administrator an allegation of abuse from Nurse B to Resident #901. Administrator interviewed Resident #128, who reported she witnessed Nurse B 'manhandling' Resident #901 twice. The first time Nurse B grabbed Resident #901's shoulders from behind and slammed her into the wheelchair. He (Nurse B) then moved her wheelchair closer to the wall so she was facing the wall. Resident #901 stood up unassisted and Nurse B grabbed her shoulders sitter her in the wheelchair . Staff on duty 5/25/16 during the 3-11 shift were interviewed. During the interview process, two staff members were identified providing inappropriate/rough physical touching. These staff members were: CNA A and Nurse B. Other staff members: CNA C, and LPN D. Was identified in witnessing the inappropriate/rough physical touching . Neither of them advocated for Resident #901 or took action to stop and prevent further inappropriate actions by staff . On 5/27/16 Detective (E) arrived at the facility to begin his investigation. He interviewed Resident #901 and her mother. Additionally, he interviewed Resident #128. The Detective reviewed the process of beginning criminal investigation with pending charges involving CNA A, and Nurse B with both residents and Administrator . Conclusion: After interviewing Resident #901, the staff and residents on the unit we did substantiate this allegation. On 6/2/16 at 10:40 a.m., the following written statements were reviewed: Resident #128's written statement, dated 5/26/16 at 9:00 a.m., revealed the following documentation: On 5/25/16 around 10 p.m., I witnessed the nurse (Nurse B) 'man handle' Resident #901 twice. The first incident he, without speaking to her, grabbed her shoulders from behind and slammed her into the wall. She was forced to face. Resident #901 use the railings and got up again. This is when Nurse B went back to her, grabbed her by the left arm and again flung her into the chair. Again, he moved w/c (wheelchair) closer to the wall. Resident #901 got up a third time, this time Nurse B yelled at her to sit down several times. CNA A's written statement, dated 5/26/16 at 1:00 p.m., revealed the following documentation: Resident (#901) kept attempting to stand and ambulate. I brought resident in wheelchair and faced her against the wall in hallway. I told Resident #901 to sit down and put my hands on her shoulders. I did not push on her shoulders. CNA C's written statement, dated 5/26/16 at 1:15 p.m., revealed the following documentation: On 5/25/16, resident was very active and needed to be redirected by all of staff. I have no recollection of interceding between a staff member and the resident. I witnessed the nurse (Nurse B) tell Resident #901 to sit down, he put his hands on her (#901) and moved her forcefully into her wheelchair. Nurse B's written statement, dated 5/26/16 at 2:40 p.m., revealed the following documentation: Resident (#901) has been difficult and combative and constantly gets out of her wheelchair. She constantly needs to be redirected to sit down, both physically and verbally .When she (#901) gets up and walks I physically bring her back to her chair and sit her down .I did not instruct the CNAs to place resident (#901) facing the wall. Staff has placed resident facing the wall in the past as a way to redirect resident. Supervisor F's written statement, dated 5/26/16 at 3:15 p.m., revealed the following documentation: On 5/25/16 during evening shift I observed resident (#901) to be restless and frequently attempting to stand .I observed Nurse B walking toward Resident #901 when she was standing unassisted. He had an angry/aggressive look but when he saw me he calmed down . Employee G's written statement, dated 5/26/16 at 5:30 p.m., revealed the following documentation: I did notice Resident #901 was placed in a wheelchair facing the wall. I asked nurse B why is she (#901) facing that way. Nurse B stated it was so that she doesn't fall. Nurse D's written statement, dated 5/26/16 at 6:30 p.m., revealed the following documentation: I witnessed the nurse (B) approach resident (#901) and tell her to sit down, then he put his hands on the resident's shoulders and forced her down in the wheelchair. I also saw the CNA place resident in the wheelchair facing the wall. Resident attempted to stand and hit her head on the wall. Resident stated you pushed me. CNA stated no I didn't, you did that to yourself. Upon driving home I reflected upon evening events and considered that the situation may have been potential abuse. On 6/2/16 at 10:45 a.m., the Administrator was queried regarding the location of Resident #901. The Administrator reported that Resident #901 was not available for interview as she was admitted into the hospital for complications of her diabetes. On 6/2/16 at 1:30 p.m., the Administrator stated, The Resident (#901) came to me with the concern on 5/26 at 9 a.m. The investigation was started immediately. We called the police and staff were suspended and then terminated. We will report this to the State Board. The Investigator has not provided us with his findings yet. The Administrator reported that Nurse B and CNA A were terminated for the substantiated abuse towards Resident #901. Nurse D and CNA C were terminated also because they had witnessed the abuse and did not report it. On 6/3/16 at 10:45 a.m., Resident #901 was called at the hospital for an interview, but there was no answer. On 6/3/16 at 11:50 a.m., Resident #901's son (Son #1) stated during an interview (via phone) regarding the abusive incident, They (the facility) called me regarding the incident. She (#901) has some sort of brain damage. They kept shoving her down in her chair. I am POA (Power of Attorney) for my mom. The detectives went to talk to her (#901). They (the facility) have a video tape of the incident. You really can't interview her (#901) right now. She has some confusion and she is unable to focus long enough. There was no further information provided. ( )

This citation has two deficient practices Deficient Practice #1 Based on observation, interview, and record review, the facility failed to follow safety interventions to prevent falls consistent with the plan of care for two residents (#706 and #717) of nine residents reviewed for falls out of a total of 30 sampled residents, resulting in resident #717 falling from bed and sustaining injuries which included swelling and bruising of the face, a laceration of the left eyebrow requiring sutures, a hematoma and a skin tear requiring transfer to the hospital for emergency treatment; and resident #706 having multiple falls with skin tears. Findings Include: On 10/5/15 at 10:20 a.m., during the initial tour of the facility, Resident #717 was observed sitting in a wheelchair in the common area on Unit 300. Resident #717's left eye was swollen and the left side of Resident #717's face was yellow with red and purple bruises. Resident #717 also had sutures in the left eyebrow. At that time, when queried what happened, Unit Manager G stated, Resident #717 rolled out of bed. On 10/5/15, a review of the facility's Accident and Incident (A/I) form dated 10/2/15 at 4:30 a.m., documented the following: 14. Results of Investigation: Description - Certified Nurse Assistant (CNA) alerted nurse that resident was observed on the floor. Nurse went to assess and found resident on the floor with a large hematoma on the left side of the forehead with a laceration, and also a skin tear to the right great toe. Resident was showing signs and symptoms of pain. Sent to local hospital for sutures and CT (CAT) Scan (x-ray pictures of the head) . Further review of the A/I form dated 10/2/15 listed the following: - Care Planned Interventions Prior to Fall/Accident: Positioning pillows while in bed, concave mattress, non-skid strips to floor at bedside, low bed, non-skid socks, when changing resident at night, allow her to stay in common area until tired again if not asleep. - Were Planned Interventions in place? No. - If no list reasons: No positioning pillows in place prior to fall. - When was resident last seen? 4:00 a.m. - Last Care Provided/By Who: CNA - H A review of the local hospital discharge summary dated 10/2/15, documented the following: Patient Discharge Instructions: Your exam shows you have a contusion (deep bruise) around the face or scalp. Injures around the face and head cause a lot of swelling, especially around the eyes . X-rays were taken . You have been treated for [REDACTED]. This will usually require stitches if it is deep . If sutures come apart or fall out or if steri-strips fall out before 5 days, if the wound edges re-open, or fever over 100.0 (oral) . On 10/6/15 at 3:15 p.m., a review of the nurses' progress notes dated from 10/2/15 upon Resident #717's return to the facility at 11:15 a.m., through 10/5/15 at 01:13 (1:13 a.m.) documented care, treatment, and interventions in place (i.e., vital signs, neuro checks, dressing to great toe, bed in lowest position, and fall mat in place. However, the nurses' progress notes did not indicate if positioning pillows were in place while the resident was in bed per the care plan. On 10/8/15 at 1:50 p.m., during an interview, when queried why the positioning pillows were not in place according to the plan of care prior to Resident #717's fall, the Director of Nursing (DON) stated, CNAs and Nurses are responsible for following the care plan. On 10/8/15 at 2:56 p.m., a telephone call was placed to midnight shift CNA H, (who was assigned to provide care for Resident #717 on the morning of the incident), and a message was left on the voicemail concerning Resident #717's fall on 10/2/15. CNA H still had not returned the call at the time of exit. A copy of the CNA care guide was requested, but not provided by the end of the survey. On 10/8/15 at 2:58 p.m., a telephone call was placed to midnight shift Nurse I who stated, When I went into the room to assess the resident, there were no pillows. I checked the chair and in the closet as well. I also asked the supervisor, and she said she didn't know, she would have to check to see if it (pillows) was discontinued. Further review of the clinical record revealed Resident #717 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed an annual Minimum Data Set ((MDS) dated [DATE] that revealed Resident #717 was severely impaired for cognition, and had disorganized thinking, dementia, long term and short term memory deficits and dementia with delusions and organic affective syndrome. A review of other Accident/Incident reports for Resident #717 included the following falls: 1/28/14, 6/3/15, and 8/10/15. A review of the facility's Safety: At Risk for Falls care plan (onset) date 11/28/11, and interventions documented the following: .History of frequent falls, [DIAGNOSES REDACTED]. Approaches/Interventions: 11/28/11 - Non-skid socks/shoes when out of bed: By CNA 12/26/11 - Low bed; Limited time alone in room: By CNA 08/23/13 - Assist of one with transfers: By CNA 01/28/14 - When changing resident at night allow her to stay up in common area until tired again if not asleep: By CNA 06/03/15 - Non-skid strips to floor at bedside: By CNA and Nurse 08/10/15 - Concave Mattress: By CNA and Nurse 08/11/15 - Tilt wheelchair for resident safety: By CNA and Nurse 09/02/15 - Therapy Evaluation 09/21/15 - Positioning pillows while in bed for resident safety: By CNA and Nurse 10/02/15 - Bed to be placed against wall and mattress to be placed on floor for resident safety: By CNA and Nurse. The facility's policy titled Falls - Clinical Protocol revised February 2013 documented the following: .IPOC/Comprehensive Care Plan: .4. Interventions should be developed and implemented per the assessed needs. 5. In addition, interventions for direct care givers should be placed on the CNA care card or similar format. 6. The care plan and CNA care card should be updated as interventions change. ( ) Resident #706 On 10/06/2015 at 8:09 a.m., after leaving resident #706's room (no communication board was observed), resident #706 was observed sleeping in a wheelchair in front of the nurse medication cart for the 800 unit of the facility. Nurse L was at this medication cart at the time of the observation of resident asleep in her wheelchair. Nurse L was queried about the resident regarding what she knew about the resident. Nurse L stated that the resident speaks 'Greek.' When queried then how do you communicate with resident #706 to see how she is doing or if or whether she needed anything such as pain medications, nurse L could not offer a response, walked into the room of resident #706, and stated, there is no communication board in her room either, I don't know how we would communicate. On 10/06/2015 at 9:00 a.m., during a review of resident #706's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of resident #706's Quarterly Minimum Data Set (MDS), dated [DATE] scored resident needing a two person assist with transfer from bed to chair, wheelchair and standing position and required a two person assist with bathing and the MDS also scored resident #706's mental status as severely impaired, review of the most current quarterly MDS dated [DATE], revealed that resident #706 had two falls without injury and one fall with an injury, that resident #706 fell since admission and was a fall risk. On 10/07/2015 at 11:00 a.m., during an interview and a review of the facility's 'Incident and Accident' (I&A's) reports, nursing notes and care plans on resident #706 with the Director of Nursing (DON) revealed the following: There were a total of eight incidents which included five falls since 11/11/14 to 7/28/15;three of those falls were from 11/11/14 to 12/15/14 and two of those falls were from 1/13/15 to 7/28/15. The I&A's and nursing notes (nn) revealed the following information: 11/11/14 at 2:15 p.m. I&A revealed, observed skin with 1 centimeter by (x) 1.5 centimeter (cm) shearing to right lateral lower leg with active bleeding. This incident was unwitnessed, resident was in the bathroom alone. The I&A was unclear whether resident #706 was being toileted or how she got into the bathroom. Nursing notes reviewed dated 11/11/14 at 2;49 p.m. (Did not state resident was being toileted.) 11/27/14 at 10:45 a.m. I&A revealed resident was being showered and lowered to floor secondary to knees weakening. Nursing Note 11/27/14 at 11:03, identified the Cena was alone providing care. The Care Plan titled, Safety: Risk for falls related to altered safety awareness, decreased mobility and decreased hearing dated 2/14/13 revealed that resident #706 was to be assisted with two person assist with transfers dated, 3/1/14 and was not revised thereafter. Additionally, the MDS, dated [DATE], revealed resident #706 was a two person assist. On 1/13/15 at 6:00 a.m., per I&A, secondary to transferring to a wheelchair via one Certified Nursing Assistant (CNA) It was observed that resident #706 obtained a skin tear after the CNA got resident in wheelchair. Nursing Note dated, 1/13/15 at 6:00 a.m., revealed, Unobserved skin tear to right pinky after transfer to wheelchair possibly resident grabbed w/c. Nursing Notes 1/13/15 at 7:17 a.m., CENA reported to writer about the skin tear. 3/10/15 at 10:00 a.m., the I&A revealed - Cena called to writer, resident on the bathroom floor in room sitting straddled with back against toilet, w/c (wheelchair) in front of her, resident stated, pee-pee The I&A did not include whether witnessed or unwitnessed. 6/11/15 at 11:20 p.m., the I&A revealed, resident heard yelling, staff went into room and noted resident sitting on the floor at bedside. NN 6/11/15 at 3:07 a.m., Was unobserved. Foreign language, unable to understand resident and give an explanation. 6/17/15 at 4:25 p.m., the I&A revealed, Observed resident sitting on buttocks, knees bent, back against the wall in bathroom in room 703. Resident injury type, skin tear and abrasion to left knee. Fall was unobserved. NN 6/17/15 @ 5:41 p.m., 'no injury'. 7/28/15 @ 12:25 a.m., Observed lying on the floor on her left side next to bed near to the window. ROM (range of motion) done without difficulty resident has a skin tear to left elbow with a small abrasion to left knee. I&A documented fall was unobserved. The DON was queried as to what the policy stated concerning falls and transfering this resident, the response was, I will have to get those to you and I have to find out more on what happened then. On 10/08/2015 at 12:00 p.m., review of the CNA Assignment Record dated 9/23/2014 to 9/29/2014 revealed that resident #706 was to be toileted frequently every shift during staff rounds as requested and as needed, do not leave alone in bathroom . and Assist of two with transfers. The CNA ADL DATA Report (Activity of Daily Living) dated 9/23/14 to 9/29/14 revealed for ADL/Bed Mobility during the afternoon and midnight shift, only one person assisted with the aforementioned time frame (9/23 - 29, 2014). Under ADL/Transfer on the day shift, for the aforementioned dates, on the 25th the resident had two people assist, otherwise, was only a one person transfer indicated thereafter, the afternoon shift documented from the 24th to the 29th and had documented that entire time period as using a one person assist with transfers, the midnight shift revealed a two person assist on the 23rd, but thereafter, only one person assisted with transfers on the same dates as aforementioned. Prior to reviewing the CNA assignment record, a request was made to review all of the CNA assignment records during coinciding with the I&A report dates and timeframes for all I&A's, no other documentation was provided by the end of the survey. ( ) Deficienct Practice #2 Based on observation, interview and record review, the facility failed to ensure resident's environment was free of hazards for one (#711) sampled resident and for one (#174) supplemental sampled resident, resulting in the potential for accidental medication intake. Findings include: On 10/5/15 at 10:20 a.m. during the tour of tour of the 600 unit, a pink cream in a medication cup with no label was observed at the bedside table of resident #711. When the unit manager B was queried what was the cream and for whom was the cream, the unit manager was not able to explain. Per record review on 10/5/15 at 10:50 a.m., resident #711 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/5/15 at 11:05 a.m., during the tour of the 500 unit, two eye drop containers (artificial tears and Miro eye drops) were observed at the bedside of resident #174. Resident #174 was observed up in a wheelchair. According to the resident, the eyedrops were placed by the nurse there since the early morning. During an interview with the nurse managerB who was present at that time, statedthese should not be here. Per record review on 10/6/15 at 11:20 a.m., resident #174 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #174 was alert and verbal. ( )

THIS CITATION PERTAINS TO INTAKE # MI 155. BASED ON OBSERVATION, INTERVIEW, AND RECORDS THE FACILITY FAILED TO ENSURE THE NECESSARY TREATMENT AND SERVICES REQUIRED TO PREVENT URINARY TRACT INFECTIONS FOR 2 (#102 AND #103) OF 4 SAMPLED RESIDENTS REVIEWED FOR INCONTINENCE AND CATHETER USE FROM A TOTAL SAMPLE OF 8, WHEN STAFF FAILED TO ADMINISTER RESIDENT #102 THE ANTIBIOTICS ORDERED FOR THE treatment of [REDACTED].#102 DID NOT RECOVER, AND WHEN STAFF FAILED TO MONITOR, ASSESS, AND PROVIDE ADEQUATE INDWELLING URINARY CATHETER (FOLEY) CARE FOR RESIDENT #103, RESULTING IN hospitalization AND treatment of [REDACTED]. FINDINGS INCLUDE: RESIDENT #102 REVIEW OF THE FACE SHEET DATED 6/17/2013 REVEALED RESIDENT #102 WAS A [AGE] year OLD FEMALE. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #102 HAD NO IMPAIRED COGNITION, DID NOT WALK, WAS INCONTINENT OF STOOL, USED A URINARY CATHETER DRAINAGE SYSTEM AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL ACTIVITIES OF DAILY LIVING. REVIEW OF CARE PLANS DATED 1/15/2013 REVEALED RESIDENT #102 HAD A FOLEY CATHETER TO STRAIGHT DRAINAGE THAT EMPTIED HER BLADDER OF URINE. REVIEW OF THE MONTHLY PHYSICIAN ORDERS [REDACTED].#102 WAS TO BE CHECKED EVERY SHIFT, ANCHORED, EMPTIED OF URINE AND CHANGED MONTHLY OR SOONER IF NEEDED. REVIEW OF A URINE CULTURE DATED 3/25/2013 REVEALED RESIDENT #102 HAD NO PREDOMINANT ORGANISMS PRESENT. REVIEW OF THE TREATMENT ADMINISTRATION RECORDS BETWEEN 4/01 AND 4/08/2013 REVEALED RESIDENT #102'S URINARY CATHETER WAS TO BE CHECKED EVERY SHIFT, ANCHORED, AND DRAINED A TOTAL OF 24 TIMES, BUT STAFF DOCUMENTED THE ORDER WAS ONLY FOLLOWED ONLY 12 TIMES. REVIEW OF A NURSING ENTRY MADE 4/09/2013 AT 12:27 A.M., REVEALED STAFF IRRIGATED THE URINARY CATHETER WHEN RESIDENT #102 COMPLAINED OF ABDOMINAL PAIN AND 400 CC (CUBIC CENTIMETERS) OF CLOUDY URINE DRAINED FROM HER BLADDER. REVIEW OF THE ADMINISTRATION RECORDS FOR 4/09 AND 4/10/2013 REVEALED THE CATHETER WAS TO BE CHECKED EVERY SHIFT, ANCHORED, AND DRAINED A TOTAL OF 6 TIMES, BUT STAFF DOCUMENTED THE ORDER WAS ONLY FOLLOWED TWICE. REVIEW OF A TRANSFER RECORD DATED 4/11/2013 REVEALED RESIDENT #103 WAS SENT TO THE LOCAL AREA HOSPITAL WITH A FEVER OF 101.3 F. REVIEW OF HOSPITAL RECORDS DATED 4/15/2013 REVEALED RESIDENT #102 WAS admitted WITH A URINARY TRACT INFECTION THAT REQUIRED TREATMENT WITH ANTIBIOTICS. RESIDENT #102 DECLINED CATHETER CARE OBSERVATIONS WITH THE SURVEYOR PRESENT 6/17/2013 AT 12:30 P.M. DURING THIS INTERVIEW, RESIDENT #102 SAID THAT HISTORICALLY, HER CATHETER CARE WAS INADEQUATE, INTERMITTENT AND NOT CONDUCTED EVERY SHIFT. SHE RECALLED THAT A LAPSE IN CARE OVER MULTIPLE SHIFTS CAUSED DRIED STOOL TO ADHERE ONTO THE CATHETER TUBING, FOUND BY CERTIFIED NURSE AIDE (CNA) #5 DURING A SHOWER. DURING AN INTERVIEW 7/18/2013 AT 11:20 A.M., CNA #5 IMMEDIATELY RECALLED THE SHOWER, BUT WAS UNABLE TO PROVIDE A DATE, WHEN SHE FOUND "CAKED ON" STOOL THAT EXTENDED UP THE CATHETER TUBING TO ITS POINT OF INSERTION INSIDE RESIDENT #102'S BODY. CNA #5 SAID SHE KNEW CATHETER CARE HAD NOT BEEN COMPLETED RECENTLY BECAUSE IT TOOK A "LONG TIME" TO CLEAN, SOAK, AND REMOVE THE DRIED STOOL FROM THE TUBING. CNA #5 SAID SHE IMMEDIATELY REPORTED THE INADEQUATE CATHETER CARE TO RESIDENT #102'S ASSIGNED NURSE, THOUGH SHE COULD NOT RECALL THE NURSE'S NAME. REVIEW OF RECORDS FAILED TO PROVIDE ANY DOCUMENTATION OF THE REPORTED EVENT. DURING AN INTERVIEW 6/18/2013 AT 1:00 P.M., ICN #1 (INFECTION CONTROL NURSE) SAID NURSING STAFF WERE REQUIRED TO DOCUMENT FOLEY CATHETER ASSESSMENTS THREE TIMES A DAY ON THE TREATMENT ADMINISTRATION RECORD FOR THE PURPOSE OF CLOSE MONITORING AND RAPID INTERVENTION WHEN ABNORMAL FINDINGS OR COMPLICATIONS OCCURRED. SHE THEN REVIEWED THE TREATMENT ADMINISTRATION RECORD FOR RESIDENT #102, FOUND 16 OF THE 30 TIMES STAFF FAILED TO DOCUMENT FOLEY CATHETER ASSESSMENTS WERE COMPLETED BETWEEN 4/01 AND 4/10/2013, BEFORE RESIDENT #102 WAS hospitalized for [REDACTED]. RESIDENT #103 REVIEW OF THE FACE SHEET DATED 6/17/2013 REVEALED RESIDENT #103 WAS AN [AGE] year OLD FEMALE admitted TO THE FACILITY 3/15/2013. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #103 HAD NO IMPAIRED COGNITION OR MEMORY LOSS, DID NOT WALK, WAS INCONTINENT OF URINE, INCONTINENT OF STOOL, AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH TOILET USE AND HYGIENE. REVIEW OF THE PHYSICIAN'S PROGRESS NOTES DATED 5/28/2013 REVEALED HE WAS CONTACTED FOR A "SICK CALL" AND DETERMINED THAT RESIDENT #102 HAD A URINARY TRACT INFECTION. REVIEW OF ORDERS DATED 5/28/2013 REVEALED [MEDICATION NAME] (ANTIBIOTIC) WAS ORDERED FOR FIVE DAYS WITH 500 MG ON THE FIRST DAY, FOLLOWED BY 250 MG EACH OF THE NEXT FOUR DAYS. REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. REVIEW OF ORDERS DATED 6/03/2013 REVEALED RESIDENT #103 REQUIRED treatment for [REDACTED]. REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE MEDICAL RECORD FAILED TO DOCUMENT EVIDENCE OF PHYSICIAN NOTIFICATION WHEN THE RESIDENT #103'S REQUIRED ANTIBIOTICS WERE WITHHELD OR WHY THE STAFF WITHHELD THEM 6/04, 6/05, 6/09, ON EVENING SHIFT OR 6/10/2013 ON DAY SHIFT. REVIEW OF A PATIENT TRANSFER FORM DATED 6/14/2013 REVEALED RESIDENT #103 REQUIRED hospitalization FOR AN ELEVATED WHITE BLOOD CELL COUNT. REVIEW OF LOCAL AREA HOSPITAL RECORDS DATED 6/14/2013 REVEALED RESIDENT #103 ARRIVED TO THE EMERGENCY DEPARTMENT WITH A LOW BLOOD PRESSURE (84/43 MILLIMETERS OF MERCURY) AND WAS CATHETERIZED. THE RESULTING URINE SAMPLE WAS CLOUDY, WITH ELEVATED LEVELS OF PROTEIN, [MEDICATION NAME], LEUKOCYTE ESTERASE, RED BLOOD CELLS, WHITE BLOOD CELLS, AND BACTERIA WHEN tested . THE PHYSICIAN diagnosed HER WITH A "UTI (URINARY TRACT INFECTION) [MEDICAL CONDITION]." DURING AN INTERVIEW 6/18/2013 AT 3:00 P.M., NURSING SAFETY COORDINATOR (NSC) #1 REVIEWED THE MEDICAL RECORD FOR RESIDENT #103, VERIFIED 4 OF THE 21 ANTIBIOTIC PILLS, ORDERED BY HER PHYSICIAN 6/03/2013 AND INTENDED TO TREAT A URINARY TRACT INFECTION, WERE NEVER ADMINISTERED. NSC #1 COULD NOT EXPLAIN WHY THESE MEDICATIONS WERE WITHHELD. .

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP AND IMPLEMENT ANY SPECIFIC AND INDIVIDUALIZED INTERVENTIONS NECESSARY TO PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES FOR TWO (# 908 AND # 910 ) OF SEVEN SAMPLED RESIDENTS WHO WERE IDENTIFIED "AT RISK" FOR PRESSURE SORES FROM A TOTAL SAMPLE OF 30 RESIDENTS, RESULTING IN THE DEVELOPMENT OF MULTIPLE AVOIDABLE PRESSURE SORES. FINDINGS INCLUDE: ON 1/08/13 AT 10:00 A.M., RESIDENT #910 WAS OBSERVED LYING IN BED. UNIT MANAGER (C) REPORTED RESIDENT #910 HAD A STAGE FOUR (IV) PRESSURE SORE ON THE BUTTOCKS AND PRESSURE SORES ON THE HEELS. AT 12:15 P.M., RESIDENT # 910 WAS OBSERVED IN AN ELECTRIC WHEELCHAIR, MOVING AROUND AND ABOUT THE, "700 AND 800" NURSING UNITS. ON 1/11/12 AT 9:30 A.M., A DRESSING CHANGE AND WOUND CARE OBSERVATION FOR RESIDENT #910 WAS CONDUCTED WITH THE WOUND CARE COORDINATOR AND TREATMENT NURSE (G). TWO STAGE IV PRESSURE SORES (STAGE IV- FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDON OR MUSCLE ) AS IDENTIFIED BY THE WOUND CARE COORDINATOR, WERE OBSERVED ON THE RESIDENT'S RIGHT BUTTOCK. THE UPPER PRESSURE SORE MEASURED 2.0 CENTIMETERS (cm) X 0.7cm (CENTIMETER) AND THE BASE OF THE SORE WAS RED AND HAD MINIMAL SEROSANGUINOUS (BLOOD TINGED) DRAINAGE. THE LOWER BUTTOCK PRESSURE SORE MEASURED 1.5cm X 0.5 cm AND WAS DESCRIBED BY TREATMENT NURSE (G) AS HAVING A RED AND YELLOW BASE. AN UNSTAGEABLE PRESSURE SORE WAS OBSERVED ON RESIDENT #910'S LEFT HEEL THAT MEASURED 2.0 cm X 2.0 cm. THE WOUND BASE WAS NOT VISIBLE, AS IT WAS COVERED WITH BLACK ESCHAR TISSUE (ESCHAR- THICK LEATHERY DEAD TISSUE, USUALLY BROWN OR BLACK IN COLOR). RECORD REVIEW FOR RESIDENT #910 REVEALED THE FOLLOWING: THE ADMISSION NURSING ASSESSMENT, DATED 11/07/12, DOCUMENTED RESIDENT # 910 WAS admitted INTO THE FACILITY WITH A "PINK AREA" ON THE COCCYX (NO MEASUREMENT); A "SHEARING AREA" (TISSUE INJURY) ON THE LEFT BUTTOCK; AND A "SCAB" ON THE LEFT HEEL. NO PRESSURE SORES WERE IDENTIFIED. THE SECTION OF THE NURSING ADMISSION ASSESSMENT TITLED, "COMMENTS" REVEALED RESIDENT #910 WAS " ...PARAPLEGIC WAIST DOWN ...PARAPLEGIC APPROXIMATELY 10-15 YRS. (YEARS) ...diagnosed with [REDACTED]. THE INITIAL ADMISSION MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED RESIDENT #910 WAS ORIGINALLY admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #910 WAS DESCRIBED WITH "IMPAIRED" COGNITIVE SKILLS FOR DECISION MAKING, AND WAS NOT UNREVIEWABLE. RESIDENT #910 WAS NON-AMBULATORY AND TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY, TRANSFERS AND PERSONAL HYGIENE. THE MDS ASSESSMENT IDENTIFIED RESIDENT #910 WAS "AT RISK" FOR THE DEVELOPMENT OF PRESSURE SORES AND AT THE TIME OF THE ASSESSMENT (11/14/12), RESIDENT #910 HAD NO PRESSURE SORES AT A LEVEL OF STAGE ONE OR HIGHER. THE PRESSURE SORE CARE AREA ASSESSMENT (CAA), DATED 11/14/12, INDICATED RESIDENT #910 WAS " ...AT RISK FOR SKIN BREAKDOWN DUE TO DECREASED MOBILITY AND INCONTINENCE AS WELL AS IMPAIRED CIRCULATION AND SENSATION... HE HAS A [DIAGNOSES REDACTED].#910 THAT INCLUDED SPECIFIC INTERVENTIONS PUT INTO PLACE TO PREVENT THE DEVELOPMENT OF PRESSURE SORES. THERE WAS NO EVIDENCE A CARE PLAN WAS INITIATED TO PREVENT THE DEVELOPMENT OF A PRESSURE SORE FOR AN INDIVIDUAL "AT RISK" FOR PRESSURE SORES, PRIOR TO DEVELOPMENT OF TWO STAGE IV PRESSURE SORES. THE "CLINICAL CONDITION" PROGRESS NOTES REVEALED THE FOLLOWING: 1. ON 11/09/12 RESIDENT #910 HAD AN OPEN AREA TO LEFT LATERAL ANKLE THAT MEASURED 1.8 X 1.5--THE SAME LOCATION WHERE A SCAB WAS IDENTIFIED AT THE TIME OF ADMISSION. THE LEFT LATERAL ANKLE ULCER WAS NOT STAGED. 2. ON 11/30/12 RESIDENT #910 WAS DESCRIBED WITH "SKIN CLEAN, DRY AND INTACT. NO OPEN AREAS...BUTTOCK SLIGHTLY REDDENED..." THE LOCATION OF THE "REDDENED" AREA WAS NOT IDENTIFIED OR DESCRIBED FURTHER. 3. THE WOUND CARE ROUNDS PROGRESS NOTE, DATED 12/06/12 DOCUMENTED RESIDENT # 910 HAD ACQUIRED DESICCATED (DRIED) BLOOD BLISTERS ON THE BILATERAL HEELS. THE AREA ON THE RIGHT HEEL BLISTER/ULCER MEASURED 2.2 X 2.7 cm. THE AREA OF THE LEFT HEEL BLISTER MEASURED 2.1 X 2.4 cm. THE APPEARANCE WAS DESCRIBED AS, "...DRY, BROWN..." (STAGE II PRESSURE ULCER IS PARTIAL LOSS OF SKIN--MAY ALSO PRESENT AS AN INTACT OR RUPTURED BLISTER). FURTHER REVIEW OF THE NOTE REVEALED THE BILATERAL HEEL BLISTERS WERE INITIALLY IDENTIFIED BY THE FACILITY ON 12/04/12. 2. A BILATERAL LOWER EXTREMITIES ARTERIAL STUDY WAS PERFORMED ON RESIDENT #910 ON 12/06/12 AND REVEALED THE FOLLOWING CONCLUSION: "...THERE IS NO EVIDENCE OF A HEMODYNAMICALLY (BLOOD CIRCULATION) SIGNIFICANT STENOSIS OR VESSEL OCCLUSION (BLOCKAGE) ON EITHER SIDE..." 3. A WOUND CARE ROUNDS PROGRESS NOTE, DATED 12/21/12, DESCRIBED RESIDENT #910 ACQUIRED A PRESSURE SORE ON THE RIGHT BUTTOCK THAT MEASURED 1.1 X 2.6 cm AND WAS DESCRIBED AS RED/BROWN. 4. THE NEXT WOUND CARE ROUNDS PROGRESS NOTE, DATED 1/03/13, IDENTIFIED RESIDENT #910 ACQUIRED TWO ADDITIONAL STAGE IV PRESSURE SORES ON THE RIGHT BUTTOCK. THE UPPER PRESSURE ULCER MEASURED 4.2 cm X 0.8 cm. AND THE LOWER PRESSURE ULCER MEASURED 1.0 X 1.9 cm. 5. REVIEW OF RESIDENT #910'S CARE PLANS REVEALED THE FACILITY DID NOT DEVELOP A NURSING CARE PLAN THAT INCLUDED SPECIFIC INTERVENTIONS TO PREVENT SKIN BREAKDOWN UNTIL 12/05/12, AFTER RESIDENT #910 ACQUIRED BILATERAL STAGE II PRESSURE SORES ON HIS HEELS AND AFTER THE "SCABBED" AREA OVER HIS LEFT LATERAL ANKLE "RE-OPENED". THERE WAS NO CARE PLAN NOR INTERVENTIONS TO ADDRESS THE "PINK AREA" ON THE RIGHT BUTTOCK; THE TISSUE INJURY ON THE LEFT BUTTOCK, OR THE SCABBED AREA LOCATED ON THE LEFT LATERAL ANKLE. ON 1/11/13 AT 11:50 A.M., AN INTERVIEW WAS CONDUCTED WITH UNIT MANAGER (C) AND THE WOUND CARE COORDINATOR REGARDING SPECIFIC AND INDIVIDUALIZED NURSING INTERVENTION FOR RESIDENT #910, WHO HAD BEEN IDENTIFIED "AT RISK" FOR THE DEVELOPMENT OF PRESSURE SORES. UNIT MANAGER (C) AND THE WOUND CARE COORDINATOR STATED THERE SHOULD HAVE BEEN A CARE PLAN DEVELOPED THAT INCLUDED WITH INTERVENTIONS SPECIFIC AND INDIVIDUALIZED BASED ON ASSESSMENT, TO HELP PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES. THE FACILITY PROVIDED A TWO PAGE UNDATED POLICY AND PROCEDURE ON PRESSURE SORES PREVENTION THAT THE PROGRAM WAS "DESIGNED AS A BEST CLINICAL PRACTICE GUIDE TO CARE...STATED, "...WE AT (NAME OF FACILITY) WILL NOT ALLOW OUR RESIDENTS TO DEVELOP WOUNDS. PREVENTION OF WOUNDS IS A REFLECTION OF OUR UNDERSTANDING THE RESIDENT'S NEEDS, CONDITIONS AND ENVIRONMENTAL FACTORS THAT COULD LEAD TO WOUND DEVELOPMENT". NO OTHER INFORMATION WAS PROVIDED. ( ) ON 1/9/13 AT 11:05 A.M., A WOUND CARE OBSERVATION FOR RESIDENT #908 WAS CONDUCTED WITH NURSE'S "J" AND "K" AND A STAGE IV PRESSURE SORE (FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDON OR MUSCLE) WAS OBSERVED ON THE RESIDENT'S COCCYX THAT MEASURED 3.5 X 3.0 X 1.0 CENTIMETERS (CM). THE WOUND BASE WAS DARK PINK WITH TENDON (CONNECTIVE TISSUE TO MUSLCE OR BONE) EXPOSED. REVIEW OF THE ADMISSION FACESHEET AND CLINICAL RECORD FOR RESIDENT #908, REVEALED THE RESIDENT WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #908'S NURSING ADMISSION assessment dated [DATE] DOCUMENTED THE RESIDENT HAD A "SMALL RED AREA" ON THE COCCYX (TAILBONE). IT WAS NOT IDENTIFIED AS A PRESSURE SORE. REVIEW OF "WOUND CARE SERVICE" CONSULT NOTES DOCUMENTED THE FOLLOWING: 1. "THE WOUND BEGAN ON 7/23/12 WITH ONSET IN THE NURSING FACILITY. ON ADMISSION, HIS COCCYX WAS RED AND BLANCHABLE (AN AREA THAT TURNS PALE OR WHITE WHEN PRESSURE WAS APPLIED). ON 7/23/12, HE WAS FOUND TO HAVE AN OPEN WOUND TO THE COCCYX THAT IS UTD (UNABLE TO DETERMINE) STAGE. THE LESION COLOR IS RED, YELLOW AND BROWN. THE WOUND PRESENTS AS NECROTIC TISSUE (UNSTAGEABLE) PRESSURE ULCER LOCATED ON THE COCCYX AND MEASURES 5.5 CENTIMETERS (CM) X 5.0 CM. PLAN OFF-LOADING (REMOVING PRESSURE FORM THE AREA). LIMIT TIME UP IN GERI CHAIR TO TWO HOURS MAXIMUM ON EACH SITTING." THERE WAS NO EVIDENCE SKIN ASSESSMENTS WERE COMPLETED ROUTINELY BY NURSING UNTIL 7/23/12 (THREE WEEKS AFTER THE RESIDENT'S ADMISSION INTO THE FACILITY AND THE ONSET OF THE PRESSURE SORE). REVIEW OF "WOUND CARE ROUND" PROGRESS NOTES DOCUMENTED "IN HOUSE" COCCYX/SACRAL PRESSURE SORE AS FOLLOWS: -7/26/12: "STAGE "UTD" (UNABLE TO DETERMINE), MEASUREMENT 5.0 X 5.0 CM. WOUND APPEARANCE: RED/YELLOW/BLACK, MODERATE AMOUNT OF SEROUS (BLOOD TINGED) DRAINAGE.." -8/2/12: "STAGE "UTD", THAT MEASURED 6.0 X6.0 CM. THE WOUND APPEARANCE WAS DESCRIBED AS "75% (PERCENT) BLACK/YELLOW, LOW SEROUS DRAINAGE." (INCREASED IN SIZE). -8/9/12: "STAGE "UTD" THAT MEASURED 5.9 X 6.0 CM. THE WOUND APPEARANCE WAS RED/YELLOW/BROWN. -8/16/12: "STAGE "UTD--8.0 X 6.0 CM. WOUND APPEARANCE: RED/YELLOW/BLACK, LARGE AMOUNT SEROUS DRAINAGE." (INCREASED IN SIZE). -8/23/12: "STAGE "UTD--8.0 X 7.1 CM (INCREASED IN LENGTH). WOUND APPEARANCE: RED/YELLOW/BLACK 60 % NECROTIC (DEAD TISSUE)." -9/13/12: "STAGE IV (FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDOR OR MUSCLE)--6.0 X 7.0 X 3.0 CM AND 3 CM UNDERMINING. WOUND APPEARANCE: RED/YELLOW/BLACK. TREATMENT "SHARP DEBRIDEMENT (SURGICAL REMOVAL OF DEAD TISSUES)...". 10/18/12: "STAGE IV--5.0 X 4.1 X 1.6 CM. WOUND APPEARANCE: LIGAMENT EXPOSED TISSUE RED/YELLOW." 11/29/12: "STAGE IV--4.1 X 2.5 X 1.5, 2.5 CM UNDERMINING AT 6:00. APPEARANCE OF WOUND: RED/YELLOW TENDON EXPOSURE MODERATE SEROUS DRAINAGE." REVIEW OF THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #908 HAD SEVERELY IMPAIRED COGNITION AND WAS PHYSICALLY DEPENDENT ON STAFF, REQUIRING TWO PLUS ASSISTANCE FOR BED MOBILITY, TRANSFERS AND ALL ACTIVITIES OF DAILY LIVING. THE MDS DOCUMENTED THAT RESIDENT #908 WAS "AT RISK" FOR PRESSURE SORE AND CODED THE RESIDENT AS NOT HAVING PRESSURE SORES AT THE TIME OF THE INITIAL ADMISSION ASSESSMENT. REVIEW OF THE MOST RECENT QUARTERLY MDS, dated [DATE], DOCUMENTED RESIDENT #908 WAS "AT RISK" FOR PRESSURE SORES AND CODED AS HAVING A STAGE IV (FULL THICKNESS) PRESSURE SORE. REVIEW OF THE RESIDENT'S CLINICAL CARE PLAN SECTION REVEALED, THERE WERE NO INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE SORES. THERE WERE NO CARE PLANS THAT ADDRESSED THE POTENTIAL FOR SKIN BREAKDOWN. THE FIRST CARE PLAN TITLED, "SKIN INTEGRITY ALTERATION" WAS DEVELOPED 9/7/12, MORE THAN TWO MONTHS AFTER ADMISSION INTO THE FACILITY. ON 1/10/13 AT 11:30 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH THE WOUND CARE COORDINATOR, SHE STATED, "WE DIDN'T HAVE ANYTHING IN PLACE BEFORE THE RESIDENT'S WOUND OPENED. I WAS NOT ABLE TO FIND SKIN ASSESSMENTS UNTIL THE RESIDENT'S WOUND OPENED. WE HAD A LOW AIR LOSS MATTRESS AT ONE TIME BUT WE DISCONTINUED IT BECAUSE OF THE RESIDENT'S [DIAGNOSES REDACTED]. WE'VE SINCE REPLACED THE LOW AIR LOSS MATTRESS." REVIEW OF THE UNDATED FACILITY'S "HEALTHLY SKIN PROGRAM" POLICY REVEALED THE FACILITY FAILED TO: "... MAINTAIN AND PROMOTE HEALTHY SKIN", DOCUMENTED: "WE AT MEDILODGE WILL NOT ALLOW OUR RESIDENTS TO DEVELOP WOUNDS. PREVENTION OF WOUNDS IS A REFLECTION OF OUR UNDERSTANDING THE RESIDENTS' NEEDS, CONDITION AND ENVIRONMENTAL FACTORS THAT COULD LEAD TO WOUND DEVELOPMENT." ( ) ON 1/9/13 AT 11:05 A.M., A WOUND CARE OBSERVATION FOR RESIDENT #908 WAS CONDUCTED WITH NURSE'S "J" AND "K" AND A STAGE IV PRESSURE SORE (FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDON OR MUSCLE) WAS OBSERVED ON THE RESIDENT'S COCCYX THAT MEASURED 3.5 X 3.0 X 1.0 CENTIMETERS (CM). THE WOUND BASE WAS DARK PINK WITH TENDON (CONNECTIVE TISSUE TO MUSLCE OR BONE) EXPOSED. REVIEW OF THE ADMISSION FACESHEET AND CLINICAL RECORD FOR RESIDENT #908, REVEALED THE RESIDENT WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #908'S NURSING ADMISSION assessment dated [DATE] DOCUMENTED THE RESIDENT HAD A "SMALL RED AREA" ON THE COCCYX (TAILBONE). IT WAS NOT IDENTIFIED AS A PRESSURE SORE. REVIEW OF "WOUND CARE SERVICE" CONSULT NOTES DOCUMENTED THE FOLLOWING: 1. "THE WOUND BEGAN ON 7/23/12 WITH ONSET IN THE NURSING FACILITY. ON ADMISSION, HIS COCCYX WAS RED AND BLANCHABLE (AN AREA THAT TURNS PALE OR WHITE WHEN PRESSURE WAS APPLIED). ON 7/23/12, HE WAS FOUND TO HAVE AN OPEN WOUND TO THE COCCYX THAT IS UTD (UNABLE TO DETERMINE) STAGE. THE LESION COLOR IS RED, YELLOW AND BROWN. THE WOUND PRESENTS AS NECROTIC TISSUE (UNSTAGEABLE) PRESSURE ULCER LOCATED ON THE COCCYX AND MEASURES 5.5 CENTIMETERS (CM) X 5.0 CM. PLAN OFF-LOADING (REMOVING PRESSURE FORM THE AREA). LIMIT TIME UP IN GERI CHAIR TO TWO HOURS MAXIMUM ON EACH SITTING." THERE WAS NO EVIDENCE SKIN ASSESSMENTS WERE COMPLETED ROUTINELY BY NURSING UNTIL 7/23/12 (THREE WEEKS AFTER THE RESIDENT'S ADMISSION INTO THE FACILITY AND THE ONSET OF THE PRESSURE SORE). REVIEW OF "WOUND CARE ROUND" PROGRESS NOTES DOCUMENTED "IN HOUSE" COCCYX/SACRAL PRESSURE SORE AS FOLLOWS: -7/26/12: "STAGE "UTD" (UNABLE TO DETERMINE), MEASUREMENT 5.0 X 5.0 CM. WOUND APPEARANCE: RED/YELLOW/BLACK, MODERATE AMOUNT OF SEROUS (BLOOD TINGED) DRAINAGE.." -8/2/12: "STAGE "UTD", THAT MEASURED 6.0 X6.0 CM. THE WOUND APPEARANCE WAS DESCRIBED AS "75% (PERCENT) BLACK/YELLOW, LOW SEROUS DRAINAGE." (INCREASED IN SIZE). -8/9/12: "STAGE "UTD" THAT MEASURED 5.9 X 6.0 CM. THE WOUND APPEARANCE WAS RED/YELLOW/BROWN. -8/16/12: "STAGE "UTD--8.0 X 6.0 CM. WOUND APPEARANCE: RED/YELLOW/BLACK, LARGE AMOUNT SEROUS DRAINAGE." (INCREASED IN SIZE). -8/23/12: "STAGE "UTD--8.0 X 7.1 CM (INCREASED IN LENGTH). WOUND APPEARANCE: RED/YELLOW/BLACK 60 % NECROTIC (DEAD TISSUE)." -9/13/12: "STAGE IV (FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDOR OR MUSCLE)--6.0 X 7.0 X 3.0 CM AND 3 CM UNDERMINING. WOUND APPEARANCE: RED/YELLOW/BLACK. TREATMENT "SHARP DEBRIDEMENT (SURGICAL REMOVAL OF DEAD TISSUES)...". 10/18/12: "STAGE IV--5.0 X 4.1 X 1.6 CM. WOUND APPEARANCE: LIGAMENT EXPOSED TISSUE RED/YELLOW." 11/29/12: "STAGE IV--4.1 X 2.5 X 1.5, 2.5 CM UNDERMINING AT 6:00. APPEARANCE OF WOUND: RED/YELLOW TENDON EXPOSURE MODERATE SEROUS DRAINAGE." REVIEW OF THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #908 HAD SEVERELY IMPAIRED COGNITION AND WAS PHYSICALLY DEPENDENT ON STAFF, REQUIRING TWO PLUS ASSISTANCE FOR BED MOBILITY, TRANSFERS AND ALL ACTIVITIES OF DAILY LIVING. THE MDS DOCUMENTED THAT RESIDENT #908 WAS "AT RISK" FOR PRESSURE SORE AND CODED THE RESIDENT AS NOT HAVING PRESSURE SORES AT THE TIME OF THE INITIAL ADMISSION ASSESSMENT. REVIEW OF THE MOST RECENT QUARTERLY MDS, dated [DATE], DOCUMENTED RESIDENT #908 WAS "AT RISK" FOR PRESSURE SORES AND CODED AS HAVING A STAGE IV (FULL THICKNESS) PRESSURE SORE. REVIEW OF THE RESIDENT'S CLINICAL CARE PLAN SECTION REVEALED, THERE WERE NO INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE SORES. THERE WERE NO CARE PLANS THAT ADDRESSED THE POTENTIAL FOR SKIN BREAKDOWN. THE FIRST CARE PLAN TITLED, "SKIN INTEGRITY ALTERATION" WAS DEVELOPED 9/7/12, MORE THAN TWO MONTHS AFTER ADMISSION INTO THE FACILITY. ON 1/10/13 AT 11:30 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH THE WOUND CARE COORDINATOR, SHE STATED, "WE DIDN'T HAVE ANYTHING IN PLACE BEFORE THE RESIDENT'S WOUND OPENED. I WAS NOT ABLE TO FIND SKIN ASSESSMENTS UNTIL THE RESIDENT'S WOUND OPENED. WE HAD A LOW AIR LOSS MATTRESS AT ONE TIME BUT WE DISCONTINUED IT BECAUSE OF THE RESIDENT'S [DIAGNOSES REDACTED]. WE'VE SINCE REPLACED THE LOW AIR LOSS MATTRESS." REVIEW OF THE UNDATED FACILITY'S "HEALTHLY SKIN PROGRAM" POLICY REVEALED THE FACILITY FAILED TO: "... MAINTAIN AND PROMOTE HEALTHY SKIN", DOCUMENTED: "WE AT MEDILODGE WILL NOT ALLOW OUR RESIDENTS TO DEVELOP WOUNDS. PREVENTION OF WOUNDS IS A REFLECTION OF OUR UNDERSTANDING THE RESIDENTS' NEEDS, CONDITION AND ENVIRONMENTAL FACTORS THAT COULD LEAD TO WOUND DEVELOPMENT." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MAINTAIN A SAFE ENVIRONMENT FOR ONE OF 16 RESIDENT'S (#905) IDENTIFIED WITH FALLS, OUT OF A TOTAL SAMPLE OF 30 RESIDENTS, RESULTING IN A FALL WITH FRACTURE. FINDINGS INCLUDE: ON 3/1/11 AT 10:50 A.M., RESIDENT #905 WAS OBSERVED SITTING IN HER WHEELCHAIR IN HER ROOM. THE LEFT SIDE OF THE RESIDENT'S FACE AND THE AREA DIRECTLY BENEATH THE RESIDENT'S LEFT EYE WAS DISCOLORED (A LIGHT BROWN/PALE GREEN COLOR), IN WHAT APPEARED TO BE A FADING BRUISE. RESIDENT #905 WAS QUESTIONED ABOUT THE DISCOLORATION ON HER FACE AND REVEALED THAT SHE HAD FALLEN A FEW WEEKS AGO. SHE STATED "I WAS WALKING WITH A WALKER IN MY ROOM AND I TRIPPED AND fell FLAT ON MY FACE." THE RESIDENT ALSO REVEALED THAT SHE HAD FRACTURED HER WRIST IN THE FALL AND THAT THE CAST HAD JUST RECENTLY BEEN REMOVED THE MORNING OF THE INTERVIEW. WHEN QUESTIONED FURTHER ABOUT PAIN IN HER WRIST, THE RESIDENT STATED THAT THE PAIN LEVEL WAS A "5-6 " (USING A 0-10 PAIN SCALE, WITH "0" INDICATING NO PAIN, AND "10" THE WORST EVER PAIN). A REVIEW OF THE ADMISSION AND PHYSICIAN ORDER RECORDS, ON 3/2/11 AT 10:25 A.M., REVEALED THAT RESIDENT #905 WAS admitted TO THE FACILITY IN OCTOBER 2010 WITH MULTIPLE [DIAGNOSES REDACTED]. A HISTORY AND PHYSICAL, DATED 10/11/10, INDICATED THAT THE RESIDENT HAD A "HISTORY OF MULTIPLE FALLS, FRACTURES TO THE WRIST AND FOREARM, AND DEGENERATIVE ARTHRITIS." THE MINIMUM DATA SET (MDS), WITH AN ASSESSMENT REFERENCE DATE OF 1/1/11, IDENTIFIED THE RESIDENT AS MODERATELY COGNITIVELY IMPAIRED AND REQUIRING EXTENSIVE ASSISTANCE WITH DRESSING, BATHING AND TRANSFERS (ONE PERSON PHYSICAL ASSIST). THE MDS ALSO INDICATED THAT THE RESIDENT WAS NOT STEADY WHEN MOVING FROM A SEATED TO A STANDING POSITION OR BETWEEN TRANSFERS FROM ONE SURFACE TO ANOTHER (E.G.. BED TO WHEELCHAIR). REVIEW OF NURSING NOTES, DATED 1/16/11 AT 1:40 A.M., CONFIRMED THAT THE RESIDENT HAD FALLEN AND WAS OBSERVED "FACE DOWN, LAYING ON LEFT SIDE, AGAINST WALL, FEET IN FRONT OF BATHROOM DOOR, HEAD TOWARD BED, WALKER UNDER BIL (BILATERAL) LOWER LEGS. PT (PATIENT) STATED I WAS WALKING WITH MY WALKER, COMING OUT OF THE BATHROOM, AND I TRIPPED OVER THE WALKER. ... ...LEFT EYE SWOLLEN, HEMATOMA NOTED TO LEFT EYE, SMALL ABRASION UNDER LEFT EYE, LIMITED ROM (RANGE OF MOTION) TO LEFT WRIST, WRIST SWOLLEN." A REVIEW OF THE INCIDENT AND ACCIDENT REPORT, DATED 1/16/11, NOTED THAT ICE WAS APPLIED TO THE RESIDENT'S EYE, AN X-RAY WAS ORDERED OF THE SKULL/FACE AND WRIST, AND THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL FOR FURTHER EVALUATION. A PHYSICIAN FOLLOW-UP NOTE, , REVEALED THAT THE RESIDENT HAD SUSTAINED "L (LEFT) FACIAL/ORBITAL (AROUND THE EYE) SWELLING WITH ECCHYMOSIS (BRUISING) ...L RADIAL - WRIST FX (FRACTURE)." ON 3/2/11 AT 2:20 P.M., THE PHYSICAL THERAPIST "A", WHO WORKED WITH THE RESIDENT ON ADMISSION, WAS INTERVIEWED REGARDING THE RESIDENT'S FUNCTIONAL STATUS. THE THERAPIST STATED THAT THE RESIDENT HAD BEEN RECEIVING PHYSICAL THERAPY ON ADMISSION TO THE FACILITY AND WAS TRANSFERRED TO A FUNCTIONAL MAINTENANCE PROGRAM (FMP) WITH RESTORATIVE NURSING IN LATE NOVEMBER. SHE REVEALED THAT THE RESIDENT REQUIRED A ONE PERSON ASSIST WITH WALKING AND TRANSFERS AND THAT THE RESIDENT WAS NOT ALLOWED TO WALK OR USE A WALKER INDEPENDENTLY WITHOUT THE ASSISTANCE FROM RESTORATIVE NURSING STAFF. WHEN QUESTIONED FURTHER, WHY A WALKER WAS LEFT IN RESIDENT #905'S ROOM IF THE RESIDENT WAS NOT TO USE IT INDEPENDENTLY, THE THERAPIST INDICATED THAT SHE HAD ASKED THAT SAME QUESTION HERSELF. ON 3/3/11 AT 10:35 A.M., THE SAFETY COORDINATOR "B" AND THE DIRECTOR OF NURSING WAS INTERVIEWED REGARDING THE RESIDENT'S FALL. THE SAFETY COORDINATOR STATED THAT, AFTER INTERVIEWING THE RESIDENT, IT WAS DETERMINED THAT A FAMILY MEMBER (BROTHER) HAD RECENTLY BROUGHT IN THE WALKER FOR THE RESIDENT. ON 3/3/11 AT 1:55 P.M., THE RESIDENT'S BROTHER WAS INTERVIEWED REGARDING THE RESIDENT'S FALL AND THE WALKER. HE INDICATED THAT HE DID NOT BRING IN A WALKER TO HIS SISTER. HE ALSO REVEALED THAT THERE WAS A WALKER IN HIS SISTERS ROOM EACH TIME HE VISITED HER IN THE FACILITY. ON THE MORNING OF 3/4/11, RESTORATIVE NURSE "C" WAS INTERVIEWED. SHE REVEALED THAT SHE HAD BEEN ASSISTING THE RESIDENT THREE TIMES A WEEK WITH WALKING AND THAT THE RESIDENT WAS NOT TO WALK ON HER OWN WITHOUT ASSISTANCE FROM STAFF. SHE ALSO NOTED THAT SHE HAD SEEN THE WALKER IN THE RESIDENT'S ROOM AND ASSUMED IT WAS THE RESIDENT'S PERSONAL WALKER. REVIEW OF THE RESTORATIVE CARE PROGRESS NOTES, DATED 1/7/11, INDICATED THAT THE RESIDENT WALKED 80 FEET AND THAT THE RESIDENT REQUIRED "CG (CONTACT GUARD - DIRECT ASSISTANCE WITH THE RESIDENT FOR SAFETY), RW (ROLLING WALKER), A LITTLE SHAKING AT FIRST." RESTORATIVE NOTES, DATED 1/15/11 - THE DAY BEFORE THE RESIDENT'S FALL, NOTED THAT THE RESIDENT AGAIN WALKED 80 FEET AND WAS "VERY SHAKING AT FIRST." ON 1/16/11 THE RESIDENT ATTEMPTED TO WALK INDEPENDENTLY USING THE WALKER THAT WAS LEFT IN HER ROOM AND SUSTAINED THE INJURIES AS NOTED ABOVE. ALL OF THE STAFF INTERVIEWED WERE UNABLE TO PROVIDE INFORMATION AS TO WHY THE WALKER WAS NOT REMOVED FROM THE RESIDENT'S ROOM WHEN SEEN TO PREVENT INJURY IF THE RESIDENT ATTEMPTED TO USE THE WALKER WITHOUT ASSISTANCE. THERE WAS NO INFORMATION IN THE RESIDENT'S NURSING CARE PLAN FOR SAFETY REGARDING THE INDEPENDENT USE OF A WALKER. THERE WAS NO PHYSICIan order for [REDACTED]. A REVIEW OF AN UNDATED FACILITY POLICY FOR SAFETY REVEALED THAT THE SAFETY COMMITTEE WILL ENSURE THAT A SAFE, FUNCTIONAL AND EFFECTIVE ENVIRONMENT IS MAINTAINED FOR RESIDENTS. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT, THE WALKER WAS FINALLY REMOVED FROM THE RESIDENT'S ROOM BY STAFF AFTER THE 1/16/11 FALL. ( )